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:

No. 1, that it is not very good for the patient to be put to bed for a long time. This can be documented by much evidence, the evils of immobilization and bed rest.

Senator MCNAMARA. I am sure you said that without the explanation

Dr. SWARTZ. So that this goes on to a philosophy of this type: We get the patient out of bed, start doing for himself. Now, 20 years ago you were in bed at least 2 weeks for an appendectomy. Now he is up the first day, and so forth. So we are in a position of trying to get people to do things for themselves in the spirit of rehabilitation. Since World War II this is definitely a part of the program. Motivation; do things for yourself.

This is in this spirit that we apply the same principle to having the patient first do as much as he can for himself. If he is paralyzed there is only one way he is going to be able to use his arm and that is to use it himself. No matter what you do aside from that, it is not going to take him out of the category of a disabled individual. This is our approach to the whole problem.

Senator MCNAMARA. This makes no reference to the great numbers of people that live in the slums. I mean you are talking about something else instead of giving me an answer to the question I asked. However, Mr. Spector has a question dealing with financial problems I believe.

Mr. SPECTOR. Just some statistical.

Senator MCNAMARA. Ask him yourself. Go ahead.

In

Mr. SPECTOR. I just wanted to clarify in the record some figures. your statement here, Dr. Swartz, you mentioned by 1965, 75 percent of those over 65 will have coverage in the private hospital insurance. When Under Secretary Akins was before our committee she was discussing this point and indicated their estimates based on the projection of present trends would indicate that only about 56 percent of the population over 65 would be covered by private hospital insurance. This means, she said, that of 17.8 million people over 65 in 1965 that about 8 million would not be covered. I just wondered whether you had any explanation for the disparity in these projections as between the figures you have here and those that were developed by the Department of Health, Education, and Welfare, and then if HEW is correct, what are the possibilities of covering these 8 million indicated? About 2 million to 2,500,000 might get their medical care under old age assistance which would leave about 6 million still unprovided for. Dr. SWARTZ. I would feel much more competent if you asked me a question which was a little more in the medical field. This takes me into a little deep water, and, of course, as you appreciate, as well as I, that statistics and estimates of the future may vary a great deal. Statistics that we use were quoted from the Health Insurance Association of America. We have reason to believe that these may be quite realistic. In 1949 Dr. Louis Bower, speaking about this very matter of health insurance in the future, estimated that between 80 and 90 million people would be insured in the near future with voluntary health plans, and it so happens that at the present minute there are 123 million insured. I have no definite way of knowing whose statistics in the future are going to be correct. Certainly in a country like America where we do depend on initiative of the individual this certainly is possible.

Senator MCNAMARA. Yes.

I think that difference in the figure is probably due to the fact that the Assistant Director of HEW was talking about the problems of people over 65 and the numbers involved were 1512 million, whereas you were dealing with the whole population. This, of course, brings about a disparity in the figures we are using.

Thanks very much, Doctor.

Dr. SWARTZ. Thank you.

STATEMENT OF BERWYN F. MATTISON, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION

Senator MCNAMARA. The American Public Health Association, Dr. Berwyn Mattison, executive director.

Doctor, we would be glad to hear from you. Doctor, I see you have a prepared statement. Is it your desire that we include it in the record at this point as presented, and then have you summarize it?

Dr. MATTISON. Yes, sir, I would be very happy to do so.

Senator MCNAMARA. All right.

(The prepared statement of Dr. Mattison follows:)

PREPARED STATEMENT OF DR. BERWYN F. MATTISON, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION

Mr. Chairman, my name is Berwyn F. Mattison and I am executive director of the American Public Health Association with headquarters at 1790 Broadway, New York, N.Y. I am a physician with nearly 20 years experience in the field of public health at local health officer at both the city and county levels; as a district State health officer in New York State; and as secretary of health for the Commonwealth of Pennsylvania.

The American Public Health Association is in its 87th year and is an association of public health workers and those interested in the field of public health. We have about 13,000 members and fellows in the association representing the top leadership among American health specialists. With the additional members of our 48 affiliates, we have a total membership of approximately 25,000-the largest of any professional public health organization in the world. We have affiliated organizations in 42 of the 50 States and 3 regional branches which include groups of State affiliates in the West, in the South, and in the central part of the United States.

Activities in the field of aging.-For many years this association has been aware of the growing problem of health services for the aging. At the moment most of our activities in this field are focused in the committee on chronic disease and rehabilitaiton which is chaired by Dr. Lester Breslow of California. However, many of our other committees have contributed specific recommendations and procedures for the guidance of those who provide such services. For instance, in 1953 a subcommittee on standards for housing the aged and infirm prepared and published a document entitled "Housing an Aging Population” which covered such subjects as characteristics of the aging process, shifting burden of dependency, housing needs, financial resources available to the aged, distribution and mobility of the aged, as well as a review of various attempts to solve the problem of housing of this segment of the population. The latter considerations included European experience and some experiments in this country with retirement towns, cooperative dwellings, nonprofit units, State aided public housing, etc. I mention this not as an attempt to analyze the problem of housing for the aged-for I am no authority on that subject-but simply to indicate the kind of work which has been done by the American Public Health Association through the voluntary contributions of leading authorities in every field of health protection.

At the present time our committee on chronic disease and rehabilitation has in draft form a manual for chronic disease programs which would enable health departments to better mobilize existing resources and bring them to bear on their own particular problems and needs in the field of aging. It is anticipated