MEDICARE AND ACUPUNCTURE

HEARING

BEFORE THE SELECT COMMITTEE ON AGING HOUSE OF REPRESENTATIVES NINETY-EIGHTH CONGRESS

FIRST SESSION

NOVEMBER 30, 1983, SAN FRANCISCO, CALIF.

Printed for the use of the Select Committee on Aging

Comm. Pub. No. 98-425

U.S. GOVERNMENT PRINTING OFFICE 30-832 0 .. WASHINGTON : 1984 SELECT COMMI'ITEE ON AGING Chairman

EDWARD R. ROYBAL, California,Ranking Minority Member CLAUDE PEPPER, Florida MATTHEW J. RINALDO, New Jersey, MARIO BIAGGI, New York,1 IKE ANDREWS, North CRrolina JOHN PAUL HAMMERSCHMIDT, Arkansas DON BONKER, W ·~it1gt< RALPH REGULA, Ohio THOMAS J. DOW, 'ErY , New York NORMAN D. SHUMWAY, California JAMES J. FLORlt fi, . ew Jersey OLYMPIA J. SNOWE, Maine HAROLD E. FORD ennessee JAMES M. JEFFORDS, Vermont WILLIAM J. HUG · '3, New Jersey THOMAS J. TAUKE, Iowa MARILYN LLOYD, 'I. nnessee JUDD GREGG, New Hampshire STAN LUNDINE, New York GEORGE C. WORTLEY, New York MARY ROSE OAKAR, Ohio HAL DAUB, Nebraska THOMAS A. LUKEN, Ohio LARRY E. CRAIG, Idaho GERALDINE A. FERRARO, New York ' PER EV ANS, Iowa BEVERLY B. BYRON, Maryland JAMES A. COURTER, New Jersey WILLIAM R. RATCHFORD, Connecticut LYLE WILLIAMS, Ohio DAN MICA, Florida CLAUDINE SCHNEIDER, Rhode Island HENRY A. WAXMAN, California THOMAS J. RIDGE, Pennsylvania MIKE SYNAR, Oklahoma JOHN McCAIN, Arizona BUTLER DERRICK, South Carolina MICHAEL BILIRAKIS, Florida BRUCE F. VENTO, Minnesota GEORGE W. GEKAS, Pennsylvania BARNEY FRANK, Massachusetts MARK D. SILJANDER, Michigan TOM LANTOS, California CHRISTOPHER H. SMITH, New Jersey RON WYDEN, Oregon MICHAEL DEWINE, Ohio DONALD JOSEPH ALBOSTA, Michigan GEO. W. CROCKETT, JR., Michigan WILLIAM HILL BONER, Tennessee IKE SKELTON, Missouri DENNIS M. HERTEL, Michigan ROBERT A. BORSKI, Pennsylvania FREDERICK C. (RICK) BOUCHER, Virginia BEN ERDREICH, Alabama BUDDY MAcKAY, Florida HARRY M. REID, Nevada NORMAN SISISKY, Virginfo TOM VANDERGRIFF, Texa. ROBERT E. WISE, 'JR., West Virginia Staff Director BILL RICHARDSON,. New Mexico Minority Staff Diretl tor JORGE J. 1AMBRINOS, PAUL SCHLEGEL, (II) CONTENTS

MEMBERS' OPENING STATEMENTS Page ward R . Roybal ...... 1 � � :, . . 2 Barbara Boxer...... 3

CHRONOLOGICAL LIST OF WITNESSES Deke Kendall, OMD, Ph.D., research director, American Association of Acu- puncture and Oriental Medicine, Torrance, Calif...... 4 Dr. Peter Eckinan, Palo Alto, Calif...... 7 Dr. Stuart Kutchins, OMD, chairman, National Commission for the Certifica- tion of Acupuncture, Inverness, Calif...... 9 Art .Agnos, assemblyman, 16th District, chairman, joint legislative audit com- mittee, California Legislature ...... 22 Rosa Mei Lee, certified acupuncturist and doctor of oriental medicine, Moun- tain View, Calif...... 23 Effie Chow, Ph.D., acupuncturist, San Francisco, Calif...... 30 Barbara Sklar, planning director, Geriatrics, Mt. Zion Hospital Medical Center, San Francisco, Calif...... 38 Charlene Harrington, chair, public policy committee, Western Gerontological Society, San Francisco, Calif...... 44 Tish Sommers, president, Older Women's League, Western Office, Oakland, Calif...... 46 Donna Ambrogi, director, Bay Area Law Center on Long-Term Care, Palo Alto, Calif...... 51 Lillian Rabinowitz, chair, health committee, Gray Panthers, Berkeley Area, Calif...... 57 Maureen M. Malvern, staff attorney, Legal Assistance to the Elderly, Inc., San Franciso, Calif...... 59

AUDIENCE PARTICIPATION James Tummey, Haight-Ashbury Acupuncture, San Francisco, Calif...... 65 Herman Rifkin...... 66 Lee Grieux, social worker, Francis of Assisi Senior Housing, San Francisco, Calif...... 66 Mr. McDevitt...... 66 George Suey, member, State Commission on Aging, California ...... 66 Morris Pensky, San Francisco, Calif...... 68

APPENDIX Additional material submitted for the record: Prepared statement of Kim Man Lai, president, California Certified Acu- puncturists Association, Oakland, Calif...... 71 Prepared statement of Harry F. Tam, D.C., C.A., president of UAC, San Francisco, Calif...... ,...... 74

(Ill) MEDICARE AND ACUPUNCTURE

WEDNESDAY, NOVEMBER 30, 1983

U.S. HOUSE OF REPRESENTATIVES, SELECT CoMMITTEE ON AGING, San Franc-isco, Calif. The committee met, pursuant to notice, at 9 a.m., in the ceremo­ nial courtroom, 19th floor, Phillip Burton Federal Building and Courthouse, San Francisco, Calif., Hon. Edward R. Roybal (chair­ man of the committee) presiding. Members present: Representatives Roybal of California and Burton of California. Staff present: Jorge Lambrinos, staff director, Select Committee on Aging; Edwin Davis, Judy Lemons, and Christine Pelosi of Rep­ resentative Burton's staff. OPENING STATEMENT OF CHAIRMAN EDWARD R. ROYBAL Mr. ROYBAL. The House Committee on Aging will now come to order. Ladies and gentlemen, it is a pleasure to be here in San Francis­ co, and have the opportunity to work with Congresswoman Burton on the issues of improving the medicare program, and covering acupuncture services under medicare and medicaid. In January, the Congress will once again be faced with the prob­ lems surrounding the medicare and medicaid programs. Both pro­ grams have been hit hard by the rising cost of health care, and have had difficulty keeping up with the needs of the elderly and the poor. These pressures have made it more difficult for Congress to consider changes in services, covered by medicare and medicaid. However, I remain convinced that the Congress should keep an open mind as it considers the wide range of proposals for changing medicare and medicaid financing and covered services. One such change in covered service is the legislative proposal on acupuncture made by Congresswoman Burton. This service has re­ mained outside the medicare and medicaid programs. Acupuncture is a practice which has been used for centuries in other countries and which has gained popularity just recently in the United States. After listening to the argument by Congresswoman Burton for the coverage of acupuncture under medicare and medicaid, I agreed that the House Select Committee on Aging should include an ex­ amination of acupuncture as part of this hearing on medicare. The first panel of witnesses will focus on the issue of the coverage of acupuncture under both medicare and medicaid. During the second part of the hearing, I have asked witnesses to speak on more general issues surrounding the elderly and the

(1) 2 medicare program in general. If medicare is to be kept alive, and its covered services and eligibility expanded, we need to gain better control over rising health costs. This will require a joint effort be­ tween the Congress and the health care insurers and providers. At the same time that we are trying to contain health care costs, I want the aging committee to examine approaches for improving both benefits and eligibility for the poor and for the elderly. I trust that this hearing will touch on several issues of concern to the elderly and to the long term financing health of the medi­ care program itself. As you know, the medicare program is present­ ly operating under great difficulty. There are some who predict that we will run out of these funds as early as 1990, and possibly even before. However, we are going to look into the subject matter very carefully. I can assure you that Mrs. Burton will join me and the Committee on Aging in seeing to it that medicare is well fi­ nanced and it will continue beyond this century. I realize that it is a tremendous problem, but one that is not insolvable. I want to express my appreciation to Congresswoman Burton and her staff for assisting the Aging Committee in holding hearings here in San Francisco. This is the first hearing on acupuncture. We will go back to Washington, D.C., and hold a hearing there on the same subject matter. We will also include acupuncture in other hearings that will be held throughout the country. The committee will then prepare reports, and make recommendations to the Mem­ bers of the House of Representatives as to the type of legislation that the committee feels there should be. Each member of the committee or any Member of the Congress may submit their own ideas regarding medicare and the financing of this most important insurance program. We still have a long ways to go, ladies and gentlemen. This is the first hearing, but I can assure you that as we go throughout the country, we will con­ tinue to focus on these problems and to examine whether or not acupuncture should be covered by medicare or medicare. It brings me great pleasure to recognize Congresswoman Burton, who has been a longtime friend of mine. We have known each other for more years than I care to think about. The Chair now recognizes Congresswoman Burton. STATEMENT OF REPRESENTATIVE SALA BURTON Mrs. BURTON. Thank you, Chairman Roybal. I am not afraid to say how many years. It is over 30 years, so you know that we were both young kids when we met. My husband and Congressman Roybal and myself have been friends for many, many years. Be­ sides that, we are neighbors in Washington. So that you know that our friendship is deep. I am very grateful to you, Mr. Chairman, for being here and holding this first hearing on acupuncture. That shows what a friend he is, not to me, but to the elderly. And being the chairman of this very important committee on aging, you know that we have a friend, always. I would like to say that the witnesses that we have before us today will provide Congress with information and views that will be useful in our effort to improve the health care of our Nation's elderly. 3 May I put this in the record, and I won't take up that much time so that we will have an opportunity of hearing our witnesses. Thank you. Mr. ROYBAL. Thank you, Mrs. Burton. Without objection the entire text of the prepared statement will be included in the record. May I also include in the record, the statement of Congress­ woman Boxer, who was unable to be here this morning. Her state­ ment will also appear in the record, following that of Congress­ woman Burton. [Prepared statements of Mrs. Burton and Mrs. Boxer follow:]

PREPARED STATEMENT OF REPRESENTATIVE SALA BURTON I thank Chairman Roybal for bringing his committee to San Francisco to hold these important hearings. I know he will find that the witnesses we have before us today will provide Congress with information and views that will be useful in our effort to improve health care for our nation's elderly. San Francisco, and indeed the entire state of California, is often viewed as the most progressive area of the country-providing the rest of the nation with solu­ tions to the problems plaguing all of us. I expect today that we will find solutions to some of the problems that the elderly have in obtaining affordable and effective health care. I have introduced legislation addressing part of this problem. My bills would allow people in the Medicare and Medicaid programs to be reimbursed for the cost of acu­ puncture treatments. Acupuncture has been a part of Chinese medicine for thousands of years. In recent years it has become an accepted treatment for many ailments among the non-Chinese portion of San Francisco's varied population. Yet, just ten years ago, acupuncturists were arrested in California for practicing their skill. The ignorance surrounding this medical practice is still widespread. This hearing, I hope, will begin to establish an official record of acupuncture's effectiveness so that it can become an accepted part of American medicine. I believe the committee will be impressed by the active and accomplished senior citizens who are present today. The San Francisco Bay Area is a hotbed of a elderly activism-hundreds of people past retirement age lead a life far from the "rest and relaxation" of most peoples' retirement. My husband Phillip and I both were elected in no small part due to the active participation of the elderly in our campaigns. We will, in addition, see that San Francisco offers a wealth of professional exper­ tise on the problems of the elderly. The University of California at San Francisco, the Western Gerontological Society, Mt. Zion Hospital and several other private and public institutions devote major resources to studying the experience of growing old in our society. Once again, I thank Chairman Roybal and his staff for their efforts in bringing the committee to San Francisco.

PREPARED STATEMENT OF REPRESENTATIVE BARBARA BmtER Mr. Chairman and Members of the Select Committee on Aging: Thank you for providing me with this opportunity to express my strong support for the extension of eligibility for Medicare and Medicaid coverage for acupunture services. This needed change in coverage eligibility will benefit the great many people whose pain and suffering have been alleviated by acupuncture. There can be no doubt of the results of acupuncture treatments for many pa­ tients, and therefore it seems only fair that this proven alternative care should be included among those optional forms of treatment available to Medicare and Medic­ aid patients. The long and successful history of this ancient medical art among the Chinese community in California and the growing international recognition of its effective­ ness certainly argue forcefully for this action to be taken. Many of my elderly con­ stituents describe relief they have obtained from hitherto incurable pain. This change in the regulations governing Part B of Medicare will make this valuable treatment available to many more people. 4

In these times of ever-increasing medical costs, this relatively inexpensive treat­ ment can benefit both patients and medical care providers. I hope that this hearing willMr. begin ROYBAL. the process The to makefirst acupuncture panel will treatment be composed more widely of three available. experts. The first is Deke Kendall, Dr. Peter Eckman, and Stuart Kutchins. The Chair will recognize Mr. Kendall and ask that he start off with his statement. Mr. Kendall is the research director of the American Association of Acupuncture and Oriental Medicine. He is from Torrance, Calif., which is just adjacent to my district. Mr. Kendall, will you please proceed in any way that you may desire.

STATEMENT OF DEKE KENDALL, OMD, PH. D., RESEARCH DIREC- TOR,Mr. KENDALL.AMERICAN I wouldASSOCIATION like to say,OF ACUPUNCTUREgood morning, ANDto you ORIEN­ both, HonorableTAL MEDICINE Congresswoman Burton and Congressman Roybal. I wel­ come the opportunity to come to San Francisco this morning to talk about acupuncture, which is my favorite subject. I would just like to start offand give a little, very brief explana­ tion of what acupuncture is, because there may be some people here today that are not aware of exactly what it is. Also I would like to give a brief explanation of how acupuncture works in the body and some of the things that it is found to be useful for. Acupuncture is the practice of inserting very fine needles into specific points on the surface of the body, along some well defined lines or paths that we call meridians, to bring about some kind of positive change in the body's energetic balance, to restore an indi­ vidual back to health if there is a state of sickness. Needle insertion practice and also what we call "moxibustion" which is applying heat either to the needles or portions of the skin, is a major part of oriental or acupuncture medicine. We also use herbal medications or remedies, massage, acupressure, rejuvenat­ ing type exercises, and diet. This comprises what we call, in the general term, acupuncture. When the needles are inserted into the body, a very complex reac­ tion occurs that affects the body in an integrated fashion that tends to restore balance to a person or to an area within the body that has been disrupted because of a disease or pain process. This dynamic or energetic balance is at its. optimum when a person is in a state of good health. This concept of energetic bal­ ance that the ancient Chinese developed several thousand years ago is a very important feature in expressing the nature of disease, whether it is a functional disorder, or whether it is caused by pathogenic sources. This concept of disease was also expressed by 18th century French physiologist, Claude Bonard. He was the gentleman who had a long-term running battle with Louis Pasteur on the nature of disease. As everyone knows of course, Louis Pasteur did a lot of work with trying to prove the germ theory of disease. In Louis Pas­ teur's dying hours, he admitted that Claude Bonard was right. Bon­ ard's concept was essentially the same as the Chinese concept, but he applied it down to the cellular level. When you maintain a bal­ ance of what he called the "milieu interieur," right down to the 5 cellular level, you will be in good health, regardless of whether you are attacked by a germ or have some functional disorder. The famous 20th century American physiologist, Walter Cannon, used the word "homeostasis" to define this property of the energet­ ic balance. He postulated that this critical energetic balance in the body and in all the cellular functions was essential for normal health and function of the body. Now, the reaction to a needle: When you insert the needle into the body at acupuncture points, it triggers what is called an immune-visceral-somatic response. This means that it has three very important reactions in the body, affecting the immune system, affecting organ systems and also affecting the muscular system of the body. It goes, very briefly like this: First, it triggers and en­ hances the immune system since the body recognizes the needle as a foreign object. Second, this also causes a change in the blood flow and circulation to the organ systems; and finally, it triggers the pain and spasm relieving mechanisms. This results in nervous system changes at the spinal cord level, and in the brain itself causing the release of several neurochemicals or neurotransmit­ ters. These are little chemical messengers that neurons or nerves use to communicate with each other and also to communicate with tissue for a response in the body. We know that many of these neurochemicals are involved in the mediation of pain. This is what some of the modern researchers are talking about with hundreds of millions of people being successfully treated with acupuncture. Other modern research which has mostly been conducted in China over the past 25 years continues to confirm and substantiate all of the theories and concepts of acupuncture. China has also been suc­ cessful in integrating traditional medicine with Western medicine, to trying to get the best out of both systems. Together, they can work synergistically. Unfortunately, the United States is the only major country that has taken a position that acupuncture is an experimental system. This has perhaps been the single most detrimental stumbling block to the acceptance of acupuncture in this country. Especially in ac­ cepting acupuncture in coverage of medical insurance, and of course medicare. Now, here is a system-traditional Chinese medicine-that dis­ covered and accurately described the function of the heart, the cir­ culating system, the arteries and the veins, 2,000 years before Harvey, who was given credit for it in England. They also developed a vaccine for smallpox using killed virus, ob­ tained from dried pustules also some 2,000 years before Jenner who got credit for it in England by using cowpox virus. They also described the protective nature and flow of the lym­ phatic system more than 2,000 years ago and Western medicine has only discovered the function of the thymus gland in the 20th cen­ tury as being part of the immune system. It should be recognized that this position the Government has taken is based on the American Medical Association, and this year the AMA reaffirmed their position that acupuncture is experimen­ tal. They based this determination on a few selected articles, of what I think were poorly controlled studies.

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It should be recognized that acupuncture, prescribed and used by a trained practitioner of oriental medicine is not experimental. It is highly effective health care. Of course, it is not a panacea. It cannot cure everything. But it is a very effective system. In fact, it has been very successful in treating a many problems with which Western medicine has not been too successful. Pain is one of them-back pain, headaches, arthritis, ulcers, and colitis. There are a lot of disorders, even things like allergies and chronic sinus­ itis, where we get very effective results with acupuncture. Acupuncture in the hands of an untrained Western medical doctor, would be probably considered experimental and this may explain the AMA's position. They recognize this as something they have no background on, they have no training in, and so it would have to be considered experimental. I certainly would think that if traditional doctors of oriental medicine suddenly started practicing Western medicine, that would probably be considered experimental as well. But with a treatment system that can manipulate the immune-visceral-somatic response of the body, and restore the body's health, it should be obvious that such a system should be freely available to the public and especial­ ly to recipients of medicare. If you just consider one of these three main properties, the pain relieving, the antispasmodic and the antiparalytic aspects, pain is probably the single most common complaint as people age. Acu­ puncture has proved effective for all types of pain, including head­ ache. T M J pain, upper back pain, lower back pain, shoulder pain-including frozen shoulders-leg pain, knee pain, and on and on. All types of pain syndromes have responded very favorably with acupuncture. Acupunture has also been used in China for anesthesia. The Chi­ nese are doing some 200,000 major surgeries a year using acupunc­ ture anesthesia. In this country, it might be considered for use, cer­ tainly in the case where you have compromised patients who have immune system disorders, where using normal anesthesia may be a high risk to the patient. We don't do very much anesthesia in this country with acupunc­ ture, although I personally have done four cases. Now, functional disorders like high blood pressure, diabetes, ulcers, colitis, constipation, hemorrhoids-all of the things that the aged experience-sleep disorders, even depression and anxiety, these things respond very well to acupuncture. Stress syndrome, even addictions, drug addictions, alcohol, respond well. In fact, here is a good example. Alcohol detoxification with acupuncture takes 5 days and it costs about $250. It is on an outpatient basis. The pa­ tient comes in once a day for 5 days. You compare that to a hospi­ tal program which runs like $9,000 to $12,000. So just looking at this comparisons alone, there is a tremendous potential for cost savings. Also, we have treated many patients with pain, especially low back pain, who have had very costly surgeries only to still have the back pain. They come in for acupuncture and they get rid of the pain. Now the immune system: Most infectious diseases can be amelio­ rated with acupuncture, as well as things like chronic sinusitis, ur- 7 ticaria-there are a lot of these immune system functions that older people get. It also should be noted that the immune system starts deteriorating after about age 30. So, as the immune system starts going down, and we become more susceptible. So I feel very strongly that the Government first needs to recog­ nize that acupuncture is very effective and safe. There have hardly been any complications due to acupuncture. There have been no deaths that I know of by a trained acupuncturist in this country. The Government has got to recognize that acupuncture in the hands of a trained and certified practitioner is not an experimental system. I think once the Government accepts this position, it is going to open the door for insurance coverage for acupuncture and make it more available. Also, it should be made available to all recipients of medicare. I think that it is a system that would be well suited to their needs. I think in many cases it would prove to be lower cost, more stable and a more cost-effective system. There should not be any restrictions put on its use as far as the type of disease or the frequency of treatments. Many insurance companies do that, where they will allow acupuncture insurance for pain only, or for one or two treatments only, or by a medical doctor, not a certified acupuncturist. So it has to be along the lines, I think, of the guidelines of the California State law concerning acupuncture where it is freely available as a primary health care system, where there are no restrictions on it, with the exception of those restrictions on the treatment of cancer. Also, I think that the Government needs to fund research, and I recognize that this is a time when costs are high and the dollars are few, but we need to fund research and we also need to encour­ age research in the medical centers in this country. We must open these doors to let trained and certified acupuncturists into these in­ stitutions to be a part of these research teams. Of course, lastly, it must be made certain that acupuncture is ap­ plied by people who are trained and certified in the field. Thank you. The information follows: 1. All states allow M.D.'s to practice acupuncture. 2. The states which license, certify, register non-M.D.'s are: California, Florida, Hawaii, Louisana, Maryland, Montana, Nevada, New York, New Mexico, Oregon, Rhode Island, Washington, Utah, and New Jersey. 3. The states in which non-M.D. acupuncturists are legally permitted to practice but not certified: South Carolina, Washington, D.C., Arizona, Connecticut, Massa­ chusetts, Vermont, New Hampshire, Texas, Colorado, Minnesota, Illinois, Delaware, Kansas, Missouri, and Maine. Mr. RoYBAL. Thank you, Dr. Kendall; the Chair now recognizes Dr. Peter Eckman. Dr. ECKMAN. Thank you, Mr. Roybal. STATEMENT OF DR. PETER ECKMAN, PALO ALTO, CALIF. Dr. ECKMAN. Ladies and gentlemen, I am a licensed physician who has been practicing acupuncture for 10 years. My training in both Eastern and Western medicine has been of the highest cali­ ber, so I think I am in a rather unique position to address you on the subject of acupuncture and medicare. 8 There are four areas that I expect are of most concern to you in regard to possible legislation. These are the efficacity, safety, uniqueness and cost of acupuncture, as a covered service under medicare. I have a few words to say about each area. In regards to efficacity, it must be recognized that acupuncture is the oldest extant healing discipline in the world, and may truly be said to have stood the test of time. It is widely used throughout the world, and in some Western countries; for example, France, it is routinely practiced in the hospital setting, along with Western medicine. The biggest stumbling block to its acceptance by ortho­ dox medicine has been the lack of scientific proof of either its effi­ cacy or hypothetical mechanism of action. It is high time we real­ ized the emptiness of such an argument. A symposium on acupunc­ ture was held in Beijing in 1979, and the published proceedings cite over 100,000 cases of treatment, with highly favorable results. Such clinical findings have been observed around the world, albeit on a smaller scale, so I think we are forced to accept its clinical utility. The issue of its presumptive mechanism is in reality a spurious one. While it is true that we have no scientific explanation for much of what is seen with acupuncture treatment, the same might equally be said for most Western medicaments. Why, it's only in the last few years-with the discovery of the prostaglandins-that we've come up with a plausible scientific explanation for the effects of aspirin, our most widely used medicine. Should we not have rec­ ognized aspirin as effective until a few years ago because we couldn't explain how it worked? Of course not. Let us use the same common sense in regard to acupuncture. As for safety, there are a few simple precautions that must be observed in the practice of acupuncture. These relate to questions of sterility on the one hand, and care not to pierce any vital struc­ tures on the other. There is some evidence that incorrectly prac­ ticed acupuncture can be deleterious to the health, but all three of these concerns are adequately dealt with by reasonable licensing procedures, such as we have in California. There is, in fact, no question, that in terms of safety alone, acupuncture surpasses Western medicine. Acupuncturists have no problem with iatrogenic disease, which, however, is causing a significant percentage of hos­ pitalizations where Western medicine is used and abused. In terms of its uniqueness, acupuncture has a large role to play for the population affected by medicare. It is widely used for many of the "diseases of aging," such as arthritis, and other sources of chronic pain that are poorly treated by Western medications. It is unfair to deny our elderly population relief from such debili­ tating conditions, just because the treatment is "unorthodox." Finally, as for cost, acupuncture is worth considering. While pa­ tients are suffering, they will continue to go to doctors. In so doing, two costs are created, that of professional time on the one hand, and that of medical supplies on the other. As the professional cost in seeing an acupuncturist-physician or nonphysician is no great­ er than in seeing any other medical provider-in fact, it's usually less-we have only to consider the cost of medical supplies, which in the case of acupuncture are virtually nil. When we combine this with the knowledge that successful treatment will allow patients to stop going to doctors for these chronic complaints, we can see that 9 overall, acupuncture is very cost effective and deserves coverage under medicare. I thank you for your attention, and would like to remind you that all of my comments are based on 10 years of clinical experi­ ence, and are offered in all sincerity. Mr. ROYBAL.Thank you, Dr. Eckman. The Chair now recognizes Mr. Kutchins. STATEMENT OF STUART KUTCHINS, O.M.D., CHAIRMAN, NATION­ AL COMMISSION FOR THE CERTIFICATION OF ACUPUNCTURE Dr. KuTCHINS. Thank you, Mr. Roybal and Congresswoman Burton. I am honored by this opportunity to address your commit- tee on the subject of acupuncture and its proposed inclusion among the benefits of medicaid and medicare. Only a few years ago, acupuncturists in the United States prac­ ticed secretly, in fear of being noticed much less scrutunized by legal authority. Now in California and a number of other States we are respectable members of the health care system. In some we function, as do others of the subjugated health professions, under the supervision of allopathic physicians. In other States, we func­ tion independently as primary health care providers with a scope of practice that excludes only surgery, injection, and prescription of restricted substances. I draw your attention to this recent transition, not out of any nostalgia for the old days of outlawry, but because it begins to ad­ dress the question: Is acupuncture effective? A moment's reflection will remind us that there is nothing intrinsically inviting or glam­ orous about acupuncture treatment. In fact, it evokes everyone's basic medical terror-going to the doctor and getting a shot. The basic truth is that acupuncturists work primarily by inserting nee­ dles into people. Now imagine in California a few years ago, tens of thousands of people, going secretly to have needles stuck in them, by anyone of-say-a thousand people, about whom it could have been said for certain that they were not doctors, that they were operating outside the law, that they were offering treatment that almost any red-blooded American would regard as something between strange and terrifying. Who were these tens of thousands of people? All the kooks and masochists of the Western Hemisphere? No, they were our parents, our children, our neighbors, sick and desperate enough to try any­ thing, anything even acupuncture. My mother was one of them. At the age of 65, 10 years ago, she was so crippled by arthritis that she almost could not walk up the one flight of steps to her first acupuncture treatment. But found it much easier by the third treatment, and a couple of years later danced energetically at her granddaughter's wedding. It is the ex­ perience of tens of thousands of such Americans that has brought acupuncture out of the closet and into the spotlight of national at­ tention. But the American experience of acupuncture is still recent and smacks of novelty. However, in Europe, acupuncture has active his­ tory of about 40 years, and is widely practiced in England, France, 10

