Now, the reason for establishing these benefits, Mr. Chairman, are that they are adequate benefits considering the actuarial findings on what our older people require. For the source of that, I refer the committee to the national health survey conducted by the Department of Health, Education, and Welfare, series B-1, entitled "Physicians Services Útilization" (published by the Public Health Service in November 1958); also series B-7, "Hospitalization Services Utilization," published in December 1958. These findings were also checked against the OASI statistics for 1959. The Department comes up, for example, with the proposition that average utilization of hospital care by people over 65 is 14 days per year, and under our plan as a minimal basis you have 21 days. And so, for the care of physicians, care of nurses, and ambulatory diagnostic services, et cetera, this bill provides a minimum which is fully adequate as developed from the actuarial findings of the Department based upon fundamental studies for ordinary health care. Now, Mr. Chairman, the social security approach, and the objections to it, I am sure, have been very well discussed by the Secretary of Health, Education, and Welfare, and I would not undertake to go over that ground again, although I am perfectly glad and ready to debate the issue on the floor when we get to that point; but I would like to say in support of our own program, that it is a first cost program. There is no deductability. The subscriber gets the benefit of it at once, as soon as he needs it. It is designed on the minimum basis to provide what normally he actually needs, and it represents participation by the States and Federal Government in a cost bracket which has been pretty well accepted as the estimate of what this ought to cost. Let me explain that. As you look through these plans, in this comparison form, you find right across the board the cost is about $400 million per year for the Federal Government. Even the McNamara bill, which I think is broader than the Forand plan, if you accept that approach, because it does take in those who are on old age assistance, contemplates an expenditure of about $400 million a year for that purpose. The Forand plan necessarily encompasses that kind of an expenditure over and above what is contributed into social security. So as you look into these plans, no matter which one you take, you are going to have an appropriation of about $400 million from general revenues-this is quite apart from the social security contribution. This plan is apportioned to the need on a minimum basis where you share with the States just about what everybody agrees the Federal Government is going to pay out of the general revenues anyhow; at the same time you don't get involved in the social security system with all the argument and objection there is against getting into it. It seems to us-my colleagues and myself who have combined on thisthat it is a fair ground upon which to stand in the effort; and I understand from Mr. Lesser of my office, who was here this morning, that the Secretary made a most eloquent statement in respect to the need for legislation in this field. Gentlemen, any figure that you pick demonstrates it. For example, 60 percent of the aged have less income than a thousand dollars a year and their average medical bill is $125 a year; 16 percent of them spend as much as $500 a year. It just seems to me that people who have given their lives in the» service of our country-in terms of the economy of our country-areentitled to this kind of consideration from us in their declining years,. when they need it. I think this is one ground upon which all proponents of all bills agree, whether it is Senator Gore's bill, or any other bill. It seems to me we meet on common ground at that point, that is, we feel there has to be legislation in this field, whatever may be our differences as to the way in which it should be approached. Also, Mr. Chairman, in commendation of our plan I would like to point out that 127 million people are now under some kind of a medical care program. It may be inadequate and I think in many cases it is, especially for our older people, but there is some kind of a program. Now we build upon that by taking advantage of the fact that you just don't then have to start out from first base with the Federal Government running a national health scheme, and I think that is the fundamental problem which is presented by the social security, socalled compulsory approach. In our case you don't do that, you can build on everything that you have, and use it, and I think that has great advantages. Then, in our plan, you also build upon what the States have in the way of facilities; facilities differ very materially among the States. Some States can give a much higher level of medical care than others. There is no reason why one should be retarded over the other. And, third, and very importantly our plan is very heavily based upon physicians' care, and here I would like to refer to a seminar which I conducted at the College of Physicians and Surgeons in New York about 3 months ago, in March of this year and I would like, Mr. Chairman, to have permission to include the report of that seminar as part of my testimony before this committee if I may. The CHAIRMAN. Without objection. (The document referred to follows:) CONFERENCE ON THE "ROLE OF THE FEDERAL GOVERNMENT IN PROBLEMS OF HEALTH AND MEDICAL RESEARCH," SATURDAY, MARCH 12, 1960, 9:30 A.M. CONFEREES Senator Jacob K. Javits and staff: Mrs. Jacob K. Javits. Mr. Allen Lesser. Columbia staff: Dr. H. Houston Merritt, dean, College of Physicians and Surgeons, and vice preisdent in charge of medical affairs, Columbia University. Dr. Willard C. Rappleye, dean emeritus and vice president emeritus in charge of medical affairs, College of Physicians and Surgeons. Dr. Aura E. Severinghaus, associate dean, College of Physicians and Surgeons, and professor of anatomy. Dr. Melvin D. Yahr, associate professor of clinical neurology. Others: Dr. John Bourke, hospital survey and planning committee. Dr. Francis Browning, University of Rochester Medical School. Mr. George Bugbee, president, Health Information Foundation, Inc. Dr. Martin Cherkasky, director, Montefiore Hospital, New York City. Dr. Marcus D. Kogel, dean, Albert Einstein College of Medicine, New York City. Mr. McAllister Lloyd, chairman of the board, Teachers Insurance & Annuity Association. Dr. Aimes C. McGuinness, executive