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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 headquarters at 1790 Broadway, New York, N.Y. The American Public Health Association with its 48 affiliates in 41 States has approximately 25,000 members representing 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 "Resolved, 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 which 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 individuals?

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 knowledge 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 estab lished 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 department 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

through additional support for recruitment and training. Coordinated programs making available all these preventive and ancillary as well as medical services at the State level should be devised with proper precautions to assure high standards of quality. These steps, in addition to the continued extension of prepaid medical and hospital insurance, will be needed to improve the health situation of the elderly.

STATEMENT OF THE NATIONAL ASSOCIATION OF MANUFACTURERS WITH RESPECT TO H.R. 4700 AND SIMILAR BILLS

The National Association of Manufacturers wishes to record its opposition to H.R. 4700 for the following reasons:

Protection for the aged against the cost of medical care should be provided by individual initiative. This protection should be obtained either through such instrumentalities as the insurance industry or the various service organizations or provided by the individual or his family through savings or other means of private initiative.

The Federal Government should not enter this field in any way. Such entry would be unnecessary and unwarranted. Further, such an action would impede or halt the very real progress now being made through voluntary methods.

American industry has already done much and will continue to provide such coverage. It will encourage the full development of voluntary efforts to the end that all individuals have available the opportunity to obtain such voluntary coverage.

Since it is recognized that no normal protection program can meet all situations, assistance on a needs basis through State and local programs should be continued.

The National Association of Manufacturers further believes that the basic "Reasons Advanced as to Why the Federal Government Should Not Take Action," expressed on pages 1, 2, and 3 of the report submitted to the Committee on Ways and Means by the Secretary of Health, Education, and Welfare on April 3, 1959, are valid and persuasive and should be accepted.

PROVIDENCE, R.I., July 15, 1959.

Hon. WILBUR D. MILLS,

Chairman, Committee on Ways and Means,
House Office Building, Washington, D.C.

DEAR SIR: Associated Industries of Rhode Island, Inc., wishes to record its opposition to H.R. 4700, the bill introduced by Representative Forand which would amend the Social Security Act to provide for the Federal purchase of certain health-care services for social security recipients. The bill provides for compulsory hospital insurance for the persons collecting social security benefits and would be financed by the imposition of additional social security taxes on employers, employees, and the self-employed. It provides for an additional payroll deduction and is therefore inflationary in its effect, since it would inevitably result in demands for higher wages. Our older citizens are the ones who suffer greatly from inflation. Congress can best aid them by halting inflation which limits their access to the medical care and facilities which they may need.

We submit that the bill is the first step toward socialized medicine. In addition, there are now pending in Congress several bills for a complete socialized medicine program under which a national payroll tax would be levied and a system somewhat similar to that in England would be set up. The experience in England has not been good and it would be a mistake to set up a similar system here which would virtually destroy the remarkably successful voluntary health plans.

Great progress has been made in voluntary hospitalization insurance. In the State of Rhode Island 70 percent of the people over age 65 are members of the Blue Cross and 50 percent of them are covered by physicians service. What has been done in Rhode Island can be done in other States. Health need costs should be handled at the local State level.

We urge you most strongly to defeat the proposed legislation.

Very truly yours,

ASSOCIATED INDUSTRIES OF RHODE
ISLAND, INC.

By FRANK S. SHY.

STATEMENT BY WALDEN P. HOBBS ON BEHALF OF THE NATIONAL RETAIL MERCHANTS ASSOCIATION REGARDING H.R. 4700 AND RELATED BILLS TO ENLARGE THE SOCIAL SECURITY PROGRAM BEFORE THE HOUSE WAYS AND MEANS COMMITTEE, JULY 20, 1959

INTRODUCTION

My name is Walden P. Hobbs. I am the chairman of the social security committee of the National Retail Merchants Association with offices at 100 West 31st Street, New York, N.Y.

The National Retail Merchants Association has a membership of over 11,500 department, specialty, and chainstores located in every State of the Union and many countries abroad. Its members provide empolyment for several hundred thousand of our citizens and do an annual volume of business exceeding $19 billion.

SOCIAL SECURITY: ITS PURPOSES AND PRINCIPLES

Before addressing ourselves to the legislative proposals now before your committee, to amend the Social Security Act, it appears appropriate to review the basic purposes and principles of the American social security program.

The overriding purpose of social security is to provide a means by which a person may be assured a minimum amount of income to support himself when unable to work because of old age. The American people through their elected representatives have deemed it to be in the national interest to protect our society from the adverse consequences--social, economic, and political of large numbers of our senior citizens being without means of support in their declining years through a program of social insurance.

The social security program, however, as originally conceived, was not to be administered, insofar as benefits were concerned, on a "needs" basis. On the contrary, benefits were to be related, at least to some degree, upon a past record of average monthly earnings. In addition, standards of eligibility were established for all persons which were to be met before an individual became entitled to receive benefits.

Another basic principle of the American social security program is that the system should be financed on a pay-as-you-go basis. Congress provided that benefits would be payable from a special trust fund to be established through the medium of payroll taxes levied (1) equally on employees and their employers, (2) on the income of self-employed persons, and (3) through interest earned on the trust fund. This fund, it was envisaged, would be sufficient to meet all benefits being paid currently so that over the long run receipts from payroll taxes plus interest would match the benefits payable.

WHAT H.R. 4700 PROVIDES

H.R. 4700 and related bills are entirely unique in the area of social security in that they go far beyond the usual provisions for increasing old-age benefits or broadening eligibility under OASI. Simply stated, under H.R. 4700, the social security trust funds are to be made available for the payment of hospitalization expenses incurred by anyone eligible for social security benefits, whether or not such benefits are actually received. The pertinent provisions of H.R. 4700 are as follows:

1. Hospitalization benefits would be available to men at age 65, to women at 62, as well as survivors of persons covered under the Social Security Act.

2. The social security fund would be available to pay hospital services for persons eligible up to 60 days in any one year. The term "hospital service" includes such services as are usually furnished in semiprivate rooms and includes bed and board, ambulances, operating room, drugs, etc. In addition to hospitalization services, nursing home care incident to hospitalization would be provided up to 120 days per year (less any time spent in a hospital during such year for which payment has been received).

3. The patient may choose his own hospital or nursing home, provided the institution enters into an appropriate agreement with the Government.

4. The Government may not exercise any supervision or control over the administration of any hospital which enters into any such agreement with the Government.

5. Social security taxes for both employees and employers would be increased about 8 percent.

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