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RESOLUTION

Whereas the Ways and Means Committee of the House of Representatives of the Congress of the United States is currently holding hearings on H.R. 4700, the Forand bill which proposes to pay for hospital, nursing, and surgical expenses incurred by the recipients of the old-age and survivors insurance programs; and

Whereas this measure is inflationary in nature and will require an increase in social security payments on the part of the American public, including the employer; and

Whereas the President of the United States, in his address to the house of delegates of the American Medical Association in Atlantic City, in June 1959, called upon the physician members of the association, of which this society is a constituent, to assist in halting inflation by accepting lower fees for professional services rendered to the Nation's older citizens; and

Whereas this society does not believe it advisable to accept lower fees if, in turn, the Congress of the United States, through passage of the Forand bill de mands more money from the physician employer for the expansion of the society security program benefits; and

Whereas more importantly, medical care for our Nation's older citizens necessitates flexibility of medical approach and technique which do not appear possible in the proposed Forand program; and

Whereas a nationalized program of this magnitude would weaken the doctor. patient relationship: Therefore be it

Resolved, That the executive committee of the Dauphin County Medical Society does hereby go on record recommending that the committee does not take favorable action on H.R. 4700 or any other similar legislation.

U.S. SENATE,
COMMITTEE ON LABOR AND PUBLIC WELFARE,

July 29, 1959.
Hon. WILBUR D. MILLS,
Chairman, Ways and Means Committee,
House of Representatives,
Washington, D.C.

DEAR MR. CHAIRMAN: There is enclosed a copy of a self-explanatory telegram in opposition to the Forand bill, H.R. 4700, from Dr. William R. McCune, Martinsburg, W. Va., in behalf of the 40 members of the Eastern Panhandle Medical Society.

I shall appreciate it very much if you will give consideration to Dr. McCune and the other members of the medical society and make the telegram a part of your official records on this legislation. With kind regards, I am Sincerely,

JENNINGS RANDOLPH.

MARTINSBURG, W. Va., July 28, 1959. Senator JENNINGS RANDOLPH, Senate Office Building, Washington, D..C.:

We the 40 members of the Eastern Panhandle Medical Society wish to voice our opposition to the Forand measure (H.R. 4700).

Dr. WILLIAM R. McCune, President, Eastern Panhandle Medical Society.

ARIZONA STATE DENTAL ASSOCIATION,

Phoenix, Ariz., July 17, 1959. Hon. WILBUR D. MILLS, Chairman, House Committee on Ways and Means, House of Representatives, Washington, D.C.

DEAR SIR: On behalf of the 350 members of the Arizona State Dental Association, we wish to go on record as being opposed to H.R. 4700, the Forand bill.

May we ask that you insert this letter in the printed record of the hearings on this bill. Thanks kindly for your cooperation in this matter. Yours very truly,

WILLIAM G. BURKE, D.D.S., Secretary.

CALIFORNIA STATE DENTAL ASSOCIATION,

San Francisco, Calif., July 13, 1959. WILBUR D. MILLS, Chairman, House Committee on Ways and Means, House Office Building, Washington, D.C.

DEAR CONGRESSMAN MILLS: This association, by vote of its board of directors and of its house of delegates, is opposed to H.R. 4700, the so-called Forand bill. It is believed that health-care problems of the aged can be met without resort to the type plan provided in H.R. 4700.

We urge you and other members of the House Ways and Means Committee to vote in opposition to H.R. 4700. We also request that this association's opposition be recorded in the official transcript of the committee's hearing. Very truly yours,

G. THOMAS QUIGG, D.D.S., President.

TAMPA, FLA., July 14, 1959. Hon. WILBUR D. MILLS, Chairman, House Committee on Ways and Means, House of Representatives, Washington, D.C.:

This society, a component of the Florida State Dental Society, is vitally opposed to H.R. 4700. A bill that could lead eventually to Government-sponsored health care for the general population, and requests you and your committee note this opposition in the written record of hearings on July 15.

F. A. FINLEY, President, West Coast District Dental Society, St. Petersburg, Fla.

NEW ORLEANS, LA., July 14, 1959. Hon. WILBUR D. MILLS, Chairman, House Committee on Ways and Means, House of Representatives, Washington, D.O.:

Our association strongly opposes bill H.R. 4700 before your committee. Urgently request for and on behalf of membership that this legislation be unfavorably reported. Further respectfully ask that this request be noted in the written record of the committee hearings.

STANLEY S. LEVY, D.D.S., President, Louisiana Dental Association.

VIRGINIA STATE DENTAL ASSOCIATION,

Roanoke, Va., July 31, 1959. Hon. WILBUR D. MILLS, Chairman, Committee on Ways and Means, House of Representatives, Washington, D.O.

DEAR SIR: The Virginia State Dental Association wishes to register its opposition to H.R. 4700, the Forand bill.

