With respect to availability of health insurance for persons over 65, California has many existing group insurance plans under which retirees may continue health and welfare benefits. Our Blue Shield and Blue Cross plans have for years incorporated the continuance of membership after retirement as a right-rather than a privilege-and we have over 150,000 retirees currently enrolled. During the year, three large insurance companies, through statewide newspaper announcements, made available at modest cost, contracts for individuals over 65, on an individual enrollment basis, providing indemnification for hospital costs and surgical fees.

The California Medical Association, after years of study of both the medical and economic needs of the aged, directed California's Blue Shield plan-California Physicians' Service—by a unanimous vote of the house of delegates, to offer to all Californians aged 65 and over an individual enrollment contract providing service benefits for surgery, and physicians' care, both in the hospital and, most importantly, on an outpatient basis, in the home or the physician's office. CPS immediately developed this contract, and on June 1, 1959, made it available throughout the State. I offer to you for the records of the committee, copies of the newspaper advertisement that appeared June 1 and June 9 throughout the State of California.

I should like to emphasize that the contracts offered by the insurance carriers and Blue Shield in California are not merely in the planning stage. They are in being, and available on the market.

You will note that the Blue Shield program concentrates on professional services. It does not cover hospitalization. The reason for this is that California physicians have agreed to provide service benefits for low-income retirees at reduced fees, in order to hold the monthly dues rates within the ability of the low-income group to pay, and in order to provide the home and office outpatient eare which constitutes the greatest day-to-day medical need of the aged popula tion, and the greatest drain upon its income.

This program dovetails with that of the California county hospital system. For almost a century we have had a system of county-owned and operated hospitals, staffed voluntarily and without charge by the physicians of the State. By custom and by law in California, the facilities of our county hospitals are open to persons who have income or resources of their own, but which would not be adequate to cover the cost of private hospital care.

We believe that we have more than made a start toward economic security for our aged population in the area of medical care costs, through existing voluntary health-care plans, including the right of continued coverage after retirement, as well as through our individual contracts for those 65 and over. Further-and this I wish to emphasize our programs are available to all persons 65 and over. They are not restricted to those covered under the Social Security Act. They are available as well to those who were self-employed or otherwise not qualified for social security. In this respect, our voluntary approach is more inclusive than the proposed legislation before you.

The California Medical Association urges that Government should not provide compulsory health insurance for those over 65 until and unless it has been proved that voluntary insurance cannot do the job. In the area of health care of the aged, we are confident that voluntary efforts toward budgeting the cost of illness for the aged will continue to develop rapidly and will solve the problem Enactment of compulsory insurance at this time will destroy many programs now in effect.

I beieve there is a parallel in an event that occurred in California some 14 years ago. In January 1945 our State legislature was urged to enact compulsory health insurance on the ground that voluntary health insurance had proven inadequate.

At that time our Blue Shield plan was barely 6 years old and still pioneering an idea that was strange and new to the public, and to medical personnel as well. Its acceptance as a viable mechanism had not been great, and total membership stood at a little over 106,000 persons. Commercial insurance carriers, watching our performance, offered little to supplement it.

Nevertheless, the California Medical Association opposed the compulsory proposal and urged the legislature and the people of California to give private initiative, which had made a bold beginning, a reasonable opportunity to develop and establish itself. The legislature heeded the plea and rejected the compulsory proposal.

In the next decade, voluntary health insurance coverage literally spread like wildfire. In the 5 years from 1945 to January 1950, our CPS-Blue Shield mem

bership increased more than eightfold. In various combinations of benefits, insurance carriers entered the medical field in great numbers and with competitive vigor. Blue Cross extended its well-warranted influence in the market. Group practice plans competed for the public's attention. The concept of labormanagement "trusteed" health and welfare plans quickly took root in California, after the Inland Steel decision in the late 1940's.

The Health Insurance Institute has reported that California leads the Nation in the amount of disbursement under health-insurance contracts in 1958. Carriers paid out over $316 million in our State to meet liabilities incured for hospital and physicians' services.

The extensive availability of coverage following retirement has resulted in millions of Californians being protected against the cost of illness and injury by voluntary health-insurance programs. Private initiative, coupled with social responsibility, has made this achievement possible.

