2. With the patient's incentive to regain his feet and leave the hospital undermined, we would expect a significant increase in length of stay among patients in this group. Therefore, convalescent patients whose need for facilities may be dubious, can be expected to occupy beds urgently needed by others in today's crowded hospitals.

3. The increased utilization of hospitals that we expect would make it impossible to project reliable cost figures for the Forand bill. Experience in Saskatchewan, where a program similar to this proposal exists, indicates that hospital utilization rates among the aged are nearly three times the U.S. average. Thus, the $2.3 billion per year estimated necessary to implement the bill might well pay for less than half of its actual cost.

As a practical matter, health care for the aged is not more than one aspect of the group's greater problem, which is financial and social integration with the community. Housing, recreational facilities, food and shelter are also to be considered. We question the wisdom of embarking upon a program of indiscriminate financial aid involving enormous expenditures for a relatively small segment (surgery) of one aspect (the medical) of such a multifacet problem, particularly when, in our opinion, such an approach is unnecessary. The implications of the approach, in terms of all phases of the problems of the elderly, are staggering.

I want to make it perfectly clear that we in Delaware do not feel that we have arrived at final solutions to the health problems of the aged. But we do feel that we, in common with many other States, are making definite and significant progress. It is our opinion that steps taken on the State level much more nearly fit the actual needs of the aged than do those proposed by H.R. 4700. It is the great weakness of the Forand bill that it completely ignores the area in which the elderly patient most needs help. The aged sick person most often needs long-term medical care. This bill offers relatively short-term surgical care. We cannot help but conclude that this approach shows as much concern for the dramatic appeal of the bill as for its actual usefulness, and that it has been conceived by persons who simply fail to understand geriatric medicine. We feel that State and local programs, administered by persons close to and intimately familiar with the problems of persons in their jurisdiction, can aid the elderly more efficiently, more intelligently, and with better use of available funds than could any Federal program designed for rigid application in all 50 States.

Respectfully yours,

ALFRED R. SHANDS, Jr., M.D., President.

THE MEDICAL SOCIETY OF THE DISTRICT OF COLUMBIA,

Washington, D.C., July 10, 1959.

Hon. LEO H. IRWIN,

Chief Counsel, Ways and Means Committee,
House of Representatives, Washington, D.C.

DEAR MR. IRWIN: At the request of the executive board of our medical society, I am conveying to you its views with respect to H.R. 4700, the so-called Forand bill.

The board, speaking for the society, supports the American Medical Association in its opposition to H.R. 4700. At the same time, the board is conscious of the urgent need for an adequate medical care program for the aging population.

Elaborating upon the latter point, the board is encouraged by the progress now being made by Blue Shield plans and commercial insurance companies which are providing greater protection against medical care costs for the aged at reduced rates. However, the cost of physicians' services is only one facet of the problem, the most serious being that of the costs of hospitalization and nursing home care.

Obviously, nonprofit voluntary prepayment hospitalization plans such as Blue Cross cannot reduce rates to subscribers unless there is a corresponding lowering of rates by hospitals. The hospitals, on the other hand, must maintain their present rates and perhaps increase them if they are to remain solvent. Obviously, there is no easy answer to this problem. The board, however, does not believe the Forand bill to be the best solution. It is of the opinion that voluntary

methods, even if supplementary funds are required, should be given a fair trail before the Government assumes the responsibility.

Our society naturally concerns itself primarily with the situation in the District of Columbia. Through its council on rehabilitation, with the assistance of Government funds, it is concluding a 3-year study of the handicapped in the metropolitan area. In this category is a sizable segment of the aged. Its committee on public health has long been concerned with raising the standards of care in nursing homes. The committee on medical care has developed a relative value unit scale (a guide for physicians in setting their fees) which it is planned will be used in developing a plus-65 prepayment program in cooperation with the District's Blue Shield plan, Medical Service of the District of Columbia. The society is also actively cooperating with and is well represented on the District Commissioners' Committee on Aging.

