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hospital of your own choice with care being supplied by your own private physician.
Through legislative enactment funds have been set aside and the Blue Cross and Blue Shield plans have been designated as the fiscal agents for Colorado's hospitals and doctors, almost all of whom are cooperating thus in giving health care to our aged. In effect these pensioners are holding Blue Cross hospitalization and Blue Shield medical care coverage and are using it in the same fashion as though they were buying insurance themselves. In this particular instance the funds are paid from various State excise and sales taxes. The care is still being administered, however, at a local level where we have an opportunity to see actually what the aged pensioner is receiving for his money.
We have a strong feeling against the Federal Government becoming involved in this type of health care. Predominately we worry in Colorado about the tremendous shrinkage in tax dollars that pass through the Federal Treasury. When we send a dollar to Washington it comes back to the community as a mighty small piece of change. We are sure that this is wasteful and extremely dangerous, with taxes ever mounting and becoming an almost insufferable burden to bear.
We of the medical profession have been accused of narrow sightedness and selfinterest in opposing this legislation. These charges are made by people who themselves have special interest in the legislation. Health, gentlemen, in all of its aspects and ramifications is our business, just as government is your business. We do have a better working knowledge of what is good and what is bad in health matters as regards the general population than any other group. We doubt very seriously that the Hoffas, the Becks, and the Reuthers have contributed anything to the advancement of modern medical care, as we know it today.
The very fact that has brought the problems of the aged into focus is the increase of life expectancy during the past 55 years. It is medicine, with its skills and techniques and its devotion to duty, which has raised the estimated expectancy from 47 years in 1900 to 70 years in 1955. During all of this time it has been the system of medicine that has evolved in this country (the greatest the world has ever known) which is responsible for this change. For a few persons now to suddenly come on the scene and insist that what American medicine has been doing for 55 years is wrong and that only they know what is best in medical care is absurd. The choice that is being presented seems to be for our country to abandon all that we have that has proven to be workable and good, in favor of a type of Federal centralization and control which has been proven in other countries to be inferior.
I would like to urge, gentlemen, that this proposed legislation be discarded and that every encouragement be given to the care of our aged at the local level by whatever plan seems to best fit each given situation. It is common knowledge that the growth of voluntary health insurance plans, even in its short history of operation, has already covered a large segment of the aged population. This can be increased and strengthened if given a chance. The free enterprise system is not dead, gentlemen, nor is it decadent. If given only a fair chance it can solve the problem which we have before us. The solution is not in wasteful Federal centralization and control. This approach to the problem will only lead to compounding more problems as time goes on. The ever-increasing population of the aged will assure this. Their medical management cannot be accomplished by waving the magic wand of Federal legislation followed by the creation of another bureaucracy with all of its weaknesses and faults. Aging is a continuing problem that we all must face and it should be faced at the community level.
STATEMENT OF THE CONNECTICUT STATE MEDICAL SOCIETY, RE H.R. 4700, 86TH
CONGRESS, SOCIAL SECURITY AMENDMENTS OF 1959, BY ELLWOOD C. WEISE, SR., M.D.
I am appearing here today as the representative of the 3,220 physician members of the Connecticut State Medical Society, who have authorized me to present the views of the medical profession in my State concerning the Forand bill, H.R. 4700.
It is the considered opinion of our society that H.R. 4700 is not merely another program which, if enacted, must of necessity increase the already heavy burden of taxation on all the people. While the unquestionably tremendous cost of this scheme is a matter for major concern to every taxpayer, our examination of the
Forand bill has disclosed in it a basic but undeclared provision which is of far greater importance to Americans than money. This well-concealed foundation on which all of the other provisions rest, reflects a philosophy which we believe to be foreign to our way of life and one which seeks to make legal the abrogation of the cherished freedoms of every man, woman, and child in the Nation. Connecticut doctors have always viewed Forand-type bills as pieces of "foot in the door” legislation, which are designed to further break down the traditional American system and open the way for full-scale Government control of our economy. Once the basic freedoms of those who provide medical care have been surreptitiously taken away, the writing will be on the wall for every other productive segment of our still comparatively free society. Nor will the inalienable rights of the present and future recipients of medical care on these terms remain inviolate.