secretary, New York Academy of Medicine. The Honorable George P. Metcalf, State senator. Dr. David Seegal, professor of medicine, College of Physicians and Surgeons. Dr. Martin R. Steinberg, director, Mount Sinai Hospital. Dr. Thomas Thacher, superintendent of insurance, State of New York. Dr. Frederick D. Zeman, chief of the medical services, Home for Aged and Infirm Hebrews. Members of the press. Summary MEMORANDUM The problem of health care for those 65 years old and over is distinct from the problem of health care for those under that age; Federal assistance is necessary in handling any health care program for the aging; and any such health care program should be voluntary, with contributions by the beneficiary as well as by State and Federal Governments. These are the major conclusions that may be drawn from the papers and discussions of those who engaged in the conference. Discussion-1 The first paper was delivered by Dr. Frederick D. Zeman, chief of the medical services of the Home for Aged and Infirm Hebrews, who spoke on medical preventive services for the aged. He said that the problem of caring for the aged so far as medicine is concerned starts on the day the individual is born, and stressed the need for retraining professionals so that they could handle the problems that older people present. He described the advantages of a geriatrics institution, the specialized equipment used by such an institution as contrasted with the hospitals. There were no operating rooms, no X-ray laboratories, etc., but the geriatric institution could provide better postoperative care than a general hospital and had many advantages in caring for those 65 and over. Zeman emphasized that the problems of care for those 65 and over are quite different from those we usually anticipate. He pointed out that of the 100,000 or more who are institutionalized in New York State mental hospitals, many are over 65. At Central Islip, for example, more than 50 percent are 65 years old and over. However, he said, these 50 percent were not necessarily hopelessly insane; their mental illness is part of the whole process of aging, and with proper care they could be taken out of this kind of an institution. Prevention of disease among the older people is part of the larger picture of preventive medicine, and begins long before the individual has reached the age of 65; a dynamic aggressive approach to the problems of preventive medicine with particular reference to the early detection of chronic illnesses before they become obvious in the aged is what is needed. These preventive services are extremely important. Dr. Martin Cherkasky, director of the Montefiore Hospital in New York, pointed out that the older patients primarily suffer from chronic illnesses as contrasted with the acute character of the illnesses that strike younger people. He said it is impossible to provide adequately for the older people because there is a wide gap in the amount of knowledge that physicians have about treating them. One should start in preventive medicine long before the patient reaches the age of 65. General medical care must exist first if the program for the older patients is to be considered. Dr. Cherkasky said that to prevent chronic illnesses, one must be able to detect them at a very early stage. Usually the onset of a chronic ailment is insidious, the patient doesn't even know that he has it. The patient, therefore, must have "easy" access to physicians if chronic illnesses are to be checked in their early stage. It must also be "easy" for the doctor to use all the tools of preventive medicine, and in this connection the economic obstacles must be overcome. The complexity of moderu medicine means that the group treatment, the group setup, is important for proper diagnosis and treatment. Dr. David Seegal, professor of medicine at the College of Physicians and Surgeons, pointed out that great progress has been made in the last 40 years in the treatment and knowledge of chronic diseases and that 38 diseases which then were fatal are now under control. He pointed out, however, that medical schools need considerable strengthening if specialized training for aging people is to be developed to any great extent. He suggested that in the accurate treatment of the aging, the word "appraisal" be substituted for "diagnosis," and "management" for "treatment." An important point was made by Dr. Martin R. Steinberg, director of the Mount Sinai Hospital. He pointed out that younger physicians usually attempt to make a complete cure of the patient. Insofar as the aged are concerned, Dr. Steinberg pointed out accurate diagnosis and complete cure are not as urgent as the need to keep these older people up and about. Being ambulant is probably the most important part of the treatment. Another important suggestion was made in this early morning discussion by Dr. Martin Cherkasky. He said that older patients needed a variety of services and he outlined an ideal community situation in which the hospital was the centralized medical agency around which was linked the nursing home, homecare programs, and other measures designed to get the patient on his feet as fast as possible. Outpatient services would broaden the services of the hospital but custodial institutions were also needed, all of them linked with the central hospital. This was the way in which an effective community program could be organized. Dr. Cherkasky visualized a community set up in which the hospital with all its medical and diagnostic services would be the first to take the older persons, who would then be transferred as soon as possible either to nursing homes, to outpatient services, or to some other custodial institution as quickly as possible, thereby providing adequate service without placing too great a burden on the hospital itself. Dr. Zeman stressed the need for "clinical humility," by which he meant that doctors should develop at an early stage a realization that they can achieve only limited goals. He strongly supported Dr. Cherkasky's suggestions. Dr. Willard C. Rappleye, dean emeritus and vice president emeritus of the College of Physicians and Surgeons, pointed out that one should not focus only on those 65 years old or over. He stressed that one had to consider the whole practice of general medicine, medical education, and the ways and means of financing this education. He enlarged upon this at a later stage in the discussion. Dr. John E. Deitrick, dean of the