Dr. MOUNTIN. That is right.

Senator AIKEN. I was a school director for 15 years in my town, so I know when children are healthy they study better, and they learn more, and I have felt for a long time that we should have a new department of the Government covering it. Health education, and I wanted to find out how far you thought we should go and how much you should include under such a new department if it were established, as I hope it will be.

Dr. MOUNTIN. I am not sure that all I have said is applicable at the Federal level; I was speaking of the integration of services at the operating level.

Senator AIKEN. I do not see how you can separate child health from education.

Mr. MILLER. Could I interject there that the President in making some studies of reorganization, and that there is an agreement between the Secretary of Labor and myself, that functionalizing should be brought together. As to the exact complexion of such pulling together, we have nothing to offer at the moment because the matter is now being considered for later presentation to the Congress. The CHAIRMAN. You may proceed.

Dr. MOUNTIN. I started to mention another phase of public health: that is, geriatrics, in which medical men are commencing to specialize and which I anticipate will grow in importance.

In a sense, it complements pediatrics. Pediatrics conditions the growing human organism for the environment in which it lives. Geriatrics conditions the declining human organism to the environment in which it has to live. Altogether too many people are now dying around forty-five years of age, largely because they have not learned how to live with their infirmities and how to adjust to declining physical resources. Geriatrics addresses itself to the disease problems of later life. But again I would repeat that specialization or sharpening up of programs had better be done within the general framework of administration for a comprehensive program, rather than segregating out the particular problems for separate administration and independent financial support.

There is another part of title I, part C, which concerns grants to States for medical care of the needy. Mr. Altmeyer will give testimony on that item tomorrow, but there is just one passing comment that I would like to make. I hope in the provisions of the act relating to approval of State plans there will be expressed a strong preference for integrating this service with the general medical care program. I am hoping such an arrangement will be carried out because it would be unwise socially and administratively to set the needy apart from the general population. Mr. Altmeyer may have some comments to make on that and other related subjects in reference to part C of title I.

IMPORTANCE OF RESEARCH

With your permission, Mr. Chairman, I should like to change the order here a bit and say a word about grants for education and research before discussing personal health benefits. First, let me mention research. A medical care program and, in fact, any human enterprise, is bound to become sterile, routinized, and spiritless unless there is infused into it a well thought-out, aggressive, and substantial

plan of research. And this bill very wisely makes provision for that. A specific sum is authorized for the first 2 years, and thereafter a - percentage of the personal health service fund may be used for education and research.

There are innumerable subjects that need to be explored. Some of the most common ailments are not understood; consequently we do not know what to do for them. There is, for example, the cold, the most common of human ailments, and we are utterly helpless in doing anything about it that is really effective.

Dental disease is another malady that is universal. We have a little inkling as to what may cause tooth decay, but the mystery is by no means solved. Everybody has it, practically, and yet we do not know what to do except to fill the cavities and replace teeth. That gives one a chewing surface to work on, but what we need to do is prevent the cavities from forming.

Cancer is another disease that needs exploration from many angles. Senator AIKEN. What diseases are on the increase?

Dr. MOUNTIN. Notably, those of later life-cancer, diabetes, heart diseases are three striking examples.

Senator AIKEN. Are they increasing in actual numbers or percentages?

Dr. MOUNTIN. They are increasing in actual numbers and in percentages, too, but let me explain: The population is aging. There are more people over forty-five than before, and more over 65 than before, In increasing numbers we are reaching what we speak of as the diabetes and the cancer age. It is also the period of life when the heart starts to give out or when the arteries become brittle. Because of that, alone, we would naturally expect more people to be afflicted with those conditions and to be dying from them.

There is some evidence to suggest an absolute increase in the occurrence of such conditions quite aside from the age factor; but the fact remains there is a very striking over-all increase. Mortality from the three diseases that I have mentioned has more than doubled since 1900. We have reason to believe that the true incidence of the disease itself has increased in proportion to the mortality.

Those are the groups of diseases that are increasing: the so-called degenerative diseases the diseases that are closely identified with the aging process. Infections, for the most part, are being brought under control; dietary disorders, too.

