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The fact is that we are not going to let these old people just starve and die on the streets.

Mr. ALGER. Do we do that now?
Do we let the people of this country starve and die on the streets?
Mr. CRUIKSHANK. No.

Mr. ALGER. Throughout your statement is this matter which the gentleman from Missouri and others have mentioned of the indigent.

Could you give us a documentation for our information here of cases and examples throughout the country where people needing medical care are not getting it ?

Mr. CRUIKSHANK. Yes.

Mr. ALGER. Yesterday we heard from Philadelphia where they are putting out $20 million a year just in free care,

Mr. CRUIKSHANK. We can give you some examples of that and I would be glad to document that.

(Information referred to follows:)

3. UNMET MEDICAL NEEDS OF THE AGED

We were asked by a member of the committee for documentation of cases and examples throughout the country where people needing medical care are not getting it. This request followed our statement that although we do not let old people just starve and die on the streets, the medical care needs of the aged are not now being adequately met.

Much material was presented to the committee at the hearings by a wide variety of witnesses substantiating the position that many people needing medical care are not getting it in the necessary quantity or quality. We do not mean to imply that a person who staggers or is brought into a hospital with an emergency condition would not almost always receive attention. But many elderly people and others who would benefit from the Forand bill are not now receiving effective medical services and treatment sufficient to prevent the development of acute and chronic conditions that could be avoided or ameliorated.

A very large number of persons with meager resources have great difficulty managing to stretch those resources to cover essential needs for food, housing, clothing, carfare, and other necessities. Three dollars or five dollars spent for a doctor's visit mean cutting down somewhere else that month. Bills for elaborate diagnosis or hospitalization or an operation would mean financial disaster. Therefore, elderly people who do not feel well do not go to the doctor under many circumstances which medical men agree should result in medical attention.

Major as well as minor symptoms are tolerated, with the hope that they are only aches and difficulties to be expected with advancing years. Even with acute symptoms, elderly people take a chance and postpone seeing a doctor. Sometimes nothing serious develops, although they may suffer unnecessarily for lack of the proper care or drugs. But sometimes delay gives cancer or heart disease or another ailment the necessary time to become extremely serious, and the doctor gets the case too late to avoid complications and perhaps death.

Psychological and economic barriers which keep many middle-income people from turning to public assistance for aid with medical bills were described in the prepared testimony presented by the AFL-CIO.

Vice President Walter P. Reuther in his statement referred to specific studies in Minnesota, Michigan, and Boston confirming the picture of unmet needs. He also cited official reports on the inadequacy of nursing homes.

Witnesses representing organizations of the aged, in Detroit and in New York, illustrated the existence of a real problem, citing personal experiences. The unmet needs of older people were discussed by outstanding physicians such as Dr. James P. Dixon, representing the Hospital Council of Philadelphia, Dr. George Baehr of the Health Insurance Plan of New York, Dr. Caldwell B. Esselstyn of Group Health Association of America, Dr. Leo Price, medical director of the Union Health Centers of the International Ladies' Garment Workers Union, and Dr. Frank Furstenberg of Sinai Hospital in Baltimore.

The need for such Federal legislation if the aged are to receive proper care was emphasized by spokesmen for the welfare professions, including former

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Commissioner of Social Security, Dr. Charles I. Schottland, and Prof. Wilbur J. Cohen.

Even witnesses who opposed the bill stated that many elderly people are not getting the care they should.

Dr. Frederick C. Swartz, of the American Medical Association, for example, said of the “mentally afflicted,” that “their medical problems have not been solved." Many persons in mental institutions are above the age of 65. Many of them would not be there, now or in the future, if there were adequate financial arrangements for caring for them effectively outside mental institutions, for example, through prompt treatment in general hospitals, or in their homes, with the aid of visiting nurses.

A spokesman for the American Dental Association argued that it would be a mistake to initiate the program proposed by the Forand bill for aged persons because "with the existing shortage of practitioners," it "might cause serious imbalance in the availability of care as between age groups." His statement and other evidence shows that older people are not getting enough dental care, partly because there are not enough dentists to give service to all who desire it.

In his report of July 10 to the chairman of the committee, Secretary Flemming in effect admitted that needs are not being met. He said: "The advances of modern medicine, which have made possible not only more years of life but the prevention or amelioration of conditions previously regarded as hopeless, have intensified the importance of providing adequate health services to older persons. The principal obstacles to achieving this objective are existing shortages and inadequacies in the availability of medical personnel and facilities, and the special difficulties older persons face in meeting the cost of medical care-difficulties occasioned by the combination of their greater-than-average medical care needs, their generally lower-than-average incomes, and, at the present time, their less-than-ordinary opportunity to insure themselves against the costs of medical care."

