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although some support is available from OEO, from National Institutes of Health, from the Public Health Service granting mechanisms. I am sure we could use more.

The big problem with demonstrations is that if you put enough money up, you can do nearly anything. It is not difficult if you want to spent $5,000 a patient to give sparkling medical care. The kinds of demonstrations we need are the ones that can develop and grow without that kind of unusual support.

Senator MONDALE. Yet if you undertake an optimum program and do a good job of appraisal-that might be the best way of starting the perfect program to do a good job appraisal-you come down to a more sophisticated level that you could fund.

Dr. JAMES. That is right.

Senator MONDALE. I think one of the problems in these kinds of programs is that you never really do a good job and then properly appraise it so we can show what can be done if we do our best.

Dr. JAMES. Dr. Charles Goodrich, who did the Cornell study, is now in my institution and is developing our entire outpatient ambulatory service on the basis of medical practice units with pediatricians as consultants. We are going to take all of the people who walk into the clinic and treat them as private patients, with 1,500 families per doctor. He, therefore, is building on this Cornell experience. He, incidentally, is documenting this and it is going to be published between hard covers. The results of the program were thoroughly evaluated and the costs clearly delineated.

So he is going to be able to take the best of this demonstration and support it through medicaid. It will be no more expensive than running a poor set of clinics as my 76-year-old man was subjected to. It will be even cheaper and more effective with home care and backup services.

There will also be linkages for medical supervision with nursing homes, so that it will be possible to follow the patient in the nursing home. At the same time, this will permit the hospital to have a better basis for discharging certain categories of patients from the parent institution to nursing homes, and also bringing them back to the hospital when necessary.


In conclusion, let me emphasize that we are only on the threshold of an attack upon the complex problems of medical care for the aged. Medicare and medicaid are largely aimed at the removal of financial barriers to care there are many high fences still to be removed. As a matter of fact, strictly speaking, medicare and medicaid are not medical care programs but income maintenance ones. There are many aspects of medical care, including attention to the high quality to which they have not even gotten close.

The hospital emergency room has too long been the inept resource used for chronic care of disease; the traditional proprietary nursing home has too long been a dismal answer to crying medical and emotional needs which have gone unheeded. The key demonstrations for improvements have been performed and several major enterprises are well under way. Much more must be done to improve their efficiency

and effectiveness. We desperately need packages of care we can afford. One thing, however, is certain. At the current rates of increase of our aged and their concomitant higher incidence of chronic disease, these problems cannot be ignored.

Senator MONDALE. Dr. Ostfeld testified the other day that most of the killers of aging are diseases that result from bad and long-term habits: oversmoking, overdrinking, overweight-habits that should have been corrected earlier in life. One of the things I have been toying around with here is a proposal which I have not worked out yet but call for preretirement counseling at some point in life, say age 40, where we would actually encourage a couple to take some time off to consider the life that remains ahead, their own careers, whether they want to do something different or whether, as Secretary Gardner put it, they are already psychologically retired and bored and maybe they ought to do something else. Look at their retirement financial problems and get them under control. With regard to health, have a checkup at that time and have a doctor tell them the truth about their habits and their health and what they ought to do if they want a long-term, improved health picture.

Does that make sense to you?

Dr. JAMES. Yes, that is an excellent idea. One should begin with what I call the first-stage problems, these things that make an individual more or less at risk of developing disease at any time. The retirement counseling program would be an excellent way to begin with this group. Of course, it would be even better if we had people coming to us as part of families all through their lives receiving this type of counseling.

Actually, if you look at the diseases which we have controlled in this country, like polio, diptheria, measles, smallpox and so on, almost all of them have been diseases we have attacked in the first stage and not by using clinical medicine, waiting for the patient to have a symptom. We have made some progress in controlling these diseases after symptoms occur but it looks like only when we can develop some method of attacking them before they start can we really make a major impact upon them.