Austria, Germany, Switzerland, Italy, and many Eastern Bloc coun­ tries. Of course, in the Orient it is even better established, in Japan, Korea, China, Vietnam, Sri Lanka, et cetera. The World Health Organization recently reported that over one-fourth of the world's population received acupuncture routinely as part of the health care system in China alone. In the Orient, acupuncture has been practiced perhaps since before histories were written. It was already a highly sophisticated, fully articulated system by the time of the composition of the earli­ est existing textbook, "The Canon of Internal Medicine," which critical scholarship now dates at about 2,500 years ago. The long history of acupuncture is not a logical proof of its effec­ tiveness, but it is a powerful sociological statement. Billions of people may be fooled about the efficacy of a medical treatment for a few years, a few decades, perhaps a few centuries. But the prac­ tice of acupuncture as a system of medicine has a documented con­ tinuous history longer than virtually any institution in the West. Acupuncture has been clinically tested on billions· of patients by more than 750 generations of physicians. No system.of medicine in history has been subjected to more rigorous clinical trial. Conven­ tional Western allopathic medicine is by comparison a bag of novel­ ties of uncertain impact on the long-range health of the species. The Federal position to date, exemplified by rulings of the Food and Drug Administration, has been that acupuncture should be re­ garded as experimental, something to be tested under medical su­ pervision with a research protocol, as if it were a medicine like motrin or thalidomide awaiting the scientific stamp of approval. However, acupuncture is not a treatment, but a system of treat­ ments. A medical system with its own theoretical basis, diagnostic methods and therapeutic techniques. To ask the American medical community to evaluate it is like asking the College of Cardinals evaluate Methodism. Acupuncture has been practiced for millenia, and is currently practiced as a safe and effective treatment in a wide variety of acute and chronic disorders. It is best known for the treatment of pain, but is widely useful for a variety of musculoskeletal problems and functional disorders of the digestive, genital, urinary, and cir­ culatory systems. It is also an effective, conservative treatment in many gynecological and obstetric disorders, and also effective in many neurological and endocrine diseases, and for some dermatolo­ gical conditions as well. While my personal experience in treating elderly patients has been somewhat limited, it has also been rather positive. With acu­ puncture, it is as with other forms of treatment, difficult to undo the organic degeneration that eventuates in chronic illness. But often, the degenerative process can be stopped or retarded, and normal function may be maximized. It is important to remember that acupuncture works by optimiz­ ing the body's own function. It is eminently safe, nontoxic, with a minimum of side effects. It does not unduly stress the organism and is therefore able to have a broad spectrum of beneficial effects. For example, in one case, I treated an elderly woman who was having trouble walking due to arthritic changes in her knees. She 11 had for some time been under very competent medical care, but had continued to worsen. I say "competent medical care" quite sin­ cerely. It was my familyphysician who was seeing her. I was not able to restore her mobility by much, but the pain was reduced, degeneration stopped, her digestion and energy level im­ proved, and shortness of breath was eliminated. Now some years later, she is still living at home, relatively self-sufficiently. Where­ as, when treatment commenced, it seemed likely that she would soon need institutional care. Had she been dependent on medicare for treatment, unable to afford acupuncture, the cost to the system might have been enormous-and her situation much worse. Of course, it is difficult to predict exactly the financial impact of adding acupuncture to medicare and medicaid benefits. But the cost of acupuncture treatment, even extensive treatment, compares favorably with just a few days in the hospital, a few consultations with specialists, a few batteries of tests. It can be predicted with some confidence that many people would be cured, or significantly improved, who would otherwise worsen or remain unimproved. Thank you very much. Mr. ROYBAL. Dr. Eckman, I would like to start the questioning by asking you about your background. I understand that you are a li­ censed physician. Are you an M.D.? Dr. ECKMAN. Yes, that is correct. Mr. ROYBAL. It is also my understanding that you have another degree. Is that correct? Dr. ECKMAN. I am also a Ph. D. in physiology and I have several degrees in acupuncture from England. Mr. ROYBAL. All right, so you are eminently qualified as an expert to testify on this subject matter? Dr. ECKMAN. Yes, sir. Mr. ROYBAL. Now, I am going to ask you some question that may immediately show my ignorance with regard to the subject matter that we are discussing. Can you tell the committee what is includ­ ed in iatrogenic diseases? Dr. ECKMAN. Iatrogenic means a disease that is caused by the kind of treatment that is rendered with the hope of curing it, but by some strange quirk of fate, makes the disease process worse or brings on a new disease. For instance, people who take steroid medication and develop, for example, they can develop diabetes, high blood pressure, things like that, are iatrogenic. It is caused by the physician, rather than by the illness itself. Mr. ROYBAL. Yes, but you have stated that acupuncturists have no problem .with these diseases. Dr. ECKMAN. What I mean by no problem, is that their treat­ ment does not produce iatrogenic disease. In contrast, Western medicine uses very powerful medicine and kinds of treatment that often produce iatrogenic disease. Mr. ROYBAL. In other words, your position is that the regular medical practice and acupuncture differ in that acupuncture does not produce iatrogenic disease? Dr. ECKMAN. Yes, that is correct. Mr. ROYBAL. Is there any scientific evidence that would back up that particular statement? 12 Dr. ECKMAN. One of the problems is that, if you scan the medical literature, less than 1 percent of any kind of medical studies are devoted to the area of oriental medicine or acupuncture. And so, the question is, where do you go to do a study of looking for the incidence of iatrogenic following acupuncture treatment? I have never seen such a study coming from the sources in the Orient where there is a much larger caseload for looking at that. As I mentioned, there is a symposium that was published and held in Beijng in 1979 that is a massive volume of hundreds upon hun­ dreds of clinical studies, and there is absolutely no mention in that of iatrogenic disease. Further than that, I can't answer your question. It sounds like that would be an interesting study to do. In order to do it, you first have to validate and honor the system of oriental medicine, so that you can test it. Mr. ROYBAL. That is a problem that we have with most anything. In this particular instance, we have a practice that has been going on for more than 2,000 years, but as of this moment, we do not have scientific evidence to back up that particular practice. Now, I am going to ask the same question of both Mr. Kutchins and you, Doctor. We need new scientific evidence. How come we have not received any effective evidence or provided money for research in this field? Mr. KuTCHINS. Mr. Roybal, the reasons for not having provided money for research would be easier for you to answer than for me. That is precisely the kind of question that I would like to ask of you, sir. It is clear that funds for research and development in acu­ puncture are very important. The whole issue of scientific proof, however, is one that we have to look at very carefully. What I was trying to get at, but I guess didn't say explicitly in my presentation, is that no system of medicine is tested scientifical­ ly. Sometimes certain medicines are singled out for experimental testing, and their efficacy are proved or disproved. Sometimes one is proved only to find out later, as in the case of one of them that I mentioned-thalidomide-that it has disastrous effects. But a system of medicine is never proved. It is merely accepted or not accepted within a society. We have some idea that modern medicine is scientific but it has never been subjected, and no medi­ cal system has ever been subjected, entirely, to any kind of scientif­ ic proof. Where will we find proof of modern conventional Western medicine? There is no proof of that. There is a collection of articles, of books, of studies and so forth talking about the outcomes of partic­ ular treatments. But no system of medicine is subjected to proof per se. Mr. ROYBAL. Well, is it not true that we do not have any system of providing information with regard to acupuncture? Mr. KuTCHINS. There is information. As a matter of fact, I no­ ticed in an article in a recent acupuncture journal, which was made to a 34-page bibliography of articles and book in Western lan­ guages on acupuncture. Relatively little has been written in Eng­ lish, because the history in the United States has been very short. But the point about the evidence of acupuncture, is that acupunc­ ture has already collected, over a period of some thousands of 13 years, more effective evidence of its efficacy than has ever been mounted to demonstrate the usefulness of any medical system in the history of mankind, including the currently used medical system in the United States. Mr. ROYBAL. There is no doubt that the information is made available to acupuncturists. However, the medical professions ap­ parently have not even looked at it. Mr. KuTCHINS. That is exactly my point. Mr. ROYBAL. Baseq on the testimony that you have given this committee, the medical doctors of the United States have just ig­ nored it completely. I am interested in this subject matter. I am on the appropriations committee. As you know, I put in the first moneys for various things like AIDS and Alzheimer's disease, even though the administration was in complete opposition. I felt, and the committee felt, that more research was needed at that particular time on AIDS and Alzheimer's disease. Now, sup­ posing that the opportunity did come up for me to recommend x amount of dollars for research in this field, it would go to a Federal agency that would conduct that study. However, you have told the committee that if you leave this up to the medical profession, acu­ puncture therapy will not meet with any approval. How can we get this done? I ask that question of both Dr. Eckman and you, Mr. Kutchins. Mr. KuTCHINS. I am going to turn the microphone to Dr. Eckman and think about an answer. Mr. ROYBAL. Doctor, how do you think that we can get that done? Dr. ECKMAN. I think that that is a real important question and not an easy one to answer. Within the acupuncture community itself, there are institutions that while, they have a much shorter history of existence than the institutions in Western medicine, can be a beginning of a network for distributing money to do projects, such as is done with Western medicine. There is as Stewart Kut­ chins mentioned, the National Institution for the Certification of Acupuncturists. There is a National Institution of Acupuncturists. There are alternative routes for the distribution of research funds, than through the Western medical establishment. I think that it would be a good idea to use those routes, since those are the people who are interested in sharing with the rest of the world, the history of the efficacy ofacupuncture. Mr. ROYBAL. Doctor, suppose I am prepared at this moment to make a recommendation that x amount of dollars be made availa­ ble for research in this field. If that is adopted by the committee, the money will go to the National Institutes of Health. But if the National Institutes of Health is not interested, we cannot force them to use that money for that particular purpose. Now, looking at it strictly from a layman's viewpoint, I say that the doctors in the National Institutes of Health, may need as much education in this field as I do. Dr. ECKMAN. I think that that is correct. Perhaps, you could ap­ point some sort of a committee, or the Government could appoint some sort of committee to act as a liaison with the NIH. Mr. ROYBAL. Now, what I plan to do, Doctor, is to invite research­ ers from the National Institutes of Health to attend a hearing simi-

30-832 0-84--3 14 lar to this in Washington, and see if we cannot start on this educa­ tion process. We have to start somewhere, and perhaps that is a place to start. One of the main arguments in favor of this, based on statements that you have made, is that it is going to cost less. I think that you, Dr. Kendall, made the point that in just the field of alcoholism alone there is the great difference of $250 versus $12,000. Now, can you give me arguments that I can use with regard to costs, other examples? Dr. KENDALL. I think, that in the case of the addictions, like the alcohol which takes about 5 days for a detoxification-that is pretty straightforward. The success rate with it is highly substan­ tial, the same as with, if you look at the success for detoxing from other drugs, including heroin and methadone, where you know the Government is supporting a very large methadone program in this country. You can detox a methadone or heroin addict in about 7 to 10 days, and the cost is around $300. This gets them off of using the substance rather than giving them a substitute to keep using. In the case of a lot of the pain disorders, where people have been on treatment for pain disorders for a number of years and they still have the pain, we frequently can get rid of this pain and they will respond favorably after 5 to 10 treatments. Take simple things like ulcers, for example where people will be under treatment and the drug of choice is tagemet, they may be on this medication for a year or a year and a half and still have the ulcer. The ulcer will usually respond in three to five treatments with acupuncture. So there is a very, very significant reduction in the costs, as far as the amount of treatments that you need and also the increased effectiveness. Now, concerning the research aspects, I think that once the Na­ tional Institutes of Health could hire on their staff, a certified acu­ puncturist, whether he be a Western trained physician who is also trained in acupuncture, or is a certified traditional acupuncture doctor, this would be the first step. So you have somebody that is on the inside looking out for acu­ puncture. Because as soon as you give any kind of funds to the es­ tablishment, any kind of establishment is always busy keeping itself established. So they would use the funds on themselves. As far as the efficacy of acupuncture, there has been a stagger­ ing amount of scientific data accumulated over the past 25 years. Unfortunately, most of this is in Chinese, and Americans are very prone to what we call the NIH factor-not inverted here-and so when it is in Chinese, they want to downgrade it. They will say that their techniques are not good, et cetera. But it turns out that the Chinese are doing some extremely outstanding work. They are looking at the neurochemical aspects of acupuncture and they are doing research that is rivaling anything that we are doing in this country. Mr. ROYBAL. Dr. Kendall, I heard a statement, coming up in the elevator, that perhaps you gentlemen would be interested in. He said in essence that they ought to leave acupuncture the way it is. 15 He felt that if it were covered by medicare, acupuncturists will in­ crease their fees and let the Government pay the cost. Now, this is a very significant statement coming from someone who comes from the general public and did not know that we were holding this hearing here. How would you respond to such a state­ ment if it were made. If I were to make it here, how would you respond to me? Dr. KENDALL.I would respond in this way. I think that it is true, that if acupuncture is covered, without qualification, then you are going to find that a lot of people, especially Western trained physi­ cians, will start doing acupuncture. My statement earlier was that acupuncture should be authorized for certified acupuncturists or those physicians who are trained-Western physicians who are trained in acupuncture. Now, in the State of California, as it turns out, any licensed M.D. can practice acupuncture, because under his license, he can insert needles into the body. Also, we even have dentists practicing acupuncture in this State, because they can insert needles. So the restriction has got to be-acupuncture by acupuncture doctors, Western medicine by Western medical doctors. It is true that if you just open it up completely, I am certain that all of a sudden, there are going to be a lot of expert acupuncturists crop­ ping up all over the United States, and starting to treat a lot of people. So, I think that it has to be kept within its own field. Mr. ROYBAL.One last thing, Dr. Kendall. The only way that we can control medicare is to first of all control costs. Dr. KENDALL.Correct, I agree. Mr. ROYBAL.If the statement that I heard in the elevator is true, it would mean that the cost of acupuncture would go up. We have to contain costs both in acupuncture or whatever is covered by medicare currently. If we do not, we will not be able to provide medicare services in the year 2000. Dr. KENDALL.I agree with that point, and I think that the point is, that if you provide acupuncture coverage, these people are not going to be going to a Western doctor. So, it is going to be a one-for­ one trade off, especially, if the cost is comparable for treatment. The other thing is that you don't have the staggering costs of the drugs and the medication. In this country we are spending over $20 billion a year just on drugs-these are prescribed drugs. So there is a large segment of this cost that people on Medicare are using-an enormous amount of drugs. This cost goes away. What we are talking about is getting rid of these problems more effectively, and so the number of treatments, comparable treat­ ments is going to be less. It is true that there is going to be more acupuncture. There should be a corresponding decrease in Western medical treatment. Dr. ECKMAN.Mr. Roybal, I think in answer to your last question, there is a precedent for evaluating what effect expanding the cov­ erage of services will have on the medicare program. As chiropractic medicine became more generally acceptable under insurance coverage, one could look at the impact that that had on the fees that chiropractors charged. I think that will give 16 you the answers, most likely, as to what is going to happen if acu­ puncture-- Mr. ROYBAL.Well, could you tell the committee whether the fee that the chiropractors charged increased or decreased? Dr. ECKMAN.I am not a chiropractor nor have any particular ex­ pertise in that field, but the data is available. Mr. ROYBAL.You see, Doctor, I am an accountant by background. If I had my way, I would put a cap on all medical services. I would then see to it that those services are paid for under the present fi­ nancial plan of medicare. That is not happening today. The physi­ cians receive medicare payments and then, in most instances, the senior citizens of this country pay the balance. These are the people-the poor and the elderly-that can least afford it. These are the people that have more ailments, I don't think that is the right way for us to be treating the senior citizens of the United States. This matter of cost, I think you agree, is the main issue with regard to medicare in general. Is that correct? Do the three of you agree with that? Mr. KuTCHINS.Yes. Dr. KENDALL.Yes. Dr. ECKMAN.Yes. Mr. ROYBAL.All right, thank you. Mrs. Burton? Mrs. BURTON.I would like to tell you, Mr. Chairman, and the au­ dience, we called the California Medical Association and we were trying to get witnesses. Evidently the California Medical Associ­ ation, because we wanted to hear their side, as any hearing does­ they are divided on this issue. A number of years ago, I think they were all on one side, where they were against acupuncture. But now they are divided on this issue, so what is happening, and they didn't give us a witness-what is happening is that there are evidently some changes. Now, I would like to ask Dr. Eckman, did you have to take any courses in order to become an acupunc­ turist, outside of your medical profession? Dr. ECKMAN.The question is of two parts. One is what I had to legally do in order to practice as an acupuncturist, and the second part is what is-what I felt was the responsible thing to do. They are quite different. Legally as a physician in California, I need no further training to practice acupuncture. So, the day you finish medical school, get your license, finish your internship, you can practice acupuncture without legal sanction. However, that is a most irresponsible thing to do. In my own case, I studied acupuncture at a number of institutions around the world and I am actually still in training. I think that certainly a period of several years of training is essential for anyone who wants to practice a new system of health care. Mrs. BURTON.Now, I want to ask Dr. Kendall. What does one have to go through if you are not a medical doctor, who immediate­ ly can practice-and I am very surprised at that, by the way. I would assume that this is a specialty and one, regardless of being a physician, one ought to learn something and know something about the specialty. That really surprises me. 17 Dr. KENDALL.That is why I brought up that point. If you just say acupuncture is going to be covered on medicare, then a lot of physi­ cians in a lot of States, may just start offering acupuncture, al­ though they may not have the training. Some physicians, like Dr. Eckman, have gotten interested in it and have taken the time to get professionally trained, and so there has got to be that kind of restriction. Now, in California, to be an acupuncturist, requires a 3-year program in the field of acupunc­ ture medicine. Mrs. BURTON.Do you take a test afterward? Dr. KENDALL.Afterward there is a State board exam which is ad­ ministered by the Board of Medical Quality Assurance, the same board that provides the exam for the physicians as well. This is the minimum requirement, a 3-year training program that includes a 1-year internship. There also were some provisions under the law that people who had been trained in traditional acu­ puncture, understudying another acupuncturist, could set for the state board. I think this is going to change or it has already changed, so that professional training will be required. Mrs. BURTON.I wanted to ask Dr. Eckman, what kind of medi­ cine did you practice before you got into acupuncture-or do you do both? Dr. ECKMAN.Well, I still use some Western medication, Western medical treatments when they are called for, although most of my patients come to me because they are interested in acupuncture treatment and I'm personally more excited by that. Mrs. BURTON.Are you a general practitioner? Dr. ECKMAN.My own training is in general practice. Mrs. BURTON.You said that it takes 3 years to be certified. Dr. KENDALL.In the State of California. Mrs. BURTON.And where do you study? Dr. KENDALL.There are, in California, there are three or four colleges that teach traditional acupuncture. This includes a very strong training in physiology and also Western medicine, because when you are dealing with patients, you have to be able to recog­ nize when you are dealing with a problem that is beyond the scope of what acupuncture can deal with, and you must be able to refer these people on to specialists in the medical field. There are at least four colleges in the State, two here in the San Francisco area, two in the Los Angeles area, and I think that there is going to be some newer schools starting up that are providing the full 3 year professional training. Some of these offer a 1 year graduate study as well, in advanced studies and research to get a doctorate in oriental medicine. Mrs. BURTON.How many States have certified and licensed acu­ puncturists? Dr. KENDALL.The only other State that has a law similar to Cali­ fornia is the State of New Mexico. Now, one of the differences with the New Mexico law is that you have to be a resident of New Mexico to get a license. You can go take the State board and pass it, but you can't get a license until you become a resident. In California, almost anybody from any country can come in and take the State board exam. It is legal in many other States. In some States, it is provided under the care of a physician. You have 18 to either go to a physician, or some acupuncturists are required to practice under the supervision of a physician, which in my opinion is analogous to letting the coyotes watch ,YOUrchickens. It is not a very healthy thing to do. In some States, such as Texas, it is almost completely illegal. There the acupuncturists fought a very hard battle to get it legal­ ized, but it is virtually completely illegal in that State. New York is one of the States that requires the physicians who practice acupuncture to have a minimum of 100 hours training in acupuncture before they can get certified. So it is kind of a whole mixed bag. The course that we are work­ ing on now is trying to get some kind of national recognition and some national standards, so that we can have a pretty uniform re­ quirements through all the States. Mrs. BURTON.Now, can someone come from another State come here-you said yes-and practice-do you have to pass an exam, like you would the bar? Dr. KENDALL.Yes; for example, if you were trained in China, in a traditional school and came to California, you could sit for the State board. It is given in English, Mandarin Chinese, Japanese, and Korean language, so you could come from almost anyplace in the Orient and be able to sit for the State exam. You don't have to be a resident of the State of California. Mrs. BURTON.Dr. Eckman, do you practice in one of the-it says Stanford University, are you connected with Stanford University? Dr. EcKMAN. That is old data. I submitted my current CV to the committee. I practice in San Francisco and Palo Alto, not at Stan­ ford University. Mrs. BURTON.Are you still a member of the California Medical Association? Does one have to be a member? Dr. ECKMAN.One does not have to be a member, and I am not a member of the CMA. Mrs. BURTON.I see. I think that is it on my part. Mr. RoYBAL. All right. Thank you. We have received some infor­ mation on the States which license, certify, and register non­ M.D.'s. They include California, Florida, Hawaii, Louisiana, Mary­ land, Montana, Nevada, New York, New Mexico, Oregon, Rhode Island, Washington, Utah, and New Jersey. Now these States certify and register non-M.D.'s. M.D.'s appar­ ently do not have to go through the system of certification and reg­ istration. The States, in which non-M.D.'s are legally permitted to practice acupuncture, but are not certified, include South Carolina, Washington, D.C., Arizona, Connecticut, Vermont, New Hamp­ shire, Texas, Colorado, Minnesota, Illinois, Delaware, Kansas, Mis­ souri, and Maine. Would you recommend a national system of certification or would you recommend that each State have a certification board? If I were to ask you to make a recommendation only on those two alternatives, which would you select? Mr. KUTCHINS.Mr. Chairman, I guess that I will have to give a prejudiced answer. You will recall that I am the chairman of the National Commission for the Certification of Acupuncturists, which is specifically committed to a national standardized certification process. I think that in the long run, that is the most promising 19 approach. Obviously, every State is going to have to license individ­ ually. It is the prerogative of each State to license its health care providers. But in terms of establishing standards for certification, standards of excellence, I think that the best approach is to do it on a national basis, to establish a national consensus, on what con­ stitutes safe and effective practice. Mr. ROYBAL. Are M.D.'s permitted to practice any place in the United States, once they become M.D.'s and complete their-- Mr. KUTCHINS. As far as I know, there are only a very few juris­ dictions-New York being the only one that comes to mind, in which M.D.'s are restricted from practicing any form of medicine ad libitum. As a matter of fact, I think that M.D.'s can do just about anything they want. The real issues are what they can hold themselves out as. For example, I believe that M.D.'s can perform almost any sort of surgery, provided they have correct relationship with an institu­ tion, but they cannot hold themselves out as surgeons, unless they have a speciality. But I don't think that there are restrictions on their practice. Mr. ROYBAL. All right, then, would you recommend a national system? Mr. KuTCHINS. Do you mean a Federal system? Mr. ROYBAL. Yes; a nationwide system of certification. Mr. KuTCHINS. I don't believe that a Federal certification exists for any of the health care professions. Mr. ROYBAL. But would you recommend it for acupuncture? Mr. KuTCHINS. Before making a recommendation on that, I would want to give it very careful thought, sir. Mr. ROYBAL. You see, Mrs. Burton's bill will be going to a com­ mittee in the House. That committee is going to hold a hearing on this issue. It is our intention to make recommendations with regard to the Burton bill. I am asking these questions in the event that the committee agrees that this recommendation should be made. Also it would be made because we have the backing of your national organization. While I am not going to ask you whether that is going to be the case or not, you are going to have to go back to your organization. Mr. KUTCHINS. I think that not only for my organization, but there are others also that should be consulted. The American Asso­ ciation for Acupuncture and Oriental Medicine one of them. The idea of developing a Federal licensing for acupuncturists, I think, is a very important decision. It is an idea that should be discussed widely and would take a little time. It would be, I think, an innovation in health-care licensing. I don't think that the Federal Government licenses any health-care providers. It is all done on the basis-of State jurisdictions and all of the national certification processes are intraprofessional. For example, the national boards for physicians is not licensing, it is certification and that is handled within the profession. The Federal Government doesn't license anyone to practice medicine of any sort. Your proposal affects not only acupuncturists, but involves changing Federal policy in health care licensing. I think that you are going to have to talk to a lot of people about that. 20 Mr. ROYBAL.Well, by the time that the committee reaches the point where it makes a recommendation to the House, we will of course have had hearings all over the country. The Burton bill will be heard by the authorizing committee. When it finally gets down to needing an appropriation it would be coming to my committee. So it is a long time between the introduction of a bill and its final enactment. What I am saying is that the Burton bill is going to have some difficulty, like all bills. Nevertheless, we should try to come up with sound constructive arguments in favor of passing this bill to include acupuncture in the medicare program. Before that is done, we have to be very sure that the recommen­ dations that we make are based on fact, and past experiences. We want to be sure that it will not be easy to punch it full of holes as has happened on many occasions on the floor of the House. Now, Dr. Eckman, what do you think about either a State or a national system? Dr. ECKMAN.I think what Stuart Kutchins was referring to is important, and that is that, for instance, in conventional Western medicine, there is a national board of medical examiners that ex­ amines, tests, candidates for medical licensure around the country. But that is simply an evaluation system for the individual States to use at their will in deciding whether to grant licenses to doctors. Many States recognize national boards in lieu of State boards as evidence of suitability for licensure. But, it is ultimately up to the States. I think the same thing might be developed with respect to acupuncture. We might have a national board of acupuncture ex­ aminers who would act to evaluate the qualifications and education of acupuncturists, and make recommendations that the States could then follow or not follow at their own will in terms of their own individual licensing. But that is not a Federal body, nor is the National Board of Medical Examiners. That is a private organiza­ tion and as far as I know has no governmental links. Mr. ROYBAL.If noncertified acupuncturists are going to be receiv­ ing any Federal funds, somewhere down the line, these people have to be certified by someone. What I am trying to determine is, which is the best way to certify them? Certify them on the national level, or on one-State level? States that permit uncertified non-M.D.'s to legally practice acu­ puncture would not get my patronage even if I needed it very badly. I would be somewhat reluctant to go to those who are not certified. The first thing that we need to do is recommend certifica­ tion, and possibly include it in the bill. We don't know how we are going to amend the bill yet. It is going to be subject to amendment. I would like to get your opinion with regard to certification. How should we do it nationally, or on a State-by-State basis? Mr. KuTCHINS.Mr. Roybal, I would like to address the issue. It is one that I have been working on a great deal for about the last year, and it is a very complex one. The National Commission for the Certification of Acupuncturists is just exactly the sort of com­ mission that Dr. Eckman was describing, operating as a national board of examiners. There are a couple of different issues here. We are talking about "certified acupuncturists," and "certification" usually means some­ thing different from licensing. Those are two different things. "Cer- 21 tification" is usually done from within the profession. They evalu­ ate the training and competence of the professional practioners. "Licensure" is handled by governmental jurisdictions and it means conferring the right to practice. Even if you developed a Federal licensure there would be no place for people to practice under the Federal licensure, since the right to practice is governed by State and not by Federal law. . In California and in Florida, licenses are called "certification" but it is just confusing terminology. A Federal licensure is not likely to get anywhere, because there would be no way of providing people holding Federal license jurisdictions in which they would be permitted to practice. They would still need State licensure in order to be able to practice within the jurisdiction of the States. What I would recommend is that the committee consider recom­ mending Federal acceptance of certification by the National Com­ mission for the Certificaton of Acupuncturists, which has adopted the guidelines of the National Commission of Health Certifying Agencies, and is working very closely with this quasi-governmental agency to guarantee valid certification, determining who is a safe and effective practitioner. But in terms of granting licensure, I think the Congress will have no choice but to leave that to the discretion of the States. · Mr. ROYBAL.That is one of the problems that we have with making effective legislation. We always have to leave it up to some­ one else. It seems to me that in this instance, as in many other in­ stances, the Federal Government should set some guidelines. Now, one of those guidelines could possibly be that all those who are cer­ tified cannot reach that plateau of certification until such time as they complete a course and pass an examination for certification. And that would include MD's. If something like that were established as a guideline, perhaps it would be more acceptable, and would diminish the reluctance of many to include acupuncture in the medicare system. Neverthe­ less, we will have some strong opposition. Hence, I think that if the guidelines included in the bill are well thought out, the bill will have a much better chance. Mr. KUTCHINS.I agree with you, sir, and that is one of the of rea­ sons why many of us felt that it was necessary to develop national standards, and to develop a national certification process-to enable people like yourself and the Congress of the United States to a look at us and deal with us as a cohesive and established pro­ fession. Thank you. Mr. ROYBAL.Mrs. Burton, anything else? Mrs. BURTON.Not right now, except that we ought to keep both of you involved, to continue with us, and give us new information and new ideas, so that when we do finally go to the House of Rep­ resentatives, we have a bill as the chairman said, that is fireproof. Mr. ROYBAL.I thank the three gentlemen for their testimonies. It has been most interesting. We could go on with more questions. I learned a great deal in just the short time that we have had. I am assured that subsequent hearings will provide even more knowl­ edge on this subject matter. If we who are in the legislative field are not enlightened about certain aspects of the medical field we cannot vote intelligently.

