older patient in a hospital or nursing home.

Medically, this is unsound. Physicians do everything within their power to keep the older patient out of the nursing home or hospital. Recovery is faster, health is better when the older person is at home, among familiar surroundings and when he remains within the mainstream of community living.

We know, from long experience, that the best defense against sickness is full use by the individual of his physical, mental, and social capabilities.

We must think in terms of total health, which involves far more than hospitals, nursing homes, or a physician's care.

Total health takes into account the older person's other requirements in life, whether these be housing, recreation, community understanding and acceptance, the right to be useful, the courtesy of being treated as individuals, or the opportunity of living as self-reliant, respected members of society.

If I were asked to choose the major problem affecting the health of the older American in this mid-Twentieth Century, I would state unhesitatingly that it is the problem of segregation--in employment, in the family, and in the community as a whole.

Yet this segregation will continue as long as the people of this country cling to their misconceptions about aging. Mr. Chairman, as long as our older people are thrust aside by a society infatuated with youth, a stream of lonely, idle, disheartened men and women will seek whatever emotional shelter they can find.

Too often, the only shelter to be found is within the hospital, the nursing home, the public institution.

H. R. 4222 offers to provide that shelter at the taxpayer's expense. If the bill became law, the very existence of such a program would be reason enough for the elderly to use it. But, frequently they would seek institutionalized shelter not for medical but for emotional and spiritual reasons.

SECTION III

PROPOSED LEGISLATION BASED ON FIVE FALSE PREMISES

As the members of this Committee are well aware, the controversy over national compulsory health plans has raged for many years in this country. And let us make no mistake about one thing: H.R. 4222 is a compulsory national health plan for one segment of our population-the elderly. It differs from other legislation proposals of this sort only in degree.

It hardly matters, for the purposes of this Committee, whether support for H.R. 4222 stems from humanitarian motives on the one hand, or political maneuvering on the other. Facts are facts, and it is the intention of this Committee, as we understand it, to deal with facts-not fictions or misapprehensions--in its consideration of this legislation.

In our opinion, the supporters of H.R. 4222 build their case on the following five false premises:

(1) The sociological problems of older people can be solved through legislation.

(2) Most, if not all of the aged, are in poor health.

(3) Most, if not all of the aged, are verging on bankruptcy. (4) The problem of the aged in financing their health costs will get worse before it gets better; thus a permanent program is essential to its solution.

(5) Voluntary health insurance and prepayment plans, private effort, and existing law will not do the job that needs doing.

FALSE PREMISE NUMBER ONE

-

THE SOCIOLOGICAL PROBLEMS OF

OLDER PEOPLE CAN BE SOLVED THROUGH LEGISLATION

From our experience as physicians, we have learned two things:

First, the aged would rather give than get.

Second, the aged are far more concerned with the process of living than with the process of aging.

There is no doubt that some of our older people suffer from ill health and poverty. This group is being, and should be, helped. But most people who have passed the age of 65 are not in need of the sort of help envisioned by this measure. Although determined efforts are being made to organize the nation's elderly into a voting bloc, and to seek their political support in return for blank-check promises, these efforts have thus far failed--and for a very good reason:

The elderly are not primarily interested in more money, more benefits, more handouts.

More than anything else, today's older Americans want involvement--involvement within the mainstream of society.

They worry less about health and finances than they do about rejection. They are oppressed with the feeling of not being wanted any longer, of not being useful, of not being important. They feel that they have been stripped of their value, and hence of their dignity as human beings.

problem.

Broadly speaking, Mr. Chairman, this is the sociological

With the best wishes in the world, we cannot suggest a quick, easy solution for it. But we can say that this legislation is not the

answer.

Society is falling down on the job, not government.

The older person wants just about the same things that the rest of us do: to be part and parcel of his environment; to be loved; to belong; to feel that his skills and talents have value, and that they will be used and appreciated.

Congress cannot pass a law to change the attitudes of society.

