It is by this yardstick that the physician measures his reply. And it is by this yardstick that the members of the medical profession have formulated their position with respect to H.R. 4700 and similar bills. I would like to discuss some of the fundamental reasons why we believe that this proposed legislation is neither practical nor realistic. Medical care is not susceptible to production line techniques. Care for any segment of our population, the aged included, calls for a cooperative attack on the problem by nurses, doctors, hospitals, social workers, insurance companies, community leaders, and others. It requires flexibility of medical technique, an ingredient which would unquestionably vanish the moment Government establishes a health program from a blueprint calling for mass treatment. If we abandon the community approach in favor of a rigid national health program, we will, in effect, have constructed another Procrustes' bed. The mythological Procrustes, you will remember, developed a bed that was just right size for everybody. There was only one trouble with it: Procrustes, instead of altering the bed to fit the person, altered the person to fit the bed. He accomplished this feat of legerdemain by trimming off the legs of the tall, and stretching his shorter victims on the rack. I am sure we all agree that it is sounder to tailor the bed to fit the patient. In the case of the aged, their health problem primarily involves acute illness and the so-called degenerative diseases. In a very large percentage of cases, the main need is not for an expensive hospital stay or a surgical operation, but for medical care at home or in the doctor's office. In other cases, the important requirement is nursing care in a nursing home or the home of relatives. And, in still others, custodial care in a nursing home or public facility may be the only answer. The point is that the medical needs of this particular segment of the aged are subject to countless variations. Any workable system of care must be tailored to meet these variations. An example of a faulty program is the mass attack approach that has been forced on medicine in the handling of the mentally afflicted. They are removed from society, but their medical problems have not been solved. If H.R. 4700 were enacted, it would mean that the Federal Government would finance the health care of OASDI beneficiaries through compulsory and earmarked taxes; the Federal Government would control disbursement of funds; the Federal Government would determine the benefits to be provided; the Federal Government would set the rates of compensation for hospitals, nursing homes, dentists, and physicians; the Federal Government would audit and control the records of hospitals, nursing homes, and patients; and the Federal Government would promulgate and enforce standards of hospital and medical care. When government at any level guarantees services which it cannot. itself provide, it inevitably tends to control the purveyors of these services. I doubt that anyone here intends or seeks such control, but there is no doubt that it would take place. Disclaimers notwithstanding, if a single Government agency were to buy 10 to 20 percent of all care in the Nation's general hospitals, it would be utterly impossible to limit that agency's power to influence the overall operation and management of hospitals. One predictable consequence of such a national program would be the overuse and overcrowding of our hospital facilities. It is certain that a substantial increase in hospital use would result during the first year of this proposed program, simply because a Government plan had been put into operation. As doctors, we believe that patients should be placed in hospitals, nursing homes, and other institutions, only when necessary. We believe the length of their stay, as well as the therapy rendered, should be dictated only by their medical condition and not by limitations of legislation or regulations. The problem is far more than a matter of economics, or even of medical technique. For we must also deal with the human spirit, which flourishes best in those who are determined to stay in the mainstream of day-to-day living. H.R. 4700 would have further bad effects: It would curb community incentive to support hospitals, for the tendency would be to shift this responsibility from the shoulders of private and local government sources to the already overburdened shoulders of the Federal Government. It would discourage, at the community level, the freedom to experiment with new techniques, such as home care programs, day hospital service, homemaker services, progressive patient care, and new concepts for treatment through outpatient departments and doctors' offices. And it is at the community level that such innovations are developed and made to work. It would discourage families from taking care of their own. It would restrict beneficiaries in their choice of hospitals and physicians. For only those physicians and those hospitals and nursing homes entering into agreements with the Federal Government would participate. The professional relationship between the doctor and his patient, the basis of all effective health care, would be severely handicapped. Government regulations would be imposed on the physician, and on the patient as well, bringing a third and intruding party between them. Required conformance to administrative regulations could also hamper the