30-832 0-84-4 22 This is one of the reasons why we are holding this hearing. We want to be able to get all of the information that we possibly can, make the proper presentation, and fight for the Burton bill. May I thank you, Mr. Kendall, Dr. Eckman, and Mr. Kutchins for your testimony. Mrs. BURTON.And may I thank you too. Mr. ROYBAL.The next panel will be made up of Rosa M. Lee and Ek Meng Lau of the United Acupuncturists of California. They will give a demonstration to the committee. With them will be Effie Chow and Jane Murphy. While they are coming up, I would like to include in the record, a very strong support from a joint legislative audit committee member, Mr. Art Agnos, who is the assemblyman for the 16th Dis­ trict of California. Without objection, this letter will be included in the record at this point. AssEMBLY CALIFORNIALEGISLATURE, November 30, 1983. Hon. SALABURTON, Congresswoman Fifth District, House of Representatives, Golden Gate Avenue, San Francisco, Calif DEARSALA: I am very pleased to learn that you have re-introduced legislation that would allow acupuncture treatments to be covered as a reimbursable cost under Medicare/Medicaid. As Chairman of the Assembly Ways and Means Sub-committee on Health and Welfare, it was very gratifying that the sub-committee was successful in having acu­ puncture treatment included as a reimbursable service under California's Medi-Cal program. With then Speaker Leo McCarthy and Assemblyman Willie Brown's support, the Legislature recognized that acupuncture is a most important health treatment alter­ native with great potential and positive benefit in this state. That is why I am especially glad to know that legislation has been introduced to consider this health care issue on the federal level. Although I regret that I will be unable to attend the Select Committee on Aging hearing, I am sure that there will be many acupuncture practitioners, and medical consumers who will articulate the many positive benefits derived from acupuncture. With a very large elderly Asian constituency, I know that there is very strong interest and demand in having acupuncture available as an alternative treatment. For years, my elderly constituents have found acupuncture to be a safe, sound and economically favorable alternative medical service. I look forward to the day when the federal health care system will include acu­ puncture as a reimbursable treatment under Medicare/Medicaid. Warm regards, ARTAGNOS, Chairman, Joint Legislative Audit Committee. Mr. ROYBAL.Now, Mr. Dave Nelson will be the patient, and he is from the University of Santa Clara. Will you please proceed in any manner that you may desire? Mrs. BURTON.And Mr. Nelson, I understand, is a football coach, right? Mr. NELSON.At Santa Clara. Mrs. BURTON.At Santa Clara University. 23 STATEMENT OF ROSA MEI LEE, CERTIFIED ACUPUNCTURIST AND DOCTOR OF ORIENTAL MEDICINE, MOUNTAIN VIEW, CALIF., ACCOMPANIED BY DAVE NELSON, UNIVERSITY OF SANTA CLARA Ms. LEE. Mr. Chairman, Mrs. Burton, I am Rosa Mei Lee, certi­ fied acupuncturist and doctor of oriental medicine. I have a pre­ pared statement that I would like to submit for the record. Mr. ROYBAL.Without objection, it will be received. [The prepared statement of Ms. Lee follows:]

PREPARED STATEMENT OF RosA MEr LEE I, Rosa Mei Lee, Certified Acupuncturist and Doctor of Oriental Medicine, and Ek Meng Lau, Certified Acupuncturist and Dentist (Burma) will testify the validity of acupuncture and its benefits for senior citizens in the United States. As you know, acupuncture has been practiced in China for over 4000 years. Its benefits to the human body were unknown to the American public until President Nixon's visit to the People's Republic of China in 1972. In the Orient, we use acupuncture as a preventive medicine. We not only treat the symptoms, but also the sickness of the body. We also balance and rejuvenate the body to build up the resistance against diseases. Modern day acupuncture is also applied to drug detoxification, obesity, slowing the aging process, and many other conditions. I have invited a patient, Coach Dave Nelson of the University of Santa Clara foot­ ball team, and President of the Referees Association, who is getting favorable re­ sults for acupuncture. History: (A) Fracture of the right patella 15 years ago of the right knee, and oper­ ated to remove pieces of the patella. (B) Two ligaments, Quadriceps femoris and Li­ gamentum patellae were shortened by the operation afterwards. (C) Numerous cal­ cium deposits around the knee area. There is pain upon pressure. (D) Whenever rain comes, the knee hurts. (E) The mobility of the right knee is limited. Treatments: (A) Acupuncture-insertion of needles. (B) Electrical acupuncture stim­ ulation to increase circulation and relief of pain. (C) Cupping. (D) Moxibustion. Prognosis and Results: (A) Less pain. (B) More circulation. (C) Better agility and mobility. Although he is getting along splendidly at the moment, he still requires occasion­ al acupuncuture treatments to keep the results we accomplished. The prospect of Coach Dave Nelson as a senior citizen will be bleak when he reaches that stage. (1) Arthritis of the knee will be worsened because the increases of the calcium deposit. (2) Pain will increase. (3) Mobility and agility will be non-existent if anklosis devel­ ops. (4) Will have to depend on crutches to walk. Possibility of being bedridden. Acupunture as a preventive medicine: · If we acupuncturists are able to treat senior citizens under health care, the above problems would not arise. Our fee to keep patients like Coach Dave Nelson are not exorbitant. The cost-effective treatments are much less than the medical treat­ ments. We are keeping them from the hospital and their high costs. That is why we feel that acupuncturists should be given an opportunity to offer their services, so that senior citizens may be given an option if they desire to choose so. Thank you. I offer this testimony as a California and Florida States Acupuncture Examina­ tion Commissioner. Mr. ROYBAL.May I now ask some questions of the coach before you proceed. Coach, how long have you been treated by acupuncture? Mr. NELSON.I've been treated by acupuncturist Dr. Lee for three treatments. Mr. ROYBAL.And over a period of how long a time? Mr. NELSON.Approximately a month. Mr. ROYBAL.And your condition is much improved? Mr. NELSON.Yes, it is. Mr. ROYBAL.How has it been improved? Mr. NELSON.The pain has been alleviated. 24

Mr. ROYBAL. By "alleviated," do you mean you still have some pain? Mr. NELSON. I have some pain but not as much as I did have. And with every treatment, it seems to get a little bit better. Mr. ROYBAL. Did you go through any other medical treatment before going to an acupuncturist? Mr. NELSON. I've had four operations on my knee. One was 1959, I had a mediomeniscus removed because of a football injury. I think 7 years ago I had what they call a Pez transfer. I think some of the doctors in the audience could verify this, or explain it a little better than I can, a Pez transfer where they transfer ligaments from one area to another area to stabilize the knee. After that op­ eration, which took a long time in recuperating and therapy, I was-I had to go back in for an arthroscope. That is a microscopic type operation to remove a loose body in the knee. Then I was-I had to go back in again for an arthroscope because of a loose body, and I think the loose bodies were either small pieces of bone or it could have been something breaking off in the knee. Mr. ROYBAL. I'd like to ask the following question: Could the condition that the coach has described have been treat­ ed by acupuncture before he went through the various operations? Mr. NELSON. Before they answer that, I'd like to say that I last went to my medical doctor-and I respect him very much and I'm glad that I had him to do the surgery. He said that within 10 years, I would have to have my whole knee joint replaced because of the problem with my knee. My father, who has arthritis and is under the treatment of corti­ sone-I felt pain in my knee and I had to go back to the doctor and he injected it with cortisone. And I didn't like to have something injected into my body such as cortisone because I saw the results that my father has gone through, very discoloration of the skin. He gets a bump and it bruises very easily and that's a side effect of cortisone. And I've had pain since that cortisone shot, not because of the cortisone, I don't think, but because of the knee itself. I'd like to not go back for cortisone because I don't want the same condition to my skin that occurred-to occur as it has with my father. So this is the reason that I sought acupuncturist. Mr. ROYBAL. The question still has not been answered. Could the procedure that was followed medically in your instance have been prevented if acupuncture had been used? Mr. NELSON. Yeah, I can't answer that. Mr. ROYBAL. Will you proceed then with the demonstration please. [Acupuncture demonstration.] Mr. RoYBAL. The committee will go off the record at this point and we will pay our full attention to those who are administering the demonstration. [The committee went off the record.] Mr. ROYBAL. Let the record show that the demonstration is now going on, that it will take approximately 15 minutes for comple­ tion. The record must also show that alcohol was used as a disinfec- 25 tant, that disposable needles are being used, four in total, and that electricity is being used. Now, my question is since this is a practice that started approxi­ mately 2,000 years ago, when we had no electricity, why the new concept using electricity in this instance? Why do we use electricity today when the practice of acupuncture did not use electricity 2,000 years ago, at which time I was told just today, it was just as effective as it is today? Ms. LEE. As we understand it, the use of electrically operated machines to assist in the practice of medicine has been in use only during this past century. Acupuncture therapy has been in use for thousands of years. Finger manipulation was used, generating elec­ tricity through the hands, and charging it through the needle to the patient. Using this continuous manipulation, the twirling of the needle, the patient could be treated for sedation or tonification. Mr. ROYBAL. So what is happening at the moment is that those needles are being manipulated? Ms. LEE. Yes, but that procedure has been replaced. Instead of using the fingers continuously, we use acupuncture therapy ma­ chine, which is battery operated and safe. Mr. ROYBAL.Now, may I ask the patient, what do you feel? Do you feel electricity, do you feel any manipulation? Mr. NELSON.I feel a slight tingling. Mr. ROYBAL.But absolutely no pain? Mr. NELSON.No. Mr. ROYBAL.Now, I understand that your cartilage was re­ moved? Mr. NELSON.Yes, four operations. Mr. ROYBAL.Therefore, in that particular leg, you would say it is much different from your left leg? Mr. NELSON.Yes. Mr. ROYBAL.But you continue to feel pain in the right leg but the pain is much less now than it was before you took acupunc­ ture? Mr. NELSON.Yes, it is. Mr. ROYBAL.You told the committee that you went through a long process of medical care, including an operation. Mr. NELSON.Four operations. Mr. ROYBAL.Four operations. So it must have been very expen­ sive, was it not? Mr. NELSON.Well, yes, it is expensive. The next operation will cost me between $18,000 and $20,000 to have my knee joint com­ pletely replaced, which I'm trying to avoid right now. Mr. ROYBAL.All right. Now, Dr. Lau, I asked the question a little while ago. We heard the patient tell us that he went through a long series of medical treatments, including four operations. If he had sought your help, or the help of an acupuncturist prior to the time that he sought medical care, could all of this have been pre­ vented, in your opinion? Dr. LAU. Yes. Mr. ROYBAL.Let the record show that the witness has responded by saying, yes, that it could have been prevented had they gone to him or to an acupuncturist prior to the time that you went through the regular medical process. 26 Is that a correct statement now, both Dr. Lau and Ms. Lee? Ms. LEE. Yes. Dr. LAU.Yes, it's correct. Mr. ROYBAL.Is Ms. Murphy in the audience? Ms. Murphy, while we're waiting, will you please proceed with your testimony. STATEMENTOF JANE M. MURPHY,ACUPUNCTURE PATIENT, SAN FRANCISCO,CALIF. Ms. MURPHY.I haven't a prepared statement. I am a patient. This of course is a golden opportunity for anyone to talk about their health and have people listen. But I've been a patient of Dr. Collin Dong since about July. I waited about 3 or 4 months to get an appointment with him. I have had arthritis, severe arthritis, both rheumatoid and ostearthritis for about 7 years. I was lucky I didn't get it as a young woman. And being a senior citizen now, I am suffering a good deal from it. Actually, I had a hip operation, in fact two of them: One on Jan­ uary 11, 1977 and the second hip was done 2 weeks later. At the time of the second hip operation, the sciatic nerve was injured and so it has meant that I have what they commonly call a "dropped foot," I think. It's partially paralyzed. I feel like I have a steel ski boot on my right foot up to about my calf, the middle of my calf, all the time. It's painful and it's gnawing. Although I am over 70, I am very active and hope to be active. I have lots of interests and I pursue them as energetically as I can, and it just makes me so mad not to be able to do things that I feel like doing except for the fact I can't walk very well and it hurts so much. So anyway, I went to Dr. Dong-who is an M.D., and a graduate of Stanford Medical School and was born in Watsonville, but he went back to China to learn acupuncture after he received his medical degree. So I think he's well qualified, both medically and acupuncturally, if that's a proper word. In any event, the reason I went to him was that I was taking a great deal of medication I have a very good rheumatologist and I have no question of that at all. Dr. Dong doesn't change the medi­ cation except as my rheumatologist wants me to change it. In any event, I went to Dr. Dong because this foot was just not responding to anything and it was getting worse rather than better as I grow older, and heavier, I might add. And so I went to Dr. Dong and finally got an appointment with him. And immediately he put me on his diet and I lost 25 pounds in about 2 months. And then he gave me acupuncture and with that treatment I was able to reduce my prednisone, which is a derivative of corti­ sone from 12 milligrams a day to 5 and I'll probably have to stay on 5 the rest of my life because of my age and so on. But in any event, I was able to reduce my diuretic, furocymide, considerably, and my blood pressure went down. As a matter of fact, it went down too far for a while and they had to bring it up again, but I have low blood pressure normally but it had gotten pretty high for me. 27 And in any event, my whole physical feelings and-well, my whole physical being was really changed and was improved consid­ erably. Now, I don't think I'll ever be able to dance or anything like that, but if I could walk more than two or three blocks I'd ap­ preciate that at least, and not be in constant pain. To get to the cost, of course operations-my operation was about $25,000. Now, I don't know whether I would have been all right if I had gone to acupuncture first or not. I doubt if Dr. Dong or my other doctor knows or anybody else whether I would be as far as that is concerned. But it sure helps me now, and that's important to me, it seems to me. It keeps me up and it keeps me at the things that I want to do and I hope are useful. It is expensive now because medicare takes care of the part of Dr. Dong's treatment that is not connected with acupuncture. But it doesn't take care of the acupuncture. I see him-well, for 2 months I saw him every week, ane then I'm now seeing him every 2 weeks. And I assume I will eventually get to the point where I'll see him less often. I also had a carpal tunnel operation on my right hand. I had three paralyzed fingers and I had that done. And now it's much better. But that was costly too. But then this hand started and, like arthritis, you know, it just goes around and it's not anything that you can ever put your finger on for very long. I mean, if one part gets fixed, the other part goes blooey on you. Anyway, this left hand began doing that. And then I had acu­ puncture and that has just absolutely stopped. It's fine. I'm not swollen, It's not anything. It's just as good as it has ever been. So there's that. I just-it costs about $50 a treatment and that's expensive for a person on a fixed income. I'm glad that I'm fortunate enough that I can afford it, but it is expensive plus all, of course, of the other things that you pay for. So that's my testimony and as a patient I am very happy with acupuncture. I think it's been my salvation and I hope I've got an­ other maybe 10 years, maybe 5, I don't know, but I hope I have that so I can finish up some of the things I've started. Thank you. Mr. ROYBAL.Thank you, Ms. Murphy. Mrs. BURTON.I just want a moment of personal privilege. I wasn't here when Jane Murphy started speaking. Jane is an old and dear friend of mine and most of ~ou know that she is the vice­ chair of the police commission. She s a great community leader. But a few people might not know that she was a regional director of the social welfare department in the State of California. And that gives her an understanding of health, medicine, and the things we're talking about today. And I'm very grateful to you, Jane, for being here. Thank you. Ms. MURPHY.I'm very privileged to be here. This is the first time I've ever done this and I think it's wonderful. Thank you. Mr. ROYBAL.Thank you, Ms. Murphy. I do not have any ques­ tions at this time. We would like to complete the demonstration. Let the record show that at this point the demonstration has been completed and we will proceed by asking the patient how he feels. Mrs. BURTON.Can you run around the table? 28 Mr. NELSON.You know, at times I've had as many as 8 or 10 nee­ dles put in my knee. There's no pain. Mrs. BURTON.Now, do the needles stay, are they in now? Mr. NELSON.No, no, they extract the needles after the treatment is through. Mrs. BURTON.You extract the needles. There is no time that the needles remain with the person who has had a treatment? Ms. LEE. No. Mrs. BURTON.Any kind of treatment? Mr. NELSON.And I might add that the needle goes into the flesh. It doesn't just go into the skin and stay there, superficially. It's-I would say when he pulled the needle out, I was looking at it, and it was a good half inch into the knee. And it doesn't bother you at all. Mr. ROYBAL.Well, what did you feel? Mr. NELSON.I felt a slight tingle when he inserted the needle and then when he put the electricity on, I felt just a tingle, just a tingling sensation. Mr. ROYBAL.You have no pain now? Mr. NELSON.No. Mr. ROYBAL.May I ask the following question, based of course on testimony you have given. Ms. Murphy has stated that she went through an operation that cost approximately $25,000, yet it has not been determined whether or not that could have been prevent­ ed if she had gone to an acupuncturist. On the other hand, Dr. Lau and Ms. Lee have stated that in your case, Coach, that had you gone to an acupuncturist before you went through the medical process and it is quite possible it could have been prevented. Now, there appears to be a discrepancy between the two as to what one believes would have happened under almost similar cir­ cumstances. Excuse me, Ms. Murphy, did I misstate your testimony? Ms. MURPHY.I think you did. I didn't say that not anyone knew. I said that I didn't know. And the reason I said that is because my hips were ostearthritis, which is a deterioration of the bones that comes with age. And that, you know, you don't get any younger with acupuncture obviously, at least you might not show that you are as old as you are, but the bones might decay. And that's the reason I say that. And that is not scientific at all. I don't know what my doctors would say or what Dr. Lau or Ms. Lee would say. It might have been. If it had been, I could kick myself all over for not doing it before then. I should have. I'm sure I should have. Mr. ROYBAL.We are going to try as a committee to look into this particular subject matter very closely and get experts to testify before the committee as to what, in their opinion, would have hap­ pened under certain circumstances. We will also have other experts who will no doubt dispute it. Based on testimony of experts, the committee will then, will have to make a decision. It is we who are the nonexperts who will final­ ly decide what to do with this. This is why it is so important that we get the best information and that whatever we do with the bill is based on sound facts. Is there any further question? 29 Mr. NELSON.I'd like to offer a layman's opinion. I think there should be a combination of medical doctors and acupuncturists working together with this type of thing. I know, and I think the acupuncturists know and the medical doctors know also that there are certain things that you cannot treat with acu­ puncture, such as maybe a broken bone. I'm not up in the field of acupuncture, but I mean things such as a compound fracture of a bone, compound meaning that the bone comes out of the skin. To me it would very hard to correct that with acupuncture. Surgery might be involved and so on. After having had studied a little bit about acupuncture, I have learned that acupuncture can be used as an anesthetic for dental work or even open-heart surgery instead of having an anesthesi­ ologist administer anesthetic, acupuncture can be used and the pa­ tient is awake and there's no danger of losing the patient on the operating table. The old saying goes that the operation was a success but the ~a­ tient died. That might be alleviated. And I think there's-we re just at the beginning and I'm glad that I'm part of the foundation of what's going on here because I think acupuncture certainly has a place in the medical field. Arid with the combination of both the medical doctors and the acupuncturists getting together, it will even be that much better. Mr. ROYBAL.Thank you, Coach. Mrs. Burton. . Ms. MURPHY.I have a question about bones that comes with age, and that, you know, getting any younger with acupuncture obvi­ ously. At least you might not show that you are as old as you are, but the bones might decay. And that is the reason that I say that. And that is not scientific at all. I don't know what my doctors would say or what Dr. Lau or Ms. Lee would say. It might have been. If it had been I could kick myself all over for not doing it before now. Ms. LEE. Mrs. Burton, acupuncture is not a miracle cure-all for everything. It is a special practice like any_other special practice in the medical field-and we need more public education. In the old days, acupuncture was used mainly in the relief of pain, particularly with arthritis. It was also used as an anaesthe­ sia. It was also used in the treatment of some internal disorders. Acupuncture with the use of herbs was used as a preventive form of medicine. As I stated before, there are many things that acupuncture cannot do. It cannot mend broken bones. For that you use other means. Herbal packing is used for healing. After the bone mends together, acupuncture can be applied to increase better circulation. If your leg is stiff after surgery, acupuncture will enable you to have more mobility and better circulation, prevent­ ing a calcium deposit. What can acupuncture do in modern days? We have had very good results in drug detoxification, with many successes in Hong Kong where detoxification has been done in the use of heroin, opium, et cetera, except PCB. Acupuncture is also used in the treatment of obesity. It can also help build up the immune system of the body, preventing disease. This is done ahead of time, not when you're sick.

