Senator NEUBERGER. I wish you would comment on a passage in your prepared statement. You refer to Blue Shield and that is what made me think of this.

It must not be forgotten that in most instances a well-taken history and physical examination by a physician plus several well-chosen procedures can elaborate the basic disease process, and a complete screening is neither necessary nor warranted.

In other words, you are talking about physical examination or clinical testing instead of health screening. What you say is that it is preferable to screening; is that it?

Dr. RAPPOPORT. Well, I think we have to put it in the proper framework. If we are examining an ostensibly normal population, then obviously we are talking about a screening, we are searching for possible occult hidden disease. In this case, of course, we have to use the most subjective procedures that we can possibly devise in order to clarify whether or not there is an abnormality, a biochemical procedure, immunizing procedure.

The patient says, "I feel well," but the test says something is going wrong before it becomes clinically manifest. Obviously the subtlety of the disease is matched only by the subtleties you use to find it. You must expect to exert more effort to clarify that.

For the person, however, who has a hernia, it requires no great sophistication to find out that a person has a hernia. Should we balance off, you see? Let's take the patient with hernia. Look at the hernia, see the hernia and let it go at that, so that we can utilize some of the subtlety or sophistication or talent for those cases which need that degree of sophistication.

As an attorney you can look at the problem and it is immediately there. You don't have to write a 50-page brief. Maybe you do, I don't know. The point I make is, let's balance the effort for the results we gain, and when it is very difficult to elucidate, then we turn the whole gamut of our diagnostic procedure off. Let's not say "wait"— that same effort, for obviously clearly definable and regularly recognizable situations. There are adjustments as to the expendituresSenator NEUBERGER. I am sorry. We will have to curtail this, we are running into the next witness' time. I believe Senator Williams wanted to know this.

I believe the question he wanted to ask you: Where does pathology come in with the hearing test given in the mobile unit-glaucoma, et cetera ?

Dr. RAPPOPORT. I think, Senator Neuberger, no hospital pathologist is-and I will not belabor the point. There were lots of diseases here which the laboratory in a conventional sense is already involved, diabetes, anemia, chest X-ray, tuberculosis. We are involved in practically everything there, and if there is something wrong, it will be up to some pathologist to find out why.

I think we will have to agree, at least we have always thought that the pathologist is always the hub of the diagnostician in medicine. That is a balanced diagnostic study, but we are talking about pathology, laboratory, clinical pathology, laboratory techniques, and we are talking of the best way to achieve the mostest of what we have. It is not blue sky and we have to spend our waking hours and know-how and people in the best way possible.

Senator NEUBERGER. Thank you very much. We enjoyed having this discussion. We have had the medical school, sociologists, clergy, and we certainly consider the pathologist an important part of this. We welcome your appearance here and I do hope I get up to your exhibit. I am counting on going.

Dr. RAPPOPORT. Thank you.

Senator NEUBERGER. I now welcome Mrs. Dorothy P. Rice who will be our last witness in this afternoon's session. She is a medical economist, Acting Chief of the Special Studies Branch in the Division of Health Insurance Studies in the Office of Research and Statistics in the Social Security Administration.

We are glad to have you, Mrs. Rice, and we are looking forward to hearing your statement.

STATEMENT OF DOROTHY P. RICE, MEDICAL ECONOMIST, SOCIAL

SECURITY ADMINISTRATION

Mrs. RICE. Thank you, Senator.

I am happy to have this opportunity to appear before the Subcommittee on Health of the Elderly to discuss the cost of chronic illness and its impact on the economy. In this statement, I will present data on the annual expenditures for medical care of chronic disorders affecting almost half of our total population and more than 7 out of 10 persons aged 45 years and over. In addition to discussing their annual direct expenditures for medical care, I will cover the indirect costs or the value of the losses in output to the economy resulting from ehronic illnesses.

