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practitioners (about 900), Cases requiring specialist treatment are referred to the hospital eye service.

When spectacles are supplied there is a charge of 10 shillings, for each lens, with a further charge where a patient asks to be supplied with plastic or safety lenses. A patient also pays the full cost of the frame chosen from the wide variety available under the National Health Service. Children's glasses in a frame of one of the standard types are free of charge. Patients may hare lenses supplied under the supplementary ophthalmic services fitted in private frames if these are suitable. A patient who cannot afford to pay the charges can apply to the National Assistance Board for help in the ordinary way.

LOCAL HEALTH AUTHORITY SERVICES

The local health services, a series of services mainly concerned with the care of patients in their own homes, are the responsibility of the major local authorities, county councils, and county borough councils. These are known as local health authorities (there are 146 of them in England and Wales) and they work through health committees. The duty has been placed on them of providing such services as midwifery; antenatal, postnatal, and infant welfare clinics, and dental services where practicable for expectant and nursing mothers and young children; health visiting; home nursing; ambulances; provision of domestic help on health grounds; special care and aftercare of the sick; local mental health services; and also vaccination and immunization. The setting up of health centers is also a duty of local health authorities, but at present it is felt that the extensive provision of centers should wait on the experience to be gained from the use of a limited number of experimental centers and developments in group practice.

All these services are free of charge except for domestic help and, in certain cases, provision of residential accommodation, meals, nursing requisites, bedding, etc., for which a charge may be made according to means. Since June 1952 local health authorities have also had power to make charges for the use of day nurseries. The local health authority may only charge what is reasonable, having regard to the means of the users.

Cost of the service (England and Wales)
Actual expenditure (net):
July 5, 1948, to March 31, 1949..

£179, 281, 787 1919-50

305, 288, 243 1950-51.

336, 559, 753 1951-52.

348, 457, 732 1952-53_

384, 155, 261 1953–54.

367, 947, 357 1954-55_

388, 860, 290 195:1-56

423, 796, 675 1956-57

468, 012, 590 Estimated expenditure (net):1 1957-58_

485, 305, 085 1958–59_

472, 459, 430 1 The net cost represents the amount to be met by the exchequer.

Ministry of Health (Public Relations, Intelligence Section) Savile Row, W.1, September 1958.

The CHAIRMAN. Any further questions of the Secretary?

If not, Mr. Secretary, we thank you and those accompanying you at the witness table for your appearance this morning and the information you have given the committee. For the benefit of everyone, I felt that it was

already understood the subject matter of your report of April 3, 1959, is presently before the committee as I indicated in my opening statement and that information as well as the provisions of H.R. 4700 are open for consideration by the committee.

We thank you, sir, for your appearance and the information you have given the committee.

Secretary FLEMMING. Mr. Chairman, may I express my appreciation for the opportunity of presenting our views, for the questions that have been addressed to me, and may I state that if as a result of further testimony in connection with these hearings there is additional information that you would like from us, we will, of course, be more than happy to supply it.

The CHAIRMAN. We will contact you sir in that case.
Secretary FLEMMING. Fine.
The CHAIRMAN. Thank you, sir.

Mr. FORAND. Mr. Chairman, I ask unanimous consent that there be inserted in the record immediately following the testimony we have already received, a telegram from Arthur J. Altmeyer, who was for 18 years Commissioner of the Social Security system.

The CHAIRMAN. Without objection that may be included in the record at this point.

Mr. FORAND. I should say it is in favor of the bill. (The telegram referred to follows:)

MADISON, Wis., July 8, 1959. Hon. WILBUR D. MILLS, Chairman, Committee on Ways and Means, House of Representatives, Wushington, D.O.:

Regret cannot appear personally to testify in favor of Forand bill providing hospitalization, nursing home, and surgical benefits for QASDI beneficiaries. Unreservedly support this bill. Nongoverninental insurance plans particularly nonprofit plans have done much but because of their very nature cannot cope with problem of insuring groups requiring above average amount of medical care but possessing below average amount of income This problem can only be solved by Government-insured plan which spreads cost over lifetime of all groups. Argument of opponents that Forand bill is administratively unfeasible is same argument made against original Social Security Act and against permanent total disability amendment based on my administrative experience as administrator of social security for 18 years. I am confident this bill can be administered satisfactorily to achieve its beneficient purpose of providing much needed protection for the unprotected. Warm regards and appreciation of your efforts throughout the years in behalf of social security.

