Mr. Benson's married son by his first marriage lives in Hamilton, Ohio, and according to his father cannot assist them due to his own financial difficulties.

Third: With the means test there comes the fear of losing savings which, in most part at least, must go, under public assistance regulations. The savings represent often a lifetime of sacrifice and scrimping, and are a psychological bulwark, no matter how small, against disaster. "All my savings went" is the voice of tragedy to the poor. We know how small these savings often are-but how great a sense of protection they give.

Mrs. Mumo is a widow in her late sixties who lives in a public housing project. The cost of a cancer operation 2 years ago forced her to spend virtually all the savings and insurance her husband had left her. She had been covered by hospitalization insurance, but did not have surgical benefits. She has an income of $59.30 a month from social security. From this income she must pay for all subsistence needs, for medicines, hospitalization, and doctors' fees. These medical expenses average about $25 a month. She has been able to manage so far because of small savings which have gradually dwindled to nothing as her health needs mounted.

Mr. and Mrs. Crone are in their middle sixties. Mr. Crone has recently recovered from the fourth of a series of strokes and heart attacks. His wife is almost completely blind, has high blood pressure, and diabetes. Although they own a modest home, their only source of income is social security payment of $116 a month and a $26 monthly pension from his former firm. Their combined hospitalization, doctor bills, drug bills are so overwhelming that they have finally asked help from friends and relatives to keep their heads above water. From a total income of $142 a month, they pay $51 a month for doctor bills, hospitalization, and drugs. They are now slowly trying to pay up on an overdue doctor's bill of $170.

We realize that the provisions of H.R. 4222 will not cover all the health needs of all people over 65, but they will go a long way toward meeting in a self-respecting way, the major needs of those on social security, which after all means 13 or 14 million people. Of course, in extreme cases of illness there will have to be recourse to public assistBut it should be remembered that at the present time care differs greatly with each State and it does not look as though there would be speedy use by the States of the Federal funds made available by MAA to meet the health needs across the Nation. To quote from the staff report to the Special Committee on Aging of the Senate:

ance.

Only seven States, and I believe it is now eight, as of March 31, 1961, had operating programs under MAA.

More discouraging than the complexities encountered by the States in gearing into the Kerr-Mills program is the statement in the summary of the same report which says:

Four out of every five dollars which State and local governments indicate they are planning to appropriate for their MAA programs would be dollars taken from other existing medical programs, mostly old-age assistance.

We know medical aid to the aging through public assistance is necessary for all those not covered by social security. We are aware also that the proposed bill has limitations, which will involve in some cases

some form of public assistance supplementation. But we urge strongly that the first line of health defense be through social security that we enable our workers to protect themselves through their own efforts in their earning years. Taking away to some extent one of the worst fears associated with growing old-being sick and not being able to pay for it.

May I end with a story which happened at Henry Street. It has been quoted many times. It illustrates so simply what I have been trying to say. Some 5 years ago a very personable older man joined our "Good Companions." A number of widows among the group quickly set their caps for him. Finally, one of them seemed to be in the lead and our worker asked her whether she was planning to marry him. "No," she said, shaking her head. "It is this way. He is a good man. He is a kind man. He is a polite man. But he is on welfare and I am on welfare and I want a man on social security."

Mr. IKARD. Thank you very much, Miss Hall, for bringing us your views.

The committee will stand in recess until 2 o'clock.

(Whereupon, at 12:15 p.m., Wednesday, July 26, 1961, the committee adjourned, to reconvene at 2 p.m., the same day.)

AFTER RECESS

(The committee reconvened at 2 p.m., Hon. Hale Boggs presiding.) Mr. BOGGS. The committee will reconvene.

Is Dr. Seigle present? Dr. Stewart P. Seigle. Dr. Seigle.

STATEMENT OF DR. STEWART P. SEIGLE, IMMEDIATE PAST PRESIDENT, AMERICAN SOCIETY OF INTERNAL MEDICINE

Dr. SEIGLE. Mr. Chairman and members of the committee, I am Dr. Stewart P. Seigle of Hartford, Conn. I am appearing today as the representative of the American Society of Internal Medicine, a confederation of societies of internal medicine in 46 States, the District of Columbia, and Puerto Rico, representing nearly 8,000 physician specialists in internal medicine. Our prime area of activity is the diagnosis and treatment of diseases in adults and we attend a high percentage of aged persons. I wish to discuss with you some of the dangers I think are inherent in the Health Insurance Benefits Act of 1961.