This is an age of small homes and smaller apartments; of increasingly urbanized living; of a national accent on youth. There is no need to explore, in great depth, the sociological factors involved. For the most part, they are self-evident. Children who are sometimes too concerned with raising their own families to worry about their parents; the compulsory retirement of capable, active, people; the too frequent disinterest of the community in the well-being of its older citizens. These and other reasons contribute to the feeling that many of our older people have of being discards, of being obsolescent or obsolete, of being citizens emeritus.

In this golden age of medicine, we physicians have become accustomed to scientific wonders. But we do not have, and do not expect to acquire, a specific against loneliness, an antibiotic against rejection,

a tranquilizer to enable human beings to live without dignity.

We have reached a point in our civilization at which industrial uselessness has not yet been offset by social adjustment. Having arbitrarily established 65 as the age of obsolescence--and we are now moving to lower that age further--we have not yet compensated the hardships of economic discard by some degree of social appreciation.

We can no more provide a statutory solution to this situation than we can legislate juvenile delinquency out of existence.

Aging is not a new problem. People have always gotten older. Our problem stems essentially from the social segregation of the aged. As to health in its broadest sense, physicians, hospitals, nurses, scientists can go only so far alone. The rest is up to the society in which they function.

Do the people of the nation want their elders to be healthier? Then they have a job to do. They cannot discharge their responsibility by turning the problem over to the government for a quick, easy solution.

We physicians can practice preventive medicine of the highest type, seeking diligently to forestall the disabling illnesses that threaten old and young alike; but society must also take the necessary steps to meet other existing needs that are just as important. The problems of the aging must be considered and tackled in their entirety, not in terms of a single aspect.

Otherwise, we shall be taking a piecemeal approach to matters susceptible only to broad-gauge solution.

FALSE PREMISE NUMBER TWO--MOST, IF NOT ALL OF THE
AGED, ARE IN POOR HEALTH

In any consideration of this subject it is essential to remember that the health problems of the aged involve far more than hospital or physician care. They involve the older person's other requirements in life, whether these be housing, recreation, community understanding and acceptance, the right to be useful, the courtesy of being treated as individuals, or the opportunity of living as selfreliant, respected members of society.

We can, for example, diagnose an illness in an older person, put him in a hospital, and in due course discharge him as cured.

But if that person cannot find an opportunity to use his skills, talents, and capabilities upon returning to his community; if he cannot

obtain the emotional support he needs; if he cannot win a place of acceptance within his family or his circle of friends; it is probable that he will seek, sooner or later, a return to the only shelter available. That means the artificial haven of a hospital, a nursing home, or a mental institution.

Bearing this in mind, let us talk of health in a somewhat

narrower sense.

Most older people are, in fact, in good health. The diseases to which they are susceptible are no different from the diseases to which people in any age group are susceptible. There are no diseases of the aged; there are simply diseases among the aged.

There is a greater degree of chronic illness among older people. But it is important to understand what "chronic illness" really is, for the term is generally misunderstood.

The term "chronic" refers to a recurrent condition, or one that persists over a period of time. It may, but it does not necessarily, imply disability.

For instance, a person with impaired hearing is chronically ill-although he may function normally with the assistance of a hearing aid. Similarly, a diabetic is chronically ill--although with the help of insulin he can lead a perfectly normal life. I could give you countless other examples; but I think it is sufficient to say that chronic illness should not be confused with disability.

Beethoven's deafness was not disabling. Several years ago,

a diabetic represented the United States on the Davis Cup team. Franklin Delano Roosevelt was chronically ill as a result of polio. And President Kennedy's back condition qualifies him for description as chronically ill.

Yet in all of these cases, we are simply saying that certain medical conditions limit certain of the individual's capacities. These conditions do not disable, in the important sense.

I make this point in some detail because the higher incidence of chronic illness among the aged has been interpreted to mean that most older people are sick and debilitated. They are often represented to be, but they are not. I repeat, most older people are in good health.

When physicians make this statement, they make it as experts. And their statements are borne out by every survey that has thus far come to our attention.

Thus, although it is true that 77 per cent of those 65 and over have chronic ailments, only 14 per cent experience any significant limitation of activity; and only five per cent have major limitations of