(2) The practical problems of having companion governmental systems to reach the heart of the nursing care needs of the elderly make it unwise to adopt a Federal system based on the theory of benefits "as a matter of right." (3) Local systems can work; local systems have worked.

Thank you.

STATEMENT OF SEYMOUR S. GUTHMAN, PRESIDENT, POTOMAC VALLEY NURSING HOME, INC., IN RE PROPOSED LEGISLATION RELATING TO MEDICAL CARE FOR THE AGED

My associates and I are erecting the Potomac Valley Nursing Home in Rockville, Md., and Woodbine Nursing and Convalescent Center in Alexandria, Va. These are two skilled nursing homes which will provide a total of 310 beds for use by persons in need of convalescent and nursing home care. General experience indicates that perhaps 90 percent of our clients will be over 65 years of age; many will be in their seventies and eighties. Most if not all of these people will be in failing health, at least to some degree.

Since our homes will be models of safety, convenience, and comfort and will be administered and staffed by skilled professionals, we have reason to hope that physicians and hospitals would be happy to recommend their patients to our care. But we are not now affiliated with or controlled by a hospital, a requisite for inclusion in the proposed legislation. We may or may not become so affiliated in the future. If H.R. 3920 should be enacted in its present form, 310 of the finest nursing beds in this heavily populated region might fall outside the legislative coverage, and thus outside the financial reach of those who most need the excellent care that we will be able to give them.

This is far more than a self-serving plea. Last year, the respected Medical Care Research Center at St. Louis, Mo., estimated that of the some 362,200 skilled nursing beds available throughout the United States, only about 7 percent (24,114 beds) were in facilities affiliated with hospitals. An additional 2.886 such beds were then reported under construction or in the active planning stage.

We are fully aware of the shortcomings of some of the existing homes. We plan to cooperate actively in seeking a workable accreditation program for all nursing homes, which could conceivably lead ultimately to a far greatest number of hospital proprietary nursing home affiliations. But we are fully cognizant of the fact that all things being equal, this will not come about very soon. Meanwhile, the number of ailing elderly people of meager or modest means multiplies. Where shall they go?

Certainly cooperation between the nursing homes and the hospitals in a given vicinity is most desirabble. There are today many examples of informal, effective cooperative arrangements which might suggest to this committee a more general, flexible standard than that which is now set by the bill's present "skilled nursing facility" definition and requirements.

As

There is still another provision in the bill which, like the one discussed above, would snatch away with the left hand what is proffered with the right. we understand this legislation, the general purpose of H.R. 3920, is to make nursing home care available to the aged so that this group of people may not so heavily burden the hospitals and in turn be spared the burden of general hospital costs. Yet this proposed legislation stipulates that nursing home benefits will be sanctioned only upon direct transfer from a hospital.

Previous hospitalization is also required in most instances by the several dozen private insurers who offer some sort of nursing home coverage.

No one, so far as we can ascertain, has estimated what proportion of nursing home inhabitants come directly from hospitals and what proportion from elsewhere. But there is complete agreement that the overwhelming majority are not hospital transfers. Wouldn't it be reasonable to suppose that if H.R. 3920 were enacted in its present form, the very group Congress had intended to help would be forced either to resort to subterfuge in order to qualify for the benefits, or to forgo the benefits altogether?

Moreover, many of the so-called nursing homes formally affiliated with hospitals-particularly those physically located on the grounds of hospitals or commonly administered with hospitals-tend heavily toward chronic disease patients rather than toward aged people with their special needs and problems. We appreciate the fact that Congress has the necessity and the duty to set standards for the benefits which it confers. We submit, however, that the two 27-166-64-pt. 5-21

provisions discussed above severely limit and even undo the very good that Congress proposes to bestow.

Since H.R. 3920 clearly acknowledges the important role of the skilled nursing home in the modern health care complex, it becomes especially pertinent to note that in many States the public assistance reimbursements to both public and private nursing homes at the best cover minimal standards of care. Certainly this could not be what Congress desires either for the nursing home inhabitants or for the establishments which are constantly being exhorted to upgrade themselves. We respectfully suggest that this is still another facet of health care for the aged that urgently requires legislative attention.