30-832 0-84-5 30 Acupuncture, at this point in time, is limited to the treatment of certain things. For example, it cannot treat a brain tumor or cancer. That requires a medical doctor. We should work together with the medical field for research in such things. It cannot cure AIDS. People claim that they can cure AIDS. At this stage, nobody has come to that yet. So I would prefer to say that those are the few things still in the research stage. Acupuncture treatment for such things will not be applied until the research is completed. Mrs. BURTON.Thank you. Mr. ROYBAL.Thank you. One last word of wisdom. Mr. NELSON.I don't mean to prolong this but I have two cases. No. 1, my son was a wrestler in high school and injured his knee. It was swollen so badly that he couldn't walk, the pain was so bad. I took him to Dr. Lee and Dr. Tam's office. They performed acupunc­ ture. He had to be assisted into the office. He walked out of the office and a day later he wrestled in a wrestling tournament and it was amazing. It couldn't believe it. The other case was one of my football players at Santa Clara University was complaining of a bruised knee. We took him to a medical doctor. The doctor examined it, X-rayed it, and said there's nothing wrong as far as cartilage or ligament damage. He said it was just bruised and it will take you a couple of weeks before he can get around. I took him to Dr. Tam and Dr. Lee's office on a Thursday and Saturday he played fullback for us. He's a starting fullback. And it didn't bother him. So if we're going to limit this just to the aging, I hope that you don't limit it just to the aging people. Mr. ROYBAL.Well, this is the Committee on Aging and we are interested, of course, in people who have reached at least the age of 55. On the other hand, I think you should know that at one time we held a hearing and I wanted to find out from experts what-when you become a senior citizen. And there were three of the top ex­ perts in the Nation together. They consulted and finally they came back with this answer. You become a senior citizen when you are 45 years old plus 6 months and 1 day. You should have seen the faces of members of my committee. Mrs. BURTON.They were all senior citizens then, right? Mr. ROYBAL.We are interested in the senior citizen, but are also interested in the young population of the United States because if they are lucky, they will be the senior citizens of tomorrow. I would like to hear now from Ms. Effie Chow. Will you please proceed. STATEMENT OF EFFIE CHOW, ACUPUNCTURIST, SAN FRANCISCO, CALIF. Ms. CHOW.Thank you for inviting me to testify at this hearing. And thank you also for your insightfulness to the needs of the people. Mr. ROYBAL.Ms. Chow, if you so desire, we can put your entire written statement in the record and then permit you to summarize. 31 Ms. CHOW.Right, but I would like to augment it with a demon­ stration if I may. Mr. ROYBAL.Without objection, that will be the order. Please, proceed. Ms. CHOW.Yes; but I would like to illustrate one of the theories which I have stated in my written testimony as one of the key principles as to why traditional acupuncture, Chinese medicine, is successful whereas other systems have failed. This is the theory of working with energy systems and body immunological competence. There are meridian, or energy, pathways and points on the body. You saw a demonstration on acupuncture. I would like graphically to demonstrate to you to you how it works by utilizing the energy meridian and the points on the body. Mr. ROYBAL.Ms. Chow, we will then include your written text in the record at this point and you may proceed then with the demon­ stration. Thank you. [The prepared statement of Effie Chow follows:]

PREPARED STATEMENT OF EFFIE Pov YEW CHow, PH. D., R.N., C.A., PRESIDENT, EAST WEST ACADEMY OF HEALING ARTS, SAN FRANCISCO, CALIF. Honorable Chairman Edward Roybal and Honorable Sala Burton, making acu­ puncture services available to the elderly and the poor through medicare and medic­ aid reimbursement will mark one of the most important and creative contributions to the quality, cost-effectiveness and humaneness of health care in the United States and to the field of health promotion/disease prevention thus fostering healthy aging instead of degenerate aging. Thank you for inviting me to testify at this hearing of the House Select Commit­ tee on Aging and thank you for your insightfulness to the needs of the people. I am a public health and psychiatric nurse, behavioral scientist, and educator and a California Certified Acupuncturist; China-born, Canada-raised and now home­ based in San Francisco. As president of the East West Academy of Healing Arts, a private clinician, teacher and consultant, my extensive travel and contact with many thousands of people each year, my words (even though I am speaking for myself personally here) will reflect my dialogues with and input from this extensive network. This network is of all ages, cross-cultural identity, full range of socio-eco­ nomic status, and all levels of health or sickness. It includes health professionals; administrators; consumers; media people; traditional Chinese medicine-acupuncture masters from here and abroad; other healers; curious individuals; lawmakers; major institutional policy and management people; university faculty and educators; et cetera ... The traditional acupuncture system of therapy has a great deal to offer our West­ ern health care system and with noteworthy benefits, both cost-effective and safe for our target population ... the elderly. Before responding to the specific questions placed before us, I would like to clarify my reference base pertaining to acupuncture. · Acupuncture is not a technique, method or modality; is not a cook-book recipe to be memorized for a certain disease. If practiced in that fashion, there is a high prob­ ability for failure or minimal results and the reputation of acupuncture will be tar­ nished. My frame of reference is traditional acupuncture, a 5000 years old therapeutic system within a major medical/health system with its origin in China. A system that historically enjoyed the same status in China just as Western medicine enjoys in the USA. A system that has proven successful for keeping one-third of the world's population healthy. A system that has accomplished many miracle-like feats such as: analgesia with one needle to facilitate a resection of a part of a lung; or a patient wide awake sipping tea, eating mandaring orange segments and conversing with a doctor while undergoing a craniotomy or lobectomy (NBC films); an arthritic 32 wheelchair-bound patient with immobile lower and upper extremities, clawed-hands, and constant intense pain, is suddenly pain-free and able to move arms, legs and fingers after one treatment; or a hemiplegic stroke patient with a hopeless prognosis regaining full function after several treatments. Yes these cases and many others similar have happened and are still happening, for these types of cases, their recovery are often spectacular in nature. Many people not understanding the principles of acupuncture unfairly expect this type of re­ sponse for all cases and if there is not an immediate miracle-like response, will brand it ineffective. However, I would like it reinforced and understood that traditional acupuncture/ Chinese medicine is a very complex system of practice requiring extensive and skill­ ful knowledge in theory, diagnosis and application. Therapy more often than not re­ quires a reasonable number of sessions comprising a course of treatment before sig­ nificant results are realized or for long lasting effectiveness. For some conditions there may be a period of rest between repeated courses of treatments. Others may require a regular "booster dose" such as once a month or a few months' time, e.g., for promoting health and preventing disease. The best course of therapy is deter­ mined by the nature of the condition and by the practitioner with cooperation of the client. Acupuncture therapy often are augmented by herbs, exercise, nutritional counseling, acupressive and other practices of Chinese medicine. A few key principles of traditional acupuncture/Chinese medicine believed to render the system especially successful (and also for cases where other methods have failed) are the following: (1) The immunity system of the person is enhanced and maximized therefore cre­ ating a healthy host which can resist external agents such as germs, weather, etc. It is thus a health promoting/disease preventing system. (2) The philosophy of an inherent micro-marco relationship, duality forces (poles) of yin/yang (negative/postive), harmony and balance of man to nature and envirn­ ment represented by the five phases/elements. These concepts are closely associated by physicists (such as Fritjof Capra, a high-energy physicist from Berkeley Laurence Laboratories) to modem Quantum Physics. (3) The many dimensions of the whole person-physical, mental, emotional and spiritual-are considered inseparable and essential to the diagnosis and plan of treatment. To treat the person in a whole manner, the system of approach must be whole in that acupuncture therapy is enhanced by teaching the client to be self­ sufficient, to consider nutrition, herbs, exercise such as Qi Kung, Tai Chi Chuan, meditation, changes in values and behavior, strengthening relationship and so on. (4) Most importantly the theory of Energy System and points, the Ching-Lo System, is primary to the basic tenents of traditional acupuncture. The endorphine theory is an exciting and major breakthrough to bridging Eastern and Western ter­ minology and understanding. It is still a small segment of an extremely complex Chinese system of medicine. (5) There is no possible dangerous addiction or drug side effects. (6) It is far less expensive to administrator and does not involve elaborate expen­ sive technology. It is with the above parameters in reference to traditional acupuncture as a system that I qualify my response to the first question: Is acupuncture (an) effective method (system) for treating certain health care problems? Unequivocably, Yes! Be­ cause of the status (or non-status in some states) of acupuncture in the US, there are not any to my knowledge, extensive proper research studies carried out on its efficacy or cost-effectiveness. However, in China clinical research is ever-increasing to validate the old and establish the new findings. Many studies are being done on the elderly population. Dr. Xi Yong-jiang (Chief of the Acupuncture Department of the Shanghai College of Traditional Chinese Medicine, the Vice-President of the Shanghai Acupuncture Association and on the National Committee for the Evaluation and Granting of Aca­ demia Degrees) reports a 70 percent effectiveness from a clinical research study car­ ried out on 1000 cases of Congestive Heart Disease patients all showing angina, full­ ness in the chest and arrhythmia. They were four types of patients: (1) usually about 50 years old with dyspnoea, insomnia and generalized fatigue, (2) usually well over 50 years with intolerance to cold, lack of spirit, pulse is slow, fine, thready and deep, (3) usually patient is fat so he/she is out of breath, can hear sputum rolling, pulmonary function is decreased, has epigastric discomfort, anorexia and nausea, (4) the most common-where the chief factor is the emotional one whereby the patient is tense, has insomnia, chest pains and eventually angina, shortness of breath. Herbs which act similarly to nitroglycerine are given-or patients can continue on nitroglycerine at the same time that they are receiving acupuncture. After two 33 months of needling, 60 percent of the group no longer needed nitroglycerine and the remaining 40 percent showed a noticeable decline in its use. Sixty percent had ECG improvement and a lowering of blood pressure and of blood cholesterol. Dr. Yan Liu, also of the same institution as Dr. Xi, reported that the system of Scalp acupuncture is good for geriatric patients. It employs traditional acupuncture methods and modern understanding of cerebrovascular functioning. It is especially effective for CVA's stroke sequelae, and encephalitis. The following are sample cases which have been helped by principles of tradition­ al acupuncture/Chinese medicine. Some have been labeled hopeless. The results are as directly reported by the Director of Nursing of the institution(s). To protect their confidentiality I shall not name them nor the institution. Case: 76 year male. Parkinson's Disease for 10 years. Institutionalized 5 years. De­ creased circulation and loss of sensation in lower extremities with foot drop. Severe pain left head, body and lower extremities. On aspirin. Difficulty walking with walker. Staccato-type speech with severe stuttering. Following first session, regained sensation throughout lower extermities. Speech smoother easier to understand and immedicate decreased stuttering. Decreased aspirin intake since. Case: 83 year female. Herpes Zoster right rib cage 5 years ago which was resolved but left a residual constant intense pain of right shoulder and arm. Institutionalized 2 years. Placed on many narcotics for pain, became addicted-now on methadone to no avail. On TENS with no results. Remains in fetal position with arms and legs contracted, sits drawn to right side with right shoulder-drop. Could not sit up straight nor lie on back for several years. Reactive depression because of pain. De­ manding and very negative behavior. With initial session-very remarkable. In 1 hour pain was completely gone, stopped complaining, furrows of eyebrow gone, sat in straight position, no longer in fetal position, arms and legs nearly straight and laid on back relaxed. For over a month-relaxing faster, lies flat on back and falls asleep. Less negative response upon approach. Can accomplish pain relief within 20 minutes with my special relaxation methods that I taught her. Now no longer com­ plains of pain and have not used TENS nor taken methadone since beginning ses­ sions. Staff gives support therapy for her two times a day. The degree of disturbance and additional cost this lady created for the institution and the subsequent change of behavior was unbelievable. This patient was on a heavy skilled care floor and was responsible for many burned-out staff turnover every week. Patient had to be moved at least once a month from room to room or from floor to floor because patients also couldn't bear to share the same room for long. Since patient had the first session two months ago, there has been no staff changes nor room changes and they do not anticipate further need for it. There is reduced stress level on the whole floor with improved attitudes of other patients too, who want to learn some of the things which this patient is learning to do. Staff and patients who used to resist approaching this patient now no longer feel resistive, The turnover of staff and the changing rooms were additional dollar expenses for the insitution as well as additional wear and tear on staff. Case: 82 year female. Severe rheumatoid arthritis and degenerative joint disease. Institutionalized 4 years. History of bleeding ulcers. Not walked 2-3 years. Severe rheumatoid fingers, hands, elbows, knees. All joints with edema and pain upon movement. On Tylenol. Immobility of joints 6 months to 1 year prevents her from feeding herself or doing ADL. Could not close hand into fists. Nurse is not able to take blood pressure because of excruciating pain_and couldn't move arm. After first session there was dramatic relaxation, freedom from pain and patient could move left arm above shoulder and could feed herself, Decreased hand edema and no pain, could close hand into fist. Brought hands up to touch forehead and continued to do so. This she had not done for two years. Decreased use of Tylenol now. Case: 78 year female. Parkinsons. Tremor of head. Admitted for hip fracture. In­ stitutionalized 1 ½ years. Discharged to a group home 1 ½ years ago walking. Had a fall in the group home. Returned to institution 5 months ago in wheelchair. Con­ stant back pain, could not ambulate individually. Had vertigo. With walker and as­ sistant went only from bed to toilet, then 25-50 feet. Memory poor-could not re­ member what happened immediately before. During first session two weeks ago, pain completely gone. Walked independently more than 200 feet. Mind was clearer and could recall one moment to another. Now no further complaint of vertigo. Con­ tinues walking independently. Increased circulation with notably clearer mind and improved memory. Not asked for pain medication since first session. Case: 69 year female. Alzheimers. Institutionalized 2 months for hostility, aggres­ sion. Wanders into other patients' rooms. Strike and bite staff. Ran out of facility. Brought back and restrained. Continued agitation. Usually used heavy dose of 34 Valium, put in session, patient calmed down so that the prepared Valium injection was not used. Besides those conditions mentioned in the sample cases, there are many others that may be effectively treated with traditional acupuncture/Chinese medicine be­ cause of its system's approach to building up body immunity. Also because of this factor, an important function of acupuncture is to promote healthy aging or slow down the aging process. There is also recognition that there are some conditions that will have less or no response to traditional acupuncture. One such condition generally recognized is bone deafness. A good practitioner will acknowledge both the pros and cons of the system. The second question: Should Acupucture be covered under Medicare and Medic­ aid? Unequivocably, Yes! Hopefully the sample cases also shed light on the potential savings in dollars and emotions. With the following statistics of the nation's popula­ tion and health care costs, if acupuncture can help reduce even one day hospitaliza­ tion and cut down one half of pain medication and tranquilizers used, the savings would be tremendous. Every day 4000 more Americans reach age 65; about 3000 die, so there is a net gain each day of 1000 survivors over 65 years of age. Coupled with near-zero popula­ tion growth, this trend is causing a change in age distribution in the US. In 1900 there were 3 million persons or 14% of the population who were over 65 years. Today, 25 million or 11% are over 65. In 2030, the projection is 50 million or 17% will be over 65 years of age. Medical treatment for above 65 year old people comprized of about 30% of our Nation's total health expenditure. People over 65 cost more than twice as much to treat, they have more complicated and more severe diseases. 80% of older people have one or more chronic conditions. Our health costs have tripled in the last decade: 1979 $206 billion (30 percent to elderly-61.80 billion) 1983 :i;362billion (30 percent to elderly-120 billion); and 1993 $1 trillion anticipated (30 percent to elderly-330 billion). The figures are truly frightening. Without medicare reimbursement, the elderly patient must now pay out-of-pocket for acupuncture treatment or continue to miss out on potential benefits of acupunc­ ture. The acupuncturist in turn would not get the patients or would have to volun­ teer services. Knowing that I can help certain debilitating conditions even though the person couldn't afford it, I wind up volunteering a great deal of time and serv­ ices. The third question: What other changes should be made in the Medicare and Medicaid programs? At this time I have no recommendations on this, but I would like to respectfully request that the House Select Committee on Aging to facilitate a funded project to gather the proper and much needed data on the cost-effectiveness of acupuncture for our health care system. Information is available for collection and analysis. However, it takes time and money to properly gather meaningful sta­ tistics so that it is more than anecdotal information. I shall be happy to participate in such a worthwhile project. The Columbia Lutheran Center for the Aging with a progressive board and ad­ ministration and for whom I am a consultant, is attempting to incorporate princi­ ples of traditional acupuncture and Chinese medicine. Some cases are from this in­ stitution. I invite you to visit the Center to personally feel some of their excitement. I have very recently returned from the People's Republic of China where I deliv­ ered a paper to the Shanghai Second Medical College and observed Acupunture/Chi­ ness medicine practiced in many hospitals in total harmony with Western medicine with very excellent results. In many cases one system alone would not be as effec­ tive or be effective at all. It reinforced my conviction on the value of integrating traditional acupuncture/Chinese medicine for the ultimate benefit of the people in the USA. Again thank you for the privilege of being a part of the hearing and if there is something else that I can do to help with this worthwhile mission, please call on me. Dr. CHow. In Chinese medicine, it is stated that we are a unit of energy and perhaps seeing this demonstration will help you under­ stand why sometimes it is difficult for Western scientists to under­ stand its rationale, and also why it may be difficult and minimizing its traditional effectiveness to carry out strict basic research on it at this time. It is possible that new methodologies or policies in re- 35 search may need to be established in order to do fair research on this particular system of practice. [Male subject participated in demonstration.] I'd like you to stand up and put both your hands together, arms straight out and up at eye level. I'm testing his energy by pulling down on his raised arms as hard as I can; and I cannot budge him. He's strong. There are many channels in the body. In this case, I'll use the conception vessel energy channel which runs up and down central­ ly in the front of the body. I'll use my fingers to trace down from the chin along the channel in one direction. Now I want you to resist in the same way when I again try to pull down your arms. You can see that there is a definite change, a weakening, in his energy level and strength. We have dispersed his energy in this in­ stance by using my fingers instead of a needle. In acupuncture, the needle operates under the same principle' so that with the needle pointing opposite to the direction of the energy flow, the energy is sedated. Now I'll trace my fingers up the channel of the conception vessel. Again, put up the arms and resist my pull. He has now regained his strength. I'm pulling even harder than before. So that now trac­ ing my hands in the opposite direction to the previous action, this time going with the flow of the meridian, you can see that his energy is strengthened. There are many other exacting theoretical principles. But time is limited, so I'll just use one other example; that is use of a gentle touch versus a hard touch. Now using a point on the forehead called gall bladder 14, one inch above the eyebrow, I've touched it very lightly. Put up your arms again and resist. Resist my pulling down. You can see that his energy is affected, it is dispersed again. One can say that we have weakened the host. Now using a very heavy pressure on the same point-up with your arms and resist again my pulling them down-there again he has regained his strength. So that heavy pressure or heavy stimulation, calls energy to the point and to the body. You have witnessed a brief demonstration on the effects of work­ ing with energy pathways and points. Basically needles in acupunc­ ture treatment affect energy similarly. As do moxibustion, herbs, nutrition, the meditative process, and the Qi Kung or Tai Chi Chuan martial arts exercises which are all various practices of the Chinese medical and health system and which all augments the practice of acupuncture. Thank you. Mr. ROYBAL.Will you please remain at that seat? You are now a sworn witness. Mrs. BURTON.Should I say that Mr. Ed Davis, the person she demonstrated on, is my administrative assistant from Washington, and the two of them don't know one another so there is no hanky­ panky, this is a real demonstration. I was amazed myself. Dr. CHOW.I do a lot of lecturing and teaching of health profes­ sionals; physicians, nurses, psychologists and so forth. Energy sys­ tems is one theoretical tenet along with many other scientific the­ ories which I use to teach. It is hard theory like the fact that if you 36 cut into an artery, you get red spurting blood; if you cut into a vein, you get dark blood that oozes. Energy theories underlie work­ ings of acupuncture and other methods of Chinese medicine. Mr. ROYBAL.Now, may I ask a question? And I am asking the question of you, Ms. Chow, and then the patient. In one instance, your finger went down and that decreased his energy. Ms. CHOW.Right. Mr. ROYBAL.Then what you did after that, was to increase his energy by putting your finger up. Supposing you had not gone up. What would happen to his energy for the rest of the day? Ms. CHOW.It depends on the health status of Ed. He could be weaker for numbers of days or may be weak until someone helps to stimulate him again. It depends on his mental and physical status. If he is basically balanced, his dynamic homeostais, then his whole body would reorganize and rebalance itself. Mr. ROYBAL.Now, in one instance as he held his arms out, you were having difficulty bringing his arms down. His strength was up. Ms. CHOW.Yes. Mr. ROYBAL.Then you went through certain procedures that weakened his strength, or it appeared that his strength was weak­ ened. Now, did you try just as hard when your finger went up as you did when it came down? Ms. CHOW.When-- Mr. ROYBAL.I am asking him. Mr. DAVIS.Yes, it did. I'm sweating right now. I don't sweat a lot. I was sweating quite a bit, each time she was pulling down on my arms. I simply had no strength or very little. And by the way, I had not discussed this, but I've discussed with Ms. Chow before about coming here to testify. I had not talked with her about this demonstration before half an hour ago and in fact had no idea what she was going to be doing. Mr. ROYBAL.A half hour ago. Did she tell you exactly what she was going to do? Mr. DAVIS.No. A demonstration of acupuncture theory is what she said. Mr. ROYBAL.Because this particular theory is not a matter of mind at this point. Mr. DAVIS.It certainly convinced me. I simply could not keep my arms up. Mr. ROYBAL.I know that something like that is used in various martial arts, and in the preparation for competition for martial arts. Is it possible then that in such competition or any place else, that if the energy was reduced, that the athlete's ability would also be reduced? Ms. CHOW.I didn't quite understand the question. So you mean like one part of his body would be stronger and the other part weaker? Mr. ROYBAL.Yes. Supposing that he was preparing for a context of some kind. Could his energy be reduced by just merely running a finger down as you did? Ms. CHOW.Yes. 37 Mr. ROYBAL.So that would reduce then his athletic ability. Ms. CHOW.Yes. See, that's the powerfulness of this system which is not generally realized. So powerful that one little needle can pro­ duce analgesia-you feel but you don't have pain so its analgesia, not anesthesia-strong enough for a lung resection operation. We have an NBC film which shows that and other operations. And as Ed says, he was really sweating. What we've done is almost like suddenly opening up the energy circuit. I've acted as a catalyst to open up some blockages and energy channels in him so that it's like giving him a powerful jolt. He is he feels all wet in fact from sweating. Mr. ROYBAL.That's a most interesting demonstration. Mrs. BURTON.I hope you've restored him to his original energy. Ms. CHOW.He's even been made stronger. Mrs. BURTON.You did? Ms. CHOW.Yes. Mrs. BURTON.We have a Burton machine team in Washington, and play ball, and you know, Ed, this is an interesting thing. We could win all those ball games. I would like to ask you a question. Has this ever been done with animals? Ms. CHOW.Oh, animals-- Mrs. BURTON.Or does it work on animals? Ms. CHOW.Yes. Animals also have meridian channels. There are charts that show the channels on elephants, cows, dogs, cats, and horses. Mrs. BURTON.Because the chairman said something very inter­ esting when you said that in case you have an athletic meet, I just wonder whether people would use this sort of thing in a betting game, you know. Let's say two boxers, a football game. Ms. CHOW.This can be used to great advantage for the sports people. Mrs. BURTON.I hope not. I hope they don't do that. Then it's not a real contest, you know, someone has been tampered with. Ms. CHOW.You know, it-- Mrs. BURTON.It's a fascinating thing. Ms. CHOW.Well, the exercises that exist in the Chinese system, Qi Kung Tai Chi Chuan, the martial arts, all utilize these princi­ ples. I just came back from China, made a presentation at the Shanghai Second Medical College and also had a chance to observe acupuncture in China. We exchanged dialogs regarding the energy phenomenon, and we equated it to the Qi which is energy, that they speak about in Qi Kung exercises. Further discussion was held on the utilization of that energy in acupuncture and other forms of healing. Mrs. BURTON.Now, are you a registered nurse? You said you were in public health. Ms. CHOW.Yes, right, and psychiatric nursing. Mrs. BURTON.Are you a registered nurse? Ms. CHOW.Yes, I am a registered nurse. Mrs. BURTON.And you have worked with medical doctors prior to going into acupucture? Ms. CHOW.Yes. Mrs. BURTON.Do you still do regular nursing or-- 38 Ms. CHOW.Yes, I do. I have been active in a psychiatric situation whereas I use these skills to help reach the patients. It helps to open them up so that they can be more receptive to psychiatric in­ tervention. Mrs. BURTON.You also feel it helps in terms of psychiatric pa­ tients? Ms. CHOW.Yes. Many of my patients have depression syndromes and pain and are referred to me by physicians or psychiatrists. In my practice, I prefer that my patients have both a Western medical diagnosis and workup, as well as, a complete Chinese diagnosis. Mrs. BURTON.This will be my last question. Are psychiatrists dis- posed or are there some psychiatrists that are disposed to you-­ Ms. CHOW.Some psychiatrists, yes. Mrs. BURTON.Thank you. Mr. ROYBAL.Ms. Chow, may I thank you for your very interest­ ing testimony. Ms. CHOW.Thank you. Mr. ROYBAL.And I also thank the patient. Without your help, I don't think we would have been able to conclude this part of the demonstration. The next panel will be made up of the following people: Barbara Sklar, Charlene Harrington, Tish Summers, Donna Ambrogi, Lilian Rabinowitz, and Maureen Malvern. Now, this is a panel on medicare and medicare solely. I'm going to ask Mrs. Barbara Sklar to start the discussion. STATEMENTOF BARBARASKLAR, PLANNING DIRECTOR, GERIATRICSMOUNT ZION HOSPITALMEDICAL CENTER Ms. SKLAR.Thank you. I am starting the discussion but I am not going to cover the eminent crisis that we're hearing about in the general terms. Mrs. BURTON.Will you identify yourself? Ms. SKLAR.My name is Barbara Sklar. I am the director of plan­ ning at Mount Zi9n Hospital here in San Francisco and a member of the executive board of the National Council on Aging. In front of you, you have the written text of my testimony which identifies the issues in utilizing alternatives in long-term care. One of the things that isn't in the writing is that all of my comments reflect years of research and service delivery to actual consumers. Most of the statements are and can be verified by those of us who are either over 45 and 6 months or over 65. I'm not sure which term we want to use today to describe the "elderly." All have agreed-and I don't think it's even open for discussion anymore­ that the system of long-term care health delivery in the country is now inappropriate and inadequate. That when it does exist in some small pockets in this country it is often inaccessible and very ex­ pensive. Of course the increasing numbers of frail elderly are contribut­ ing to that cost. But we believe that much of the responsibility lies in the reimbursement bias toward long-term care and acute care institutionalization. 39 In addition, the separation between the acute care and long­ term-care systems, and between health and social services further exacerbates the situation. Research and demonstration projects have been defining the ele­ ments that cause these problems, examining methods for correcting them, and developing models for providing improved delivery sys­ tems for the chronically ill elderly. I believe in the research and demonstration projects, but I think we have to be cautious and re­ member that they are just what they say they are, they are just projects and although each contributes to the body of knowledge, no one single project will come up with all the answers. We can't use a cookie cutter approach in saying OK, this one worked, that's it, it's going to work everywhere. There must be flexibility in developing programs at the local level. A further problem which we have identified in several demon­ stration programs in health care is that the results are examined by the Health Care Financing Administration in the aggregate and the aggregated results are looked at. But inherent in being a demonstration program, they are prov­ ing different things. They all look a little bit different and to aggre­ gate them and to determine a means you are taking the ones that were very successful and those that were not so successful and those that were actually failing to do what they set out to do. De­ termining an average from the results is therefore inaccurate, un­ scientific, and a waste of time. I would propose that as you, as policymakers, look at the infor­ mation, you look at the results individually and look at the individ­ ual successful projects in long-term care rather than having them all brought to you as a package and looking at the average of what succeeded. The Brown University hospice study which combined successful and unsuccessful project is a perfect example of that. I've spent in England and looked at the National Health Service and every area that I visited in that country identified significant savings by adding in home and adult day health care services to their long­ term system. Yet an aggregated study known as "222" found the same programs in the United States were too expensive. Right here in California, we have had over 4 years in adult day health care being part of the medical system. We run such a serv­ ice at Mount Zion Hospital. And with only 24 centers open, about a third of what was projected, there was over $1.5 million annual savings from the diversion and avoidance of inappropriate institu­ tionalization. In fact, when our center was reviewed, they told us 98 percent to 99 percent of our patients would have been institutionalized if it was not for this alternative level of service in the community. Statewide, 63 percent were identified as eligible for institutional placement. For the past 5 years I have been a director of a health care fi­ nancing administration long-term medicare demonstration project which is based on the case management system. We were deliver­ ing services to 220 frail elderly. I wished that I would have had the final report for you today but I do not have it. I hope that I may send it on to you. It will be ready by December 31, but we do see 40 significant savings and more appropriate utilization of services by the elderly we were serving. Because of these experiences-and a State medicaid project at Mount Zion-we have found that one of the major problems is the myriad of funding sources at every level of government, starting at the Federal level. And that these sources of funding should be put together under one Federal authority. A single State agency, should receive consolidated funds, then contract with providers in the community to provide coordinated services. We believe that cost savings would result by reducing administrative costs, bulky paperwork, duplication of services and contradictory eligibility re­ quired for various programs. I'm not telling you that home health care costs will be dimin­ ished by expanding home health care, but I am saying that is a better way to spend money. Rather than building more nursing home beds and there are studies that show that any time you build a nursing home bed, it is going to be used, let us provide choices. If we move somebody out of the hospital and save administrative days in that hospital we can reduce rehospitalization. Let us pro­ vide choices. Remember the preference of the consumer is to have alternative home health services and not be in either one of those beds. I think as we're looking down the road at the DRG's becoming part of our system, we have not made any plans for posthospital care for people that are going to be asked to leave the hospital in a much shorter period of time. We don't know what that system is going to look like but we need to prepare for more home delivered services as we try to develop DRG's. Ms. BURTON.Would you tell me what DRG is? Ms. SKLAR.Oh, yes. That's a "diagnostic related group." It's the new medicare way of paying hospitals for service. Whether you spend 25 days in the hospital or 10 days in the hospital, a preset reimbursement based on your diagnosis will be the determination of how much is paid. Therefore people are going to leave the hospi­ tal earlier because the hospitals are only going to get paid a cer­ tain amount of money no matter how long you stay. That's got to be tested. And I think it's a way of beginning to look at controlling health care costs. However, we have not simul­ taneously put together a posthospital system for people who are now going to be sick leaving the hospital. So we need to expand that home system for them. To summarize the proposals that we make for establishing incen­ tives, expanding medicare benefits, controlling utilization and rede­ fining eligibility, first I will start with the services that we propose by listing them. To include a case management system of assessment, care plan development service coordination, and advocacy. To expand existing home health care services, especially because of the development of DRG's. To provide adult day health care as a proven. way of reducing costs and a humane way of treating people. To increase transportation benefits so people can get to the health care services. 41 To provide respite care to the families. We really have a strong belief that families do stay involved. There are statistics that show they do, but the harder their job is the less likely they are to stay involved unless we provide them some respite from this care. Not listed are the whole areas of hearing care and vision care that really need to be examined again under Medicare services. We recommend also relooking at the eligibility requirements. A subset of criteria under medicare for those people who are func­ tionally limited should be put in place. The long-term care studies do show that the age at which people need these services is much higher than the 65-year limit so that age itself is not enough of a factor for this eligibility. It is essential that these eligibility re­ quirements do address the functional limitations of the individual. We recommend a whole series of incentives for combining the funds, as I mentioned before, including the provider level. I think there have to be caps put at the provider level to make sure that, per capita, we do not exceed the amount that had been spent for someone who was being placed in a nursing home in that geograph­ ic area. Until we put those caps on the providers in addition to the hospital, we won't be able to control costs. In summary, as I said, funding sources should be consolidated and put on a capitation basis to a single State agency. That State agency should contract with local providers. Various models and multiple entry points are essential to this system so they reflect the location of the elderly in each community and the services those elderly use. Hospitals can be one of those host agencies. Medicare benefits should be expanded to include case manage­ ment, home health maintenance services, adult day health care respite and nonemergency services. We must reexamine the eligibility criteria and develop a su9set of criteria for severely functionally limited elderly; a series of in­ centives that would focus on the use of less costly noninstitutional services should be developed at all levels. . While these stand on their own merit, I think-and I was not going to talk about the broader issues-that I should compliment the panel for looking at where medicare is going. This reflects what the consumer wants. We have shown the consumer wants cost sav­ ings. As I said, ·1 can't give you the total results, but we do see that we're saving 15 percent on medicare by providing these additional services. And I think that is up to you. Now that we can provide you with this information, you must take the leadership role and act on pro­ viding community-based long-term care to our elderly citizens. Mr. ROYBAL. Thank you. [The prepared statement of Ms. Sklar follows:]