Obviously, if the patient comes to you with symptoms, we have to do the best we can. If he comes to us after he has the chronic incurable disease, we still do the best we can. But it is far better to accent just what you suggested, types of activities which reach into their lives and try to keep them healthy.

Senator MONDALE. You are dealing with health problems as distinct from financial arrangements, new careers, and some of the other things that might be explored at some midpoint.

Dr. JAMES. Very good.

Senator MONDALE. What is the likelihood after you have diagnosed a 40-year-old person and he is smoking too much and drinking too much that these things will happen when he gets older, bad habits? What happens? Doctors do this all the time.

Dr. JAMES. First of all, it would be better if he stopped than continued. Even if he has had a 20-year experience of bad habits, it is better if he stopped. Our success in getting people to change their habits is rather poor, but there is a challenge. Our success in curing

coronary heart disease is equally poor, if not poorer. That does not mean that we stop trying; we have to keep working with them.

Of course, as far as smoking goes, if we can keep pressure on the system we might come up with some other answers. For example, a safe cigarette would fit into a person's existing motivation rather than the more difficult, alternate task of attempting to change that motivation. We are not going to get these answers unless pressure is continued.


Senator MONDALE. I am always impressed by the deep suspicion that one encounters among the elderly. What you talk about pops up almost all the time. The elderly are suspicious that if they go to someone other than a doctor they will not get to see the doctor. Half of them will not go to this very convenient chronic clinic which is provided because of one fear or another. There apparently is a deeply suspicious, fearful psychology among our elderly in this country. It pervades almost everything that they do.

Dr. JAMES. That is true. That is why ideally if we could get families to come in when they are well for routine checkups, the physician and the surroundings and the health team become friends. Medical care becomes a predictable situation.

Senator MONDALE. But you have to overcome this barrier of suspicion. It takes a while for these friendly visitors just to get their confidence. People come in to talk to them. We think this is the first thing lonely people want but they are suspicious.

I remember one time when I was campaigning and somebody told me it would be a good idea to go down to a senior citizens project and shake hands. They were playing cards and they said, "Get out of here, we don't want to see you people; we are sick of you politicians." I think I lost the town.

Bill, do you want to go into that medicare question?

Mr. ORIOL. I have several questions but perhaps you want to hear from Professor Roemer.

Senator MONDALE. If that would be all right, we will hear from Dr. Roemer and then we will have questions afterward. Dr. Roemer, we are very glad to have you.


Dr. ROEMER. Thank you, Mr. Chairman. I feel honored to be invited to make some comments to this Special Senate Committee on Aging on this question of the costs and delivery of health services to older Americans.

Since 1936 when, while still a medical student, I undertook studies on the social aspects of medicine-earning a master's degree in sociology in 1940, the same year as receiving the M.D.-I have been exploring the problems of delivering the fruits of medical science to meet the needs of people. For 14 of these intervening years I have worked in public health tasks at local, State, National, and international levels and for 12 of them I have taught at universities-Yale, Cornell, and now at the University of California.

The vast achievements of medical science are well known, but the failures and gaps in delivering these benefits for persons, old and young, who need them, are less well understood.

Medical service delivery is, in a sense, a more complicated task than scientific medical diagnosis and therapy. The latter, technical tasks, require great knowledge and skill, but once a logical decision is made, the various measures of surgical or pharmaceutical or other types of medical management can be readily prescribed. The actual delivery of those services to large human populations, however, requires coping with enormously complex social, psychological, economic, political, and cultural forces. There are vast pressures of tradition and numerous vested interests that can obstruct the implemention of logical decisions. Delivery of medical services to the aged is made difficult by all the same problems that face any other age group, compounded by further problems of the older years. In these years, the burden of sickness is far greater, the individual's financial resources to meet it are less, and the physical procurement of needed medical care is impeded by numerous problems of transportation and understanding.