This was the primary reason which caused our house of delegates, on April 29, 1958, to go on record as being opposed to the Forand bill and allied bills. This opposition was neither blind, nor selfish, nor political. Since 1958, our attitude toward the Forand bill has not changed. We still consider it to be a costly, illconceived, and potentially dangerous legislative measure to which we are unalterably opposed.
Over the years, refinements and modifications of the original proposals have been made, each designed to entice first one group in the medical care field and then another into lending their support to the bill. These several enticements have not had their planned effect. They have not been successful because they have failed to conceal the basic danger of the program. We fervently hope that the members of this committee will consider it significant that as recently as June 1959, a joint statement was made by the Joint Council To Improve the Health Care of the Aged, which was subcribed to by representatives of the American Medical Association, the American Hospital Association, the American Nursing Home Association, and the American Dental Association :
"All four member organizations of the joint council are unequivocally opposed to compulsory Government health insurance for any segment of the population.”
It has been frequently stated by some that organized medicine merely opposes legislation; that it has a negative attitude and that while rejecting the hastily contrived solutions to health problems offered by others, proposes none of its own. If indeed such statements were ever true in the past, it has been forcefully demonstrated that this is not the case today. Under the competent direction of the American Medical Association, component State and county medical societies all across the Nation have been diligently working to determine the health care needs of the aging and are giving their fullest cooperation to allied health agencies in the development of prepayment and insurance plans to meet these needs. This job is being done by people who are really qualified to undertake it and they are making almost unbelievable progress toward their goal, all within the framework of a free society and at almost no cost to the Government.
Connecticut physicians are actively participating in this work. Through the Connecticut State Medical Society, they have been represented at the First National Conference of the Joint Council To Improve the Health Care of the Aged. In preparation for the White House Conference on the Problems of the Aging, to be held in 1961, our Committee on Aging is planning to hold joint meetings with Connecticut chapters of the American Dental Association, the American Hospital Association, and the American Nursing Home Association and to participate with these agencies in a New England regional meeting for the purpose of working out methods of providing medical care to our senior citizens at reasonable cost. On April 28, 1959, our house of delegates unanimously adopted the resolution:
“That the Connecticut State Medical Society pledges its continued support to the development of effective health and prepayment programs for all individuals, including those over 65."
The society is conducting a relative value study which will be of aid to Blue Shield and private insurance carriers in making better programs with broader coverage available to those over 65 at the lowest possible cost.
In pursuing these several efforts, some rather startling facts have come to light.
(1) There are approximately 200,000 residents of Connecticut over age 65.
(2) Of these, well over half have some form of insurance against hospital costs, more than 100,000 being entitled to protection by Blue Cross alone.
(3) In addition to some 16,000 covered by welfare agencies on the State level, a very substantial percentage of our senior citizens have found it financially possible to insure themselves against the cost of physicians' services. This large number has increased by literally tens of thousands since the first of the current year. Two private carriers had a tremendous enrollment of new members during the months of January and February and other private companies are beginning to report similar experiences.
Connecticut Medical Service, our Blue Shield plan, reports that over 26,000 subscribers covered under group plans are over age 65 and that there are additional thousands who have retained coverage on an individual basis since their retirement. On April 1, 1959, Connecticut Medical Service offered for sale its society-approved individual contract and, in the first 3 months enrolled some 6,000 new subscribers over 70 years of age as well as over 6,500 new subscribers in the 60-69 age group.
(4) Most of this insurance coverage is reasonably adequate and, with the cooperation being given by the medical profession and other groups, will be made more complete in the near future and without greatly increasing its cost.
(5) While, as physicians, we are primarily concerned with medical service, our evaluation of the cost of such service as being almost prohibitive under Government control is shared by others.
The widespread unrest of Americans as they watch the soaring costs of Government ventures is reflected in our press every day.
