H.R. 5018 would require that not less than $3,000 of the assessed valuation (less all encumbrances) of real and personal property be disregarded when determining the need of recipients of blind aid and, in determining the need of an individual who has an approved plan for achieving self-support, such additional amounts of other income and resources be disregarded as may be necessary for the fulfillment of the plan. The requirement in the present provisions of title X, that all property and resources of a blind aid recipient (except a certain portion of his earned income) must be utilized exclusively for his maintenance as a prior condition for receiving assistance, has succeeded only in impoverishing the individual who becomes a recipient or compels him to live in impoverished circumstances without assistance. This situation hardly serves to encourage a person to attempt self-care, let alone self-support. We certainly endorse section 132 of H.R. 10032 which would make permanent the increased Federal money made available for the three adult aid titles in last year's social security amendments, but we urge that this provision be amended so as to require that the additional dollars be passed on to recipients as was originally the case in the Senate-passed version of this increase. But even this action will be of slight benefit to recipients-at best only 80 cents per recipient monthly. We vigorously recommend, therefore, that you adopt H.R. 5016 to improve the depressed financial condition of blind-aid recipients by providing for an increase in the matching of State funds by the Federal Government whereby it would pay $30 of the first $35 of the average blind-aid payment, and from 50 percent to 65 percent (in accord with the variable grant formula) of the difference between $35 and $75. This proposed changes in the matching formula alone will assure that blind-aid payments in the States will more adequately meet the actual financial needs of recipients while they are in distress. The consequences of the present low Federal ceiling on matching has been that many of the States have been unable to keep pace with rising living costs, thus imposing even greater poverty and distress upon the needy blind persons of the Nation who must depend solely upon public assistance for survival. According to the January issue of the Social Security Bulletin, a publication of the Department of Health, Education, and Welfare, there were 104,394 blind-aid recipients as of last September, receiving an average monthly grant of $67.29. The highest average State payment was $110.58, and the lowest was $38.49. This was at a time when, according to the Bureau of Labor statistics, the average hourly industrial earning was $2.33; at a time when the national minimum wage had become $1.15 a hour. The dire distress of the 104,394 blind-aid recipients is obvious from this comparison. We urge the adoption of H.R. 5016 as a remedy to this grievous condition. In conclusion, Mr. Chairman, and members of the committee, for many years we of the National Federation of the Blind have urged that rehabilitation and restoration, not relief and resignation, should be the objectives to be served by the federally supported public assistance programs in the States. For years, we found few adherents to this doctrine in high places. Now, we are extremely gratified by the declarations made and the proposals offered by this Department of Health, Education, and Welfare. I thank you very much, Mr. Chairman, for this opportunity to present the views of my organization. The CHAIRMAN. Mr. Nagle, we thank you, sir, for bringing them Are there any questions of Mr. Nagle? to us. Thank you, Mr. Nagle. Mr. NAGLE. Thank you very much. The CHAIRMAN. Is Dr. Jaeckle present? Without objection the committee will adjourn until 2 p.m. this afternoon. (Whereupon, at 12:25 p.m., Tuesday, February 13, 1962, the committee was recessed, to be reconvened at 2 p.m. the same day.) AFTERNOON SESSION The CHAIRMAN. The committee will please be in order. I understand you are to speak in lieu of Dr. Dryden, is that right? The CHAIRMAN. If you will identify yourself and give us your name and address and capacity in which you appear, we will appreciate it. STATEMENT OF CHARLES E. JAECKLE, M.D., MEMBER, BOARD OF TRUSTEES, NATIONAL MEDICAL FOUNDATION FOR EYE CARE Dr. JAECKLE. My name is Charles E. Jaeckle. I am a physician. I live and practice in Defiance, Ohio. The CHAIRMAN. You are recognized, sir. Dr. JAECKLE. I am here as a member of the Board of Trustees of the National Medical Foundation for Eye Care. Mr. ALGER. If I might interrupt, I would like to say this. Dr. Jaeckle would have been greeted today by Congressman Betts, our colleague, had he been here. I am filling in for him and I welcome you here today, Dr. Jaeckle. We are glad to have you here. I welcome you in Mr. Betts' name, also. Dr. JAECKLE. Thank