The enactment of the medicare amendments to the Social Security Act in 1965 has been a great step forward in reducing the financial handicaps of the aged with respect to certain sectors of medical care. In a sense, however, this law has only tended to give the aged a certain parity of health insurance coverage with the young and self-supporting population. Before this important law, only about 50 percent of the aged had any hospitalization insurance, they had less of other types, and most of that was meager in benefits; now close to 100 percent are covered and the benefits are much more liberal.

The effective delivery of medical service, however, requires more than underpinning of the bills, and this is especially true of the aged. It requires an organization of the technical services that meets the complex demands of science and needs of sick and disabled people. It requires medical care that is comprehensive in scope, continuous over time, physically accessible, scientific in quality, and humanistic in spirit.


While we have made a great deal of progress over the last 30 years in the United States in financing medical services, for both young and old, our social machinery for delivering those services has remained almost at a horse-and-buggy level. Perhaps it is a team of horses, rather than an old gray mare, that deliver the product, but medical care organization has hardly caught up to the motor-car era, let alone the jet plane.

The crucial fact is that most of the expanded economic support for health service has been applied to a framework of medical and dental practice in isolated individual offices and a patch quilt of hospitals, drugstores, and laboratories which are characterized by extravagance, inefficiency, and frustration for the patient and provider alike. Half the Nation's general hospitals are of under 100 beds-a size much too small to render optimal scientific services soundly and economically. Eighty-five percent of clinical physicians and 95 percent of dentists hold forth as solo practitioners, despite the enormous development of specialization demanding professional teamwork.

Thousands of small, independent drugstores dispense a bewildering array of drugs at very high prices, inflated by the cost of a fantastic

volume of competitive advertising, robust manufacturing profits, and an elaborate network of middlemen between producer and consumer. Dental treatment absorbs the scarce and expensive time of highly trained professionals, doing tedious tasks that could be readily assigned to technicians under supervision.

Preventive medicine is widely preached but seldom practiced, while geriatric rehabilitation is a fiction in the thousands of small proprietary nursing homes that accommodate the vast majority of chronically ill and aged patients whose numbers are increasing daily.

Though this is a grim capsule sketch, Mr. Chairman, it could be easily documented with reams of facts and figures. While American medical science at its best is capable of wonders in reducing disability and saving lives, these wonders are applied far less than they could be. Our age-adjusted mortality rates in the United States are higher than those of many other countries of lesser wealth and, at that, spending lower proportions of their gross national product on health care. The difference lies in the way we spend our health dollars. Our social machinery has simply not caught up with our scientific capacity.


The history of social and legislative action to correct these organizational anachronisms is one of piecemeal efforts. Special laws have been passed to help a worker who has been injured on the job, but they don't help him if he gets injured or sick off the job. The crippled child can be helped if his diagnosis happens to be on the approved list in the State where he lives and if he is poor enough. A veteran may get first-class medical care for a military-service-connected disability, and sometimes for other disabilities, but if a physical handicap barred a man from military service in the first place, he is, of course, outside this ball park.

There are literally hundreds of other specialized piecemeal programs for selected categories of American citizens or selected types of medical diagnosis. On top of these governmental programs is a vast jungle of medical care plans and agencies, supported by voluntary insurance, donations or industrial expenditures.

If one adds up all the dollars spent by these organized health service programs, through hundreds of administrative_channels-both governmental and voluntary-and relates them to the total dollars spent on health in the Nation, one finds an important trend. In 1965, of the $38,500 million spent on health, about 55 percent was passing through some organized fiscal channel, and this was a large increase from the 20 percent so spent in 1930. With medicare and other new programs of the last 2 years, this social sector of health expenditures is now probably about 60 percent of the total.

In recent years everyone has become acutely aware of the rising costs and prices of medical care. Since the medicare enactment in July 1965, medical prices have taken a steep spurt upward, as this guaranteed support led hospital nurses and other employees to seek longoverdue wage increases, and as the increased demand on a fixed supply of physicians led-following the usual economic laws-to fee elevations. The point is, however, that medical costs have been rising steadily

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