An editorial in the July 9, 1959, issue of the New Haven (Conn.) JournalCourier entitled “ 'Free' Medicine in Orbit” is a recent example. It cites the dismal financial experience of Britain's National Health Service as a warning and states that "In the first full year of operation, 1949-50, the socalled free health service cost £440 million to operate, which was nearly triple the amount of the estimate when the law was passed * * *. In 1958, the cost really zoomed into financial outer space to £705 million * * *. This year the service is going to cost more still-£740 million, or $2 billion. And Britain has a far smaller population than the United States, and all prices
and costs are much lower there than here." It would appear then that, in Connecticut, there is actually little need for the costly and freedom-restricting measures which are proposed in the Forand bill, and that such remaining need for medical care of the aging as still exists is being rapidly dissipated by voluntary plans and local community responsibility. We are confident that this experience will be shared by most other States. We feel that, whatever their intent may be, the knowledge, the interest, and the judgment must be seriously questioned with respect to those who demand haste in meeting the health needs of the aging and who continue to insist that it must become a function of the Federal Government. When any individual (or group) starts out to do good, he must consider carefully whether the immediate good which may result will not be more than outweighed by the ultimate harm which may be done, not only to those who were supposed to be benefited, but also to other groups of the society and even to society as a whole.
Gentlemen, this concludes the statement of the Connecticut State Medical Society. It is our sincere recommendation that H.R. 4700, 86th Congress, not be favorably considered by this committee.
MEDICAL SOCIETY OF DELAWARE,
Wilmington. Representative WILBUR D. MILLS, Chairman, Ways and Means Committee, U.S. House of Representatives, Washington, D.C.
DEAR CONGRESSMAN MILLS: In view of the limited time available to your committee to receive testimony from the various State medical associations regarding H.R. 4700, the Medical Society of Delaware has waived its opportunity to speak before the committee in favor of the American Medical Association, so that a more comprehensive verbal statement might be presented for your consideration. We would appreciate, therefore, your having the following statement from the Medical Society of Delaware read into the record of the committee's deliberations.
First, let me say that the Medical Society of Delaware is entirely sympathetic toward the intent of H.R. 4700, which is to assure the availability of hospital and surgical care for the retired. Neither I nor the society for which I speak would deny for a moment that this is a desirable end. We support it whole heartedly. On the other hand, we feel most strongly that the methods proposed by H.R. 4700 are neither the best nor the most desirable means for accomplishing the purpose.
In circumventing the functions of State and local governments, this bill strikes at the heart of our federated and democratic form of government. This is no question of national defense, flood control, organized crime or other problem with implications beyond the legal and moral responsibility of local governments. It can and should be dealt with on State and local levels. We feel that passage of the bill would further erode community government, and would pervert the role of social security, which has been the provision of an income floor for those unable to provide it for themselves. We do not oppose this traditional role. We emphatically oppose the use of social security as a vehicle for creation of a welfare state.
Local efforts toward voluntary care and insurance programs which are now in planning and in operational stages could be so undermined by H.R. 4700 that the aged person needing financial assistance would find no agency to which to turn execpt the Federal Government. If such a situation would not actually constitute a welfare state, it would certainly put us irrevocably on the road to one.
In our own State, Delaware, we cannot deny that some aged persons have had significant problems in financing health care. There are, however, forces that have been at work to alleviate these problems and I should like to discuss them.
We feel that there is little unusual about Delaware's aged population, as compared to that of the Nation as a whole. That is, about one person in 12 in our population is 65 years of age or older, and that person utilizes hospitals about 37 times as much as one in the below 65 age group. In common with other States, we have found State facilities for care of the aged overcrowded and understaffed. But the State has been acting upon its problems, has made real progress and has demonstrated that it is possible to resolve difficulties of this kind on a state level.
At the State welfare home, a hospital primarily designed for care of the elderly, we have been caring for 471 patients in space designed for 386. In addition, the home has maintained a waiting list of 70 or more, whom it has been absolutely unable to accommodate. Now, however, we are ready to open, on August 1, a new building of 200 beds, designed specifically for use as a chronic disease hospital. This building has been erected with State funds, supplemented by Hill-Burton funds, whose help we readily and gratefully acknowledge. With these additional facilities, we will now be able to redistribute the patients to an optimum use of the facility, and accommodate the entire waiting list. We shall have vacant beds immediately available for those Delawareans who wish to enter the hospital. We expect, in short, to be equipped to meet the need for the services of the hospital.
While the welfare home deals with many types of disease, it is by no means alone in providing care. All cases of mental illness are referred to the State Hospital for Mental Diseases which has at the moment approximately 500 patients aged 65 or over. Chest diseases are referred to the State-owned Bissell Hospital, which is caring for 33 patients over 65. Thus, approximately 2.9 percent of the State's aged are cared for directly by State institutions. This is without regard, of course, to those receiving public assistance or welfare grants. Similar supportive funds and facilities are available through voluntary health agencies, religious and fraternal organizations, families and, of course, health insurance.