We submit that California's newest voluntary prepaid medical-care plan for the aged is not the perfect plan anymore than were our initial efforts with our Blue Shield program. However, we are making a start; we are heading in the right direction.

Changes in a voluntary plan can be made as experience indicates, and these changes can be made to conform with varied local needs.

The problems of the aged are manifold and sensitive. Physicians are in a unique position to evaluate some of these problems for when we see these elderly people they usually tell us about their problems-medical and otherwise. I am taking the liberty of filing herewith an address I delivered a few weeks ago to the western branch, American Public Health Association, in which I expressed some additional thoughts on this subject. I hope the ideas developed in it may be useful to you in your deliberations. I still believe, as I stated before, there is a lot more to all this than the passing of a law.

I want to express our appreciation for the opportunity to discuss this matter with this committee.

MEDICAL SERVICES FOR OVER 65 GROUP FROM THE PRACTITIONER'S STANDPOINT

(By T. Eric Reynolds, M.D., president, California Medical Association) (Presented before the western branch, American Public Health Association, San Francisco, June 1, 1959)

I realize that much of what I am about to say may seem to be somewhat heretical. In fact, the theme of this presentation is a belief that I do not think is commonly held and one that may seem startling to you; but it is one that I have found to be true in my office practice and that I am sure is supported by other practitioners. This is the belief that the problems, even the medical problems, of the older aged patients are as much problems of the community and family as they are of the physician.

When we used the termed "aged" by definition we mean those 65 or older. Actually, no such arbitrary dividing line is sensible from a clinical point of view; for, as we all know, chronological and physiological age differ widely in different people. However, for statistical and actuarial purposes, we have to accept some birthday as an end point (or should I say beginning point?) so it may as well be the 65th birthday.

There are few statistics as to why people of any age consult doctors. There are even fewer figures on the motivation to see physicians of those over 65 years old. Comparing my own records with a study made at the University of Washington, published in 1955, and drawing on my memory and opinions, I have come up with a few ideas of what brings the elderly group into the physician's office or causes him to see them at their home. Leading the list in frequency is cardiovascular disease, including, of course, coronary artery disease, hypertension, angina pectoris, cerebral hemorrhage and thrombosis, valvular heart disease and venous conditions, especially varicosities, thrombosis, and hypostatic skin disease and leg ulcers.

Arthritis and all the related musculo-skeletal diseases, including low back strains and neuralgic symptoms such as sciatic neuralgia and muscular headaches, bursitis, and tenosynovitis, come a close second. Next, perhaps, in the order of frequency, would come the respiratory diseases, not only the viral and microbial infections but asthma, emphysema, fibrosis, bronchiectasis and

the various manifestations of cardio-pulmonary insufficiency. Somewhere below this in frequency come neoplasms, hernias, especially direct ones-abdominal and diaphragmatic-and fractures, anemias, and prostatic disease. It is interesting that hip fractures, especially in female patients, and prostatic obstructions in males, are two of the largest hospital expense items for conditions of the older age group. All of the above diagnoses account for considerably less than one-half of the visits to the physician's office. One large category of the remainder is psychoneurosis, especially with conversion symptoms referable to the digestive tract. Dietary fads and inadequate food habits are common among this group.

Management of geriatric disease is often made more difficult because so many oldsters do not have a clear understanding of their medical problems for various reasons, such as education, insight, forgetfulness, childishness, and general lack of a realistic approach to the symptoms of disease. Many simply do not accept their age and its implications. So one finds them shopping around, often to quacks and soothsayers-with symptoms that have been explained by their physicians as irremediable, except for palliation.

This age group has a high incidence of morbidity at a time when economic resources, or at least income, is the lowest. As time goes on, more and more older people should come under arrangements for paid-up insurance, extended benefits, and such devices.

The employment and extension of visiting nursing services, better nursing homes, convalescent hospitals, homemakers services, "meals on wheels," and such things, need to be fostered and extended. Rehabilitation, as far as it can apply to the older age group, is highly desirable.