The resolution adopted by the governing council of the American Public Health Association last October, which was submitted for the record by Dr. Bernard Mattison, states categorically:

"Whereas, health services for the aged are inadequate throughout the Nation * * *

The resolution of the American Hospital Association states that "retired aged persons face a pressing problem in financing their hospital care."

The New Jersey Commission on Aging has submitted for the record a resolution which refers to a recent survey of persons 65 and over conducted in Paterson, N.J. This resolution states that “28 percent had not seen a doctor in the last year.” Surely this is an indication that a significant proportion of older citizens are not receiving sufficient medical attention to assure effective preventive care and continuous treatment of recognized ailments.

The shortcomings of public assistance programs were described by a number of witnesses. Perhaps these statements may be usefully supplemented by the following quotation from a paper given by Pearl Bierman, medical care consultant of the American Public Welfare Association, at the University of Michigan Conference on Aging, June 23, 1959 :

"If we look at the development of medical care in public welfare programs in this country from the long view, or even if we look back over a period of only 10 years, we find that there has been substantial progress. At the same time, when we examine the gaps and deficiencies which still exist in some States with respect to the provision of medical care for the needy aged and other needy persons, we know that we cannot stop working for improvement in this area of public welfare administration.

"Why are there such gaps in medical care programs? Far too often they are due to a deficient legislative base. In some States, for example, the categorical assistance agency is given neither legal authority or responsibility for meeting medical need. This responsibility remains with the locality, often with county or town government. In other States, even though there is appropriate legislative authorization, funds are quite insufficient. Ageucies must decide how much money can be spent for medical care from limited appropriations. I can think of one Southern State, for example, which has legislative authority permitting it to define the content of medical care for which it will take responsibility in very comprehensive terms, but which has so small an appropriation for public assistance that not only is it impossible to finance medical care but basic maintenance needs cannot be fully met. Then there are administrative complexi

ties which sometimes arise and make it difficult, if not impossible, for an agency to help certain individuals meet their medical requirements.

“As a result, there are between 15 and 20 States in which the needy aged persons can receive all the medical care he requires with the assistance of public funds. In other States we can find all sorts of variations and patterns. There are a few States, particularly in the southeastern part of the country, where only hospital care is provided from public funds. In other States public assistance funds may be used for physicians and drug bills but hospital care is provided through public institutions or through subsidies to certain groups of hospitals. And then there may be all gradations of comprehensiveness of service between the two extremes indicated. We cannot condone the develop ment of such fragmented programs since we must recognize the indivisibility of health care and that this is one time when the whole is more than the sum of its parts. This is especially important as the growing volume of medical problems in the old age assistance group becomes increasingly evident."

The July 13 issue of the AMA News, in addition to attacking the Forand bill, contains a story headed “Bill Collections Build Practice" (p. 15). It starts off: "The patient who owes you, goes to another doctor. This may not be true 100 percent of the time, but it happens more frequently than not.” By way of illustration, it cites the experience of a Dr. Jones. One of his patients "was an elderly lady and her case particularly interested him. When he asked her, Mrs. Bright, why haven't you been back to see me?' she replied, 'Dr. Jones, I just couldn't keep coming back to you when I owed you all of that money.'”

The AMA may assume that this patient and similar ones with heavy bills somehow get good medical care. But the testimony of others supports the idea that there are serious deficiencies in the medical care obtained by many older people.

Mr. CRUIKSHANK. My point is that this matter of taking care of the older people is a social cost which some way this enlightened Nation is going to take care of. We aren't any more giving them something for nothing if we take care of it through the social insurance mechanism than we are if we take care of it some other way.

Somebody says cover them all under Blue Cross. Does that mean that we are going to wait until they have paid contributions into Blue Cross for 10 years before they have a right?

Whatever mechanism is used, public or private, we will come up against this problem of new entrants into the system.

Mr. ALGER. You have not presented a case here to show that people are not getting medical care. Granted that we would like to all have more money and everyone would like to provide better for their older years, particularly when they have not accumulated savings, I am simply wondering how strong your case is.

Mr. CRUIKSHANK. I did not present this case because most people do not deny it. The American Medical Association says they are not getting the kind of medical care they should get.

Mr. ALGER. We know there is a problem.

Mr. CRUIKSHANK. I started with the premise that we all admit there is a problem.

Mr. ALGER. If I may read from the introduction of the HEW report which has been called to our attention, it says:

In our society the existence of a problem does not necessarily indicate that action by the Federal Government is desirable.

In my mind it does not follow that this problem must be solved by the Federal Government, unless you present the kind of case showing that medical care is not being provided.

On this matter of right which you spoke of, I want to ask you one other thing relative to it, and it troubles me. It gets into this matter of compulsion.

Supposing the doctors do not get into this. Supposing they do not want to. How are we going to get them into it?

Mr. CRUIKSHANK. I don't think in this particular program the matter of the doctors getting into it is the problem.