ARTHUR J. ALTMEYER,

Former Commissioner for Social Security. The CHAIRMAN. Our next witness is Dr. Herbert Berger.

Will you please identify yourself for the record by not only giving us your name and address but the capacity in which you appear

STATEMENT OF HERBERT BERGER, M.D., F.A.C.P., PRESIDENT

ELECT, NEW YORK STATE SOCIETY OF INTERNAL MEDICINE, MEMBER OF LEGISLATIVE COMMITTEE, AMERICAN SOCIETY OF INTERNAL MEDICINE

Dr. BERGER. I am Herbert Berger. I practice internal medicine in Staten Island, N.Y. I am president-elect of New York State Society of Internal Medicine and I appear here as the representative of the American Society of Internal Medicine.

The CHAIRMAN. You are recognized for 10 minutes. Dr. BERGER. I am here to bring the views of the American Society of Internal Medicine, an organization composed of over 6,000 specialists to you. We have requested this opportunity to appear because many, if not most of the medical problems of the aged are eventually referred to us. We are specialists in that branch of medical practice which deals with the diagnosis and treatment of serious medical illness comprising for the most part those disease states which affect the heart, lung, digestive system, kidneys, brain, and blood.

Since practically all internists (specialists in internal medicine) are also members of the American Medical Association I shall not (to conserve your time) repeat the statements they have made nor anticipate those still to be brought to this committee by that body. Internists of the United States agree wholeheartedly with these sentiments. We concur that the socialization of medicine to this segment of our population would be inimicable to the best interests of those older persons who are sick and would place intolerable burden on those younger individuals who are well and still working.

We contend, in addition, that a nation cannot survive half socialized and half free enterprise any more than, prior to 1860, our country could endure half free and half slave. Certainly if we embrace this much socialism then it will follow that ancillary medical professions, pharmacy, hospital management, nursing, and dentistry will be forced to accept this same ideology which is so foreign to that which has made our country great. Many of you gentlemen are members of the bar. Is it not evident that your profession will eventually be socialized as will our business enterprises? Does it not seem inconsistent that we should be fighting such communism in Geneva while introducing legislation supporting it in Washington ?

Obviously as a practicing physician these statements may seem outside of my own sphere of competence but physicians are citizens too, and your

deliberations are of great moment to us and even more to you who are, or who one day will be, our patients.

My colleagues join me in recognizing the difficulties that beset the members of this committee. Certainly we understand that if an enemy were to violate the geographical borders of our country we should feel constrained to protect them with our every resource. A nation is not, however, merely a number of square miles. Much more important is its people. We in internal medicine agree that a disease which invades this all important area, our citizens, must also be repelled by every expedient available to us.

It becomes apparent then that by opposing H.R. 4700 internists and other physicians are not being negative but are averring with all positivity that our citizens, young or old, must be protected against the ravages of disease. We contend, however, that socialization is not the best method for providing the health care which we all desire for our older citizens.

The American Society of Internal Medicine has requested this audience not for the sole purpose of agreeing with the statements of the representatives of the American Medical Association we could have done that by letter--but rather to present our own unique experience with the group of patients whose protection you are now considering. This information may prove useful as you seek the answers to this perplexing problem.

1. The major health needs of the aged are not surgical. They suffer, for the most part, from emotional disturbances, engendered by their separation from the main current of life in their communities, by their feeling of uselessness, by their inability to properly manage their new

found leisure, by the extra time they have to reflect on their disappointments. All older people have these, for none have accomplished all of the aims of their youth. H.R. 4700 makes no provision for the services of an internist, the individual who, as a doctor's doctor, is the final arbitor of these problems.

2. Following nervous disorders, these aged people are subject to the diseases of degeneration; hardened arteries, bad hearts, kidneys and lungs, weakened digestion and anemia. The more serious of these illnesses are seen in consultation by the internist. Does H.R. 4700 recognize this?

3. There is no question that the aged have many economic problems. Surgical, hospital, and nursing home care are only a small part of these. Certainly, as long as we give people half pay for no work when they must still pay full prices for food, lodging, clothes, transportation, and medical care, there is bound to be some economic travail for those who haven't provided for their future. Perhaps this isn't the place to say it, but if these people were given full pay for a half day's work their economic and their emotional problems would disappear.