One thing is certain, almost every case has to be individualized and managed according to circumstances of (1) family situation, (2) economic status, (3) temperament, (4) vigor, and (5) mentality. Certainly just putting people under custodial care with many others, often worse off, tends to undermine the mental and emotional stamina of many oldsters to the point where they become hopelessly passive and dependent. Whereas such a simple expedient sometimes as an arm to lean on for an older person to take a short walk, perhaps to visit a friend or relative, or a visit to a day-home or an occupational center, might keep this same individual active and alert.

To a great degree the medical problems of the aged are rooted in the mores of our culture. Also, to a great extent, our medical problems after the age of 65 are determined by such things as (1) the care of the individual before that time, (2) his or her attention to infections, (3) mental cultivation and relaxation, (4) physical fitness and exercise, (5) smoking habits, (6) the use of alcohol, (7) weight control and, lastly, food habits. Perhaps vitamins and hormones, both natural and otherwise, play some part, and certainly part of it is pure caprice, such as the factor of injury or exposure and stress and strain beyond the control of the individual. Heredity is definitely a factor in the medical problems of older people. Indeed, barring accidents, the choice of ancestors often determines whether an individual will qualify to reach that category.

It is my opinion that the two most prevalent difficulties of old age are (1) boredom and (2) loneliness, and that much of the medical attention sought by them is based on these two underlying conditions.

Our society has moved from a relatively simple agrarian economy with handicraft production to a vast complex of industrial capitalism. Technology and automation have made employment less meaningful to most workers, except in terms of earnings and working conditions. For instance, the button pusher in a great shoe factory simply does not have the pride and interest in good shoes that a handicraft cobbler formerly had. Hours of labor are shorter and inevitably will be still shorter and hence chances for leisure will be greater. But what is done with leisure? Or rather we should ask what is not done with it. Fewer and fewer people are self-employed. Everything is biggerfactories, farms, banks, and stores-and so the emphasis of necessity has shifted from individual initiative to security. The standard of living is higher, life is easier and in most respects better, and the sweatshops have all but disappeared. How does all this prepare one for leisure and retirement? Or does it? Now the man or the woman off work, or retired, can sit in front of a TV screen and be spoon fed on a cultural diet which, to say the best for it, leaves something to be desired. Its purpose is to sell deodorants, detergents, patent medicines, beer, and cigarettes, and programs are beamed accordingly. That in itself is not so bad but what is bad is that this occupation is so completely

passive. I think that we all recognize that some aspects of patient loneliness have been relieved by this medium but I think that we must realize that the total cultural effect on the developing community may not lead to the kind of inner resourcefulness that should be the greatest asset of the declining years. Let us ask ourselves to what extent do the radio and television supply the sitter who has gone from 8 hours on the assembly line or at necktie counter with resources with which to enjoy 20 years of social security benefits, after mandatory retirement at the age of 65? Not too much, I am afraid. These I know are extreme examples but they illustrate a point. Perhaps we need to approach these problems by education for leisure as well as by providing paidup insurance. Perhaps Aunt Emma darning socks or granddad weeding a small cabbage patch has some merit after all. In case you think I am just saying these things by way of cracker-barrel philosophizing, I am not. Time and time again in my own clinical experience men approaching retirement age have answered my questions as to "What preparation have you made for retirement?" by the statement "Oh, this is no problem, doctor, I will go fishing" or "Oh, I just want not to have to catch that early bus each morning" or "I will read more" or "just sit around." And what happens, after the novelty wears off? Boredom sets in, little pains become bigger ones, anxieties mount, father begins to look for dust on picture frames around the house, mother's friends don't drop around to call because hubby's home all the time, and tempers flare. What was once a healthy wholesome household atmosphere becomes strained, and psychoneurotic manifestations appear in both members. These are actually observed cases of my own experience, many times multiplied. So perhaps busy hands and busy minds are also happy hands and minds. This is what I meant by stating that much of this is rooted in our society and in our culture. Somehow or other the idea has come about that work is degrading, but it is my opinion that merely sitting and watching entertainment, fishing, hunting, bowling, or even golfing are not enough and may lead to frustration. The mind requires a challenge to keep it flexible, just as muscles need exercise.