I am engaged in the private practice of internal medicine in Hartford, Conn., but in the past few years I have discussed many of the social and economic changes which threaten the continuation of high quality medical care with other doctors throughout the country. I think we are living in the most fascinating era in medical history. The last 50 years have seen fundamental changes in medical care which derive basically from advances in science and technology--but also from evolutionary changes in our democracy.

Scientific advances have directly resulted in improving the quality and increasing the complexity of medical care. They have resulted in greater specialization within the profession and in the development of many auxiliary groups and agencies who perform specialized services. All of this has increased the cost of illness, but not so much as have the rising costs of labor and materials and the cost of living.

Further, these advances have been so effectively publicized that there has arisen a curious and fallacious concept that modern medical care is a commodity suitable for mass production and mass distribution.

On the theory, which I believe is erroneous, that people over 65 are not getting good medical care, there is proposed under H.R. 4222 a method to pay for hospitalization and hospital diagnostic outpatient facilities through the social security mechanism.

First let us examine the benefits offered under the heading "Utilization of Hospitals by Aged Persons."

From the medical point of view, getting more elderly people into hospitals is not necessarily the best way to improve their medical care. Yet any Government policy which sets a premium on hospitalization is bound to result in more hospital admissions. A 1957 report by the Blue Cross Commission indicated that utilization of hospitals among Americans over 65 averaged 2.5 to 3 days per year per person. In Saskatchewan, Canada, which has "free" medical care, utilization within the same age group averaged 7 days per year. The reason ascribed is that the Saskatchewan plan is oriented toward hospital care as is H.R. 4222.

As a matter of medical fact, many of the ills of the elderly are better cared for in the home and the office than in the hospital. Taking an aged person out of his own environment and hospitalizing him can be a dangerous experiment both psychologically and physically. Specifically, an elderly person taken out of his own surroundings is apt either to become completely dependent upon hospital care, or, conversely, he may become disoriented, develop pulmonary or urinary tract infections and present a more serious problem in medical care than he did at the start.

With modern armamentarium of antibiotics, diuretics, chemotherapy for malignant disease, drugs for arthritis, effective means for lowering blood pressure many diseases formerly requiring hospital care are now better treated on an ambulatory or home basis.

When hospitalization is necessary, it can be extremely beneficial, but the decision for hospitalization should be a medical rather than an economic one. Since H.R. 4222 is institutionally oriented and would offer "free" care once the initial deductible expense was met, there would result an undue pressure from elderly people and their relatives for hospital admission.

Let us now examine the heading "Utilization of Hospital, Diagnostic Outpatient Facilities."

In spite of all the technological advances in medicine, the best way still to make a diagnosis in medicine is for a conscientious physician to sit down with a patient, take a comprehensive history and then do a thorough physical examination. Out of this preliminary work should come well-founded ideas of what specialized tests or examinations, of the thousands available, are necessary to confirm the preliminary diagnostic impression. This is much the same approach which you gentlemen take in your considerations of such an item as H.R. 4222 which we are discussing today.

Out of the welter of medical technology, however, has arisen another philosophy to which nonmedical people attach some significance. That is, if you toss a patient into a complex diagnostic gristmill of tests, X-rays, electrocardiograms, special examinations, and so forth,

there will be cast out some recognizable shreds leading to a diagnosis and pointing the way toward treatment.

Under H.R. 4222 diagnostic services which are customarily furnished by a hospital to its outpatients for the purposes of diagnostic study would be covered.

I am fearful of such coverage of diagnostic facilities, even though the need for tests must be certified by a physician, because I believe it will lead to more testing and less thinking-a state of affairs which will not improve the health of the elderly. Also, diagnostic tests done in hospital outpatient departments are often more expensive than those done in the physician's office or in certified laboratories available to him. Finally, this mechanism makes unavailable to an elderly person far removed from a hospital outpatient department diagnostic facilities which might well be present in his doctor's office.