I propose to cover most of the material that I have included in the prepared statement and because it contains quite a few figures, I would like to hold closely to it although I will not necessarily read all of it. Medical advances in the prevention and control of formerly fatally infectious diseases such as pneumonia, typhoid fever, and tuberculosis have made it possible for an increasing number of Americans to reach an age at which they become more vulnerable to arthritis, rheumatism, heart disease, cancer, and other chronic illnesses. As a result, chronic diseases causing limited or total disability now constitute a major health problem.

An estimated 87 million persons, or almost half of the civilian noninstitutional population, reported one or more chronic conditions for the 12-month period ending June 1965.

I have also prepared several tables and they are appended to the statement and you may want to refer to them.

Senator NEUBERGER. They will be included in the record.

(The information referred to follows:)

LISTING OF MAJOR DIAGNOSTIC CATEGORIES AND SELECTED SUBCLASSIFICATIONS

Tuberculosis.

Neoplasms.

CHRONIC CONDITIONS

Allergic, endocrine, metabolic, and nutritional diseases:

Allergic disorders.

Disease of thyroid gland.

Diabetes mellitus.

Diseases of other endocrine glands.

Avitaminoses and other metabolic diseases.

Diseases of blood and blood-forming organs :

Anemia.
Hemophilia.

Diseases of spleen.

Mental, psychoneurotic, and personality disorders.

Diseases of the nervous system and sense organs:

Vascular lesions affecting central nervous system (stroke).
Inflammatory and other diseases of central nervous system.
Diseases of nerves and peripheral ganglia.
Inflammatory and other diseases of eye.
Diseases of ear and mastoid process.

Diseases of the circulatory system:

Rheumatic fever and rheumatic heart disease.
Arteriosclerotic and other diseases of the heart.

Hypertension.

Diseases of arteries.

Diseases of veins and other diseases of circulatory system. Diseases of the genitourinary system:

Nephritis and nephrosis.

Other diseases of urinary system.
Diseases of male genital organs.

Diseases of female genital organs.

Diseases of bones and organs of movement:

Arthritis and rheumatism.

Osteomyelitis and other diseases of bone and joint.
Other diseases of musculoskeletal system.

Congenital malformations:

Monstrosity.

Congenital malformations of circulatory system.
Cleft palate and harelip.

Symptoms, senility and ill-defined conditions:
Symptoms referable to symptoms or organs.
Senility and ill-defined conditions.

ACUTE CONDITIONS

Infective and parasitic diseases:

Venereal diseases.

Diseases attributable to viruses.

Typhus and other rickettsial diseases.
Malaria.

Diseases of the respiratory system:

Acute upper respiratory infections.

Influenza.

Pneumonia.

Bronchitis, acute and chronic.

Other diseases of respiratory system.

Diseases of the digestive system:

Diseases of buccal cavity and esophagus (dental conditions).
Diseases of stomach and duodenum.

Appendicitis.

Hernia of abdominal cavity.

Diseases of liver, gallbladder and pancreas.

Pregnancy, childbirth, puerperium (maternity).

Diseases of skin and cellular tissue.

Certain diseases of early infancy:

Birth injuries, asphyxia, and infections of newborn.

Other diseases peculiar to early infancy.

Injuries and adverse effects of chemical and other external causes.

TABLE 1.—Number and percent of persons with 1 or more chronic conditions, by sex and age, July 1964-June 1965

Source: U.S. Department of Health, Education, and Welfare, Public Health Service, "Current Estimates From the Health Interview Survey, United States, July 1964-June 1965," Public Health Service Publication No. 100, series 10, No. 25.

TABLE 2.-National health expenditures: Amount and distribution, by object of

expenditure, 1963

1 May include some expenditures for personal services, such as immunization programs.

Source: U.S. Department of Health, Education, and Welfare, Social Security Administration, Research and Statistics Note No. 10-1965. "National Expenditures for Health Care Purposes by Object of Expenditures and Source of Funds, 1960-63."

TABLE 3.-National health expenditures-Selected categories: Estimated amount for chronic and acute conditions, by diagnosis and object of

expenditure, 1963

Acute conditions, total.