Now that we have been given an opportunity to voice our suggestions, we would like publicly to express our thanks on a separate but related score. As organizers and owners of skilled nursing homes, we have had widespread and frequent contact with those agencies of Government involved in the construction and licensing of nursing homes, as well as with the development of information concerning such homes. I have in mind particularly the Washington, D.C., offices of the Federal Housing Administration and of the Department of Health, Education, and Welfare. The people with whom we have dealt in these agencies have not only been knowledgeable about Government requirements in the matters under discussion, but intelligent, efficient, and courteous in all their dealings with us.

STATEMENT OF MISS DANA HUDSON, R.N., CHAIRMAN, COMMITTEE ON LEGISLATION, GEORGIA STATE NURSES ASSOCIATION

Mr. Chairman, I wish to express my sincere appreciation to you and the committee members for hearing the views of the nursing profession in Georgia. In behalf of the Georgia State Nurses Association, wish to place myself and our association on record as strongly opposed to H.R. 3920.

I am Dana Hudson, R.N., of Douglasville, Ga. I am a registered nurse and have been practicing nursing for the past 30 years in Georgia. I have just retired from the position of director of nursing at Georgia Baptist Hospital in Atlanta, Ga., where I served for 21 years and where I am now director emeritus.

Currently, I am president of the board of examiners of nurses in Georgia. This board administers the nurse practice act of our State. I was appointed by the Governor of Georgia to serve on the Georgia Commission on Nursing which undertook studies and recommendations relative to nursing care problems. For 10 years I served on the Georgia Hospital and Nursing Licensure Commission and I also was appointed by the Georgia Association of Nursing Homes to serve on the accreditation commission for nursing homes.

I am a member and former president of the Georgia State Nurses Association and also a member of the American Nurses Association. It is in my capacity as chairman of the Georgia State Nurses Association Committee on Legislation that I give you the views of our association in opposition to H.R. 3920, the Hospital Insurance Act of 1963.

Founded in 1907, the Georgia State Nurses Association is a constituent unit of the American Nurses Association. Our primary purpose is to elevate and maintain the standards of nursing; to protect the public; as well as to do all other things incident to the nursing profession. The Georgia State Nurses Association, representing some 3,000 registered nurses in the State of Georgia, has 14 district nurses associations which are organized under the State association to improve the standards of nursing care.

My brief statement will emphasize our reasons for opposition to proposed legislation to finance health care of the aged through the use of the social security system. As recently as November 8, 1963, the Georgia State Nurses Association voiced official opposition to King-Anderson type legislative proposals. We well understand that our position is in opposition to previous stands taken by the American Nurses Association on this issue. Nevertheless we sincerely believe our views are both significant and valid. Our State association regrets that time did not permit discussion of the ANA stand at the ANA 43d Biennial Convention held May 14, 1962-at which time we wished to present the position of the Georgia State Nurses Association in the hope that we might prevail in getting ANA to reconsider their policy on King-Anderson type legislation. Therefore, we believe it most important that our views be given directly to the committee at this time.

We are concerned and opposed to legislation that employs tax moneys to provide benefits regardless of the recipient's need for such benefits. In Georgia, at the present time the Kerr-Mills law is providing financial assistance for onethird of our total population over age 65. These benefits include up to 60 days per year hospitalization and up to 365 days per year of nursing home care for any illness or injury requiring either hospitalization or nursing home care. Of a total of 300,000 persons over age 65 in Georgia, some 95,000 are eligible for old-age assistance health care benefits under Kerr-Mills. Gov. Carl Sanders has given indication of his interest in initiating the second phase of Kerr-Mills early next year. It is our contention that in view of the successful operation of the Kerr-Mills law in Georgia, there is no necessity for additional legislation. Our association cannot support legislation which provides financial assistance to all persons regardless of their individual need for such assistance because their assistance has already been or soon will be provided by Kerr-Mills to those senior citizens in Georgia who have actual need for assistance in meeting health care costs.

As employees of hospitals, we are also opposed to the Federal control of hospitals by directive and regulation which would necessarily result under H.R. 3920 through the contractual relationships established by the administering Federal agency and participating hospitals. As nurses in a hospital, we recognize the importance of local control, because hospitals must serve their communities as communities vary, so must the services of the hospital vary, depending on the needs of the community. For a central governmental agency far removed from the site of the hospital to stipulate the organization of such hospital by contractual rules and regulations would not be in the interests of better patient care. We believe, that of necessity, such control would go far beyond the voluntary standards that are self-imposed such as the recommendations of the Joint Commission on Accreditation of Hospitals and the Georgia Hospital-Medical Council accreditation service for smaller hospitals.