Voluntary health insurance is doing a much better job of protecting the aged than is usually realized. In our State 45 percent-nearly half--of all persons over 65 are covered by Blue Cross-Blue Shield alone. There are, as you know, an increasing number of private or commercial companies who are actively expanding their underwriting for persons over 65. The Health Insurance Council, representing carriers of over 90 percent of the Nation's commercial health insurance, estimates that 80 percent of the aged who need and want health coverage will have it by 1975. Other informed estimates range as high as 90 percent by 1970. While we cannot reasonably distinguish between these
estimates on our information we feel confident that the interest in the elderly now manifested by nonprofit carriers will both raise the percentage and lessen the time.
As an example, our local Blue Cross-Blue Shield plan began only last month to offer hospital-medical-surgical coverage designed especially for the over-65, and limited to that group. The plan dispenses with services not needed by the elderly, such as maternity benefits, and provides services not available to the young, such as nursing visits at home. Surgeon's fees, anesthesia, X-rays and consultations are on the same basis in both plans, although hospital stays are more limited in the over-65 policy.
The concept of home care of the sick, under the physician's supervision, is growing and offers, in our opinion, one important means of caring for the chronically ill while materially decreasing the cost of care. One Delaware hospital has been experimenting with this program for about 3 years, and reports excellent results. We expect home care to become a significant factor in geriatric medicine, as it is refined and developed. We also feel that Blue Cross's action in paying for home care visits will accelerate its utilization.
Each hosptal in Delaware receives from local government $550 per bed per year, which is used to defray, in part, expenses incurred by patients who are unable to pay. Deficits beyond that amount are made up through philanthropy and other methods common to hospitals everywhere.
As mentioned earlier, we find more aged with some type of prepayment plan for medical care than without one. Still, the indigent patient does not pay the physician. Delaware physicians, as a group, have always, on their own initiative, accepted reduced fees from those for whom full payment means hardship, and waived fees from those who could not pay. All physicians have worked in hospital clinics without expectation of pay. It is a time-honored privilege and duty of the physician to set his own fees and to work without compensation if he so chooses. The Medical Society of Delaware sees no necessity for departing from this custom.
Having outlined, briefly, Delaware's program for the aged ill, I should like to discuss for a few moments our reasons for thinking this approach superior to that of H.R. 4700. First, Delawareans, by coping with their problems locally and finding at least some of the solutions have found pride in their hospital system. The community problem has given rise to community responsibility and has, we think, strengthened relationships between the aged patient and the rest of the population to a very desirable extent. Woman's auxiliaries and service groups have undertaken the entertainment and emotional support of patients in State institutions to a degree seldom if ever found in the general hospital.
Second, operating costs per capita are much lower in chronic disease institutions than in general hospitals. This is true, among other reasons, because many expensive emergency and acute illness facilities necessary to the general hospital are dispensed with as unnecessary to the chronic disease hospital. This results in care costing from 50 to 80 percent less than care in general hospitals. Patients in these facilities who need major surgery are transferred to general hospitals and transferred back for convalescence. I want to emphasize that care in these public facilities is by no means inferior to that in general hospitals. It is merely different, and requires different equipment and different expenditures. The enormous saving to the taxpayer is obvious.
Provision of care at general hospital rates, as advocated by H.R. 4700, would tremendously increase the financial burden upon the taxpayer. In Delaware, a very small State has been able to erect and maintain facilities for providing these specialized types of care. On a per capita basis, it should certainly cost no more to provide similar care in larger States. It is obvious that the rates for maintaining these institutions would not go up at the same rate that patient capacity could be expected to rise.
To the beneficiary with marginal financial resources, H.R. 4700 would provide an active incentive to enter a general hospital and to stay there as long as possible, within the limits of 60 days' hospital and 60 days' nursing home care. This would be true simply because it would be cheaper to be hospitalized than not hospitalized. The situation would have three immediate effects :
1. It would result in pressure upon physicians to treat by surgery rather than by more conservative means. We do not especially fear the effect upon the physican, but we do depend upon patient cooperation and we doubt that economic pressure created by the bill would encourage the patient to cooperate with conservatism.