physician from prescribing treatment which, in his profes sional opinion, was indicated. It would discourage the individual approach to patient care. When this has been disregarded in the past, the result has been mass tragedy rather than mass cure. It would attempt to chart a health program for the aged without accurate knowledge of the problem's dimensions. The statistics presently available on the subject are neither conclusive nor complete. To use them as the basis for so far-reaching a program is akin to prescribing for the patient without first making a diagnosis. Basically H.R. 4700 simply proposed a form of national compulsory health insurance. For the moment, it would be limited in scope; however, there are many who are testifying before this committee this week who admittedly seek to extend the program to every segment of the population. It should be remembered in this connection, that if the Federal Government at some future date adopts a medical care program for the total population, it will be assuming a medical bill of more than $20 billion annually. A report published by the Department of Health, Education, and Welfare, based on 1957 statistics, indicates that private health care costs approximate $15 billion and that public and philanthropic costs amount to about $5 billion annually. The bill would establish a dangerous precedent. Instead of cash benefits, it proposes service benefits irrespective of need. In effect, the Federal Government would furnish the beneficiary with compulsory hospital and surgical insurance whether he needed it or not, whether he wanted it or not. In this connection, let me say that the American Medical Association has never opposed the Social Security Act per se. H.R. 4700 is, however, a major and dangerous deviation from the original concept of the system. We must also face the fact that any single program of health care for the aged should not embrace every aged person. The pending bill would cover millions of people who do not need or want Government medicine. Further, it is a misconception to think that this measure would aid those who receive public assistance, the vast majority of whom are not covered by social security. These indigent are now receiving their medical care through welfare programs. Aside from the help they get from many private, fraternal and religious organizations, the indigent now receive more than $4 billion annually in Federal and State aid for medical and other expenses. I should like to comment briefly on what this proposed legislation would cost. It would be staggeringly expensive. The costs of this program during its first and second years have been estimated as in excess of $2 billion a year, a figure which can be expected to increase during the ensuing years. There is absolutely no way of predicting the cost of H.R. 4700 in the years ahead. These programs expand. They never contract. And once they are on the books, they are there to stay. Yet the problem of financing health services for the aged is a temporary, not a permanent one. As Dr. Larson indicated, voluntary health insurance is making tremendous progress, through expanded coverage and broader protection. Dozens of different type policies are now available. Among them are policies guaranteed renewable for life; policies to cover those now over 65; coverages that will continue after retirement; and group policies that may be converted to individual coverage upon termination of employment. Much of this progress has been made in just a few years. This indicates that the hospital costs of our aged are being met, in a large measure, by prepayment plans and insurance as they steadily gain experience in this relatively new field of coverage. Much progress is also being made in the development of new and improved facilities specially tailored to the particular health requirements of the older citizen. As a part of this program, the American Medical Association has supported a loan program of the F.H.A. type for nongovernmental hospitals and nursing homes, whether of a nonprofit or proprietary nature. It has also recommended changes in the Hill-Burton Act to help the individual States earmark more money for nonprofit nursing homes. The American Medical Association continues to back further experiments in progressive hospital care; home care programs; and homemaker services, all of which have the common purpose of improving the quality of medical care by reducing the length of hospital and nursing home confinement through the earlier discharge of patients. The record shows that sustained and heartening progress is being made throughout the United States toward meeting the needs of our older citizens promptly and positively. I do not have the time to specify here the details of the massive job that is being done. The fact is that voluntary methods—supported by the cooperative efforts of many thousands of our citizensare meeting the challenge and will continue to meet the challenge, given the continued opportunity. So that this committee has at its disposal the American Medical Association's six-point program for older citizens, we are appending a discussion of that program which I had the privilege of giving last month before the U.S. Senate Subcommittee on the Problems of the Aged and Aging, which I would like to have included in the record. In closing, one fact seems to me to be crystal clear: The health professions and other private voluntary groups