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problems, who repeatedly urged the son with whom she lived to accept part of her own limited income for household expenses. The son neither wanted nor needed the money, but finally agreed. It was not at all important to him. But it was important to her. She felt she had regained her self-respect. Her health improved accordingly.

We believe it is society's responsibility to assist older people in their desire to be treated as individuals, each with different physical chemistry, different hopes, different needs. For the 15 million persons we are talking about are alike in only one way; they are all 65 years of age or older. They are not a homogeneous group. They have no uniform list of wants that can be met by some convenient all-encompassing master plan. They are individuals and we must always remember it.

Moreover, we believe it is society's responsibility to encourage our elder citizens in their desire to be useful. Actually, this is more than a desire; it is a right. The right to be useful should be just as inalienable as the right to dissent or any other right.

Somewhere, someone, sometime once decided that 65 was old. It was as unsound a judgment as it was arbitrary. But once uttered, it was the first step to the conclusion that 65 was too old; and the idea spread. Today it is widespread. As ridiculous as it seems, numberless Americans now believe that 65 candles on the birthday cake disqualify a man for anything better than babysitting, whittling, or sleeping in the sun.

This is shockingly evident in the field of employment, where a man's right to be useful is frequently abridged by compulsory retirement policies. Many of the same firms that hire so carefully, taking into account the individual's training, skills, attitudes, and potentials, find nothing inconsistent in the retirement of a valuable employee by a chronological rule of thumb.

This is a case were nobody wins, neither the employer nor the worker compelled to retire. For most of our older people want to work and need to work. And good employees are not that easy to find.

Personnel policies should be flexible enough to take this into account and use the yardstick of ability instead of the yardstick of age. Again, it may not seem that the matter of compulsory retirement has much to do with health. But I can assure you, as a physician, that it does. I have seen this happen time and time again:

A man who has spent a quarter of his life learning to become independent, and a half of his life being independent, is suddenly cut off from his work. Suddenly he has been denied the right to be useful.

Unprepared for the sudden change in status, he finds himself at loose ends, burdened by a leisure he has not learned how to use. All at once he notices a subtle change in the attitude of his family, of his friends, of his community. For he is no longer the breadwinner. He has become overnight a man who no longer works for his living, a man whose time hangs heavily on his hands, a man whose stature has mysteriously diminished.

To compensate for that which he has lost he often develops aches and pains. And whether some of them are imaginary or not he suffers just the same. We must, therefore, think of the medical challenge as only a segment of the total challenge.

While the physician practices preventive medicine and seeks to forestall the disabling illness which can cripple an older person, society can also take the necessary steps to meet other existing needs that are just as important. Society must, through education, prepare people for retirement and old age. It must think in terms of the older person's many other requirements, whether they bein housing, recreation, or community understanding. Until society recognizes this fact, we will be taking a piecemeal, hit-or-miss approach to a problem that demands a broad-spectrum solution.

Let me point out that in much of the world there is no challenge posed by a large number of old people. In much of the world they just do not get old. They die young,

Thank God we in America have the "problem" of 15 million Americans who constitute one of our greatest assets. And thank God an increasing number of persons and groups have accepted the challenge and are beginning to meet it.

The medical profession and many others who work in the field of health is proud of having increased the life span of the average American. This increase in years has been accompanied by a rise in health levels for all ages, including those over 65.

Clearly, it is the responsibility of all our citizens to work together to insure that the lives we have helped proiong are as satisfactory in their later years as they were in youth.

I promise you, gentlemen, that the American doctor will do his part and more. But the answers that must be found, the solutions that must be reached, involve every segment of our population; every profession, occupation, industry, labor organization, religious denomination, civic group, community, and most important of all, family unit.

All must share the common responsibility.

I am proud that the solutions are being found, that real progress is now being made through the cooperative efforts of private citizens. Working voluntarily, they are proving their ability to do the job in their own communities, and do it effectively and well. A few specifics from their record of accomplishment are appended to this testimony.

The medical profession has continued in its role of providing leadership and support to the overall voluntary effort.

