Dr. ESSELSTYN. I don't have the breakdown.

Two, a study by the Senate Committee on Aging shows that many nursing home patients are rarely, if ever, seen by doctors.

Three, Hill-Burton agency studies show that 2 out of 5 nursing home bed facilities are in facilities that are unacceptable.

Four, Margaret Jacks, supervisor of welfare services in the Florida Department of Welfare, reported in 1962:

There are literally thousands of old people in this State and in other States who are going without needed medical care because of inadequate income.

Five, on the White House Conference for the Aged, from the White House Conference on the Aged-Arizona, slightly more than 17 percent reported that they were unable to have the type of medical care they should have had because of lack of funds.

Massachusetts: A large portion of old, chronically ill, handicapped persons are in nursing homes or county hospitals where the care often is exclusively custodial.

Michigan: The rates paid for public care patients in most areas are totally inadequate to provide quality care.

Missouri we will come to later.

Texas: It seems accurate to say that Texas is rehabilitating about one-sixth of the number of persons who are disabled each year, not touching the vast backlog. Lack of funds has caused the management of the Texas Rehabilitation Center to operate at only 55 beds, or half the capacity.

There is little brightness in the picture of the aged adult.

Then when we get to your State, Mr. Congressman, in the report of the subcommittee on the problems of the aged before the White House Committee on the Aged, carried out by the University of Missouri, one of the first statements we find here is:

The fact that an increasing percentage of aged people find it difficult or impossible to receive the amount of care they need calls for a review of the mechanism or method by which medical care is rendered.

Then we go on and we find that in Missouri, one major problem exists in the field of nursing home care. This relates to the growing number of boarding houses which came about by the passage of the nursing home license law which specifically forbids the inspection of any institutions which cannot be provided-which cannot be provedto be nursing homes. The conclusion is that in these homes, that is, the boarding houses, fire safety equipment is not required, adequate nutrition is not required, nursing home care or sanitation is not required, and so on.

Then we get to the business of home nursing services. Were it possible for communities in this State to develop home nursing services, it would permit many older citizens with minor illness to leave hospitals and be in their homes. We find there is only one home care service, the Jewish Hospital in St. Louis, actually in operation in the State of Missouri.

Then if we go on, we find that the number of patients who were admitted to mental hospitals where the death rate is 36 percent in Missouri is largely because of the fact that there is no other place they can put people who are elderly and become a little disturbed mentally.

Finally, I would just like to end up with the fact that when nursing homes were upgraded, many children of older people moved their parents from improved nursing homes to uninspected, unlicensed, and uncontrolled boarding houses as soon as the cost of caring for their parents exceeded the amount of money they were receiving under old-age assistance.

In many cases, county courts placed them in a boarding house in order to save money. There appears to exist in this State a lack of comprehension of the problem of the aged and of the need for cooperative effort for its solution.

This is from Missouri.

The CHAIRMAN. I yield to Mr. Curtis.

Mr. CURTIS. I was simply saying, and I am sorry we don't have the time to take up each one of those-I assure you I will. Most of them, as you were reading them, were general conclusions which I have heard time and again which I have been trying to reduce to specifics. Most of them, I might also say, related not to whether there was someone who couldn't get care because of financial problems, which is what we are dealing with specifically, but it was related to the lack of services or facilities, which I am very much concerned about. I have been the author of legislation which has moved this thing forward in the nursing home care particularly.

I will take each one of these citations you have given me. I will direct to you my comment on them and any further data that is necessary to establish the one point-that is, whether or not in any of these cases that you have mentioned they can be reduced to where we have individuals by name who are over 65 who are not getting what care is available. I am talking now about what service and facilities there are, in relation to the cost aspect, because this bill relates to providing the financing of the services. If the services aren't there, and the facilities are not there, this bill is going to be of no avail.

So the question is, "Is there an older person who, because of financial need, is not getting the health care that is available in the community?" I mean because of financial inability? If such a case is called to my attention, or the authorities' attention, we will be glad to dig into it and it may be, by following through on that case history, suggested to us ways of improving it.

Maybe collectively these cases will reveal something further. But, Doctor, you have really simply put on the record the general conclusions that I have heard for years, and I have been seeking to go behind them to find out if the details will support them.