Assuring you of the society's deep interest in this urgent problem, I am

Very truly yours,

W. LEROY DUNN, M.D., President.

MEDICAL ASSOCIATION OF GEORGIA,

Atlanta, Ga., July 16, 1959.

Representative WILBUR D. MILLS,

Chairman, Ways and Means Committee,

U.S. House of Representatives, Washington, D.C.

DEAR CONGRESSIONAL MILLS: The Medical Association of Georgia, representing some 2,800 doctors of medicine in Georgia, is strongly opposed to the Forand bill (H.R. 4700) because it would authorize a federally subsidized and controlled system of hospital, surgical, nursing home, and dental care for approximately 14 million social security beneficiaries, irrespective of need.

The Forand bill would legislate the aged population into a state of dependency. This bill would stifle community responsibility and initiative and discourage the further advancement of voluntary medical and health programs.

In 1957, and again in 1958, the Medical Association of Georgia's 145 representative delegates unanimously adopted resolutions stating that this type of Federal legislation would be detrimental to the health needs and health care of Georgia's senior citizens.

In Georgia, the medical association, cooperating with other organizations and agencies, has initiated programs and plans to improve voluntary ways and means of health care of the aging. The four major health organizations in Georgia, namely, the Georgia Hospital Association, the Georgia Dental Association, the Georgia Association of Nursing Homes and the Medical Association of Georgia, have approved a positive action program under the auspices of the Georgia Joint Council To Improve the Health Care of the Aging.

The Georgia joint council, in liaison with State, county and local governmental agencies and interested civic groups, will participate in the Governor's commission on aging. This council, realizing its responsibilities, is making progress in assuring health care to the aged and in devising ways to meet economic problems of patients with prolonged illnesses.

The Medical Association of Georgia supports the tradition of local jurisdiction that the care of the sick and aged is a family problem; a local community problem; and in some aspects a State problem. The association believes that solution to the health needs of this segment of the population in Georgia can best be met and adequately provided for at these primary levels where patient care is a personal responsibility and duty.

In summary, the physicians of Georgia urge rejection of H.R. 4700 as this bill would ultimately destroy the very community incentive that can best provide for the needs of the aging. The medical profession in Georgia, along with other health care facilities and civic agencies, must be allowed to fulfill the responsibility of providing health care which H.R. 4700 would transfer to Federal Government.

Our association wishes to thank you and the other members of the House Ways and Means Committee for the consideration of our views presented herein. Sincerely,

LUTHER H. WOLFF, M.D., President.

STATEMENT OF THE IDAHO STATE MEDICAL ASSOCIATION, RE H.R. 4700, 86TH CONGRESS, BY DONALD WORDEN, M.D.

I am Donald Worden, M.D., of Lewiston, Idaho, immediate past president of the Idaho State Medical Association. I was one of the original group that founded our Idaho Physicians Service-a physician-sponsored medical and hospital prepayment plan-and have continued to serve in some capacity during its 14 years of service to the people of Idaho. I have also served as mayor of my town for 8 years.

My allotted time for a statement was finally reduced to 2 minutes, and I gladly withdrew so that a more complete statement could be made by someone else.

The Idaho State Medical Association vigorously opposes H.R. 4700 because they are confident that such a program would be prohibitive in cost, would lead to overcrowding of already overtaxed hospital facilities, would result in poor medical practice as a result of the inevitable regulations and restrictions inherent in any Federal program, and would be an invitation for demands for shifting personal responsibility to the Government by other segments of the population. Abuses of hospitalization are difficult to control even in a local program where close supervision is possible. They would present a greatly magnified problem without these local controls. Fourteen years' experience in this field gives this opinion a very solid foundation.

Aside from the enormous cost of overhospitalization is the factor of overtaxed facilities. The building of new hospitals would not be an answer, as the serious shortage of graduate nurses in our area would make it impossible to staff and operate them. This is probably the most serious problem that we have to face. Our prepayment plan extends coverage to people over 65 and this contract is noncancellable. In Idaho we do not believe that people without funds are denied needed medical or hospital care. I have practiced 34 years in eight hospitals and I have never had a patient refused hospital care because of inability to pay. We would oppose such a program if it were limited to hospital coverage because this is the area that would result in the most serious repercussions.