We also wish to point out that the present Kerr-Mills law already makes provisions for private duty nursing care and many other benefits which can be utilized by States as the need arises and as they see fit at the local level.

Our association is on record in strong support of the Kerr-Mills law. We firmly believe H.R. 3920 is and would be unnecessary in view of our progress in Georgia under Kerr-Mills. We oppose the additional tax burdens imposed in H.R. 3920 which would tax generations yet to come for the provision of health care now being provided for in all States under OAA and in almost two-thirds of the States under MAA through the present Kerr-Mills law. The record is clear on Kerr-Mills implementation and proves to us that additional legislation is indeed unnecessary, unwise and financially unsound. A rise in taxes to provide health care benefits regardless of the need for these benefits is another strong reason for our opposition to H.R. 3920.

In summation, let me also state that nurses, as part of the health-care team in Georgia, have grave fear of the socialization of medicine. While such proposals may be called social insurance or hospital insurance, we in the Georgia State Nurses Association oppose those measures which would tend to control such a personal service as health care. We believe H.R. 3920 would federalize health care of the aged to such an extent as to impair individual patient care rendered by competent and skilled members of the nursing profession.

So there can be no doubt as to the position of the nursing profession in Georgia, I wish to reiterate that the Georgia State Nurses Association is strongly opposed to the passage of H.R. 3920 acting under the mandate of our membership on November 8, 1963, assembled in annual convention at Augusta, Ga.

I wish to thank the members of this committee for permitting us to present our views on this issue. We know you will give our position full consideration and we are appreciative of your interest of the health care of our aged citizens.

WILBUR D. MILLS,

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

ST. PAUL, MINN., November 19, 1963.

Minnesota hospitals oppose passage of H.R. 3920. Financing of medical and hospital services of quality standards is not provided aged needy in Minnesota through old-age assistance. University of Minnesota hospitals and public hospital in metropolitan area an additional financial resource for purchase of

health services becomes available for the liberally defined medical indigent aged person on July 1, 1964, through passage at the last session of the Minnesota Legislature in enabling legislation to qualify under Kerr-Mills amendment to Social Security Act. WILLIAM WALLACE,

President, Minnesota Hospital Association.

STATEMENT OF ILLINOIS HEALTH IMPROVEMENT ASSOCIATION IN OPPOSITION TO H.R. 3920

(By Henderson May, Executive Director)

Gentlemen, in August of 1961, the Illinois Health Improvement Association was given the privilege and the honor of testifying before the House Ways and Means Committee objecting to the King-Anderson bill to provide medical care for the aged. The executive director, W. Henderson May of Springfield, Ill., accompanied by the president, John Rehkemper, of Highland, Ill., made this presentation. In a recent communique from Chairman Wilbur Mills, the Illinois Health Improvement Association has again been given the opportunity to testify in person or file a written statement which will be a part of the printed record of the hearings.

I would ask the members of the House Ways and Means Committee who desire to review the story of the Illinois Health Improvement Association to refer to this publication: "Health Services for the Aged Under the Social Security Insurance System"-hearings before the Committee on Ways and Means, House of Representatives, 87th Congress, H.R. 4222, volume 4, page 1863.

The association would like to reaffirm its stand that the volunteer movements and nongovernmental insurance programs across the Nation are adequate to provide for hospital-medical care for all classes of people. While the proponents of the King-Anderson bill may have been proposed in good faith-there are better ways. Enacting the King-Anderson bill might be likened to having the Federal Government set up a special A.T. & T. telephone system for people over 65— when we have the greatest private telephone system in the world. Such action in either the telephone or health-care fields would be impractical, wrong, and costly.

DAYS OF CARE

The Illinois Health Improvement Association would like to substantiate its statement by quoting some figures. Prior to March of 1962, only 120 days of hospital-medical care was available to the 70,000 farm family members belonging to the Illinois Health Improvement Association. In March of 1962, 245 days of care were added for a total of 365 days. We are happy to report that there were only 32 single admissions reported during the first 12 months after the 365 days of care were made available, who used more than 120 days of hospital care. We think this is a significant figure and it shows that through the volunteer approach, even though 365 days of care are available, that people are not abusing the program but are using the program.