At this time it is enough to say that retirement villages, new nursing homes, chronic disease care centers, home care programs, recreational facilities, and research projects are being set up from coast to coast in substantial number. Further, many, many more are on the way.

Our State and local medical associations have moved promptly to make the American Medical Association's six point program, which I discussed with this subcommittee in June, an effective and workable instrument.

The medical needs of the aged involve the chronic illnesses and the so-called degenerative diseases. In a large percentage of cases, the main need is not for an expensive hospital stay or a surgical operation, but for medical care at home or in the doctor's office. In other cases, the important requirement is nursing care in the patient's home, or the home of relatives. And in still others, custodial care in a nursing home or public facility may be the only answer.

The point is that the medical needs of this particular segment of the population are subject to countless variations.

Whenever possible, we try to keep our older patients out of institutions and functioning in society. This has been particularly true in two research projects in the field of mental health where the number of people sent to mental institutions have been reduced to 1 of 12 by the mere use of out-patient dispensary work. Our object is to help them lead lives as normal as possible which will minimize their dependency. This means that we want them to have easy access to medical and hospital services, adequate and suitable housing, specialized and personal services, and sources of rehabilitation where needed. We are working to reduce the cost of services, which calls for new and improved facilities specially tailored to the particular requirements of the older citizen.

The American Medical Association has therefore supported a Government-insured loan program of the FHA type for nongovernmental hospitals and nursing homes whether it be of a nonprofit or proprietary nature. It has recommended changes in the Hill-Burton Act to help the individual States earmark more for nonprofit nursing homes. The American Medical Association continues to back further experiments with progressive hospital care, home care programs, and homemaker services, all of which have the common purpose of reducing the length of hospital and nursing home confinement by allowing the earlier discharge of patients.

To encourage the trend to private health insurance, the American Medical Association House of Delegates adopted a proposal which applies specifically to those over 65 with modest resources or low family income. In this proposal, the American Medical Association urged physicians to set their fees at a level which will permit the development of insurance and prepayment plans at a reduced rate. The reaction by State and local medical associations, has been heartening.

I am happy to report that there are now 25 plans in 23 States in which Blue Shield plans enroll those over 65, and all Blue Shield plans now permit persons over 65 to continue their coverage. Further, in almost every other State in the country, our medical societies, in cooperation with the plans they sponsor, are working out programs of a similar nature.

We believe the solutions we seek are to be found in private and voluntary action at the community level, and in private health insurance and prepayment plans which have made revolutionary progress since World War II and are still increasing their gains. At the end of 1945, only 32 million people were carried under such voluntary plans. But by the end of 1958, the number had soared to 123 million.

This is important, for it indicates that prepayment plans and the health insurance industry, by providing more and expanded health coverage for all age groups, are anticipating and solving tomorrow's health care financing problem.

Each year more and more of the Americans who are reaching 65 are covered. The problem of financing health services for the aged is therefore a temporary not a permanent one.

Dozens of different type policies are now available. Among them are policies guaranteed renewable for life, policies to cover those over

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65, coverages that will continue after retirement, and group policies that may be converted to individual coverage upon termination of employment.

According to the Health Insurance Association of America, 60 percent of our senior citizens who need and want health insurance will have protection by the end of next year. Further, that percentage will increase until three-quarters will be covered in 1965, and 90 percent in 1970.

In other words, the problem of financing the health care of our older people is being met by private insurance and prepayment plans; and the particular hospital and medical needs of the aged are being met by voluntary effort by private citizens at the community level. The health professions and the communities are doing the job, a job they know and understand.

Dr. Michael M. Dasco, director of physical medicine and rehabilitation at New York's Goldwater Memorial Hospital, recently expressed in Life magazine an opinion with which I thoroughly agree. He said: In our society, the responsibility for taking care of the old person rests primarily with his family. If the family cannot fulfill this responsibility, then it passes to the community, then to the State.

Only as a last resort should the Federal Government step in.

