(2) A HEALTH MAINTENANCE PROGRAM IS NECESSARY FOR EVERY INDIVIDUAL: The physician has a key role in encouraging his patients to follow a health maintenance program. The individual has primary responsibility for maintaining his own health, however, and must do certain things for himself. These include: (a) attention to proper diet, exercise and living habits in earlier years to ensure healthier later years; and (b) regular physical checkups and early treatment of disease or disability which may prevent the latter's progression.

Full use of rehabilitation and restorative services so that all persons, who are ill or disabled, may return to independent or partially independent living as soon and as far as possible is inherent in the physician's direction of health maintenance programs. Emphasis on helping the patient to help himself is important even when unrelated to vocational goals.

(3) VOLUNTARY HEALTH INSURANCE AND PREPAYMENT PLANS CAN AND SHOULD PROVIDE THE BASIS FOR MEETING HEALTH CARE COSTS FOR MOST PEOPLE: State and county medical societies should continue leadership in encouraging development of voluntary health insurance plans for older persons, both employed and retired. Particular emphasis should be given to the development of health insurance and prepayment policies tailored to meet the needs of patients requiring long-term nursing home and homecentered care.

While personal health care is primarily the responsibility of the individual, when he is unable to provide this care for himself, the responsibility should properly pass first to his family, then the community, then the state, and only when all these fail, to the Federal Government. Religious and fraternal groups are especially suited to provide the first support in the event of impaired ability of individual or family.

(4) MORE PERSONS INTERESTED IN AND WORKING WITH THE OLDER PEOPLE IN MEDICAL AND OTHER PROFESSIONAL FIELDS ARE NEEDED: There should be increased emphasis at all levels of medical education on the growing opportunities for effective use of health maintenance programs and restorative services with older persons, and the importance of a total view of health embracing social, psychological and vocational aspects. Medical school training for care of older patients should not be departmentalized, but should be given within the framework of established medical education programs.

(5) MORE ADEQUATE NURSING HOME FACILITIES ARE AN URGENT HEALTH NEED FOR SOME OLDER PEOPLE IN MANY COMMUNITIES: Constituent and component medical societies and individual physicians should cooperate with nursing homes, hospitals and other community leaders in effective efforts to improve nursing home standards and to expedite construction of new nursing home facilities where needed.

(6) FURTHER DEVELOPMENT OF SERVICES AND FACILITIES ARE

REQUIRED: This includes:

(a) such home-centered services as home care programs, homemaker, and visiting nurse services to provide a basis for improved health care of many older persons; (b) experimentation in such other new methods of providing better health care as rehabilitation education services in nursing homes, chronic illness referral centers, and progressive patient care in hospitals; and (c) an increasing number of community councils on aging and special study projects. Because health receives so much emphasis in all these activities, it is imperative that the medical profession provide its special knowledge to such programs and vigorously make its leadership felt.

(7)

EXTENSION OF RESEARCH IN BOTH MEDICAL AND SOCIO-ECONOMIC ASPECTS OF AGING IS VITAL: This should be supported and implemented by the medical profession to the fullest extent. Despite the maze of statistics which have been produced, the profession feels that the total picture which has been presented is both inadequate and confused.

(8) LOCAL PROGRAMS FOR OLDER PERSONS, ESPECIALLY THOSE WHICH EMPHASIZE THE IMPORTANCE OF SELF-HELP AND INDEPENDENCE BY THE SENIOR CITIZEN, SHOULD BE A MAJOR CONCERN OF MEDICINE, BOTH COLLECTIVELY AND INDIVIDUALLY: The Association endorses community activities for older people such as may be found in churches, senior achievement groups, "Golden Age Clubs" and day centers. Emphasis in all such programs and activities should be placed on active, day-by-day integration of the older person with the community as a whole, encompassing all age groups, and not just those in later years.

(9) LOCAL MEDICAL SOCIETY COMMITTEES, ALONG WITH OTHER LEADERS IN COMMUNITY SERVICE, SHOULD BE EQUIPPED TO APPRIASE THE ADVANTAGE OR DISADVANTAGE OF PROPOSED HOUSING FOR OLDER PEOPLE: In evaluating all kinds of senior citizen' housing, recognition should be given to the need for older people to continue as active, independent, integral parts of community life as long as possible. As an alternative to institutional care of the extremely old person, the development of special housing facilities with medical supervision and other supportive services should be encouraged by medicine at all levels.

Mr. Chairman, I would recommend the following items for further review by anyone interested in the medical contributions which have been made in this field: "Medicine's Blueprint for the New Era of Aging"; "Health Aspects of Aging"; "Homemaker Services Bulletin"; "Chronic 111ness Newsletter"; and a "Report on Regional Conferences on Aging". erence to each of these publications has been made in this section of our testimony.

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SECTION X

WELFARE PROGRAMS--PUBLIC AND PRIVATE

Thus far, Mr. Chairman, we have discussed the philosophical, economic and medical objections to this proposal as well as the contributions to the solution of the problems of the aged voluntarily made at the community level by physicians and other private citizens.

It is also necessary to point out the existence of a number of well-established welfare programs, both public and private, and the assistance they provide. It would be totally unrealistic to ignore these programs designed to help the aged--and others in need--to obtain necessary medical care at a time when additional legislation is being proposed.