you, sir. Prior to studying medicine I was graduated with the degree of bachelor of science in optics and optometry, and practical optometry 9 years. After additional science courses, I qualified to enter medical school. After receiving the degree of doctor of medicine from New York University, I was trained in ophthalmology at Northwestern University. I have served as ophthalmological consultant to the American Medical Association's Committee on the Rating of Physical Impairment. My appearance here is as a member of the Board of Trustees of the National Medical Foundation for Eye Care. H.R. 10032, through a new, constructive approach, emphasizes prevention and rehabilitation. We concur in the statement of the American Medical Association on this bill. We are concerned by one clause which in our opinion does not foster prevention and rehabilitation. I refer to section 1602(a), (12) which provides that— in determining whether an individual is blind, there shall be an examination by a physician skilled in the diseases of the eye or by an optometrist, whichever the individual may select. A similar provision is found in section 1002 (a) (10) in existing law. In stipulating that the physician who makes this examination shall be "skilled in the diseases of the eye," the Congress has taken the position that in determining physical impairment in this one area, even a complete general medical training is not enough; and the Congress has further recognized that blindness must be diagnosed, that its determination requires not only measurement of the degree of vision, but the diagnosis of the disease which is the cause of blindness, and the determination of the possibility of restoration of sight. The addition of the words "or an optometrist," following the phrase, "physician skilled in the diseases of the eye," presumably indicates that those who drafted this clause regarded the optometrist as having a competence comparable to that of such a physician which is not the case. We are certain that it was not the intent of the Congress that the individual choose between the services of one qualified and those of one not qualified. Yet such is the effect of the present law and of this provision of H.R. 10032. As a consequence, the States have commonly, having accepted the optometrist's report, nevertheless found it necessary to call for an examination by an eye physician. The eye training of every physician begins in the first week of medical school, and continues throughout the 4 years. On graduation from medical school, the general physician is well grounded in the eye. The educational qualifications of the optometrist do not approach those of the general physician, either in general subjects or in the eye. It takes at least 4 years more to make the physician into an ophthalmologist-a physician specially trained in the eye. The optometrist has an acknowledged competence in the measurement of ocular refractive errors and their correction by glasses. The need for glasses, however, is never the cause of blindness. When there is blindness, there is disease. Optometrists sometimes observe signs of disease, and then may or may not advise medical examination. The optometrist cannot always know when disease is present. Frequently when optometrists have informed a patient of the presence of such signs, they have also advised him that he needed no treatment, or that there was no treatment for his condition. The good intention of the optometrist notwithstanding, he is not qualified to diagnose disease, to determine the treatment required, or to diagnose the absence of disease. The majority of patients who come to the ophthalmologist come on the referral of other physicians or on their own initiative, and these tients arrive earlier in the course of disease, offering better prospect for prevention and rehabilitation. pa In one study of glaucoma patients, only 18 percent were referred by optometrists, and half of those were in the very late stages. An equal number in the late stages had been seen by an optometrist, but not referred. The majority of the patients were referred by other patients or other physicians, and these were usually in the early stages of disease. I have a copy of this study, gentlemen, and I will be glad to leave it if the committee wishes. The CHAIRMAN. It would be helpful if you would, sir. Dr. JAECKLE. Thank you, sir. Mr. ALGER. Is this too lengthy to be included in the record? How lengthy is it? Dr. JEACKLE. The report of the study? The CHAIRMAN. Yes. Dr. JAECKLE. It is not too long to include in the record but it would be rather lengthy to present here. The CHAIRMAN. Without objection, it may be included in the rec ord. Dr. JAECKLE. Thank you, sir. (The study referred to follows:) [Reprinted from the Ohio State Medical Journal, Columbus, Ohio, October 1961] EARLY DIAGNOSIS OF GLAUCOMA-A