A sage but unknown author, and I suspect not a young author at the time, summed up most effectively the point that age is relative when he wrote:

Youth is not a time of life. It is a state of mind. It is a temper of the will-a quality of the imagination—a vigor of the emotions. Nobody grows old by merely living a number of years. People grow old only by deserting their ideals.

Years wrinkle the skin, but to give up enthusiasm wrinkles the soul.

Worry, doubt, self-distrust, fear, and despair-these are the long, long years that bow the heart and turn the greening spirit back to dust. Whether 60 or 16, there is in every human being's heart the lure of wonder, the undaunted challenge of events, the unfailing childlike appetite for what next, and the joy of the game of living.

We are as young as our self-confidence, as old as our fear; as young as our desire, as old as our despair.

Gentlemen, this concludes my statement. I should like to thank the members of the subcommittee for the opportunity of expressing some of the views of the medical profession on the problems of the aged and aging.

I shall be glad to attempt to answer any questions that you may have.

Senator MCNAMARA. You mentioned in your statement that medical associations at State and local levels have moved promptly to put into effect the six-point program. Could you describe for us to what extent the local and State associations have adopted your proposal for lower fees for the aged and your other proposal? Is there any way to measure whether or not fees are lower for people over 65? Is this fee thing such a standard that can be recognized as being lower? Or is it rather an intangible?

Dr. SWARTZ. I suspect that fee situations are sort of an intangible anywhere you go. But in this particular field there is a definite effort being made and I think 25 plans are being offered in 23 States where Blue Shield plans are being offered new to subscribers who are past 65, this with the idea in mind that their payment by the physician

will be of such caliber that the price to the patient can be borne by one who has reduced income.

Senator MCNAMARA. You mention that Blue Shield and Blue Cross plans are now much more available than they were previously for people over 65. You are very optimistic that in the next 5 years perhaps 90 percent of the people in the same bracket will be covered. Certainly that is encouraging for me to hear that. But in these plans that are now available for people over 65, is it an increased rate to the individual?

Dr. SWARTZ. The increased cost to the individual?
Senator MCNAMARA. Yes.

Dr. SWARTZ. No. I think it is probably to a less cost.

Senator MCNAMARA. Well, then, at 64, in my experience, the Blue Cross-Blue Shield plan costs about $9 for an individual, while it is about 65 percent more for people over 65. Now is this the kind of coverage you are talking about?

Dr. SWARTZ. I think one has to make a division here because the first thing we are talking about, as I understand it, is new policies to people who are 65 years who are coming to buy.

Senator MCNAMARA. Those who were dropped from the plan because of the type of policy they had. They call that new. They are

new.

Dr. SWARTZ. Yes, sir.

Senator MCNAMARA. But actually it is continuation of the same insurance company by the same individual. And it is not new. Dr. SWARTZ. Yes, it is new and that type of policy is new.

You see, one has to take into account the fact that this is a new area, and when they started planning these programs they had only past experience to go on and so when they really got down to figuring on insurance plans where people were past 65 what they usually did was to use the experience in people under 65 and just add on to the increased expectancy of illness. They forgot to take out some things, such as obstetrics and so forth, that we don't have to deal with in the older age group. This in the years to come is probably going to influence the cost of insurance to individuals because we will have more experience to go on.

Senator MCNAMARA. This is very interesting. I hoped we would see that reflected soon in the cost of insurance.

You sum up pretty much your statement by the quotation of Dr. Dasco on page 9 when you say—

In our society, the responsibility of taking care of the old person rests primarily with his family. If the family cannot fulfill this responsibility, then it passes on to the community, then to the State.

Now this is the status quo as I understand it. This is exactly where we find ourselves when we start these hearings here. And as a result of doing just this, don't we find too many of our older people spending their so-called older years in the slum areas of densely populated cities? Do you recommend that we continue this?

Dr. SWARTZ. I think, Senator, if I may be allowed to inject in the hearings the concept of the relationship between the physician and the patient, in the philosophy of medicine, which in the last 50 years has changed the life expectancy in this country by approximately 20 years. We have developed this type of philosophy:

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