cost of such services minus the difference between the charge customarily made by the hospital or nursing facility for such services...and the charge customarily made by it for such services in the accommodations furnished. As an example, suppose the reasonable cost for a two, three, or four-bed room is determined to be $30, and that the reasonable cost for a room with more beds is established as $20 per bed. The difference between the two accommodations amounts to $10. If the patient were placed in the less expensive room, the provider would not be entitled to receive the $20 reasonably charged for the services furnished, but only $10. This sum would represent the difference between its customary charge and the difference between that charge and the higher cost of more private accommodations. It does not seem wise to us that a provider of services should be penalized for saving tax dollars, particularly in view of the fact that circumstances at the time of hospital or nursing home admission may require the use of a less expensive but available accommodation. Now let us take a look at the availability of the promised benefits. The bill sets up a number of requirements which must be met by the providers of services before they can participate in the program. I have referred to several of these. One of the eligibility requirements for nursing homes is that they have a 24-hour-a-day nursing service. According to a statement made by Representative Adam Clayton Powell (D-N.Y.) during the debate on a bill to extend the Practical Nurse Training Act, of the 23,000 nursing homes in the United States, only 9,000 had the services of either a professional or a practical nurse. Obviously, then, nursing home services--limited under the bill to conditions for which the patient was treated in the hospital--will be unavailable in many nursing homes and in many parts of the country. Similarly, there is reason to question the availability of home health services, for there are only 900 such organizations in the 3,067 counties of this country. There is even some question as to whether all our hospitals, especially those in the rural areas, will be qualified. Elsewhere I have predicted overuse of the facilities covered in the bill for a number of reasons. by the limited availability of some facilities, will result in one thing: overcrowding, preceded by increasingly long waits for admission. Finally, Mr. Chairman, I should like to point out that this is an institution-oriented measure. 76123 0-61-pt. 3-5 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 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 |