PREPARED STATEMENT OF BARABARA SKLAR

INTRODUCTION It has become generally accepted that the health and social service delivery system for the elderly in this country is inadequate, inappropriate, ineffective, and what does exist is often inaccessible. At every level of government system is frag­ mented. To add to the insult it is expensive. And, of course, cost is effected by the increasing numbers of frail elderly. Equally responsible is the reimbursement bias towards long term and acute care institutionalization. The accompanying separation 42 between the acute care and long term care systems, and between health and social services further exacerbate the situation. We must examine methods for correcting these problems. Research and demon­ stration projects have been defining the elements that cause these problems, exam­ ining methods for correcting them, and developing models for providing improved delivery systems for the chronically ill elderly. But they are just what they claim to be: Research and Demonstration projects. Each contributes to the body of knowledge in some way, but no one claims to, nor has all the answers. But there are problems in the research. One example is the "222" Adult Day Health Care and Home Care study, 8 years old, which was a poorly designed study. It set out to test if you added Home Care and Adult Day Health Care would Medicare costs be higher. Of course Medicare costs were higher. But there were corresponding declines in other expendi­ tures which the study never acknowledged. An additional problem with the "222" study and the recent Brown University Hospice report and others is that they look at demonstration projects in the aggregate. This is wrong because inherent in the demonstration process, some projects will be successful and some will not be. To group positive and negative results from very different demonstrations is to com­ pare apples and oranges and expect to get a positive result. More recent studies have made a distinction between various funding sources and between types of services such as home care services and community-based services. There has been a move away from the medical model to the health and social serv­ ices model which indicates a higher potential for cost savings as well as improved service utilization rates. In England, where the National Health Service has better control over dollars, they have indicated significant savings from the use of in-home and Adult Day Health Care (ADHC) services. Closer to home, California, has had ADHC reim­ bursed under Medi-Cal (California Medicaid) for over 4 years. Under a "sunset clause" it would have been cancelled in Fiscal Year '83 if it had not been proven cost effective. But the results showed that with twenty-four centers operating, there was an annual savings of $1.5 million from the diversion/avoidance of inappropriate institutionalization. For the past five years, I have been director of a Health Care Financing Administration Long Term Care Project, Project OPEN. We proviede a broad range of health and social services in a case management system to 220 frail elderly Medicare recipients. A final report will be available by December 31, 1983 which will indicate cost savings, improved delivery system and more appropriate service utilization by the elderly. T~ese chronically ill elderly individuals have multiple needs. The needs, for many, can be met in the community in an effective, efficient manner. However, a non-system has developed due to fragmented funding sources and eligibility criteria. We would propose that the myriad of funding sources at the Federal level, be com­ bined and paid on a capitation basis to one state agency that then contracts with local providers to coordinate and provide services. This model could reduce adminis­ trative costs, bulky paperwork and duplication of services. It would simultaneously improve coordination and access. We, therefore, beleive that Community-Based care can be cost effective. The prob­ lem is that cost savings are often confused with cost expansion. The majority of community-based service projects and programs can show that the combined utiliza­ tion costs of services spent per person in the community is less than the cost of nursing home care in the same community. That does not deny that initially the Medicare costs would be higher for people who were previously not under care in either location. The questions that are still being asked may only be answered after years of expe­ rience, not from short term projects. Policy makers are asking "What are the appro­ priate services?" "Who are the clients and what do they look like?" "What are the long term implications?" The long term care research project were short lived. Here is another instance of American impatience and the need for instant answers causing us to fall behind the Japanese. The "health industrial complex," like the car industry, looks for instant gratifications. I am reminded of the response of both countries to the U.S. Govern­ ment's strict car emission standards. When they were published, the Japanese car manufacturers hired 2,000 engineers to improve their cars to meet these standards. The American companies hired 2,000 lawyers to figure out a quick way to avoid meeting the standards. Like the American car industry, our medical industrial com­ plex leaders-researchers, academicians, providers, and policy makers want instant rewards, especially financial savings. Since they have the problems NOW, now is when they want answers. As a result, 12 months of research is allocated for a prob- 43

lem that has been accumulating for years. The results are supposed to reflect the reality of a 10, 15, or 20 year illness. The Japanese, in contrast, have done a 20 year study on the health delivery system. For an entire village (Sauauchi Village with 16 percent elderly), they pro­ vided health education, preventive services, home health, homemaker and service coordination for the chronically ill elderly. The first ten years the program grew and costs increased annually. However, by the beginning of the second decade­ costs began to drop significantly each year. They saw substantial savings in the dol­ lars spent per person in their community, especially for the care of the elderly. Other recent research projects have found-including the study at Mount Zion Hospital and on Lok in San Francisco-that acute and skilled nursing hospital ex­ penditures can be reduced. Mount Zion Hospital's Project OPEN reduced hospital expenditures and is showing a 15 percent total health care cost savings for the ex­ perimental group over the control group. Through the Project OPEN experience, we have identified the need to expand Medicare benefits, establish incentives for controlling utilization, and redefining eli­ gibility. Expanded Medicare Benefits that we propose would include the following services: 1. Case Management: Top include comprehensive assessment, care plan develop­ ment and service coordination and advocacy. 2. Home Health Maintenance: Expand existing home health service to provide re­ habilitation, homemaker and personal care to the chronically ill. 3. Adult Day Health Care: Providing nursing and rehabilitation services in a con­ gregate setting. 4. Transporation benefits expanded to include nonemergency related services. 5. Respite: To support families and other informal support systems to maintain the frail person at home. To control for utilization we recommend that Medicare develop a set of criteria for eligibility for services. Research indicates that the age limit could be raised for long term care services. It would be worthwhile to examine ages of participants in all Federally-funded LTC projects to determine what would be a more appropriate age for long term care services. In addition, we would recommend a subset of crite­ ria based on an individual's functional level. A model using a pre-screening mecha­ nism which would identify limited function in IADL or ADL and mental health should be developed-not to be used as a numbers game but as a guide to the use of the long term care system. Several proposed bills define criteria which reflect the Project OPEN position. In summary they are: Any person 65 and over should be eligible for the standard Medi­ care program. Special services would be available to persons certified to be in need of two or more of the following services for at least 6 months: Preparation of meals, , homemaker and chore, administration of medicines, home health care (maintenance level) and personal care. Eligibility in most proposed plans address the individual's limitations in performing daily activities as well as medical impairments in order to serve those most at risk of institutionalization. Our last set of recommendations concerns the issue of incentives. They range from incentives for combining funds at the federal level to incentives for providers to control service utilization. At the national level, funding has been fragmented and biased towards reimburse­ ment for acute and extended skilled care in institutions. Expanding on the Medicaid Community Care Act of 1981, similar incentives should be built into Medicare for­ mulas. These incentives should be implemented to insure cooperation between social service providers and physicians. In this way, if case managers can be given the re­ sponsibility for day to day management, it can alleviate pressure on the system and decrease costs for physician services. Some risk sharing, at each of the above stated levels, should be employed to control service utilization. In summary, we list below, the issues for policy development which reflect the results and experiences of Mount Zion Hospital and Medical Center's Geriatric Services. 1. Funding sources at the Federal level should be consolidated and paid on a cap­ itation basic to a single state agency. 2. That state agency should contract with local providers. 3. Multiple entry points to the system should reflect the location of elderly in each community. 4. Hospitals are a natural host agency for community-based long-term care. 5. Medicare benefits should be expanded to include case management, Home Health Maintenance services, Adult Day Health Care, Respite, and non-emergency transportation. 44 6. Medicare reexamine the eligibility criteria. Develop a sub set of criteria for se­ verely functionally limited elderly. 7. A series of incentives that would focus on the use of less costly non-institutional services should be developed at the state and provider level. The recommendations in this testimony are reflective of the Mount Zion Geriatric Services experience. Of course while they stand on their own merit, they must be examined in reference to the overall problem of the present Medicare system (i.e., financial viability and uncontrolled rising costs of health care). But in terms of the frail elderly population, the program must address the provision of less costly home­ delivered and community-based services to control the inappropriate utilization of costly institutional care.