Senator AIKEN. What is the stauts of arthritis? Is that increasing? The reason I ask that is, a good many servicemen call on us in getting assistance in regard to a larger disability allowance, or help in some way because they are suffering from arthritis.

Dr. MOUNTIN. Arthritis is really a group of diseases. Almost anything that happens to the muscular and skeletal system which causes pain on movement, is included under the broad term of "arthritis." Senator AIKEN. Is it on the increase?

Dr. MOUNTIN. Perhaps not except in respect to the age factor. The joints become less mobile, the muscles less pliable, as we get older, and because of the increasing age of the population one would expect a corresponding increase in arthritis.

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Arthritis, while not a prominent cause of death, shows up prominently in the causes of illness. It is one of the most disabling of conditions. It looms up very large in the total illness burden, and ir the total disability burden, too.

Senator AIKEN. Would it naturally increase as the result of the war?

Dr. MOUNTIN. It might. Exposure under combat conditions might have caused some increase. I wouldn't know for certain.

I want to say this about research; research needs to be carried on on many fronts. There are fundamental facts that need to be disclosed dealing with broad questions of physiology.

Better remedies are needed since many we now have are very unsatisfactory. Additional preventive measures present great poss bilities. I mentioned dental decay; also the common cold. A remedy or a preventive for those diseases would represent a great advance. Then we will need a substantial program of what we might cal administrative research in connection with a comprehensive health program for finding out the causes of disability in different group of the population; also to determine the best and most economica met ds of carrying out the various measures that are encompasse among the benefits."

Many questions in addition to those enumerated need to be studied and restudied. It is the sort of thing on which you are never through Knowledge is never fully probed. There are always possibilities for new developments. Take, for example, penicillin. It has reduce! the days of disability and the days of hospitalization, and correspond ingly has reduced the cost.

On education, too, I am hoping that the committee will see fit t make strong recommendations. I am speaking now particularly medical education simply, because I have more familiarity with th education of physicians than with that of the other professional groupinvolved. The situation, however, is somewhat comparable for a. the professions that contribute to medical care.

Medical education is a very expensive process. It costs the schoo alone some $1,200 or $1,500 a year to train a medical student. Tu:tion returns to the school some $400, or thereabouts; roughly, one third. The remaining about $800 has to be secured elsewhere. U to now schools have been able to draw very largely on endowment-. but as a resource, endowments are not as generous or as satisfactory as they used to be.

I am not including in that $1,200, please understand, Mr. Chairman, any of the personal cost of the student, bed and board, clothing. and so on. I am only talking about direct educational cost.

Medical education, many think, is really facing a serious situation because of the cost, unless something like what the bill proposes can i done. Because of the long process of education, the high tuition. and personal expenditures of the individual, many boys and girls limited circumstances will not be able to go to school unless these costcan be reduced or perhaps something can be set up in the way of fellowships.

I might add to that less than one-third of medical schools are ider. tified with State universities. The remaining schools are supporte by endowments and tuition. So you can see the rather difficult prol lem of financial support confronting basic medical education.

There is another phase of medical education which is, perhaps, the most neglected of all, and that is picking up the doctor after he has graduated, and providing for continuation study. Many of the things he learned in school will be forgotten if he does not have the opportunity to put them into practice continuously. New remedies are coming in, new diagnostic procedures, new instruments, and he needs to have the opportunity to refresh himself on these developments. Otherwise, deterioration will go on, and the very fine doctors now graduating from our medical schools will be not so good rather shortly unless some scheme is provided which will afford opportunity for continuing education.

Now, I want to come back to the medical care-medical care provisions in title II of the bill. That is prepaid personal health services benefits.

The CHAIRMAN. Page 35.