The existing programs I have mentioned spread the cost of medical services across the entire community to assist those unable to pay. In what way would a Federal program be an improvement, with its complete absence of individual or community decision as to which costs are to be met and which institutions are to be paid? The individual taxpayer is already contributing to these programs at the community level and the state level--programs which will be available to him in time of need, programs in which he has a much greater voice, through local supervision and local elections.

The medical profession has no desire to "pauperize" the aged-nor does it believe that the majority of state and local governments, and state and local welfare officials, have such an aim. It does believe, however, that a Federal medical care program, cutting across and in conflict with existing, operating programs, can only be uneconomical, inefficient, confusing, and, in the end, destructive of good medical care.

Today, every state in the Union has an Old Age Assistance program, designed to provide a basic income for those over 65 who are unable, without help, to meet the costs of daily living. In January, only seven of those states did not have a formal vendor payment medical care program for OAA recipients, and those seven either provide medical care through some other program or include amounts in the cash grant for the individual to purchase his own care. Most of these seven, too, under the impetus of Public Law 86-778, are taking steps to inaugurate vendor payment programs and increase the care available to OAA recipients.

This is the basic resource for the needy aged. And it should be pointed out that a number of these states will accept over-65 applicants for Old Age Assistance "for medical care only"--will enter them on the rolls and pay their medical bills for as long as they need this type of help.

Every state also has General Assistance programs, financed either by the state and local communities in cooperation with, or entirely by,

local action to provide help for those not eligible for the federallyaided Public Assistance programs. Frequently, these programs are the resource of those only temporarily in need of help--but they provide a considerable amount of medical care. Incomplete figures for January 1961 indicate almost $9 million spent on medical care through General Assistance programs, compared with $24.6 million through OAA. the medically indigent are helped through General Assistance; a few states also have programs designed specifically for this purpose.

Many of

The other three public assistance programs also provide resources for the aged, although the natural tendency is to provide most of the help for the aged through OAA. In Aid to Dependent Children, the child's guardian receives some aid; in Aid to the Blind, and Aid to the Permanently and Totally Disabled, there is also a comparatively limited number of the aged receiving help. Most of the states have incorporated medical care in these programs, as well as in OAA.

These are not the only resources available. Many states and communities have erected their own hospitals, which provide needed care for those unable to pay. Over three-quarters of the psychiatric and tuberculosis hospital beds and roughly two-thirds of the long-term hospital beds are supported by state and local governments.

A number of other state and local programs, though not strictly welfare programs, touch on the medical problems of the aged. Some may receive help through vocational rehabilitation programs, some through various programs administered by state and local health departments--such as heart, cancer, and mental health clinics.

In the non-governmental field, too, numerous programs have developed to help the needy of all ages. The various religious denominations, of course, are a prime source of help, through their charities and through their medical institutions. Service clubs throughout the nation have supported various health programs--such as the provision of dental services or the financing of the purchase of eyeglasses. Community Chest and similar community philanthropies help to finance hospital services for those who cannot pay.

Finally, even at the Federal level there are existing programs which help the aged belonging to specific population groups.

Federal hospitals provide a health resource for retired personnel of many Federal services, particularly the armed forces; the Public Health Service assumes responsibility for care of the Indian population; and the Veterans' Administration offers complete medical and hospital care for veterans with service-connected disability, and for veterans with non-service-connected conditions who are unable to pay. Since some two million veterans are now over 65 years of age, this provides a resource for a considerable portion of the aged population.

We do not claim that this spectrum of local, state and Federal

programs and facilities has reached perfection in all parts of the nation or that every program provides all the services an aged person might need. We do not claim that every such program sets a completely realistic standard of need for eligibility.

However, we do believe that these local and state programs represent the natural development and the natural implementation of the community's responsibility for its members. They recognize the individual's right to call upon his neighbors for help when he needs it; they do not force upon him a specious promise of protection in which he has no choice and which bears no necessary relationship to his real problems.

We also believe that these programs have been improving rapidly, with the basic aim of equating medical services with the needs of the community served, within the limits of medical resources which are available and which can be made available to the community's residents. We in the medical profession have been working towards this end, and we feel that, in many areas, we have achieved considerable success.

Passage of this bill can have little effect except a crippling one on these programs. The existence of the Federal-state public assistance programs has placed a continually increasing pressure on locallyfinanced general assistance programs to allow the incursion of Federal money into these programs, also. The passage of a wholly Federal medical assistance program will place a similar pressure for abolition on "competing" Federal-state programs.

For example, the existence of a Federal program providing hospital, nursing home, and home health services will place pressure on state agencies not only to avoid duplication of those services in programs in which state funds are involved, but will also bring pressure to use the Federal rather than the state program wherever feasible. It is quite conceivable that this could lead to postponement of needed treatment for those nearing the eligible age when pre-65 treatment requires the expenditure of state funds and post-65 treatment does not.

In addition to the economic pressure on the states to force as many patients as possible within the framework of the Federal program, there will be a corresponding psychological pressure on the patient himself. The propaganda for the Federal approach as the more humane has, in effect, made it more difficult to provide community assistance in a dignified fashion. The patient has been told that, if he fits his illness within the hospital-nursing home framework of this bill, he is receiving care in a dignified, respectable fashion--while if he receives help locally from his neighbors, he is being degraded. Obviously, he will tend to postpone treatment until he can take advantage of the former mechanism.

Finally, what about the development of medical facilities and services which are truly suitable to the community's needs and resources?