CONCLUSION The need to expand community-based services to Medicaid/Medicare has been identified and defined by many segments of society. Not least of which were those who analyze health care expenditures. In 1979, $20 billion was spent by Medicaid and over 40% went to Nursing Homes. We all know the human interest stories. We realize there are many questions to ask about how best to provide quality, cost-effec­ tive community-based care. To summarize, we cannot count on research and demonstration projects for ALL the answers, but with systematic growth and expansion, they can provide direction. Since we know that the present system of health and social service delivery is too expensive, we have to provide alternatives for the frail elderly. What services and when they should be provided are being identified by the demonstrations of commu­ nity-based programs across the country. With many of the questions being an­ swered, the federal government must take a leadership role. Resources, thought and time must be given. A commitment must be made at the federal level by establish­ ing an office for LTC in the the Department of Health and Human Services-multi­ ple funding sources should be combined, and non-institutional services reimbursed. There will be problems and costs connected to developing and providing new serv­ ices that never stopped the pentagon from proceeding, why should it stop HHS? Mr. ROYBAL.Ms. Harrington, will you please proceed. STATEMENTOF CHARLENEHARRINGTON, CHAIR, PUBLIC POLICY COMMITTEE,WESTERN GERONTOLOGICAL SOCIETY Ms. HARRINGTON.Thank you. I am here speaking on behalf of the Western Gerontological Soci­ ety, which is a national organization of over 3,000 members. We represent practitioners and consumers of health services and appli­ cants for the aged nationally. I am not here speaking for the Uni­ versity of California or for the Aging Health Policy Center where I serve as a faculty member. There are many ways that the Government has looked at trying to resolve the medicare crisis. There are three basic approaches. One is to raise revenues through taxes, copayments and deducti­ bles. Two is to reduce the eligibility and benefits, which, of course, would have a direct negative effect on beneficiaries. And the third way is to reduce utilization and expenditures to providers of medi­ care services. The Western Gerontological Society is strongly opposed to the many proposals that would increase the cost to beneficiaries, as most of the proposals that have been put before Congress would do. And I have given you a paper that outlines the consequences of these proposals to shift costs to the consumers. WGS is very op­ posed to any cuts in eligibility and benefits because we think the current benefit package under medicare is completely inadequate. It's heavily weighted toward hospital and physician services, while less than 6 percent of the medicare expenditures are going to what 45 we consider long-term-care benefits. This small amount for long­ term care is totally inadequate. WGS opposes more copayments and increased deductibles be­ cause already a half a million people are financially not able to pay for part B medicare. Many are not financially able to buy supple­ mental insurance, and if you increase the cost for copayments and deductibles, many people will not be able to have coverage. There are just so many negative consequences of these types of proposals. What I would like to speak about today, though, instead of what WGS opposes, is what we would like to see in terms of revising the whole medicare program. We think it needs substantial restructur­ ing and this is an opportunity to do that, but making some positive changes in the program. First of all, WGS would like to see the major approach toward controlling the costs of the program be placed on controlling spend­ ing on providers and on reorganizing the financing mechanisms for payment of providers. The payment of individual providers on a fee-for-service basis has been the cause of increased costs and it has not led to development of an organized delivery system for older people. WGS would like to see the major pressures placed on the hospitals to bring down their costs, so that the costs will not continue to increase at 18 per­ cent a year. We think that the new reimbursement methodology, the DRG system which pays hospitals prospectively, is one small step. We would like to see legislation such as the Kennedy Senate bill 814 and House bill 3261, that would control hospital costs and set rates for all payers, not just medicare rates to hospitals. This would be a major step forward. WGS recommends more stringent regulation of hospital costs as a very first step. The second area that we are recommending is a strong push toward the use of health maintenance organizations. Health main­ tenance organizations, where individuals pay in advance on a capi­ tated basis for health services, includes hospital, and physician, and other such services. Less than 2 percent of the Nation's elderly are enrolled in HMO's. We need better incentives for enrollment. Although Congress made some progress on HMO incentives last year, there really is a tremendous need to move toward payment of medicare through organized delivery systems. The third step that WGS recommends is that Congress reorga­ nize the medicare program to promote the concept of social health maintenance organizations. Your committee has had recent hear­ ings on social health maintenance organizations. Social health maintenance organizations add long-term-care benefits to the over­ all HMO package. By long-term-care benefits, we mean home health, adult day health, home care, nursing home services, and a complete range of long-term-care services. We think that this is an ideal approach because social health maintenance organizations would be paid on a capitative basis. The organizations would have an incentive to control costs. They would have an incentive to promote health, to keep people healthy, to keep them out of institutions, and to provide the most appropriate services. Until the United States can more toward some type of ca­ pitated system, the country will not be able to solve the problems of spending all of our money on inappropriate high cost services. 46 I have provided a policy paper on social health maintenance or­ ganizations. I don't have time to go into detail on that type of orga­ nizational models, but to say that there is a lot of flexibility in models and this can be a competitive system. It can give consumers a choice, if you 4ave several of them in an area. Mr. ROYBAL.Ms. Harrington, your paper will be included in the record at this point. Ms. HARRINGTON.Thank you. So I have provided that. I would be glad to answer any questions about it but we do feel that this is one major way to control costs and yet provide the much needed long-term-care services that are not now included tinder the medi­ care package. Mr. ROYBAL.Thank you. Ms. Sommers. STATEMENTOF TISH SOMMERS,PRESIDENT, OLDER WOMEN'S LEAGUE Ms. SOMMERS.I'm Tish Sommers, Mr. Chairman and Representa­ tive Sala Burton, and I thank you for the opportunity to testify today on an issue of great importance to me and to the women I represent. I am Tish Sommers, president of the Older Women's League, a national membership organization which focuses upon the concerns of midlife and older women. I'm going to summarize, too, as the others have, but first let me say that the Older Women's League has special interests in medicare, first because the majority of beneficiaries are women and because of differences in longevity women outnumber men 2 to 1 in those over 75. And they are the greater users of medicare. About 80 percent of those who live alone are women and having no one at home to care for them, women tend to be the major popu­ lation in nursing home facilities. The relative poverty of older women must also be taken into account; 7 out of 10 out of the el­ derly poor are women. So for these reasons, medicare is very much a woman's issue. Now, what about this medicare crisis. Medical costs have risen much faster than the cost of living and medicare with doctors and hospitals controlling the prices has contributed a great deal to the escalation of costs as long as those who provide the care are the primary determiners of the price tags on those services, costs will rise and much faster than in other areas where there is genuine competition. Because it is an election year and because cuts in medicare will produce an outcry, we can assure you and promise you the current administration proposals are said not to have much chance of pass­ ing in 1984. But in 1985 it may well be another story. The big ques­ tion in medicare policy is who will be cut, providers or beneficiaries and what proportion, in what proportion and what sources of income will fill the gaps. Because of those providers in the middle, medicare is a much tougher question than social security. Even efforts to curb escalat­ ing hospital costs like the DRG's may end up as costs in the quality of service. About this Bowen Commission which was mandated to do the preliminary work of Congress and to come up with proposals, this 47 cannot be compared with the Greenspan Commission on social se­ curity in any way, partly because it was an administration appoint­ ed committee and the makeup is indicative. There are 12 men and 1 woman, only 1 labt;>rrepresentative, but several from health-care provider organizations and 1 from the chamber of commerce. With recommendations due in December, some have already sur­ faced and most frightening of these is the proposed increase of eli­ gibility age for medicare, not in the gradual manner of social secu­ rity but by 1990 medicare would not be available to anyone under 67, according to the proposal. Now, let me speak on this from the viewpoint of older women. Already many women lose life insurance coverage when they are widowed, or divorced, and when their older husbands who are age 65 retire and go on medicare. There are some 4 million women be­ tween 45 and 65 without health care insurance now. Raising the eligibility age would fall most heavily on women, especially those who are or who have been medical dependents. Further, the Bowen Commission proposes to index the eligibility age to life expectancy. In other words, the longer we live, the less likely we would be eligible for medical benefits. But unfortunately long life does not preclude chronic illness. One of the President's favorite schemes is likely to be presented. That's the voucher system, a scheme to give beneficiaries the op­ portunity to leave medicare and buy what they can in the open in­ surance, or HMO, market. That may well be recommended. Consid­ ering how many older persons, especially older women, became tar­ gets of medi-gap scams, this could be a nightmare. For one thing, healthier, better risk seniors might opt out of medicare for a better deal, leaving those who are older and sicker in the system which would inevitably increase its economic problems. So what is to be done? Clearly, the struggle around medicare will be one of the most difficult that Congress will have to deal with in the coming period and the Select Committee on Aging will have a pivotal role to play as advocates for the elderly population. While we cannot surmise the specific battlegrounds, we suggest some principles for you to keep in mind. First, hold the fort. Medi­ care needs improvements, as has been suggested, not cuts. Support for medicare is very deep rooted and is building. Old people must have medical care and younger people are in no position to pick up the tab for their parents and grandparents. Second, scrap the recommendations of the Bowen Commission. These are like the foxes' recommendations for security of the chick­ en coop. One reason medicare is in economic danger today is be­ cause the reimbursement system was largely designed by medical hospital interests. Third, a medical support system designed for the elderly must recognize that chronic illness is the norm and acute illness the ex­ ception, or the prelude to dying. The present system is attuned to acute care in hospitals. Alterna­ tives for long-term care should be explored and, as has been sug­ gested, covered for medicare reimbursement. Fourth, family members, overwhelmingly women, now provide most care to the frail elderly, without pay and the considerable risk to their own future welfare. Women cannot bear this burden 48 alone. They need supportive services like respite care, adult day care, home health services and other alternatives to nursing homes. Fifth, we must be working toward a universal health policy for the future. A system of coverage for the elderly only throws the system out of kilter. For example, any cost-containment device like prospective payments must apply to privately insured patients as well as those covered by medicare or the burden will just be shifted from one group of patients to another. Sixth, force providers to accept medicare assignment. Medicare has proved to be a welfare program for physicians and hospitals. The median net income, net annual income for anesthesiologists is $150,200 after liability insurance and all other expenses and other specialties are not far behind, according to a recent national survey. Physicians have proven to be just as greedy as any other group in society. Seventh, the future financing of hospital insurance should look beyond payroll taxes and copayments, consider other alternatives such as merging the HI and SMI parts of medicare, adding to the general revenue contribution, or even an income tax surcharge. In any formula seeking a compromise, it is the low- and moderate­ income recipients who need your support. Last, thou shalt honor thy mothers and thy fathers, all of them. As long as social policy toward the elderly is based upon the chea­ pest way to keep an old person alive, there can be no honor. The United States is the only industrialized country except for South Africa to care for frail elderly persons as a business. We commend you for holding this hearing, to bring public atten­ tion to the future of medicare and thank both of you for your lead­ ership in this vitally important issue. Mr. ROYBAL. Ms. Ambrogi. [The prepared statement of Ms. Sommers follows:]

PREPARED STATEMENT OF TISH 8oMMERS Mr. Chairman and members of the committee, thank you for the opportunity of testifying today on an issue of great importance to me and to the women I repre­ sent. I am Tish Sommers, President of the Older Women's League, a national mem­ bership organization which focuses upon the concerns of midlife and older women. Founded three years ago at the White House Mini-conference on Older Women, OWL has chartered chapters in more than half the states, including nineteen in California, and our 8,000 members work for changes in public policy to improve the lot of older women today and to increase options for those who will soon be wearing our shoes.

MEDICARE AS A WOMAN'S ISSUE The Older Women's League has special interest in Medicare, first because the ma­ jority of its beneficiaries are women. Of the 26.8 million persons in the United States who were age 65 and over (as of July 1982) 16 million, or 60 percent were women. Because of differences in longevity, women outnumber men two to one, in those over 75, and are the greatest users of Medicare. About 80 percent of those who live alone are womem, and having no one at home to care for them, women tend to be the major population in nursing home facilities (72 percent). The relative poverty of older women must also be taken into account. For those over age 65, the median total money income in 1981 was $8,173 for men and $4,757 for women. The median annual income of older women comes within $400 of the poverty level for a person living alone-($4,359). For these reasons, the future of Medicare is very much a woman's issue. 49

A PEOPLE'S HEARING I had the pleasure of moderating a "community hearing" here in this same build­ ing very recently on the subject of proposed Medicare cuts, sponsored by a broad coalition of organizations, spearheaded by the Gray Panthers. A deeply felt issue had brought us together. The Administration's proposed $1.7 billion cut in Medi­ care, on top of $13.3 billion cuts in the last two years, despite rapidly rising costs, directly affects beneficiaries. Rather than control doctor's fees and hospital costs, de­ ductibles and co-payments would be increased significantly. The much touted "cata­ strophic health insurance" feature would improve hospital coverage for .6 percent of beneficiaries, but reduce benefits for the rest. And the inadequacies of the system are left unaddressed. The hearing room was filled with good reason. Those who testified "told it like it is." Here are samples: On costs not covered.­ After the cataract implant operation my doctor told me I would need glasses, I thought the price was included, but no. They cost $125.00, and Medicare doesn't pay for this. It took me two months to save up the money for the glasses." "In the last two years I have used all of my savings to pay for medical expenses. Now if something happens to my house or I get a big bill for something else, I don't have the money to pay for it." "I am speaking as the wife of a patient with an advance case of Parkinson's dis­ ease. As the condition progresses, there is the prospect of total custodial care in a nursing home, which runs locally in the range of $2,000 to $2,400 per month-an amount that just about exceeds our entire monthly income." On not accepting assignment.-"Medicare reimburses doctors for health care pro­ vided to seniors but does not require those same doctors to take compulsory assign­ ment of Medicare benefits. Instead these doctors are allowed to charge fees which only they determine and which in many cases are twice as high as what Medicare determines to be 'reasonable'." On co-payments.-"With hospital costs, drugs, therapy and nursing, we spent $10,000 above Medicare payments in 1982. Unfortunately, our medical bills in 1983 . . . will inevitably be another $10,000 or more, besides dental surgery which in not covered by Medicare. Elderly citizens have chronic illnesses, and need more help from Medicare, not higher co-payments." On over-billing.-"! spent 11 days in the hospital. The bill amounted to $14,750 for the semi-private hospital room and surgery After reviewing the bill, I found that I was billed twice for an electro-cardiogram and a medication that I did not receive. Medicare was billed for these services by the hospital . . . I called the hospital to discuss these items on the bill. The worker said, 'This is very common. We'll fix the bill.' I have yet to see the change in the revised bill." On why poor people can't afford medical care.-"My anesthesiologist bill was $1,905. Medicare approved $845 and paid $676 (34 percent of the bill) leaving me over $1,200 for this one service ... Now I can understand why people with low in­ comes don't even go to a hospital when needed. Because even after Medicare, you can't afford to pay the bill, let alone the premium to pay for supplemental insur­ ance." On prevention.-"The health care system should be as much a preventative type system as it is a salvage type system. Now we are treated after we reach a distress stage when costly tests, medications, hospitalization and operations are necessary with all the costly follow-up treatments and care." · On patients cutting costs by shopping around for less expensive health care.-"Nor­ mally, it is the buyer who decides what service or commodity to purchase, from a haircut to a motorcycle. In medicine, decisions are made mostly by the seller, which places the physician in a uniquely powerful role. Doctors not only supply the serv­ ices, but actually create 80 percent of the demand for health services-including their own." On a promise unfulfilled.-"! was part of that professional generation that worked hard to insure the initial passage of the Medicare legislation . . . It is indeed sad to realize that we here today are constantly finding ourselves preoccu­ pied with the breakdown of the support systems established to provide the better health care of which we dreamed." On the need to fight back.-" . .. statements that imply unless we-the benefici­ aries-are careful-unless we stop our agitation and our criticism, we will for sure sink the ship! This ploy has been used as we know, with other social programs under fire.'' On health care vs military expenditures.-"Reagan's proposed $1.9 billion Medi­ care cutback is equal to the cost of one Trident submarine. The national medical bill has risen to $322 billion, but this is only six times the cost of the rapid deployment 50 force (RFD) with its naval and air fleets designed primarily to intervene in the Per­ sian Gulf and the Middle East ... " The hearing ended on a high note. Those who testified, and the big crowd who came out in support, had made the statement effectively. But are those in positions to make policy ready, able and willing to listen?

WHAT IS THE MEDICARE CRISIS? Medicare, we are told, is in a crisis. Following the pattern of the Social Security crisis which preceded it, there have been a spate of headlines designed to scare us into accepting whatever is proposed. "Medicare Faces Bankruptcy", "Medicare Funds To Run Out Soon", "Panel Proposes Raising Age for Medicare", Cuts Urged in Medicare", and so on. Crises are a double edged sword. They alert us to a danger, but they can also be created in order to make the electorate accept policy changes which otherwise would be completely unacceptable. This administration has been a master of generating crises for this purpose. Medical costs have risen much faster than the cost of living. And Medicare, with doctors and hospitals controlling prices, has contributed a great deal to that escala­ tion of costs. As long as those who provide the care are the primary determiners of the price tags on those services, costs will rise, and much faster than in other areas where there is genuine competition. But is Medicare as now constituted going broke? According to various estimates, the Hospital Insurance (HI) fund will run out of money in 1988, 1990 or 1991, as things now stand, assuming that ways are not found to curb the spiraling costs of hospitals and physicians. Some efforts to curb costs through prospective payments for "diagnostically relat­ ed groups" (DRG's) are now going into effect. The incentive will be to get patients in and out of hospitals as rapidly as possible. The impact of this on patient care should be closely monitored, because the potential for abuse to Medicare patients is a real one. Most administration proposals are directed at cutting benefits or raising co-pay­ ments-presumably to discourage what is called overuse of medical facilities. There is an assumption that patients are consumers, who make choices on matters of hos­ pitalization. Let me give just one example of the absurdity of this assumption. A patient suffered sudden death by heart attack at home. Paramedics and fire depart­ ment arrived 15 minutes after cardiac arrest. The patient was not breathing and there was no pulse. CRP was continued for 40 minutes. Then the patient was trans­ ported to the emergency hospital, where he was declared dead on arrival. However, for thirty minutes, the patient was given emergency treatment. The hospital bill to Medicare was $759.45. This patient already dead, was scarecly an informed consum­ er. Because it is an election year, and because cuts in Medicare will produce an outcry, the current Administration proposals are said not to have much chance of passing in 1984. But 1985 may well be quite another story. The big question in Medi­ care policy is who will be cut-providers or beneficiaries-in what proportion and what sources of income will fill the gaps. Because of those providers in the middle, Medicare is a much thornier problem that Social Security. Even efforts to curb esca­ lating hospital costs, like the DRG's, may end up as cuts in the quality of service.

THE BOWEN COMMISSION The Bowen Commission, mandated to do the preliminary work of Congress and come up with proposals, cannot be compared with the Greenspan Commission on Social Security. It is not a "blue ribbon" commission selected both by Congress and the President, but is the administration-appointed oversight commission which looks at the whole Social Security program, including Medicare, every four years. Since the retirement income issue had been preempted by the Greenspan Commission, the Bowen Commission was handed Medicare. The makeup of the Commission is indica­ tive. There are 12 men and one woman, only one labor representative but several from health care provided organizations and one from the Chamber of Commerce. With recommendations due in December, some have already surfaced. Most frightening of these is the proposed increase of eligibility age for Medicare, and not in the gradual manner of Social Security, but by 1990, Medicare would not be avail­ able to anyone under 67. Let me speak on this from the viewpoint of older women. Already, many women lose insurance coverage when they are widowed or divorced, or when their older husbands, age 65, retire and go on Medicare. Therae are some 4 million women be­ tween 45 and 65 without health care insurance. Raising the eligibility age would fall 51 heavily on women, especially those who are, or who have been, medical dependents. Further, the Bowen Commission proposes to index the eligibility age to life expec­ tancy. In other words, the longer we live, the less likely we would be eligible for. medical benefits. But long life does not preclude chronic illness. The Bowen Commission also proposes much larger co-payments when in the hos­ pital. We could stay in the hospital as long as necessary (or as long as the DRG permits) but there would be a daily co-payment of 3 percent of the deductible (now $350 and rising rapidly). There will undoubtedly be more such horrors when the proposals are finally presented, considering the composition of the Commission. One of the President's favorites, a voucher system, a scheme to give beneficiaries the "opportunity" to leave Medicare and buy what they can in the open insurance or HMO market may be recommended. Considering how many older persons, especial­ ly older women, became targets of Medigap scams, this could be a nightmare. For one thing, healthier, better risk seniors might opt out of Medicare for a "better deal", leaving those who are older and sicker in the system, which would inevitably increase its economic problems.

WHAT IS TO BE DONE? Clearly, the struggle around Medicare will be one of the most difficult that Con­ gress will have to deal with in the coming period, and the Select Committee on Aging will have a pivotal role to play as advocates for the elderly population. While we cannot surmise the specific battlegrounds, we suggest some principles to keep in mind: First, hold the fort. Medicare needs improvements, not cuts. Support for Medicare is very deep-rotted and is building. Old people must have medical care and younger people are in no position to pick up the tab for their parents and grandparents. Second, scrap the recommendations of the Bowen Commission. These are like the foxes' recommendations for security of the chicken coop. One reason Medicare is in economic danger today is because the reimbursement system was largely designed by medical/hospital interests. Third, a medical support system designed for the elderly must recognize that chronic illness is the norm and acute illness the exception or the prelude to dying. The present system is attuned to acute care in hospitals. Alternatives for long-term care should be explored and covered for Medicare reimbursement. Fourth, familf. members, overwhebningly women, now provide most care to the frail elderly, without pay and at considerable risk to their own future welfare. Women can not bear this burden alone. They need supportive services like respite care, adult day care, home health services and other alternatives to nursing homes. Fifth, we must be working toward a universal health care policy for the future. A system of coverage for the elderly only throws the system out of kilter. For example, any cost-containment device like prospective payments must apply to privately in­ sured patients as well as those covered by Medicare, or the burden will just be shift­ ed from one group of patients to another. Sixth, force providers to accept Medicare assignment. Medicare has proved to be a welfare program for physicians and hospitals. Median net annual income for anes­ thesiologists is $150,200 after liability insurance and all other expenses, and other specialties are not far behind, according to a recent national survey. Physicians have proven to be just as greedy as any other group in society. Seventh, the future financing of Hospital Insurance should look beyond payroll taxes and co-payments. Consider other alternatives, such as merging the HI and SMI parts of Medicare, adding to the general revenue contribution of even an income tax surcharge. In any formula seeding a "compromise" it is the low and moderate income recipients who need your support. Lastly, "thou shalt honor thy mothers and thy fathers" -all of them. As long as social policy toward the elderly is based upon the cheapest way to keep an old person alive, there can be no honor. The United States is the only industrialized country except South Africa to care for frail elderly persons as a business. We commend you for holding this hearing to bring public attention to the future !)f Medicare, and thank each of you for your leadership on this vitally important lSSUe. STATEMENTOF DONNA AMBROGI, DIRECTOR, BAY AREA LAW CENTERON LONG-TERM.CARE,PALO.ALTO, CALIF. Ms. AMBROGI. You have asked, Congressman Roybal, what are the main problems for elderly people as they seek health care? And 52 I would say that the big fear and concern of people is: How am I going to pay for nursing home costs if I have to go in a nursing home? I would like to touch on that, first, by giving a scenario that's really based on the cases I am hearing virtually every day in my work with the Bay Area Law Center on long-term care. Let's take the case of Mr. and Mrs. Jones, who are retired with a house, a pension, and some modest savings, social security and, of course, medicare. Mr. Jones has Parkinson's disease. His wife has cared for him at home for several years without any help. They are not eligible for inhome supportive services, because they are too well off. He is not eligible for home health services under medicare because parkin­ son's is considered a chronic illness. There's no help for Mrs. Jones. She can't afford the full freight of those few services that do exist for private pay people in the community. Without this community support, Mrs. Jones' own health needs finally make it necessary to put Mr. Jones in a nursing home. They look over the whole financial picture. The nursing home they have chosen costs $2,000 a month. This will eat very quickly into their liquid assets apart from the house which they may keep because Mrs. Jones is living in it. In California they will have to spend down to $3,000 of their savings, before Mr. Jones will be eligible for Medi-Cal [medicaid]. Mr. Jones' pension will have to go to pay for his nursing home care. Mrs. Jones will end up with a subsistence income comparable to SSI. So what does their accountant friend tell them to do? Get a divorce. At least this way they would protect Mrs. Jones' half of the assets. This is a shocker for people who have lived together for many, many years, who love one another, and want to remain a married couple. The Joneses choose not to get a divorce. They spend down to $3,000. Mr. Jones is finally eligible for Medi-Cal, and the nursing home he is in says, "Sorry, we won't keep you when you're on Medi-Cal." It takes some time to find another nursing home that will take him. They find one 50 miles away. Mrs. Jones is rarely able to get down to see him. Shortly thereafter Mr. Jones dies. Mrs. Jones lives on for a number of years, impoverished, on SSI and social security. It's not a very happy picture. I think medicare is missing the real financial catastrophe for older people; namely, long-term care. As people live longer, more and more of the health care problems are going to be chronic ill­ nesses which are not at this moment covered by medicare. Robert Butler, who was head of the National Institute of Aging, has said: "With medicare we set up a system for old people that assumed they were 40 years old. It often has little to do with the disorders old people really suffer." Nursing home costs are one-quarter of all the health care costs of the elderly, overall. Obviously, for those elders who are in nursing homes, and their spouses, nursing home care is the major expense they have. And the fact is that 20 to 25 percent of the people over 65 will spend some time of their life in a nursing home. I would 53 hope we could reduce this figure if we had more community and home-based, long-term care services. Medicare covers only 2 percent, roughly, of nursing home patient days, and that is primarily for people who are only temporarily in a nursing home convalescing after a hospital stay. Theoretically, there is 100 days of nursing home coverage under medicare. Practi­ cally no one gets more than 14 days coverage however, and we hear again and again from outraged medicare beneficiaries who say, "How come my nursing home care isn't covered?" Nursing homes are even reluctant to apply for medicare cover­ age in most cases because such coverage is almost always denied, and in some cases this means the nursing home itself may be liable for the costs. Private health insurance covers less than 1 percent of nursing home costs. And that generally is only as supplement to medicare coverage. There are only three or four private insurance policies in the entire United States that cover custodial care, and those policies include a limit on the amount of care available, and are too costly for most people. There is, therefore, no risk sharing at all for people who are forced to go into nursing homes. There is no insurance either public or private, which is going to cover this care. And thus people are forced to bear the total costs to the point of impoverishment before they become eligible for medicaid assistance. This is a real catastrophe for those people. Sixty-five percent of persons who are in California nursing homes enter on a private pay basis, but more than half of them end up as Medi-Cal patients when they have finally spent down to this very low resource level. That means that the great majority of people in nursing homes end up being on Medi-Cal. And unfortu­ nately, my work has convinced me that it's no great thing to be on Medi-Cal in a nursing home. The amount of discrimination against Medi-Cal recipients in nursing homes is enormous. You can't get into most of them if you are ahead on Medi-Cal, and you are evicted from very many of the facilities if you convert from private pay to Medi-Cal status. In terms of alternatives to nursing homes, I think so much more could be developed if medicare covered home health care, adult day health care, and related social services. It is a catastrophe that both medicare and medicaid have an institutional bias tend to force people into nursing homes. In 20 States there is no medicaid coverage at all for medically needy people in the community; they can get medicaid coverage if they go into a nursing home. The point which I referred to in my little case history, that the couple consider divorce, is not uncommon. Many people are forced to put the ill spouse in a nursing home, not because they want to do this. They could care for the person at home with help, but there is no help. The only way they will get financial help is by putting the spouse in a nursing home. Divorce is not uncommon be­ cause of the costs to the couple and the improverishment of the spouse who is not in the nursing home, should they remain mar­ ried. 54 We need a radical overhaul of the health care system and I do believe that older people would be willing to pay something more if they had the assurance that long-term care would be covered. I would urge that you consider ways of covering the entire spectrum of long-term care services under medicare. Both community alter­ natives and nursing homes for those who need them. · I would urge that social health maintenance organizations be de­ veloped and . funded under medicare, including social as well as medical services. There are a variety of proposals that could help pay for long-term care under medicare. It is not out of the ques­ tion. One way would be to merge medicare and medicaid for the elderly because we mustn't forget that the Federal and State gov­ ernments, through medicaid, together are paying roughly half the cost of nursing home care already. To shift this cost to medicare would add $15 billion, but I would like to suggest some ways in which this could be covered. First of all, you could replace medicaid with a wraparound insur­ ance policy that would cover the cost sharing requirements of medicare and expanded benefits for long-term care for the poor. Then you could permit the nonpoor to buy this wrap around policy to receive long-term-care coverage under medicare, by a vol­ untary additional income tax surcharge. An income tax surcharge would be the most equitable way to distribute the risk because it would fall more on the wealthy than on the poor. Other mechanisms that have been suggested include reinstating a Federal estate tax for people over 65. For instance, a 10-percent tax on the estates of people over 65 would bring in $30 billion, twice the amount of the cost that would be added to medicare by covering nursing homes. Another possibility is removing the extra income tax exemption that people over 65 are now entitled to. I do believe that if people no longer had this enormous fear of being totally impoverished by having to go into a nursing home, they would be willing to pay this extra cost and it would be done in as equitable a manner as possi­ ble. I hope you will have the courage to consider these wide-rang­ ing solutions; rather than simply band-aid answers. Thank you. [The prepared statement of Dona M. Ambrogi follows:]