It is felt, by our association, that the enactment of this bill into law would increase the burden of the Federal Government and ultimately lead to Government-sponsored health care for the general population.

Further, the benefits received under H.R. 4700 should rightly be the responsibility of local or State health agencies.

Your careful consideration of our views concerning this bill will be greatly appreciated. Respectfully yours,

MYRON E. HENDERSON, D.M.D.,

Secretary-Treasurer.

TESTIMONY BY BERWYN F. MATTISON, M.D., EXECUTIVE DIRECTOR, AMERICAN

PUBLIC HEALTH ASSOCIATION, BEFORE THE HOUSE COMMITTEE ON WAYS AND MEANS, H.R. 4700, JULY 1959

This is a statement having to do with the need for increased medical and health services for the aged, being submitted by the American Public Health Association, a professional association for public health workers with headquar. ters at 1790 Broadway, New York, N.Y. The American Public Health Association with its 48 affiliates in 41 States has approximately 25,000 members repre senting substantially all of the public health leadership in this country. It is the largest such organization, with its affiliates, in the world.

STATEMENT OF NEED

Without burdening the committee with statistics which have been quoted many times, it is obvious that our aging population will experience increasingly greater numbers of cases of chronic illness during the decade just ahead. The financial burden of providing proper medical care to this growing segment of our population will be great indeed; but the unrealized potential of experienced workmanship, wise counsel, additional manpower, and increased national income which will be the result of the provision of such medical and health services is equally great. It is this vast storehouse of largely wasted potential amongst our elder citizens which makes the solution of the problem particularly urgent. Rather than regarding our senior citizens simply as a "problem," we are beginning to see that much of the cost of preventing unnecessary disability and premature death in that group will be returnable through increased national output and dollar values, as well as the human values which concern us all.

METHODS OF SUPPLYING CARE

Most of the emphasis to date has been on ways in which additional institutional care might be provided for the elderly. Much concern has been exhibited over the need for more nursing homes and convalescent or chronic disease hospitals. Actually there are two major stages which should precede that of provision of institutional care for the chronically ill : First, a great deal can be done to prevent many of the chronic diseases and disabilities; and second, much more can be done to make readily available a greater range of services (both medical and paramedical), at work and at home, which would diminish the number of elderly people requiring institutional care or at least delay that need for many years.

With regard to financing health services for the aged, the American Public Health Association, at its 86th annual meeting in St. Louis in October of 1958, considered the matter in its governing council and passed the following resolution:

"Whereas health services for the aged are inadequate throughout the Nation; and

"Whereas good health care is becoming more expensive to provide for the aged because of their high illness and disability rates, the increasing complexity and rising costs of good care, the growing number of aged persons, and their relatively small personal financial resources; and

"Whereas adequate financing is essential to support comprehensive health care of high quality for the aged; and

"Whereas the burden of the costs of good care for the aged can be minimized for the aged, their families, contributors to voluntary insurance plans, charitable agencies and taxpayers through arrangements, effective throughout the working lifetime, which provide paid-up insurance for the older years: Therefore be it

"Resowed, That the American Public Health Association support appropriate proposals to provide paid-up insurance for health services required by aged persons, which insurance financing should be accompanied by provisions to protect and encourage high-quality care, and be it further

"Resolved, That the American Public Health Association support appropriate Federal, State, and local efforts to improve the financing and adequacy of health services for needy and medically needy aged persons through the supplementary public assistance programs and through other means such as medical care programs administered by health departments, and for all aged persons through public health and related programs."

It should be pointed out that the governing council of the association did not accept the extension of suport from any one particular source as the solution of this complex and growing problem.

It should also be pointed out that planning and organization to provide not just medical care but preventive services and the auxiliary or paramedical services was thought to be vitally necessary. Some of the specific ways in which public health and related agencies can help improve the health care of the aged would include: Early diagnosis, possibly through broadening the present screening programs and encouraging the increased use of preventive technics by the medical practitioner; and home care through a systematic provision of supervised health services for the homebound (e.g., nursing services, social services, restorative services, homemaker and housekeeper services). Insurance carriers have indicated that a preliminary step, necessary for them to extend benefits, is the development of an organizational structure to facilitate the administrative of claims and to protect the financing of the plans against false claims under the use of these services. Physical therapy, nutrition services, and occupational therapy are other segments of this complex galaxy of aids to prevent premature institutionalizing of elderly patients with some chronic disease.

MOBILIZING WHAT WE HAVE

Much can be done with medical and health facilities already available, providing we have the necessary coordination and systematic planning for its use. Emphasizing one important phase of the need, in providing such services, Dr. Leona Baumgartner, president of the American Public Health Association, has recently emphasized the importance of assuring high quality services:

"While we in the American Public Health Association well realize that economic security and health are closely related * * * our competence is, of course, confined to health matters, and we are chiefly concerned with those provisions of the social security titles which deal with medical care for public-assistance recipients and for the medically indigent.