are meeting the challenge. We believe that the same people who made this the healthiest Nation in the world's history, and helped bring the gift of longer life to millions of Americans, are equipped to meet the problem of caring for the health of our older citizens. Gentlemen, this concludes my formal statement. It is our sincere recommendation that H.R. 4700, 86th Congress, not be favorably considered by this committee. Dr. Larson and I will be glad to answer any questions you may have. The CHAIRMAN. Dr. Swartz, is the material you referred to a moment ago that which is appended to your statement? Dr. SWARTZ. That is correct. The CHAIRMAN. Without objection, that will be included in the record. (The material referred to follows:) PRELIMINARY PRESENTATION BY FREDERICK C. SWARTZ, M.D., LANSING, MICH. (As requested by Senator Patrick V. McNamara, chairman, U.S. Senate Subcommittee on the Problems of the Aged and Aging, in connection with subcommittee meeting in Washington, D.C., on June 16, 1959) If it is not inappropriate, I should like first to compliment the chairman and committee members on the way in which they are beginning their study of the problems of the aged and aging. The deliberative, thoughtful approach which the committee apparently intends to follow should help provide the Senate with a clear picture of the basic needs of older persons. NEEDS OF PERSONS OVER 65 ARE COMPLEX The work of the American Medical Association in the field of aging has shown that the needs of persons over 65 are complex and that providing opportunity for these citizens to meet their needs requires full recognition of the widely varied circumstances under which they live. The calm, dispassionate approach by the committee, therefore, augurs well for its study results. If the experience of the AMA Committee on Aging is any indication, the members of this committee may even find their own concepts of aging undergoing material changes as the study progresses. PRACTICALLY NO DISEASES EXCLUSIVELY ATTACHED TO THE AGING PROCESS When our committee was first formed, it was charged with the responsibility of studying the problems of geriatics, that is, the diseases of the aged, and was no named. It became apparent early in our deliberations that there are practically no diseases specifically and exclusively attached to the aging process and that while there are diseases among the aged, there are no diseases of the aged. In the light of this, the committee recognized that its real purpose is the health of the Nation's aging population, sick or well. GOALS OF AMA COMMITTEE ON AGING The committee's goal is optimum health for each individual. This embraces the areas of (1) adequate medical care at the lowest practical cost for those who are ill, (2) promotion of better understanding and wider use of restorative services on behalf of those who are disabled, (3) encouragement of activities, both group and individual, for the prevention of illness among all older persons, and (4) the promotion of long-range positive health programs which will increase the overall capacities of persons to live active, meaningful lives in their later years. From the earliest, study of these areas showed that the health of the senior citizen is not solely a medical or health habits matter. It became increasingly plain that the health of persons over 65 depends in a large measure on socioeconomic and psychological factors which prevent many persons from exercising their potential for responsible participation in society. As long as these patterns exist, unnecessary illness will occur despite medical care and otherwise sound health programs. Likewise, the duration of illnesses may be unnecessarily prolonged, the degree of disabilities increased. THE AMA POSITIVE HEALTH PROGRAM It was in this frame of reference and after protracted study that the AMA Committee on Aging developed its positive health program for older citizens. It did so only after numerous conferences with physicians throughout the Nation and other informed persons and groups capable of providing data on aging. The program calls for: 1. Stimulation of a realistic attitude toward aging by all people The present general attitude or perspective of the public toward this everincreasing segment of itself is well-known but somewhat puzzling to understand. After a fourth of a lifetime spent in preparing to be a producer and after a half a lifetime spent in gaining experience and contributing to the public welfare, the oldster finds himself with a commodity which is still in demand but not from him. Just try to find him a market for his work. In spite of all the testimony in his favor, he is unacceptable. That which he was taught to believe made life sweet, his work, is taken from him. In addition, just let him make a little mistake in traffic-the same kind of mistake made by the younger group every day--or let him voice an unpopular thought in the meeting places, and he will be tagged by any number of names, all preceded by the word "old," as if this were an anathema that excommunicated him from all that was human. He is robbed of his ego and individualism. He is now just "Grandpop" or "Gramp" or "Grandpa." He is cashiered out of the human army. He now stands naked without rank, weapons, medals, or identification. To change this perspective will take much good, hard work. We, as a nation, can ill afford this tremendous loss of human resources. Retirement at the present |