The CHAIRMAN. Doctor, as I understood it, you were reading from a report of a study made by or at least under the auspices of the University of Missouri?

Dr. ESSELSTYN. This was background studies prepared by the State committee for the White House Conference on the Aged.

The CHAIRMAN. These were conclusions drawn by that group? Dr. ESSELSTYN. In preparation for the White House Conference. Governor Blair designated Emily Brill, the senior vice president of the General American Life Insurance Co. of St. Louis to carry it on as the chairman. It was carried out under the auspices of the University of Missouri.

The CHAIRMAN. Mr. Keogh.

Mr. KEOGH. I think, Doctor, it might be helpful if at this point the record recalled that we had earlier testimony-I think it was today, I am not sure that Missouri has the largest percentage of people over 65 in relation to its total population of any State except Iowa.

Mr. CURTIS. That is correct. We also had testimony in detail on the actual situation of the older people and their health needs from Dr. Hall. That was a detailed study which is available for, I might say to you, Doctor, to look at to see the other side of the coin.

The CHAIRMAN. Mrs. Griffiths.

Mrs. GRIFFITHS. The suggestion by anyone from the State of Missouri that they will be glad to take care of the health needs of anybody who needs it obviously falls on barren ground, because these people are too proud to come in and ask the Congressman to pay their hospital bill or take care of the situation.

Now, I would like to ask you a question I asked Dr. Hall only in a little larger frame. How many hospitals are there in this country, if you know, that are equipped to perform the operation to remove part of the artery going into the heart and replace it with a plastic artery?

Dr. ESSELSTYN. These are relatively few. This is the way it should be for this reason: We cannot have duplication and reduplication of services all over the country. There has to be regionalization not only of facilities, but of services as well. Now, it costs $45,000 to $50,000 to set up an open-heart team. Repetition, as you know, is the mother of skill. If we are going to have this done, and this is a very serious operation, the mortality is running anything from 45 to 20 percent, it has to be done by people who are doing a great deal of it. It is not the kind of thing that can be done by everyone.

So to answer your question, there are relatively few. And I can tell you that in New York State, because I happen to be on the Regional Hospital and Planning Survey Commission in the Capital District, the number of these will be controlled so that there will not be duplication and reduplication and so that there will be a few who are working efficiently at 75 or 80 percent of capacity rather than a great many inexperienced people, each taking their hand in this kind of work.

Mrs. GRIFFITHS. Would you say that there are now as much as one per State?

Dr. ESSELSTYN. Yes; I would say it was quite a bit more than that. Mrs. GRIFFITHS. Thank you very much.

The CHAIRMAN. Mr. Alger.

Mr. ALGER. I didn't ask you to yield to ask questions so much as to comment on one statement Dr. Esselystyn made when you related it to Texas. I want you to know that we checked into some of the cases of which you speak and we have yet to find those substantiated and you ran them into the thousands in that State. I have not found that here. This is old hat to us because down in Texas we are trying to find those cases, too.

I have been referring to the AMA and saying "How about it?" Senator Yarborough thought he had found one. We went round and round on that one and we laid that one to rest. I will get the exchange pro and con to show you the details. I won't take the time now. You

realize that many times Texas refuses to take any Federal aid at all. Yet we have some of the finest hospitals without Federal money. Yet Secretary Ribicoff and others did not say anything about this. There was a big void in the Federal ledger because Texas took no money. He jumped to the conclusion, and we had this out in a friendly way in this room several years ago, he jumped to the conclusion that Texas didn't have the facilities. But we did, sir. We do.

We have some magnificent hospitals there. Indeed, some of the care that goes to people who can't afford to pay is as fine as anything that can be purchased by the millionaires today. We are very proud of these facilities which we have developed without Federal aid. Thank you.

Mr. DEROUNIAN. Dr. Esselstyn, on page 1 you properly state that this bill is not a political issue and on page 2 you state that you and your group are trying to stimulate political action. Now, which is it?

Dr. ESSELSTYN. I think in order to bring about something in a democratic system the way to do it is through whatever the mechanism is. I think in this case the way to do it is through Congress.

Mr. DEROUNIAN. That is the right way, and I commend you for being interested. I think in the past, doctors have stayed out of their interest in politics to the detriment of the Nation.