Cornell University Medical College also pointed out that where the aged were concerned, prevention calls for making people happy, and to see that they get proper nutrition. He stressed the fact that poor nutrition lay at the root of a great many of the problems faced by the aging. He cited the perils of isolation inactivity and depression as part of the problem that had to be overcome. George Bugbee, president of the Health Information Foundation, seconded this observation. He stressed the need for the doctors to emphasize to their aging patients that they find ways and means to live with themselves. Another suggestion came from McAllister Lloyd, chairman of the board of the Teachers Insurance & Annuity Association. Mr. Lloyd suggested regular medical examinations by busines firms for their chief employees as one of the ways in which preventive medicine could be most effective in early diagnosis and prevention of chronic illnesses. Dr. Aimes C. McGuinness, executive secretary of the New York Academy of Medicine, pointed out that the old and aging needed twice as much care as those under 65. 2 Dr. John Bourke, executive director of the New York State Hospital Survey and Planning Committee, delivered a paper on hospital trends and the needs of those who are chronically ill. He pointed to the development in recent years of fewer but better and larger hospitals, and emphasized that the gap between the apparent need and the number of hospital beds is not as large as the statistics would seem to indicate. The gaps that do develop are the result of chronic cases being placed in the hospital where they don't belong instead of using the hospital beds for acute cases with consequent much more rapid turnover. Dr. Bourke's paper, which he summarized very briefly, provided statistics showing the differences between costs of 10 years ago and costs today. He said, however, that despite sizable increases, costs to the patient were not much higher because the average length of stay in the hospital has been short ened. This means that intensive treatment is provided over a much shorter period of time than 14 years ago. Dr. Bourke warned against overinstitutionalizing the population and emphasized that the development of nursing home units as part of the hospital complex can take care of many of the problems of the chronically ill. Dr. Bourke called for the reexamination of ways and means to cut down or avoid hospital stay altogether. He praised the Hill-Burton program and said that it has changed completely the rural hospital system in upstate New York and vastly improved medical care in that region. The hospitals were better staffed and better equipped and he had only words of the highest praise for this program. Dr. Bourke favors the large centralized hospital, and he pointed out that planning must include the full range of facilities and required services which will allow the hospital to serve as a central core for such needs as chronic disease care, the nursing home type of care, ambulatory, diagnostic, and treatment facilities and home-care programing. Sound community planning, he said, will tend to avoid unnecessary costly construction and duplication. He emphasized that it did not make good sense to keep the patient in a general hospital bed which cost $26 a day when the required care could be given in a nursing home unit for an approximate cost of $9 or $10 a day. Dr. Bourke stressed that the prevention of disease should be our primary goal and that good quality medical care and hospital care should be available to all as needed. The cost of such care, he said, should be studied within the broad framework of the health of our community and with regard to our overall economy. More doctors should be trained and more services were needed. Satisfactory methods must be developed jointly by voluntary enterprise and government so that all ages of people and all economic groups can share equally in the rich benefits which the health, and medical and related sciences have provided toward a more healthful life. Dr. McGuinness praised Dr. Bourke's presentation and went on to point out the need for more research in the administration of medical care. He pointed out that the Hill-Burton program provided only $1.2 billion for research, a ridiculously low level. Dr. Rappleye cautioned that the problem of costs in taking care of the aging will change because those now covered under lower rates will get older and then continue to be covered by some form of insurance. Dr. Steinberg urged that we look into the quality of insurance coverage, not only the number of those who are covered. Dr. Marcus D. Kogel called attention to the desperate shortage of registered nurses for round-the-clock care, and Senator Javits cited the amendment to the Hill-Burton Act which helps nursing homes. He said that we could do much more in that direction. Dr. Rappleye said that at least one-third of those in the hospital need some other kind of care. He minimized the Forand bill; but said that some kind of subsidy would be necessary if insurance were to be made available to a much larger proportion of the population. He pointed out that you cannot sell a complete insurance program once the premium reaches the point of more than 40 percent of the total cost of the health coverage. In Canada, he said they had arbitrarily picked on 33% percent as the limit. The recurrent theme in the general discussion that followed on levels of care was that any broad program needed structuring lest the load on hospitals become staggering as it would under the Forand bill. There is need for an incentive to put the patient where he belongs, not just to dump him in the hospitals willynilly. The question was raised by Dr. Martin Cherkasky as to whether the Federal Government could possibly require employers to carry a health insurance program which would meet minimum standards for their employees in a fashion analagous to workmen's compensation insurance. In reply State Senator Metcalf of New York said that bills had been introduced to require employers of more than three or four persons to provide basic insurance coverage on a 50-50 matching basis if the individual were single, and 35-65 matching if he had a family. Provision was also made for the payment of premiums during employment-there would be basic coverage only. Senator Metcalf pointed out that the Governor opposed this bill because New York State might be singled out and lose industrial business. |