4. If, indeed, these individuals must be cared for at the expense of Government, then the payment of a fixed low fee would be placing this burden, which should be borne by all the people, to a large extent on one group, the physician. This applies particularly to the family doctor and the internists, both of whom render so much of the care these people need. No provision has been made in H.R. 4700 for these services.

The medical profession has traditionally provided health services for the indigent. This altruism has not disappeared. It is, however, threatened by such discriminatory legislation. The economic problems of the aged can be met not only through the half day's work for a full day's pay mentioned earlier, but also by increasing social security benefits so that these people can defray all of their expenses, medical or nonmedical.

If the Congress feels it inexpedient to increase social security taxes sufficiently to make these added increments actuarially sound, then I am certain that my profession stands ready, in concert with the landlord, the grocer, the clothier, and the lawyer, to render services to these deserving people at reduced rates. I am sure it is not Mr. Forand's purpose to propose that the economic obligations of the aged be borne by medicine alone.

5. The bill provides for fees to be paid certain specified categories of surgeons. We have no quarrel with the principle of securing the most qualified personnel for the care of such patients, but it is statistically true that many communities do not possess a surgeon who is a member of the American Board of Surgery. H.R. 4700 has not investigated the availability of these individuals, nor whether these surgeons would render this service under Government aegis.

6. The most important decision about any surgical procedure at any age is, “Do you need it? Is this the best possible answer to this individual disease?” This is a question answered by the diagnostician, often the internist. H.R. 4700 has begged this all-important question.

7. The next most significant fact to be determined prior to any surgical procedure, particularly in the aged who may suffer in addi

tion to their surgical illness a heart condition, is, “Can the patient stand this procedure?” This question, too, is answered in our best hospitals and teaching centers by the internist. H.R. 4700 does not consider this either.

8. What about the innumerable medical postoperative complications, the pneumonia,

for example, so common in older people? What provision has H.R. 4700 made for the rendering of this vital service? This, too, falls in the province of the internist.

9. That provision of the act which refers to nursing home service makes no provision for the medical care which must be rendered constantly to these chronically ill patients. I am a consultant to the New York City Department of Welfare. My duties consist in seeing problem cases in a city-approved private nursing home of 200 patients. Each of these patients has his own private physician on the welfare panel who visits the patient either weekly, biweekly, or monthly as I direct. The other consultants and myself render opinions on patients so that each of us must visit the institution weekly. In addition, I am a cardiac consultant at the municipally operated Farm Colony which houses 2,500 such elderly patients. We have a large staff of full-time physicians at this institution, which, in addition, uses the facilities of an adjacent municipal hospital, Seaview, for those who are actutely ill.

It becomes apparent that nursing home guests or patients require more than a modicum of medical attention. H.R. 4700 has not anticipated the services of family doctors and internists whose attentions these individuals require constantly.

In conclusion, then, may I record the opposition of the more than 6,000 internists who are members of the American Society of Internal Medicine to this type of legislation both on philosophical grounds, as we recognize the inherent socialistic nature of the bill, and on specific grounds, for we have shown that H.R. 4700 doesn't begin to accomplish what it set out to do.

The Committee on Aging of the American Medical Association, the Blue Shield and Blue Cross Plans, commercial insurance carriers, and State medical societies all are seeking the answer to this problem, utilizing the freedom to investigate and study which has given the United States the finest medical care in the world.

Some years ago I had the opportunity to address a committee on the British Parliament on another medical subject. During the intermission I secured a hurried meal in a small lunchroom patronized by artisans. Two bricklayers with whom I sat entered into conversation with me about their socialized medicine plan. One of them commented on how he eventually, after endless frustrations, had to secure private care for his nervous wife—the commonest ailment in the United States, too. His deathless prose after a dozen years of experience with the scheme is the most cogent criticism of socialized medicine ever to come to my attention. He said, “The national health scheme is a fine idea as long as you're not sick."

Please feel free to call on any members of this society if we can be of assistance to you in your deliberations.

The CHAIRMAN. Dr. Berger, we appreciate your bringing to us the thinking of the American Society of Internal Medicine on the bill H.R. 4700.

Any questions? Mr. Forand.

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