Dr. ESSELSTYN. I do not think this means this is a political issue. I think this is the way it is implemented.

Mr. DEROUNIAN. Doctor, you know in the bill before us the rate of contribution for employer and employee will be an additional onequarter of 1 percent. You estimate, and I think quite properly, on page 2 that there will be a continued rise of between 5 and 71/2 percent in cost over the next 10 years. Would you feel that we should keep the contribution rate consistent with the increase in cost rate?

Dr. ESSELSTYN. I think this is something for the Congress to determine. I think this is a matter of relative values. I think it all depends how much the Congress feels the health of the United States is worth in respect to other demands on the funds that are available. Mr. DEROUNIAN. Would you think that the health should be paid for more by the individual under the social security system when costs rise, or should they be taken from general funds, because that is where we are going to have to differ in this committee perhaps later on.

Dr. ESSELSTYN. My offhand opinion would be, and I am not an economist, would be that at least it could be increased somewhat within the mechanism of social security.

Mr. DEROUNIAN. Now, Doctor, on pages 7 and 8 you talk about our general lack of health. You mention the mortality in this country and the infant mortality. Now, the present bill has nothing to do with infant mortality; does it?

Dr. ESSELSTYN. Only insofar as the grandchildren are tied up with the grandparents, the children are tied up with the care of these grandparents. There is an indirect relationship.

Mr. DEROUNIAN. Very indirect. Now, Doctor, have you always been for this type of medical insurance plan under social security in the past?

Dr. ESSELSTYN. This is the third time I have had the privilege of testifying before the committee.

Mr. DEROUNIAN. Were you for the Ewing plan back in the late forties?

27-166-64-pt. 1- -33

Dr. ESSELSTYN. No, I was not active in the American Public Health Association then. I had not gotten religion.

Mr. DEROUNIAN. Were you for the Forand bill?

Dr. ESSELSTYN. Yes, I was.

Mr. DEROUNIAN. Doctor, would you state that if the conditions of health continue as you have stated, you are not quite satisfied with it, not only in the group over 65, but in the group under 65, would you recommend that the Federal Government participate in that kind of financial care, also?

Dr. ESSELSTYN. This brings up the question of why not 64 or 63 or 62?

Mr. DEROUNIAN. Or 40.

Dr. ESSELSTYN. I think there is a great deal of reason for stopping at 65. If we go back historically, I think it is very evident that in the United States, when in the judgment of society there became a disparity between the cost of medical care and the ability for a segment of people to pay for that care, the Government has stepped into the

vacuum.

I think this is how we see the Government getting into the merchant marine to begin with, and the care of the tuberculars, and the care of the mentally ill. There has been no hesitation about allowing this. So now, I think for many reasons, there is a vacuum in the over-65 group which the Government has to fill. I think the recognition of this is in some way indicated by the fact that it is my understanding that 56 bills were introduced in the last Congress to deal with this problem.

Now, I think there is a reason why at the present time there is no need for anything under 65, because at 65, rightly or wrongly, a great many people are retired. At 65 they have to begin to pay for their insurance if they have any, on an individual, not on a group basis. At 65 in many instances the contribution of the employer is taken away. At 65 a great many commercial insurance companies cancel out. I think these are some of the things which make a vacuum and a very logical reason for having the age set at 65.

Mr. DEROUNIAN. Doctor, do you know of any reason why doctors' bills are not included in this H.R. 3920 ?

Dr. ESSELSTYN. The American Medical Association has many times said that they will always take care of the people who need help. Inasmuch as the profession has given evidence of the fact that it is willing to take on this burden, I think there is no reason for including physicians' fees in this bill.

Mr. DEROUNIAN. Yet under the Kerr-Mills Act, the physicians' fees are included when the States have implemented the law. Isn't that true?

Dr. ESSELSTYN. In some instances, and in some States, but not in all. Mr. DEROUNIAN. In New York it is true.

Dr. ESSELSTYN. In New York they are not included for in-hospital services. The only physicians' services paid for are the out-of-hospital services. When they are in the hospital they are ward cases, they are on services and anybody who is on services is the person who takes care of them.

Mr. DEROUNIAN. Weren't they the same under the Forand bill, which you said you supported?