GROWTH IN HEALTH IMPROVEMENT ASSOCIATIONS

Another figure which is of significance and should be given considerable attention by the House Ways and Means Committee in reaching a decision on KingAnderson, is that the Illinois Health Improvement Association gained almost 1,700 new members during 1963. This was accomplished by volunteers who have gone out into the highways and byways to enroll self-employed rural people in this voluntary program. This in itself is significant to show that volunteers can still do the job when faced with a challenge.

CARE FOR OVER 65

It might be pointed out here that 26 percent of the membership of the Illinois Health Improvement Association, enjoying the finest hospital-medical-surgical care under the Blue-Cross-Blue Shield program, is over 65. Thus we can conclude from these figures that health care for those over 65 in the rural areas of Illinois are being adequately taken care of.

Over the years the Illinois Health Improvement Association and its 91 county units have been carrying out the exact implication which the name implies— health improvement. Here again I would refer back to our testimony given before the House Ways and Means Committee in 1961 for this evidence.

HEALTH IMPROVEMENT FOUNDATION

The Illinois Health Improvement Association was issued a challenge some 2 years ago to provide the vehicle through which young people, choosing a career in the health sciences field, could be provided scholarships and loan funds to a greater extent than those now being offered by many organizations--including the health improvement associations. In July of this year final arrangements were made with a bank in Springfield, Ill., to become the trustee of a fund to provide such scholarships and loan funds. A brochure explaining this foundation is attached. I would urge each member of the committee to peruse this brochure in order that they can familiarize themselves with the task that these volunteers have chosen to perform.

It is not a menial task-it is a task which which will have a lasting effect on the health care of all citizens of Illinois. This idea was conceived, planned, and instigated by volunteers.

Now as to the specific suggestions:

If it is finally determined that Federal aid is essential, we suggest that it be given to the voluntary hospitals rather than to individuals. Our voluntary hospitals are not intended to operate at a profit but it was the hope of their founders that through some voluntary contributions they could support their wards and clinics. Today, the nature of the hospital has changed. It is no longer just a refuge for the ailing. It is also a training center for doctors and nurses, a research facility, a community-service center. Its labor costs, its cost of medical care, its costs for today's trained personnel and highly specialized equipment have gone far beyond the concept of its founders.

Today, practically the only individual bearing these costs is the patient. He comes to the hospital seeking relief for himself, realizing perhaps that hospital costs are higher today than they used to be because the prices of labor and food have gone up. But, he doesn't quite anticipate that in the course of seeking medical or surgical help for himself, he will also be required to subsidize research, training in the medical sciences, and the purchase of new equipment. Someone, too, has to maintain the hospital even when many of the beds are empty. It must be ready at all times for accidents and emergencies, for ambulance service, for epidemics, and even for the unpredictable schedule on which babies arrive. The cost of operating the community hospital on a "standby" basis now falls on the hospitalized patient or his family. Why should the stricken individual have the additional burden of supporting a general service to the community? Here, then, is a logical use for Government funds, a use that would indirectly but in a completely practical way provide relief to the individual-the financial aid by the Federal Government to local community hospitals.

Through such a Federal program, the entire community would benefit in the greater financial stability and security of its local hospitals. Naturally, the entire Nation could also benefit through the assured postgraduate training of its doctors and nurses-and the discoveries made through local research. Furthermore, the reduction in the individual patient's bill made possible by this subsidy could perhaps bring him back into the fold of those who could afford to pay for their own prepayment protection.

Certainly, no one can question the importance of medical education. Certainly, no one can quibble with the community need for specialized equipment and for research.

Then, we suggest, let the Government give its financial help to the Nation's 6,000 voluntary hospitals. Let it establish a formula by which hospital maintenance costs can be determined; let it then pay a fixed percentage of those costs to qualified and certified hospitals-perhaps as much as 25 percent.

But let it leave the determination of the aged individual's financial needs for medical care and the satisfaction of those needs to those who know their communities best-those who know their trade.

In closing, may I state emphatically that, given the incentive, volunteer organizations will find the tools and the wherewithal to do the planning and all the other things necessary to meet health care problems on a local level at a much less cost than could the Federal Government to provide these services.