Demands for immediate action, if heeded, usually result in the poorest probable solution. Good government, as well as good medicine, usually results from gradual evolution toward a goal and we seriously petition our Representatives in Congress to give serious appraisal to the great advances made in the past few years by the medical profession and private insurance companies in this field. I would appreciate this statement being included in the record of these hearings.

STATEMENT OF THE INDIANA STATE MEDICAL ASSOCIATION, RE H.R. 4700, 86TH CONGRESS, BY DONALD E. WOOD, M.D.

I am Dr. Donald E. Wood, a practicing physician in Indianapolis, Ind. I am representing Dr. Kenneth L. Olson, of South Bend, Ind., president of the Indiana State Medical Association. I am here to file with your committee a statement on behalf of the 4,217 practicing physicians of Indiana who comprise the Indiana State Medical Association. This statement is intended to show that the provisions contained in H.R. 4700, known as the Forand bill, do not meet the need and are not necessary so far as Indiana is concerned.

The physicians of Indiana, in cooperation with many groups such as the State board of health, the Governor's Committee on the Aged and Aging, the State universities, professional and civic organizations, and local community committees, have had a deep interest in the problems of the aging for several years. Studies have been made and are currently underway in many communities throughout the State. Experimental pilot programs in various fields have been instituted and are in operation. We believe these programs already have evidenced the ability of Indiana people and communities to solve any and whatever problem exists in the group of individuals which H.R. 4700 is intended to benefit.

From our studies of H.R. 4700 as now written, and from our studies of the problem of the over 65 age group in our State, we do not believe the Forand bill intends to solve the problem, but serves only as a vote-getting mechanism, a means of increasing the social security taxes from which the public will gain little or no benefit.

For your information and your record, let us give you some statistics on Indiana so far as the aging problem is concerned: Estimated population as of

today of people in Indiana age 65 and over, 442,000. (Estimate by Indiana State Chamber of Commerce.) (1950 U.S. census, population age 65 and over, 361,026.)

Of the above number, we know the following:

Veterans of military service..

112,000

Protected by Blue Cross and Blue Shield_

105,000

Protected by private insurance carriers_-_

128, 331

Drawing pensions or retirement from private sources_

110, 510

Domiciled in mental institutions_.

3, 381

Drawing monthly social security benefits totaling $17,978,200 per month (as of Dec. 31, 1958) –

325, 583

Own their own homes. (Report, Indiana Commission on Aged, September 1957)

Average number of people receiving medical aid per month from the
Indiana State Department of Public Welfare..

30, 875

300, 560

In a study of nursing homes in Indiana, we have studied the homes in 44 of Indiana's 92 counties and to date we find the following facts concerning census and payments for care:

People 65 years of age and over reside in nursing homes.

Paid for by welfare__

Paid for by the township trustee.

Paid for by a combination of social security and welfare__.
Paid for by private organizations---
Paid for by the individual or family.

4,334

1,083

66

301

811

1, 951

The remainder of the nursing homes throughout Indiana will be studied within the next 2 weeks by personal visit by our staff. We will have a complete picture of the type of resident in our nursing homes and facts as to who is paying for their care. Indications in the approximately 50 percent of our counties are that the majority of the residents are able to provide for their own care.

We only regret that time has not permitted a complete census of our total population over 65. This plan is off the drawing board and, in a matter of weeks, a complete census of our 65-year population, their economic status and their needs will be collected by hundreds of volunteer workers throughout the State.

We firmly believe a thorough analysis must be made of every suggested problem and every recommended remedy. We are not convinced this has been done by those who are credited with supporting H.R. 4700. Instead, they appear to be making educated guesses based on hearsay and meager localized statistical information which has been projected as the true situation throughout the Nation.