"Accumulating experience with these programs reveals some serious deficiencies and problems wh are of concern to all the States. It is becoming apparent that, in the absence of any mechanism requiring the localities to establish standards of quality or to put a premium on medical excellence, the average quality of care provided over the country is not as good as it could be. Moreover, the size and scope of these programs offer many opportunities to provide better medical care through more rational organization of services. These opportunities are being neglected. The accumulating experience which reveals these problems also provides the technology and the skill to deal with them constructively."

A number of States are currently experimenting with closer working relationships between their welfare department medical care programs and their health department preventive services. In that way they are focusing many of the presently splintered elements of medical care on the individual patient with consequent improved prognosis for the patient.

The effect of "splinteration" of health and medical services in the past has been unfortunate. For instance, even in those communities with excellent school health services, the data accumulated during the young person's school years are infrequently, if ever, made available to his employers or their occupational health program when he leaves school and goes to work. Furthermore, a child receiving services under the crippled children's program is likely to find himself cut off from continuing service when he comes of age, unless he happens to be potentially employable and therefore eligible for a shift to an entirely different program, that of vocational rehabilitation. Similarly, the special services in nursing homes and chronic disease hospitals serving elderly people have rarely had available to them information accumulated through the years by occupational health programs at the place of employment of the individual. Most adults over a period of years are now receiving some services from the health department, from their school system, from the Veterans' Administration and perhaps from welfare or other governmental agencies. This frequently leads to waste and inefficiency. There should be a continuity of preventive, therapeutic, and restorative care, not necessarily carried out by one agency but certainly utilizing the available skills in every community as well as the previous experience of each agency with the individual.

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TRAINING OF PERSONNEL

Another area of needed development is the training of ancillary health personnel in the care of the chronically ill patient. Much of this training can probably be achieved on an on-the-job basis. Professional schools can provide short course training for presently employed health personnel.

We need new methods for recruitment and training of ancillary health personnel, and we need to develop incentives of job satisfaction to reduce turnover. The Commission on Chronic Illness, of which the American Public Health Association was one of the sponsors, has already outlined many of the changes in training programs required to gain effective health workers for services to the chronically ill and aged. Recommendations of this commission need to be implemented.

SUMMARY Community studies have shown a number of gaps and shortcomings in the present utilization of medical and related services. Among them are the following:

1. Preoccupation with institutional care in spite of the fact that in some areas as many as 90 percent of long-term patients are at home;

2. Scarcity of services for patients at home; 3. Need to convert a number of institutions (such as communicable disease or tuberculosis hospitals) which are currently underused to meet the needs of the chronically ill;

4. Rehabilitation or restorative services are frequently missing from both hospitals and communities;

5. There is a lack of working relationship between general hospitals and nursing homes and homes for the aged ;

6. There is a particularly inadequate supply of certain personnel, especially psychiatrists, physiatrists, psychologists, public health nurses, physical and occupational therapists, medical and psychiatric social workers and homemakers.

7. Many long-term patients are from the lower economic groups indicating the necessity for some kind of increased prepayment based service.

The American Public Health Association and public health agencies throughout the country have five basic immediate interests in medical care and can contribute skills and experiences to answering the following questions in each of these areas:

1. How much medical care is actually being received as compared with standards of quantity, particularly by groups at special risk?

2. To what extent does the medical care meet desirable standards of quality?

3. What is the effectiveness of the specific medical services rendered to individ. uals?

4. What is the communitywide effect of the medical care?

5. Is vigorous research being performed to discover the basis for deficiencies in the quantity, quality, and effectiveness of medical service to individuals and on a communitywide basis, and to determine the promptness with which new knowl. edge is applied for human betterment?

Traditionally public health agencies have sought to fulfill such obligations by clarifying the nature and magnitude of health problems, by bringing the resources of the community to bear in such problems, by maintaining standards through regulations, by demonstration, education, and evaluation, and by providing actual care when it is not otherwise available to the individual. Health departments should be the agencies of government for planning, developing, and administering programs for medical care. This is logical and appropriate because of established relationships with the health professions and because of medically trained personnel on their staffs. Whether or not a health department assumes responsibility for the administration of such programs should be left to the discretion of each State or local government. There should be option as to whether the health depa ent undertakes the various programs in the field of medical care but under any circumstances there should be an overall plan for a coordinated program of avoiding duplication, overlapping, and gaps in the continuity of the program regardless of which agency assumes the major responsibility.

CONCLUSION

There is an urgent need to better utilize what is already available. The Department of Health, Education, and Welfare should take leadership in assuring integration of State programs for public health with programs for providing care for the medically indigent. Additional paramedical services should be developed

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