Changes in our family living have reduced both the ability and the willingness of children to provide for older relatives. Smaller houses, the migration to the suburbs, the tax structure, inflation, and installment buying of mass produced goods have conspired to make this virtually impossible. The younger relatives themselves are mostly living on next week's paycheck. Here is a real opportunity for the physician to practice preventive medicine by preparing his younger and middle-aged patients of today for tomorrow's older age. A serious talk to younger patients about the development of habits of mind as well as hobbies and games may be even more important than a perfunctory glance through a fluoroscopic screen, on a periodic examination. Preparation, while still young, for the stresses and strains of leisure, is possibly the greatest need. Now all this may sound as if I am mad at somebody or even mad at the world. Forgive me if it does sound that way for I really am not. But I would like to drive home the point to physicians, as well as to the other disciplines--as I notice you call them in your program-that there is a lot more to all this than the passing of a law, the creating of a bureau and the spending of public money. As was said before, the medical problems of the aged are manifold and a large part of this is a family and cultural responsibility. Physicians, I believe, have a social responsibility here because in a large sense, medical findings created the problem, largely reducing infant mortality and making it possible for so many to live into this later period of life. When the keys to malignancy and vascular degeneration have been found, there will probably be much more of this problem. But is it enough merely to stay alive and not to "live"? Most of us, if we could have our choice, would not think so. Here I think are some of the most urgent needs in the medical care of the aging population. By thought, study, and effort, many of them can be resolved.

The CHAIRMAN. Mr. King.

Mr. KING. I wish to concur in everything that my colleague, Mr. Utt, has said concerning Dr. Reynolds.

The CHAIRMAN. We appreciate having this very fine recommendation of Dr. Reynolds.

Dr. REYNOLDS. Thank you both, gentlemen.

Mr. Chairman, members of the committee, I am appearing on behalf of the California Medical Association, which is composed of

some 17,000 physicians. I have filed a prepared statement with the committee but, in the interest of brevity, I will condense my remarks. It is our opinion that the two most prevalent difficulties of old age are, one, boredom and, two, loneliness, and that much of the medical attention that older people seek is traceable to these two underlying conditions.

For persons who have spent 65 years developing a spirit of independence and self-reliance, we would advise as physicians that ways to prevent a continuing challenge to their minds and their hearts should be developed and we believe that voluntary health insurance can well be one of these means by which people do continue to be self-reliant.

With respect to the availability of health insurance for persons over 65 in California, we have many existing new insurance plans under which retirees may continue their health and welfare benefits. Our Blue plans have for years incorporated the continuance of membership after retirement as a right rather than a privilege and we are proud to say we have over 150,000 retirees currently so enrolled.

During this year, three large insurance companies made available at modest costs contracts for individuals over 65 on an individual enrollment basis.

The California Medical Association directed California's Blue Shield plan to offer to all Californians 65 and over an individual enrollment contract providing service benefits for medical care and surgery in the hospital and, most importantly, in the home or the physician's office.

The Blue Shield program concentrates on professional services. The reason for this is that California physicians have decided to provide service benefits for low income retirees at reduced fees in order to provide the home and office care which constitutes the greatest day to day medical need of this aged population.

Furthermore, our programs are available to all persons 65 and over. They are not restricted to those covered under social security and in this respect we think our voluntary approach is a little more inclusive than the proposed legislation before you.

The California Medical Association urges that Government should not provide compulsory insurance for those over 65 until and unless it has been proved that voluntary insurance cannot do the job and, in the area of the health care of the aged, we are confident that voluntary efforts toward budgeting the cost of illness will continue to develop rapidly and will solve the problem.

Enactment of compulsory insurance at this time would tend to destroy many programs now in effect.

In the 5 years from 1945 to 1950, our Blue Shield membership increased more than eightfold in various combinations of benefits, insurance carriers entered into the medical field in great numbers and with competitive vigor. Group practice plans competed for the public's attention and the concept of labor management trustee health and welfare plans has grown in great volume.

The extensive availability of coverage following retirement has resulted in millions of Californians being protected against the costs of illness and injury by voluntary insurance programs. Private

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