Facts readily available to the Congress can prove conditions vary in every section of our Nation. It is proved there is a segment of our population which rejects hospital, surgical, and medical care for religious belief. It is proved a segment of our population does not believe in insurance and would not accept it if given or offered for as low as a dollar a year. None of these facts has apparently been taken into consideration in the formulation of this proposed legislation. No legislation can be offered which will solve the problems of all our citizens other than under a dictatorship type in which all could be forced to follow the will of the dictator. History is full of evidence showing that even this type of government has not solved all problems, but on the other hand, has created many, and eventually unrest always develops among the masses.

From our experience, we firmly believe the majority of our people want only a few basic benefits. They want to be free souls, they want the right to make their own decisions and to determine their own destinies *** they want the opportunity to work *** they desire the opportunity to occupy a place in gainful employment so long as they are able to produce and until they themselves decide to change their mode of living *** they want the opportunity to earn their income, to spend or save as they desire, without the Government's taking all their money except that which is necessary for a bare existence. No

man appreciates living a humdrum existence because high taxes leave him little or nothing with which to do the things he desires to accomplish.

Since 1939, the people of Indiana have witnessed an increase of 1,421 percent in Federal taxes levied on them in addition to an increase in State and local taxes amounting to 687 percent during this same period. Now, you are proposing to add again to the already too high tax burden, which will leave still less for family needs and wants.

The youth of today are beginning to calculate the amount of money which legislation such as this will take from them during the 45 years of their earning capacity and comparing the benefits with those they could provide for themselves from private investments and insurance programs with this same amount. A careful analysis will soon prove H.R. 4700 is no bargain for the people of our Nation.

We have mentioned previously that many people in Indiana are actively engaged in many different experimental or test programs and searches for facts and problems in order that the people and the community together can approach an intelligent solution to whatever problems they may find. We would like, as briefly as possible, to tell you of these programs.

THE ALLEN COUNTY STROKE PATENT PROJECT

Planned in 1958, the Visiting Nurses Association of Fort Wayne undertook the responsibility of administering this project. Financial assistance was obtained from the Indiana State Board of Health for the employment of extra personnel to carry on the project.

Fifty-three stroke patients have been admitted to the project since its beginning in January of 1959. Of these, six have been moved to nursing homes, one to a boarding home, one has moved from the city, four have expired, nine have progressed to the point where health guidance only is being given. Of the remaining 32, many are making spectacular improvement, many are making better use of their remaining functions and others are learning to live with their afflictions. Several patients who have had 6 months or more elapse since the occurrence of their stroke are making good progress *** beyond their hopes. This test program had as its purpose, "to demonstrate that the stroke patient can, with visiting nurse service and housekeeping aid, carry on a restorative program at home to the end that independent living will be achieved more rapidly for more patients."

The objectives of this test program were:

(a) To define the kinds of service that are needed in homes which are reasonable in cost and effort as they relate to the standard of living in each home.

(b) To determine the number, amount and level of patient care that is needed to reach and maintain restoration.

(c) To determine whether it is administratively feasible and practical for a voluntary nursing service agency to recruit, train and utilize "housekeeping aids."

(d) To determine the influence of housekeeping aid service in extending nursing care.

The objectives of this plan necessitated the following:

A. Orienting and initiating visiting nurse staff to integrate this plan into present program.

B. To evaluate current caseload of "stroke" patients as to specific services neded by patient.

C. To establish criteria for the selection of patients to receive housekeeping aid service.

1. Patient requires some daily exercise or practice of affected parts to promote the return of normal function of affected part. These exercises are of such a nature that nonprofessional assistance, when supervised, can be useful. There is no family member available or competent to do this service as often as it is required.

2. Patients who do not have the assistance that they require to maintain daily hygiene (bathing, mouth care, elimination care) are expected to be only temporary patients and that either family or community agents will obtain permanent care.

3. Patients similar to those described in 2, above, who need assistance with nutrition and food services.