DISCUSSION BASED UPON ANALYSIS OF DATA FROM 100 PATIENTS1 The author (By Charles E. Jaeckle, M.D.) Dr. Jaeckle, Defiance, is attending ophthalmologist and director, The early diagnosis of glaucoma is subject to five limitations: (1) the knowledge of medical science, (2) the knowledge of the physician, (3) the knowledge of the patient that he needs the physician, (4) the response of the patient, and (5) the course of action of the physician. In the 1950's medical science made important strides in the diagnosis of glaucoma, as well as in its management. This has directed increased attention to the problem of applying our knowledge. The prominent symptoms and rapid course of acute glaucoma bring patient and physician together quickly. But relatively few patients with glaucoma have the acute form of the disease; the vast majority have chronic glaucoma. NO DRAMATIC ONSET No dramatic incident marks the onset of chronic primary glaucoma. The chief characteristic of early chronic glaucoma is its insidious nature. In the absence of an easily recognizable characteristic symptom to warn the patient, how are physician and patient to be brought together early in the disease? Too often they meet too late, but meet they will, for if glaucoma is insidious, it is also relentless. When blindness impends, glaucoma is all to evident. How shall we find the disease stages? Glaucoma "detection" programs have been conducted. These have been helpful in altering the profession and in educating the public. However useful such programs may be, they are not diagnostic. All persons in whom glaucoma is diagnosed pass through the office or the clinic of the physician. What factors contribute to the early diagnosis? What delays the diagnosis of glaucoma? The records of 100 glaucoma patients in an average ophthalmological practice were studied. Of 82 consecutive cases on file in 1960, two records (patients long under prior treatment for glaucoma elsewhere) were excluded because adequate early history was unobtainable. To the 80 remaining cases were added the next 20 consecutive cases of newly diagnosed chronic primary glaucoma. Those in the first group had been observed for periods of 1 to 13 years. 1 From the Department of Ophthalmology. Defiance Hospital, Defiance, Ohio. Presented before the section on Ophthalmology at the annual meeting of the Ohio State Medical Association, Apr. 9–13, 1961, Cincinnati, Ohio. Of these 80, 8 patients had been previously diagnosed and treated by another ophthalmologist. In the remaining 72 cases, the diagonsis was made either on the fist examination or on reexamination, after some years of observation by this examiner. DIAGNOSTIC CLASSIFICATION For the purposes of this study the glaucoma was classified by the following criteria: A. Early 1. Visual field-no changes for 1/1000, or any change for 1/1000 (consistent with the diagnosis), but no change for 2/1000; and 2. Optic cup within physiological limits. B. Advanced 1. Visual field-any change for 2/1000, or 2. Any cupping of disc characteristic of glaucoma. C. Late Advanced cupping and advanced field changes (includes cases of one blind eye). Each case was further classified as self-referred, referred by family physician or referred by optometrist, with reference to the examination at which glaucoma was first diagnosed. The results of these classifications are shown in table 1. Three patients in whom glaucoma had been diagnosed by another ophthalmologist prior to examination by the author merit special comment. One of these patients had advanced glaucoma. (See footnote of table 3.) Two had late glaucoma when seen by the first ophthalmologist. Of these two, one was classified as self-referred. This patient had been seen previously by an optometrist who reported that visual acuity with glasses was reduced to 20/100 in one eye. The optometrist prescribed glasses and advised ophthalmological examination. The patient did not consult an ophthalmologist until 5 years later when the disease was advanced. The other of these two late cases of previously diagnosed glaucoma had consulted the ophthalmologist when so advised by an optometrist; the disease was then in the late stages. Before the onset of glaucoma, as indicated by history, only two patients had never had any ocular complaints. All other patients in this study at some prior period in life had had ocular complaints which had led to their seeking some attention for their eyes, and glasses had been prescribed for all at some time by an ophthalmologist or an optometrist. The cases were classified as to treatment after the onset of the glaucoma as indicated by history. These data are shown in table 2. Of the two patients who had not previously required glasses, for one glasses were indicated. The other patient consulted an optometrist, no need for glasses was found, and he was advised to consult an opthalmologist. |