PREPARED STATEMENT OF DoNNA MYERS AMBROGI, MANAGING ATTORNEY, BAY AREA LAw CENTER ON LoNG TERM CARE, PALOALTO, CALIF. My message today is that the Medicare program must be expanded to cover long term care. The paramount concern of most elderly persons is: How will we be able to pay for our care if we're struck by chronic illness and have to go into a nursing home? · Let me present a case study which points up this urgent concern. John and Mary Elder were in their sixties at the time this story begins. John, who was the major breadwinner in the family, retired early, due to the onset of Par­ kinson's disease. At the time of John's retirement, Eider's assets included their home in San Francisco, John's pension, some modest savings, and Social Security. Mary cared for John at home for several years, unfortunately without the assist­ ance of any community-based services. They were not eligible for In-Home-Support­ ive-Services because their income and assets were too great. Medicare would not cover home health care for John, since what he needed was custodial care, yet the Elders could not afford to pay the private rate for home health services. Adult day health care was not available in their community, nor were respite services to re­ lieve Mary's burdens. 55

Finally, Mary's own health needs made it impossible for her to continue caring for John at home. John and Mary therefore reluctantly agreed that he should enter a nursing home. The cost for a private pay resident at the facility they chose was $2,000 a year, less than the cost of many other facilities in the area. Again, Medi­ care would not cover John's care at the facility, because under its standards he did not need skilled nursing. To their great dismay, John and Mary discovered that in order for John to become eligible for Medi-Cal assistance, they would have to spend down their assets to $3,000 (apart from their house, which Mary continued to live in). John's pension went toward the cost of his nursing home care, as did his share of Social Security (% of the total Social Security benefits they received.) In fact, all of their income except for a subsistence amount for Mary went to cover his monthly payments in the nursing home. Their accountant advised them to get a divorce, so that Mary could protect her half of the community property. After all, she might live another twenty years! But the Elders could not agree to a divorce. "Why should people who've been married as long as we have, and who love each other, be forced to get a divorce just to keep a little money in the bank?" they asked. In less than two years, their community assets were down to $3,000, and John finally qualified for Medi-Cal. But the nursing home in which John resided, al­ though a Medi-Cal provider, refused to keep John on as a Medi-Cal patient. They "dumped" him into a hospital, where Medicare paid some of his bill, while the dis­ charge planner looked for a nursing home which would accept him on Medi-Cal. The only facility she could find which would take him was 50 miles away. It was difficult for Mary to get to the nursing home as often as she was accustomed to doing previ­ ously. John died a couple of months after the move. Mary Elder lives on, now improverished, with her home her only asset, and Social Security her sole income. She is receiving Medi-Cal assistance as a Medically Needy person, but has discovered that her physician of many years will no longer treat her, now that she's on Medi-Cal. She is in great fear that someday she, too, will need to be in a nursing home, and realizes what a difficult time she will have find­ ing a facility which will take her on Medi-Cal. The story of the Elders is by no means unique. The safety net of Medicare has a big hole in it; it fails to cover the real financial catastrophe of many older people, namely, long term care. Robert Bulter, former head of the National Institute of Aging, has said: "With Medicare, we set up a system for old people that assumed they were 40 years old. It often has little to do with the disorders old people really suffer." How true that is! Overall, nursing home care constitutes one-fourth of the total health costs of the elderly, although for many persons, it is their single major expense. Twenty to twenty five percent of persons over the age of 65 spend some time in a nursing home. Medicare, however, covers only 2.3 percent of nursing home patient days, and that primarily for persons only temporarily convalescing in a nursing home after hospi­ talization. Although Medicare theoretically covers 100 days of nursing home care, few persons receive more than 14 days coverage-a great shock to many Medicare beneficiaries! Many nursing homes are relectant to apply for any Medicare coverage for their patients, for fear that denial of the coverage will leave the facility liable for the costs. Ironically, however, Medicare is a long term care program, despite itself. The Hospital Insurance Trust Fund pays more than $1 billion per year in acute hospital fees for persons waiting to enter nursing homes. Private health insurance pays for less than 1 percent of nursing home patient days, and that is generally only as a supplement to Medicare coverage (i.e., covering only the coninsurance portion for those eligible for Medicare coverage in the nurs­ ing home). Almost no private insurance policies cover custodial care at all, and the few that do have premiums so high that few persons can afford them. Private funds of nursing home residents and/or their families cover 26.6 percent of patient days, but this statistic does not adequately express the catastrophic di­ mensions of chronic illness. For this major catastrophe in the life of at least 20 per­ cent of persons over the age of 65, there is no public or private health insurance available, no risk-sharing short of impoverishment. Nursing home residents are thus forced to bear the total cost of their care until they are so poor that they finally qualify for Medi-Cal. Medi-Cal covers 71 percent of patient days in California nursing homes. Since the Federal government currently pays half of the cost of the Medi-Cal payments, and a higher portion of the Medicaid payments in some other states, legislators should 56 consider the magnitude of this already existing expense when weighing the cost of possible Medicare coverage for long term care. Sixty-five percent of California nursing home residents entered on a private-pay basis, but more than one-half of these persons are forced to convert to Medi-Cal during their nursing home stay. On the average, this conversion occurs within a year after their admission. Thus, at least one-half of all residents now on Medi-Cal were originally private-pay persons who spent down to the poverty level to pay for their care. Once on Medi-Cal, patients experience discrimination by health care providers, and this is preeminently true in the case of nursing homes. Few California facilities will accept persons already on Medi-Cal, and a large number of facilities which par­ ticipate in the Medi-Cal program nonetheless evict private-pay residents when they convert to Medi-Cal. Medicare thus fails totally to cover the real financial catastrophe of most elders. Certainly, a long stay in a hospital is such a catastrophe, but there is small likeli­ hood of this happening. Fewer than ½ percent of Medicare beneficiaries have out-of­ pocket hospital expenses of more than $4,000/year. Long term care, not acute care, is the nightmare for most elders. Paying for long term care-which usually means paying for a nursing home, since so few affordable, community-based services are available-is the paramount concern for the elderly. It's their great fear. People who've lived frugally, and saved money all their lives, say, "I'll be financially ruined. I'll have to depend on my children and maybe go on welfare. Why doesn't Medicare cover this care?" And what about community-based alternatives to nursing homes? There is no Medicare coverage for home health, adult day health care, or social services for the chronically ill. The institutional bias of both Medicare and Medicaid means that many persons are forced into nursing homes when both they and their families would prefer that they stay at home, if only public financial assistance were availa­ ble to cover community-based health and social services. The fact that only thirty states cover Medically Needy persons under Medicaid makes the situation even more critical. In the remaining twenty states, it is only by entering a nursing home that a person whose income disqualifies her for Medicaid as Categorically Needy will receive Medicaid assistance for any of her care. The situation of married couples is particularly severe when one spouse requires custodial care. Medicare offers such couples no help. For Medi-Cal and In-Home­ Supportive-Services to be available, the couple must spend down to $2500 in assets, and spend down most of their monthly income as well. Frequently, in such cases, the healthy spouse cannot afford to care for her spouse at home. If the couple live in an urban area but do not own their home, they are unlikely to be able to survive financially on the maintenance-need level available to couples under Medicaid. All too often, the spouse needing care is institutionalized not because this is absolutely necessary, but because the couple cannot afford the scarce community-based serv­ ices, or because institutionalization is the only way to protect some of the assets and income for the healthy spouse. Even then, divorce is a not uncommon painful expe­ dient accompanying institutionalization-surely a moral and psychological catastro­ phe, as the only perceived alternative to the impending financial catastrophe. There are solutions to this serious dilemma of public policy. We need to consider a radical overhaul of our health system with the goal of providing access to adequate care for all persons, and based on a risk-sharing principle, so that those who bear the burden of being ill will not also have to bear the full financial burden of obtain­ ing needed care. New reimbursement systems must be considered which will include all payors, and not only Medicare. Long-term care, home- and community-based es well as nursing homes, must be covered under Medicare and private health insurance. Such coverage would encour­ age the development of affordable community alternatives, in the long run less costly and surelr more humane than nursing homes. Social Health Maintenance Or­ ganizations, which embrace a comprehensive range of services including long term care, social as well as medical services, should be financed by Medicare and private insurance. Medicare recipients should be screened before entering nursing homes, to determine if appropriate and economical care could instead be provided in the com­ munity. One of the most creative solutions for covering and financing long term care under medicare is that proposed by Dr. Karen davis, of Johns Hopkins University. Her proposal involves merging Parts A and B of Medicare into a single deductible and coinsurance rate (e.g., 5 percent) for all services, and a maximum ceiling on costsharing (e.g., $1500). She would extend Medicare coverage automatically to all persons 65 and over, require mandatory assignment of physician charges, and re- 57 place the Part B premium by an income tax surcharge, which would fall mainly on the wealthy. Further, Davis suggests replacing Midicaid with a wrap-around policy which cover the cost-sharing requirements of Medicare, and provide expanded benefits for long term care, drugs, etc. (to be financed by Federal and state general revenues). Non­ poor persons would be premitted to purchase this wrap-around policy for a volun­ tary additional income tax surcharge. Davis estimates that 6% of their adjusted gross income would finance long term care coverage under Medicare. This integrat­ ed cost-sharing structure, utilizing an income tax surcharge rather than higher co­ insurance amounts, would redistribute the current financial burden more equitably among the sick and not-so-sick, the rich and the poor. Other proposals to finance the coverage of long term care under Medicare include: (1) eliminating the extra income tax exemption of $1000 for persons over 65, which benefits the rich most, and using the additional $2.4 billion tax revenue gen­ erated each year for long term care coverage; (2) reinstating the Federal estate tax for all persons over 65 (a 10 percent estate tax on the estate of persons over 65, exempting spouses, would yield $30 billion per year); or (3) increasing the monthly Part B premium on a sliding scale related to income. As with Davis' scheme, these proposals would serve to redistribute the financial burden more equitably among the elderly population. And such proposals, if proper­ ly explained, should be politically feasible. Older persons would not object to a modest tax increase if they were assured that they would not be impoverished by the current "medical Russian roulette", under which all their assets may be called upon to pay for the costs of long term care. Mr. ROYBAL.Thank you. Ms. Rabinowitz. STATEMENTOF LILLIAN RABINOWITZ,CHAIR, HEALTH COMMITTEE,GRAY PANTHERS,BERKELEY AREA Ms. RABINOWITZ.Thank you, Mr. Roybal and Mrs. Burton, for giving me an opportunity to address issues which are very close to my heart. My name is Lillian Rabinowitz. I am the cofounder of the Gray Panthers in northern California, of the Over-60 Clinic, a very inno­ vative clinic designed for the elderly, and serving northern Alame­ da County, and the first adult day health care center in Alameda County, as well. The years 1981, 1982, and 1983 have brought burdensome changes for health care provision for older American adults under medicare. The recommendations of this administration for the years ahead seem to project an even more fearsome prospect for this population. Between larger deductibles and copayments, many elderly are or will be having to choose between paying health-relat­ ed bills and/or decent shelter and food. Essentially these brutal plans entail shifting costs from the Fed­ eral Government to the already hardpressed consumer. Because of our regressive tax base and our administration's course aimed at world hegemony through the threat of nuclear assault, the needs of our vulnerable elderly have low priority for response. Indeed, if you will permit me to coin a word, we seem to be moving toward gerontocide. Our death camps for the elderly are not gas chambers, but poorly monitored, for-profit nursing homes, or more subtly, per­ haps, a set of policies and regulations making appropriate and af­ fordable health care increasingly less accessible. Among measure which should be taken in the short run are the following: One, make it mandatory for physicians treating the elderly to accept medicare assignment. 58 Two, support community clinics with emphasis on preventive health care and maintenance therapy for ·those with chronic ill­ nesses. Three, make adult day health care and other long-term-care serv­ ice medicare benefits, thus providing a cost-effective option to pre­ mature institutionalization. Findings from our own Over-60 Clinic point to the importance of providing two kinds of services now excluded by medicare. That is to say, dental care and podiatry. Currently dental care is provided only in cases where maxillofacial surgery for pathology, such as cancer, is present. Yet much illness, both physical and mental, can result from the deprivation of good oral health. Persons who are edentulous cannot eat the kinds of food required for good health. Moreover, the loss of facial contours and the disfiguring effect of loss of teeth causes many elderly to avoid socialization and leads to depression. I would like to allude to something that Barbara Sklar said. She talked about spending time in the United Kingdom, which offers support for findings such as we have heard here. I too spent the spring of 1980 in the United Kingdom and can say, in those coun­ tries human beings are not seen as excluding the elderly. Care is provided as a matter of right and old people do not have to worry through the longest part of their lifetimes about what will happen to them later on. Our Over-60 Clinic has been granted the services of a dentist from the National Dental Services Corp. for a period of 2 years. We now provide care, both free for medicaid recipients and for others on a sliding scale basis. Mr. RoYBAL. Mrs. Rabinowitz, would you wait just a moment, please. · Ms. RABINOWITZ. Yes, of course. Thank you. Mr. RoYBAL. Whenever you are ready now, you may proceed. We just needed to change the tape right then. Please proceed. Ms. RABINOWITZ. Although this dental service began only a few months ago, we have a 2-month waiting period already. We are in­ undated with clients who have had to do without dental care for years because of cost barriers. Our clinic also provides some podiatry done by geriatric nurse practitioners who have been carefully trained by a podiatrist to perform limited procedures. But podiatry is not provided under medicare except in the cases of pathology caused by severe diabe­ tes, advanced vascular disease, and persistent fungal infections. Yet many elderly are unable to care for their feet due to arthritis, poor vision and so forth. Frequently elders are severely handicapped by painful conditions such as ingrown toenails, bunions, and warts which make walking painful. Because of this, they forego exercise and become virtually housebound leading again to deteriorating physical and mental health. Yet private-pay podiatry is often out of the reach of those on low fixed incomes. Even those elderly who buy various Medi-Gap poli­ cies find to their chagrin that both podiatry and dental care are excluded. Many of the existing health care benefits for the elderly 59 are fragmented and therefore more costly. What is needed for all our citizens, not only the medicare entitled, that is to say the elder­ ly and the disabled, is a comprehensive national health service such as exists in all industrialized nations except for our country and South Africa. In September of this year, the National Health Service Act, H.R. 3884, was introduced into Congress. It would reorganize all health care resources, personnel, equipment and institutions, into a co­ ordinated health care system to provide health care as a free public service much as we get the care of fire departments and police de­ partments. Financing would come from a health service tax on tax­ able income of individuals, estates and trusts and of course of cor­ porations, according to ability to pay. Gray Panthers have given their strong support to this measure as a means to help us become a more caring, peaceful and healthy society. We ask for your vigorous advocacy. Thank you. I would like to add just one more thing. We have been told that DRG's will be an excellent way to cut the costs of health care. But I should like to mention a caveat. It may indeed be that we will get costs cut, but what will be the cost for the patients? This is yet to be seen. I would hope that the quality of this care will be carefully monitored. Thank you. Mr. ROYBAL.Thank you. Ms. Malvern. STATEMENTOF MAUREENM. MALVERN,STAFF ATTORNEY, LEGAL ASSISTANCETO THE ELDERLY, INC. Ms. MALVERN.I'm a staff attorney at Legal Assistance to the El­ derly, a nonprofit legal services agency in San Francisco. My par­ ticular areas of specialization are health benefits and long-term care problems. Most of our clients are eligible for medicare and many have ex­ pressed their surprise and frustration on discovering how little of their health bill medicare covers. Reduced coverage plus inflated costs have left elders with nearly as much out-of-pocket health care expense as they had before medicare began. Actually that's prob­ ably an understatement. It may be that their expense is more as a proportion of their income and before medicare began. I think the biggest surprise for elders is to discover that a system for elders is designed as an acute care system. It makes no sense. I would just like to support what some other people have said here before I go into the main part of my testimony. If you are going to have a health care system, particularly for elders, it makes no sense to think of it as an acute care system primarily. Chronic ill­ ness is the main problem for elders. And the whole system needs to be redesigned with that in mind, that chronic illness is the biggest burden that elders face. Mr. ROYBAL.Thank you, Ms. Malvern. Your entire text will be entered in the record. Ms. MALVERN.Before a claim is ever made to medicare, people are being cheated out of the benefits that Congress meant to give 60 them because of a very restrictive interpretation of the law which often prevents providers from even making a claim, lest they be held liable and have to swallow the cost because medicare won't cover it. So, particularly as to questions of medical necessity, there are many, many errors made in that area and yet people don't appeal because they don't know what's going on, they don't know they have a right to appeal. Thank you. I'm very glad you had this hearing today and I really appreciate it. Mr. ROYBAL.Thank you, Ms. Malvern. [The prepared statement of Ms. Malvern follows:]