THE PHILOSOPHY OF HEALTH INSURANCE

Dr. MOUNTIN. Page 35. The full significance of this bill, I believe, is not fully realized. We do a lot of talking and arguing as to whether the quality of medical care will be improved or whether it is going to deteriorate; whether the doctors are going to be satisfied, and a lot of similar points; but the true import, I think, is somewhat overlooked. There is a definite philosophy in this bill, and it is this: Heretofore the individual out of his own pocket, has had to finance his illness costs. This bill would change that fiscal arrangement. It would lift the cost of illness off of the crippled backs of the sick and place it on the broad shoulders of a robust society.

It is somewhat analagous to the change that was made in the support of education upward of a century ago.

I think we all should recognize this fundamental change in philosophy and appreciate the fact that as a result of our growing social consciousness, wider use is being made of Government framework to carry out the will of the people and to provide essential services which they cannot provide for themselves through their own resources.

In the testimony that has already been presented I think the need for such a change has been quite fully stressed, but if I may just impose on you for a moment I shall briefly review some of the characteristics of illness that are particularily pertinent to this discussion.

Illness is unpredictable as to the time of occurrence, severity, duration, and the cost entailed. Nobody can tell for himself or his family during any period of time what the illness experience may be.

However, for a large group of the population it can be foretold with accuracy. In other words, it is an insurable commodity. By applying the law of averages to illness, for a significant group of the population, and certainly for the Nation as a whole, you can predict the course of events with a high degree of accuracy. I might even go so far as to say that, within the limits of diagnostic accuracy, statements bordering on infallibility can be made. Likewise, the cost can be computed. Because we as a Nation have not recognized that principle, and because we have not utilized the insurance mechanism, the sick continue individually to pay the cost of their own illnesses. If everyone had the necessary funds it would not be too bad. But since some do not have funds, they do not get the care. All situations are not clear

cut, but vary within a wide range. Those that have ample funds will choose their physicians and hospitals wisely and get the finest care. because the best of our institutions in this country are among the finest in the world. People of limited means or those still further down on the economic scale get less and less medical care.

The fact that they get less is due to two factors: First, they do not have the funds to pay for care; second, since they do not have the funds, facilities and personnel likewise, are not located where such people are. These are available in proportion to a people's ability to pay for medical service. Thus, in many communities, there are few or no doctors. The doctors in depressed industrial areas and agricultural communities usually are older men who for one reason or another are staying. Few or no younger better-trained doctors are going into those communities.

The same is true of physical facilities. Hospitals have been located in accordance with that same guiding economic principle. In other words, they are responsive to that same economic force.

Hospital beds are not necessarily located where people reside, but where the funds are. Conversely, where funds are limited there may still be many people but they will have few or perhaps no hospitals. Furthermore, the hospitals that are there are often of such low quality that they do not meet the standards of the American Medical Associa tion for registration, or those set up by the American College of Sur geons. This situation has been explained to the committee over and over again. Your own publications have expressed it magnificently: and I do not think that I need to take up any more time reviewing your own evidence.

HOSPITAL CONSTRUCTION

Senator ELLENDER. Doctor, do you think that the passage of this bill would stimulate the building of more hospitals by private con cerns; or do you think it will be necessary for the Congress to provide funds to expand these facilities?

Dr. MOUNTIN. There are two elements necessary to correct the condition.

Senator ELLENDER. I understand that. You have gone through that.

Dr. MOUNTIN. One is in this bill, and another in another bill. Senator ELLENDER. The Senate passed the Hill-Burton bill som time ago. Do you think the funds provided in that bill will be su cient to meet hospital needs necessary to take care of the situation should this bill go through?

Dr. MOUNTIN. The ceiling placed by that appropriation somewhat limits its usefulness. I have some doubt as to whether it will cover the whole need, but it will go a long way.

Senator ELLENDER. The point that I want to make is that if yo provide our citizenry with the funds and the doctors and everythin else, you may be lacking in facilities to meet the emergency so that the sick can obtain adequate hospitalization.

Dr. MOUNTIN. The two need to go on together.

Senator ELLENDER. Together; yes.

Dr. MOUNTIN. We need a fund to aid in construction. We al need a fund to help pay medical cost. The hospital construction bil however, was designed to meet only one expense, and that is the construction expense.