Earlier, I said that I thought that the theory was erroneous that people over 65 could not afford or were not getting good medical care. The economic stress of World War II produced rising taxes, which resulted in deficit financing, tax-avoiding fringe benefits, and monetary inflation which have profoundly affected our culture. All of these forces created a situation where many people could not pay out of pocket for the modern medical care they were determined to have. Then, during President Truman's administration, legislation was proposed which would provide compulsory Federal health insurance for all. Luckily, this did not pass and now even the strong supporters of this former plan admit that private insurance companies and the Blue Cross and Blue Shield plans have done an increasingly good job of providing medical coverage.

We are now in the same position with people over 65. Many things conspire to make the problem confusing. People are living longer so there are more elderly persons. There has been a constant urbanization since the 1920's. The large houses that could comfortably include grandma and grandpa have given way to the small ranch homes and the split levels. However, the Secretary of Health, Education, and Welfare, in a report to the House Ways and Means Committee, pointed out on April 3, 1959, that the median total income of retired social security beneficiaries was $183 per month. The average net worth of a retired couple was $9,620, 75 percent of OASDI beneficiary couples owned their own homes, and 87 percent of these homes were mortgage free.

The average social security benefit is $73 per month, but:

(a) 1.5 million people now receive cash benefits from corporate pension plans. This number will rise in the future;

(b) 1 million retired persons receive annuities privately purchased;

(c) 1 million persons over 65 receive veterans' pensions and are also eligible for social security benefits;

(d) 4 million individuals over 65 are employed.

American democracy has always been strongest when it has built upon tried and true principles and when it has depended upon the initiative of our citizens. The continued encouragement of voluntary insurance coverage of people over 65 will, in the next few years, make their position as favorable as for those under 65, and will create no revolutionary change in our country's method of providing medical

care. In this area the Federal Government could provide help and incentive by allowing tax exemption for moneys spent by children to provide health insurance for their elderly parents. For the medically indigent, the present medical coverage will continue to function. For the near indigent or for those undergoing a prolonged or catastrophic illness, the help of the Kerr-Mills law may be invoked. Thus we shall end up with most people over 65 able to provide for themselves with the aid of voluntary health insurance and individual and group initiative will continue to cope with the majority of medical problems. Thank you very much, gentlemen, for the opportunity of presenting this statement.

Mr. BOGGS. Are there any questions?

Mr. Machrowicz?

Mr. MACHROWICZ. Dr. Seigle, you state on page 2 that the theory that people over 65 are not getting good medical care is an erroneous one. Does that mean that you feel that there is adequate medical care presently given to the average person and that there is no need for any further concern in that area?

Dr. SEIGLE. No, sir. Perhaps I should better state this, that the majority of people over 65 are getting good medical care.

Mr. MACHROWICZ. That is not what you said here.

Dr. SEIGLE. Let me put it this way: I believe that there is room for improvement in medical care of all people, both over 65 and under 65, not necessarily through a revolutionary change in our method of handling it, but rather by evolving the present methods of care to further cover them.

Mr. MACHROWICZ. I am glad you said that, Doctor, because your statement gave an impression somewhat different from what you are saying now. You say that getting more elderly people into hospitals is not the best way to improve their medical care.

What is the best way?

Dr. SEIGLE. I think the best way to improve their medical care is to evolve a method, which in a way we already have, and which allows people to go to their own doctors to find out what is wrong with them.

Now, let's assume the patient goes to a doctor and a diagnosis is made. The patient then says, "Well, if I go into the hospital I will have a certain length of time where I can be cared for, my medications will be paid for, and so on."

I do not think this is the right direction for health care to take. Mr. MACHROWICZ. I agree with you. Have you read H.R. 4222? Dr. SEIGLE. Yes, sir.

Mr. MACHROWICZ. What is there in that bill which makes the situation any different from what you say it should be?

Let me ask you this, first. Under the proposed legislation who determines whether or not the patient will go to the hospital?

Dr. SEIGLE. The doctor.

Mr. MACHROWICZ. Your statement does not say so. On page 3 you say, "When hospitalization is necessary, it can be extremely beneficial, but the decision for hospitalization should be a medical rather than an economic one."

Does not H.R. 4222 say that it shall be a medical decision?

Dr. SEIGLE. That is correct.

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