PREPARED STATEMENT OF MAUREEN M. MALVERN I am a staff attorney at Legal Assistance to the Elderly, a nonprofit legal services agency in San Francisco. My particular areas of specialization are health benefits and long term care problems. Most of our clients are eligible for Medicare, and many have expressed their sur­ prise and frustration on discovering how little of their health bill Medicare covers. Reduced coverage plus inflated costs have left elders with nearly as much out-of­ pocket health care expense as they had before Medicare began. The most basic need is a conversion of our national priorities from destruction to healing. However, today I just want to focus on two reforms which would greatly benefit people who need health care, with little if any cost to the government. First, physicians who treat Medicare patients should be required to accept Medi­ care rates as total payment, just as those who treat Medicaid patients are already required to accept Medicaid rates. Mandatory assignment would cost the govern­ ment nothing; in fact, it might help slow down the inflation of health care costs over-all. At the same time elders would benefit greatly by not having to fill the increasing gap between Medicare reimbursement and actual charges. Elders often have chronic illnesses, requiring frequent doctor visits. Paying surcharges above the Medicare rates eventually impoverishes such elders, forcing them to choose between health care and other vital needs such as food and shelter. Second, anyone who determines that a particular service is not covered by Medi­ care should be required to give the beneficiary a written notice explaining specifi­ cally why that service is not covered and how the beneficiary can appeal from de­ nials of coverage. As the Medicare system operates, many of these coverage determi­ nations are made by providers or utilization review committees before a claim is ever made to Medicare itself. The notices given beneficiaries are so general and con­ clusionary-e.g., "the services you needed did not require this level of care" -that the sick person has no idea what they mean. Moreover, determinations made by providers or utilization review committees do not provide clear appeal rights, and even notices from intermediaries just say to contact a social security office to find out about appeal rights. The result is not surprising; a minute percentage of Medicare denials are ever ap­ pealed. Yet when they are appealed more than half are reversed, indicating that errors are quiet frequent. With no new appropriation of money, then, Congress can do much to ensure that elderly and disabled people at least receive those benefits which Congress intended they receive-simply by requiring adequate notice to beneficiaries both of the rea­ sons for denying coverage and of the means to appeal. Mrs. BURTON.We appreciate all of you being here. As Barbara Sklar, whom I have known for a long time and is a specialist in the field of gerontology knows, that when it comes to the elderly, I par­ ticularly have an interest because I had two elderly parents. My father passed away a few months ago. Mother is still living, lives in her own home and she and I were trying to work out for my par­ ents' who wanted to live in their own home, and did, what we could do and I must say they were fortunate that they saved some money during their lifetime. But let me say it is going. It is going because 61 they live in their home-my mother still lives-I still can't say "they," I can't say "she," I always say "they." And what my broth­ er and I said is we want my mother to live comfortably on our in­ heritance, but you have children who don't feel this way. We're a small, close-knit family. And it is a shame that we don't have, speaking for others, not for my parents, that we don't have univer­ sal health care generally, young and old. What happens is if you have a few dollars put away, if you have a catastrophic illness, the family funds are depleted and we are the only industrial country that doesn't have it and you mentioned, with South Africa. If we want to-and you said it several times-if you want to com­ pare ourselves to South Africa, it is a sad commentary on where we're heading and I hope that someday we will have universal cov­ erage because I am for that. Thank you, Mr. Chairman. There were questions I wanted to ask, but due to your need to leave I don't want to do that. Thank you very much. These are people from this area and we can talk. Mr. ROYBAL.Thank you very much. It is true that we are all very hungry but I have some questions that I do want to ask and beg your indulgence for just a few more minutes. May I compliment each and every one of you for the statement that you have made. I think you hit the nail right on the head. You told this committee what you believe should be done to bring about some changes that would make it possible for the senior citi­ zen community of the United States to live in dignity. I serve on the subcommittee of the Committee on Appropriations that makes available moneys for health and for education. In the last 4 years, we had not been able to pass an appropriation bill from the Subcommittee on Health and Education. So for 4 years, we operated the Government on a continuing resolution. In the meantime, the Congress accepted a $22 billion reduction in medicare costs. These were mostly through increases in deducti­ bles, premiums, and coinsurance. Again, the entire burden was put on the senior citizen who can least afford it. In 1984, the fiscal year that we just passed, there was a recom­ mendation tha~ $1.9 billion be included in cuts from medicare in­ cluding $1.5 billion in benefit cuts. Now, when we got to the final markup of that bill, the committee restored all those funds, but in effect came back with a $400 mil­ lion reduction. The reason is that we were told by the administra­ tion that if we exceeded their recommendation the President would veto the bill. The end result-and I'm not going to burden you with the fight that went on with the administration-but the end was that we passed a bill in the House of Representatives that was $4 billion over the President's recommendation. That was not sufficient. However, the point I am trying to make is that we in Congress have a tremendous fight on our hands. When the recommendations coming from the administration tend to cut health and education, for example; heating assistance was cut substantially. Now, one may not need it as much in California as one would in Appalachia, but is important to the elderly. ----· 62 Housing was reduced for the senior citizens including housing under section 8, which is a subsidized form of providing rental ac­ commodations for people that need it. Now, these are recommenda­ tions coming directly from the President through his administra­ tion to the Congress. We have a problem in the House of Representatives. The Demo­ crats have a majority, but in the Senate the Republicans have the majority. And as you know, unless both Houses agree, the bill does not pass and is not signed by the President. And if the President vetoes that bill, we do not have enough votes in the House to over­ ride the President's veto. Now, those are the facts of life. I think we have evidence and tes­ timony that will substantiate a reorganization of all health care re­ sources. I have no doubt about that. There is a bill in the Congress designed to do just that. I have assigned staff of the committee to study and review health programs in England-well, all over the world-in an effort to propose to the Congress a new bill perhaps that will set up in effect a national health system, one with no re­ strictions that will take care of the individual's health need. I don't believe that the bill that is now in the Congress that deals with the reorganization of all health care resources, nor the bill that I am proposing would ever pass the President's desk. I think that based on his past performances, he will definitely veto it. Unless, of course, we were able to attach it to a military spending bill. My biggest complaint is the fact that we have a $200 billion defi­ cit. By the end of this fiscal year it will be in the neighborhood of $270 billion. This is the greatest deficit that we have ever had in the history of this country. Nevertheless, we have had the greatest reductions in health and education programs which deal with the problems of the poor-more reductions than we have ever had before in the history of the United States. I am bringing all this to your attention, not because you do not know the facts but because I want to make a point. I realize that those of you who are active in this field do not want to become poli­ ticians. In fact, I do not want you to become politicians because you are liable to run against me one of these days. But the truth of the matter is that unless there is enough pres­ sure placed on the President, we are not going to get any legisla­ tion through. The biggest example of that is the fact that the senior citizen community did respond and place on the President's desk over a million and a half letters when the administration was going to dismantle social security. The President backed away from it. Something like that has to be done now with medicare. And then we need to have the men and women in the Congress follow some of the recommendations that have been made here. They are all excellent recommendations that could actually result in a better care system in this country. I sincerely hope that a word to the wise is sufficient. We need to have letters going to the President. For some reason or another when I make that suggestion, even in my own district which I be­ lieve is the poorest in the State of California, people say we cannot write to the President. He is a very nice man. Well, no one denies 63 that he is a nice man. But he is cutting back on those vitally needed proposals in order to make available to the world MX mis­ siles and instruments of destruction. I would rather have that money spent on health care for this Nation. The only way that we can make that choice available to those people that you send to the Congress of the United States is change the attitude of those at the very top. Those at the very top know that when you -go to the ballot box you can make your voices heard. That kind of an effort I would like to see; 27 million senior citizens in this Nation can bring about some changes without asking any of the elderly to become politicians. However each and every one of them needs to become civic activists to the point where they involve themselves directly in the legislative process of this Nation, that is by compelling your Representative to vote fa­ vorably on these things. I believe that is the only way that we can bring about the types of changes that we're talking about. There may be other ways, but I think that this is the best avenue we can take to bring about this change. Now, I would like to ask some questions of Ms. Sommers. I think you made reference to the Bowen Commission. They made various recommendations with regard to copayments and voucher system. And you feel that we should pay no attention to the Bowen Com­ mission. ·1 just wanted to know, Ms. Sommers, whether or not the other participants agree with that statement. Is there anyone who dis­ agrees? [No response.] Mr. ROYBAL.Let the record show that the witnesses have indicat­ ed that they do not disagree and that they are not in agreement with the Bowen Commission. I am going through this process to expedite matters. The matter of divorce is something that is always on ones mind particularly when you see so much evidence that this is taking place. Will you elaborate on that subject matter, but just briefly, either one of you or both, as to what takes place and what prompts a couple that has been married for, let us say, 43 years, as I have, to have to separate simply because they want to meet certain medic­ aid requirements? Ms. SOMMERS.Let me try to give you an example from Califor­ nia. Say a couple have $50,000, which is a lot, in savings apart from their house. And one spouse has to go in the nursing home. As the law stands now, the spouse who is institutionalized has always a half interest in the community property assets that remain. There­ fore, if for instance, it costs $2,000 a month, after 3 months $6,000 is gone out of the $50,000. The person in the nursing home is not entitled only to $25,000 of the $50,000. They are entitled to one-half of the declining balance of the community assets. Therefore, when you are down to $44,000, the institutionalized spouse still has the right to $27,000. If the person is in an institu­ tion for 20 months, they will have used up $40,000 or the $50,000. They will still have a claim on $5,000 of the remaining assets. The consequences that out of that $50,000, even though it is com­ munity property and theoretically each one is entitled to half, they 64 would have to spend down to $3,000 before the person in the insti­ tution is entitled to medical. If the couple got a divorce at the moment when the person went in the nursing home, then each one would have $25,000 and the noninstitutionalized spouse would be able to hang on to $25,000 in­ stead of $1,500 or $3,000. I think if the noninstitutionalized spouse is relatively healthy and has a long future ahead of her and yet is not a working person but is dependent on unearned income, there is a tremendous con­ cern about being reduced to this very low level of assets particular­ ly when the couple have worked very hard and saved this money up through their earnings. I think couples do come to the decision to give that person at least some share in the community assets. The only way to go is divorce and it seems to me in a country that pleads that they be­ lieve in the value of the family, this is really a moral catastrophe as well as a psychological one in order to prevent a financial catas­ trophe. I think in other States it may even be worse than in California, by the way. And I should say that in many states people would not qualify at all for medicaid unless the person went in the nursing home and then went through this process. At least in California, by spending down you might qualify as medically needy for Medi-Cal. But that's apart from the issue-- Mrs. BURTON.You said $3,000. Is $3,000 for a couple, right? Ms. SOMMERS.$3,000 per couple, right; $1,500 each. Mr. ROYBAL.Any other questions? Mrs. BURTON.Not now. Thank you. Mr. ROYBAL.I would like to conclude this portion. However, I would like to call your attention to the fact that the Western Ger­ ontological Society is holding a conference in Anaheim, Calif., at the beginning of the year. We are going to hold hearings at that particular time on long term care and medical needs. I would ap­ preciate it if you would summarize your written testimony so that I can make that also a part of the hearing at that time. This means that we have between now and January 23 to submit that sum­ mary. Ms. Sommers, I would like you to concentrate on women and to give whatever recommendations you have, concerning on the needs of women in the United States. We are going to my district to hold a hearing there. Other hearings will be held throughout the coun­ try. We will finally conclude these hearings in Washington, D.C. At that time, I'd like to have a summary of all hearings. That is the reason I am asking for you to submit this summary. If you would be so kind as to do so, we would greatly appreciate it. It will all become a part of the record and the committee will definitely examine these recommendations and we hope that we can do some good when the time comes. I predict that we will be able to do something about medicare. May I state that I'm not pleased with the method that was used in the social security fight. I think that certain changes have to be made there so that the senior citizen has more input than they did in the commission system under the old plan. 65 We have 2 or 3 years still to work on it. But it is still not too early to start. That is why this committee has started doing this and we greatly appreciate your participation and hope that you will send that revised testimony to the committee. May I thank each and every one of you for your testimony today. Mrs. BURTON.And there is a footnote. I know there's going to be a scandal brewing on bed utilization in the hospitals. I don't know who is familiar with it, how many people. I'd like someone to give me some input on that. Do you know what I'm referring to, Bar­ bara? Ms. SKLAR.No. Mrs. BURTON.Well, you know, they have a commission or a com­ mittee that if you've been an elderly person who has been in the hospital so many days, they kick him out or kick her out. And do you know something about that? I understand there's a scandal brewing. That's all I can say to you. As a matter of fact, one of the newspaper people told me. Ms. SOMMERS.Ms. Burton, the national office of the Gray Pan­ thers has-may very well have some information on that. Mrs. BURTON.I would appreciate it if you would get it to my office. I don't want to prolong it now with discussion but whoever has some information on that, I would appreciate it and I will give that to the chairman. Ms. RABINOWITZ.Thank you, Mr. Chairman, for being here. I'm most appreciative. We in San Francisco know your history, back­ ground and efforts you have really made on behalf of the, not only senior citizens in terms of health matters but everyone. Thank you. Mr. ROYBAL.Thank you. As you know, there is a custom in the House of Representatives that has been followed throughout the years. That is, that any member has the right to speak to the House for 1 minute regardless of the subject matter. We're going to make that same privilege available to anyone in the audience who wants to make a statement. But in this instance, that statement must be directed at medicare and the subject matters that we have discussed today. Now, 1 minute is no more than 60 seconds and the Chair will carefully monitor each one who takes the floor. If you would just line up behind the gentleman at this micro­ phone. Give us your name, your address, and make your statement. Mr. TUMMY.My name is James Tummy. First of all, I'm repre­ senting Haight-Ashbury Acupuncture, which is an affiliate of Haight-Ashbury Free Medical Clinics. Currently we are treating in excess of 10,000 patients per year for acupuncture for a variety of symptoms. We have had a great deal of success, both with detoxification and the relieving of pain and allergies, headaches, backaches, depression among-just to name a few problems. I have brought with me today a patient who has been-is cur­ rently being treated at our clinic. We are a research institute and if you are in the market or looking for a professional research in­ stitute, we have done Federal research before. And I would just like to reiterate the importance of acupuncture as a health care modality in the 1980's. 66 Mr. ROYBAL.Thank you. We will hear next from your patient? Mr. RIFKIN.I'm the patient that James referred to. My name is Herman Rifkin, commonly referred to as Hi. And I became a pa­ tient at the clinic back in May 1980. I was going through the ;rroc­ ess of a stroke and I'm also an outpatient now at the VA. I m a veteran. And a doctor at the UC said, why come here when you can go to the VA and not pay anything because I was getting 80 percent off and he said I was still paying 20 percent. He said at the VA I wouldn't have to pay anything. When I started out with acupuncture treatments and I didn't have to be hospitalized but I do see a neurologist about every 3 or 4 months and I'm getting along beautifully. You would never believe that 3½ years ago I was bent over double with a brace on my foot and a cane in my other hand. And I get treated for other ailments too. For example, I avoided an operation for a hernia. And now I'm avoiding a hemorrhoid op­ eration because of the acupuncture treatments. And if it wasn't for acupuncture, it would have cost an arm and a leg all my ailments. Mr. ROYBAL.Thank you. Mr. GRIEUX.My name is Lee Grieux. I'm the social worker at Francis of Assisi Senior Housing at Section 8, 202 Housing in San Francisco. Since this new reimbursement system has gone into effect for medicare and hospitals, the DRG or whatever the initials were, I'm very concerned. People are coming home from the hospi­ tals who are very sick, who are unable to care for themselves, who are not getting adequate home care. Some of them ending up back in the hospital much sicker. It is not saving money and it's not a very human way to treat people. I do want to say I do believe there needs to be some hospital cost containment. Mr. ROYBAL.Thank you. Will you please pass the microphone to the next witness. Mr. McDEVITT.I hope, Congressman, I can preface my I-minute remarks with a few things. I have been here since 9:30. I want you to know how much I appreciated the opportunity to listen to the panelists. I also want to thank the administrative assistant, Ed Davis, who I talked with on the telephone yesterday. He invited me-he called me later and asked me to sit on the panel. I'm not an expert and most of the people were professionals. I'm strictly a layman and I'm here representing myself and my wife in the inter­ est of Congresswoman Burton's acupuncture bill. I have just a few remarks to make. I have filed this letter. Mr. ROYBAL.Thank you, sir. Mr. McDEVITT.This hasn't been brought out this morning, but we know of two instances where acupuncture-acupuncture offers great possibilities of pain relief to terminal cancer patients who now are being given mind altering drugs. Mrs. BURTON.Thank you. Mr. ROYBAL.The next witness, please. Mr. SuEY. I'm George Suey, a member of the State commission on aging. And all these complaints that you heard about medicare. I was here to speak for the acupuncture but I thought the most im- 67 portant was the medicare. We hear about the rise in costs of medi­ care. I am appalled that this Nation is picking on the seniors in the country. I have just returned from 1 ½ months in China, invited by the Chinese Government to study their elderly problems. And just looking at the other countries, how they treat their elderly and our country here, the most financially sound Nation in the world, it's very appalling and I am disgusted at the way the seniors in this Nation are being treated. Most of the people don't realize that some of the people that live in the Tenderloin District are eating dogfood. This shouldn't happen in this Nation. Let us treat our own first without all the other countries being treated. We fight their wars for them, we treat their elderly, we supply them with all the money and fi­ nances. Let's take care of our own here. Give the elderly in this Nation here the dignity that they deserve. They have built this Nation into one of the world's strongest nations. Let us give some kind of a help to some of the ones that do need it. It is indeed fortunate that we do have two Congressmen such as you two here to help with the elderly problems. But many of the other legislators don't seem to want to have any kind of-anything to do with the elderly problems of this Nation. And it is very sad to see that we have to depend on some people with some kind of a feeling toward the elderly in this nation today. Thank you. [The prepared statement of Mr. Suey follows:]

PREPARED STATEMENT OF GEORGE Y. SUEY I am George Suey a member of the State of California Commission on Aging, and National Executive Director of the Chinese Amercian Citizens Alliance of America, an organization with over two thousand members in principal cities of the United States. I am here to speak in behalf of this pending bill before Congress. We feel that any citizen of this country should be allowed to choose any method of medication to alle­ viate their ills and pains, and they can compensate persons that can alleviate these ills and pains through medicare payments. I have had many contacts with pain suffering elders that seek any method of medication that can give them relief, but are unable to pay out of their pockets for this treatment. We feel that medicare should allow us to choose the way we want to cure our pains. It is important that medicare should pay for this method of medica­ tion. To allow us to determine our cure or our method of cure. Today in California this method already recognized and the payments accepted by medical. It has proven a god sent method to some of the aged in this state. This affords the sufferers more choice to cure what illness they have. It has proven a success in this state. It can also prove to be a success in the nation. Acupuncture has been proven successful in China for many centuries. It it were not successful it would have faded into obscurity during that time. Today it has flourish with many nations recognizing its many benefits and accepting it as a medi­ cal treatment that can help the medical profession in its fight to cure illness and pain. It is high time that we in this nation recognize this important fact. We ask this committee to grant us our choice to cure our illness and pains. We ask this commit­ tee to pass this legislation immediately to help the many that cannot help them­ selves, that may need this method to cure their pain and illness. Thank you members of the committee for your kind attention to our pleas for this legislation to help our needy. Mr. ROYBAL. Thank you. 68 Mrs. BURTON.Thank you. Mr. Chairman, Mr. Suey is one of those active citizens you talked about. Next year he is going to be very, very active. Right? Mr. ROYBAL.Good. Thank you. UNKNOWNWITNESS. I have had acupuncture now off and on for about 5 years and it really works and I, you know, the trouble I've got is getting the money to keep it going until I can get everything all fixed up. And by the time my money runs out, I'm still-I've still got a ways yet to go. And I was hoping that medicare could do something for that. And I hope it passes through. Mr. ROYBAL.Thank you very much. May I compliment those who took advantage of the 1-minute rule. They complied with the 1-minute rule and you did a lot better than Members of the Congress. The Members of the Congress usu­ ally exceed it. May I compliment you for that effort. May I, before closing, again--- Mr. PENSKY.My name is Morris Pensky. I'm a retired seaman of many years. I have to agree with most of the people that spoke here. And it all leads to one thing: You Representatives, I hope you were listen­ ing to these people. They were speaking bubbles of wisdom that make more sense than Reagan or Jackson or O'Neill or any of them. Now, the thing is that what it all boils down to is that medicare is so patched up and being amended that there won't be nothing left to amend pretty soon. I don't know why O'Neill become a Republican in the middle of the job but that's what he is. He's an out and out Republican. There's no question. And yet the Democratic Party at no time has criticized him. Mr. ROYBAL.Your minute is just about up. Mr. PENSKY.For not staying on the line and fighting for us. You know, they were elected for that purpose: peace, jobs, and security. Mr. ROYBAL.Thank you. Your minute has expired. Mr. PENSKY.Mr. Representative, do you know that this State of California has passed two amendments, two times, transfer amend­ ments, to take the money that the administration has stolen out of the peoples' social conditions into defense spending and transfer it back. Two times overwhelmingly. And I hope that you people that do that-I mean, you people want an issue to fight on, you've got plenty of them. It seems to me that the offensive is carried out by reaction and the liberals seem to be stunned by this offensive against them. He threatens them, you know, that Reagan is threat­ ening the whole world. You can't go around threatening the people with nuclear death and getting away with it like he is doing. And that is where the money is going. Mr. ROYBAL.I'm going to have to cut you off because you have already exceeded your minute. Mr. PENSKY.How about under Carter? We had a national health bill. What happened to that bill? People don't bring the issue up any more. Mr. ROYBAL.Well, we had Carter and then we elected Reagan and that's what happened to it. 69

Mr. PENSKY. He helped to kill it, oh, yeah, him and Ted Kenne­ dy, they're both a pair. Mr. ROYBAL. Thank you. [Whereupon, at 1:30 p.m., the hearing was adjourned.] APPENDIX

PREPARED STATEMENT OF KIM MAN LAI, PRESIDENT, CALIFORNIA CERTIFIED ACUPUNCTURISTS AssOCIA TION f.7yname is Kim i:an Lai. I am the president of the California Certified Acupuncturists Association. I am here today to speak on behalf of our association as well as the medicare people who need acupuncture treatment. Rep. Burton's bill on f•'.edicare and nedicaid have two significances: first, to give an opportunity to senior citizens to have freedom of choice for their own treatments; second, to recognize the true value of acupuncture. Because of these two significances, in my opinion, the congress should pass these bills. f·ledicare is primarily designed to help senior citizens. Elderly people usually have different kinds of pain, like pain from arthritis, pain from traumatic injuries, pain from degeneration of the whole physical system, etc. Acupuncture is well known for pain relief although its efficacy is not confined to it. Therefore, elderly people need treatments of acupuncture. Actually, numerous senior citizens have benefited from acupuncture. I see no reason for congress not to pass these bills • .~cupuncture is cost-saving too. An r,ustralian M.D. conducted a research on the efficacy of acupuncture in low back pain. He found that acupuncture not only would provide quick relief but also result in enormous cost-saving. His paper is presented herewith to the committee as an evidence. In view of this, if Medicare pays for acupuncture treatments for senior citizens, the government will definitely save a lot of money. Acupuncture does not have side-effects as certain kinds of drugs or pain killers do to people. Manyelderly people cannot stand the side-effect of drugs. Whenside-effect is developed, more medical care is required and it means more expenses are to be involved. In such a case, acupuncture treatments are most appropriate for them. lkupuncture will give them a straight forward and natural effect and again it is an effective treatment and cost-saving. Wth all these reasons, we, The California Certified Acupuncturists Association, s ncerely urge congress to pass Burton's bills so that all the people concerned w 11 benefit from them.

(71) 72

RE: ACUPUNCTUREBEtlEFITS FOR SENIORCITIZENS

IT HAS BEENBROUGHT TO OURATTENTION THAT MANY OF OURPATIEllTS NOW ON MEDICARE FIND ACUPUNCTUREALL EV I ATltlG l'.ANYCONDITIONS MID A TREf'.ENDOUSSOURCE FOR PAIN RELIEF. HO~EVER,THEY ARE HAVINGDIFFICULTY PAYING FOR TREATflENTS- SINCE THE SERVICESOF THE CERTIFIED ACUPUNCTURISTARE NOTCOVERED BY t·'.EOICARE.

IF YOUARE INTERESTEDIN GETTHIGt'.EDICARE TO RECOGtHZETHE BENEFITSOF THE CERT!Fl ED ACUPUNCTURIST,PLEASE SIGN BELOW. THANKYOU.

NAt·'.E ADDRESS 73

RE: ACUPUtlCTUREBENEFITS FOR SENIORCITIZENS

IT HASBEEN BROUGHT TO OURATTENTION THAT MANY OF OURPATIENTS NOW ON MEDICAREFlllO ACUPUNCTUREALLEVIATING f-'.ANY CONDITIONS ANO A mn:rnoous SOURCE FORPAltl RELIEF, HOIIEVER,THEY ARE HAVJIIGDIFFICULTY PAYltlG FOR TREAmEIITS SIHCETHE SERVICESOF THE CERTIFIEDACUPUNCTURIST ARE NOT COVERED BY f·'.EDICARE.

IF YOUARE ltlTERESTEDIN GETTING1:EDICARE TO RECOGtllZETHE BENEFITS OF THECERTIFIED ACUPUNCTURIST, PLEASE SIGN BELOW. THANKYOU,

ADDRESS 74

PREPARED STATEMENT OF HARRYF. TAM I am Harry F. Tam, D.C., C.A., President of U.A.C.. I want to testify before the Select Committee on Aging for acupuncture as the most economic alternative heal­ ing for senior citizens. It is cost effective and kills pain of arthritis and chronic dis­ ease. As you already know, the history of acupuncture dates back over four or five thousand years to the time of the Yellow Emperor of China. Acupuncture was not known in California or the United States until January of 1972 when the first American President visited China. Acupuncture was introduced to the American public when New York Times reporter, Mr. Heston, suffered an appendix attack. He was operated on in the Peking Medical Hospital, using acupuncture as an anesthe­ sia. He did not suffer any pain, discomfort or side effects. The media and newspa­ pers around the world shocked the American public by showing that acupuncture is a safe and painless anesthetic to be used during operations, and that is also effective in the healing of acute and chronic medical conditions. Today, we acupuncturist use acupuncture for drug and alcohol detoxification, relief of mental stress, face lifts and body rejuvenation. In California in 1975, State Senator, George Moscone, (who later became major of San Francisco), wrote a bill, SB 86, to legalize acupuncture in the state of California. It passed both houses and was signed into law by Governor Edmund G. Brown, Jr. At the time, we acupuncturists had to have medical doctors supervise and diagnose the cases before we treated the patients. Then in 1978, the UAC sponsored the "Art Torres Bill", AB 1391 which did away with this referral diagnosis and supervision by medical doctors. Since then AB 3040 has given California acupuncturists the right to use herbs, vitamins, electrical stimulation and Oriental massage. The Social Security System has been in a deficit due to the high price of health care for hospitals and physicians services. We, the acupuncturists, can actually reduce the hospital population. Many chronic diseases such as: prostate enlarge­ ment, varicose veins, bleeding ulcers, severe sacral-iliac strain, tendonitis, asthma, allergies, hemorroids, colitis, and numerous other conditions can be improved by acupuncture treatments and herbal supplements. As for the cost effective office visits, the acupuncturist fees are 1/3 that° of a gen­ eral practice physician and 1/10 the fee of a specialist. Besides, there are no expen­ sive drugs to prescribe to the helpless seniors residing in convalescent hospitals, many of whom are sedated to a stupor and left to sleep 90% of the time. Many medical health care providers double bill the Medicare System. This fraud­ ulent billing causes a deficit in the system. There should be other alternative health care systems to take care of the elderlies. The acupuncturist can keep the most chronic-diseased patients out of hospitals. That type of benefit can certainly cut the cost of hospitalization for the elderly. These senior citizens have contributed much toward the advancement of our American society. If acupuncture can remove the senior citizens' pain, regenerate their energies, and help them maintain their senses, it will provide these sick senior citizens with a much more meaningful life. 0