Mr. ALGER. Is it recognized it might be a problem if the doctors chose not to get into it?

Mr. CRUIKSHANK. If the program was in existence and all the doctors said, “We are not going to participate in it because we just don't believe in this method of payment,” we would have a problem, that is true, but frankly I am not concerned about that because with all I say about the American Medical Association, I think the doctors of the country will go along with any payment that is devised. If social insurance payment of hospital bills is set up, I do not believe that doctors will let their patients suffer by going on strike against them. I just don't believe it.

We have seen it in other things. The doctors came in here and told this committee that if disability insurance were passed in 1956 this would socialize medicine; it was the beginning of the end and the temple was about to fall around their ears.

Well, it was passed, and the temple has not fallen and the doctors are participating

Mr. ALGER. If there is a Federal law in any given field we have to abide by it: there is compulsion behind Federal law; is that not correct?

Mr. CRUIKSHANK. The only compulsion here is on the collection of a tax. There isn't any compulsion to participate in the program.

Mr. ALGER. Yes; that is the compulsion all right.

What is the right that you speak of, this inherent right of the American people who force others to pay the tax of those people who may not want to pay the tax?

Is that not the worst kind of compulsion in free society?

Mr. CRUIKSHANK. It is the same kind of compulsion on which our public school system rests and our highway system rests. A group of people acting in a democracy make a decision and the minority decides to go along.

I don't see how we can get away from that. Mr. ALGER. Can you tell me why this should be limited to people 65 and over ?

Mr. CRUIKSHANK. It isn't, as a matter of fact, Congressman. It is limited to those people who are the beneficiaries of the social security system or potential beneficiaries.

We believe that this is the group which, by their nature, the other programs are most prevented from helping.

Mr. ALGER. Are you saying it is not limited to those 65 and over? Mr. CRUIKSHANK. No; it would also be, for instance, the young widows.

Mr. ALGER. I know what is in the bill.
My question is, Why do we limit it there?

Mr. CRUIKSHANK. Because this is the social security mechanism and this is a big chunk of the problem that we think it is practical to undertake in this way.

Mr. ALGER. The greatest amount of free care is given to those under 65, we were told yesterday. It is a cutoff point. I am just trying to follow your logic.

How would it affect the fees?
How do you think the Government is going to be able to do that?
Do you see any problem there?

Mr. CRUIKSHANK. I think there would be a problem just as they are problems now.

Blue Cross is having fees trouble, fees with hospitals; but it would be done by mutual arrangement in which all parties concerned would participate.

Mr. ALGER. I am asking you the same question, and we will keep the record open in case you want to add to it, that I have asked of the HEW-Mr. Flemming--so you know I am trying to get some information on this.

For example, have you studied by any chance the other experiments, such as the British experiment, where we might get lessons, where the Government has moved into this field ?

Mr. CRUIKSHANK. We have been very interested in the British experiment because of our close ties with the British trade union movement.

Incidentally, the national health scheme in Britain was put in by the Tory government, not the Labor government. We followed it very closely and we think there are quite a number of lessons that we could learn from that.

Mr. ALGER. Would you provide such for the record ?
Mr. CRUIKSHANK. We will be glad to make a comment; yes, sir.
(The information referred to follows:)

4. MATERIAL ON THE BRITISH NATIONAL HEALTH SERVICE

RETROSPECT AND PROSPECT:

Conceived by a Liberal, nurtured by a coalition government under a Conservative Prime Minister, and brought to life by a labour government, the National Health Service can justly claim to be a national institution. Inevitably-and rightly—it has been criticized in detail, but the concept as such has not been seriously challenged. Mistakes have been made, but an impartial review of the past 10 years indicates that the Nation has good reason to be proud of its health service. Much of the credit for this must go to the rank and file of the medical profession. At the same time due praise must be given to the promulgators of the service for the degree of freedom granted to doctors within it. By traditional civil service standards this was generous, and the civil servants concerned are to be congratulated for the way in which-on the whole they have adapted themselves to this new approach to the management of a government service.

As judged by the health of the nation since its introduction, the service has been an unqualified success. The material mortality fate and the infant mortality rate two of the most sensitive indexes of public health-have reached record low levels. Tuberculosis—once the major scourge of the nation-is rapidly coming under control. Pneumonia has lost many of its dread attributes, and surgeons now successfully perform operations which a decade ago were still looked on as well nigh impossible. The credit for these advances, however, can be attributed only partly to the National Health Service. They would have come about in any case. What the health service has done is to insure that the discoveries of the research laboratories and institutes of the world are made freely available to every citizen of these islands to an extent that was not possible under the pre-1948 system based on the tripod of the panel scheme, the voluntary hospitals and local authority services. To get further than this as some have done and suggest that there is any direct cause and effect is to show

1 Editorial from the London Times Supplement on the National Health Service, July 7, 1958, p. 11.

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