6. It seems clear that the problem will grow as the numbers of aged persons increase, as inflation reduces the value of their income, as costs of health care increase, and as the total need for services continues increasing.

and

7. Voluntary health insurance faces great difficulties in meeting this problem. As we say in the statement, they are going a long, long way, much further now than they were even a few years ago.

The extent of their ability to overcome these difficulties needs further careful appraisal.

8. The goal should be to develop a program which will keep individuals in their old age financially self-sufficient rather than to drive them into a state of indigency because of their health needs.

9. The financial solvency of the aged is of great importance to hospitals and the whole community.

10. The continued and increased support of voluntary health insurance by the working population must be encouraged, and no program for meeting the health needs of the aged which harms voluntary health insurance is a satisfactory answer.

11. To the extent that Government financing is needed for a satisfactory solution, the Federal Government will have to participate in such financing on some basis.

The fourth area of questioning is the one that deals with the relative responsibility of various groups. I will just read quickly two or three paragraphs only from that.

It is difficult, if not impossible, to dissassociate the health needs of aged persons from their other needs. We believe the problem is such that it cannot be satisfactorily solved except by the participation of all concerned, including the individual and his family, the local community, all of the various voluntary agencies, and of the government-local, State, and Federal. There are numerous activities which can be undertaken at the local community level which can have an important effect upon reducing the need of aged persons for care in hospitals and other institutions.

Hospitals must increase their efforts to make available services to aged persons as ambulatory patients and their efforts to provide the care needed so that it may be less costly than acute general hospital

care.

Efforts by hospitals and by others to provide nursing home facilities are essential. Great effort must be made to increase the level of quality of care rendered so that aged persons entering facilities called nursing homes may be assured basic health services. The States have real responsibility to improve the standards for nursing homes and to strengthen their enforcement. A differentiation should be made between purely custodial institutions and health care facilities.

We believe, for example-and we spell out various points therethat the Federal Government is going to have to participate and we believe increase its participation with respect to the meeting of the facility needs for acute hospital care, for nursing home care, and for chronic disease facility care of the aged, and for necessary housing, as I mentioned.

Substantial increases in Federal funds are needed through grantsin-aid, we believe, to bring this change about.

We have concluded that the Federal Government will have to participate with State governments in the financing of the cost of education of nursing personnel, and this is a critical problem we think we face for the future.

Mr. Chairman, as I consider the overall problem of aged persons, I believe there are two fundamental issues concerned.

The first of these is the very difficult question as to the basic validity of earmarking 65 as the date when an individual is said to become aged. As I heard said recently, there is no wondrous magic that takes place during the night when an individual passes from age 64 to age 65 that makes him a different sort of a person. What is the basis today of keying retirement to age 65? Do not the facts indicate that, by and large, the retirement age now averages 68 years of age?

There is evidence that the sharp rise in the use of health services by aged persons is more closely associated with retirement than with age 65. If employers could be persuaded to lengthen the work years, that might in itself help materially in reducing the problems of health needs of the aged.

The second basic question, I believe, is what can be done to develop a whole new basis of acceptance of the retired aged person. I believe this has meaning for his health. What can we do, in a society which measures the worth of every individual in relation to his ability to produce, to foster acceptance of retirement and the years of nonproduction as also being worthwhile?

We appreciate this opportunity to express our views before this subcommittee on a matter which we feel is of primary importance. We are confident that the work of this subcommittee will contribute greatly toward a better understanding of the problem and toward development of solutions.

Thank you, Mr. Chairman.

Senator MCNAMARA. Thank you, Mr. Williamson.

We have just time for a few questions of you.

The statement that you make here stresses the need for financial medical care for the aged.

However, you have expressed the position of your association as not favoring the Forand bill now. It seems from the recommendation you make, that it is itself a pretty good recommendation for the Forand bill.

You also indicate that you think we should have further study before you are able to recommend any specific legislation of the Federal Government in this field.

When do you expect these studies will be completed?

Mr. WILLIAMSON. Mr. Chairman, we are, as you say, opposed to the Forand bill. We believe that voluntary health insurance can go a lot further and is going further. We think the work of this committee and the hearings on the Forand bill have given new impetus without doubt and deserve great credit just for that. How far the voluntary health insurance can go, we do not know. Anybody is on hazardous ground, we think, to forecast the future.

It is proven that it has already gone way beyond anybody's imagination. But there are hard facts associated with the possibility that voluntary health insurance can solve the problem, and we think these also must be faced.

As we looked at all the problems we concluded, as I have stated, that the participation of the Federal Government as nearly as we could see must come about in some way. We think that the social security approach is not the best way.

We spell out real dangers which we honestly see in it.

We believe that other approaches, possible ways in which Government might participate ought to be explored more completely than they have been.

We go so far, I might say, as to explore also other ways that the social security system might be used besides the so-called Forand approach, ways that might be better for the people and the country as a whole.

Senator MCNAMARA. Your studies are underway now?

Mr. WILLIAMSON. We have no studies at this moment, Senator, on this problem. What we are putting our energies in now is to help voluntary health insurance to go further and see how for it has gone and continue to appraise what is going on.

Senator MCNAMARA. I think your statement is very helpful, and I hope by the time you get to the White House Conference on the Problem of Aged and Aging you will have a more definite recommendation.

You indicate, and we agree with you, there are many new plans being developed now, and it is too early from your association's viewpoint, to make a firm recommendation, but I hope you will be able to do it at a very early date because your experience is very helpful to the subcommittee.

Now, we have Senator Clark with us. Do you have any questions or comments?

Senator CLARK. No; except to apologize for not being here earlier, and to say that, Mr. Williamson, unfortunately I did not hear all your testimony but I gathered from what Senator McNamara has just been discussing with you that you agree, speaking in terms of the income level, that there are many millions of Americans, aging Americans, who are never going to be able to afford the most generous voluntary hospitalization plan. That is true; is it not?

Mr. WILLIAMSON. Well, as we see, a fairly comprehensive program of voluntary health insurance would cost for aged people from $15 to $20 a month. Some figures were cited here earlier around $9. A $9 rate is conceived on the basis they will be included in the communitywide rating. That has special problems as we found, but whether and the extent to which aged people with the income they have, how many of them can afford $15 or whatever it may be in that area I think poses the question which you suggest, Senator.

Senator CLARK. We do know there are literally millions of them that cannot afford it.

Mr. WILLIAMSON. That cannot.

Senator CLARK. Yes.

Mr. WILLIAMSON. We surely do. There are about 600,000 OASI recipients on public assistance.

Senator CLARK. Thank you.

Senator MCNAMARA. Senator Randolph, have you any comment or questions?

Senator RANDOLPH. Mr. Chairman, have you any estimates that you could provide for the record that might be current for so-called cost of home care-that is, a person coming into the home in the capacity of a nurse or attendant for the daylight hours rather than during the night? Comparing those costs alongside of the nursing home itself?

Mr. WILLIAMSON. I believe we can give you some figures, Senator. There are several experiments. Home care, the kind you describe, is yet in an experimental stage very much. There are some good experiments and I believe we have some indications of comparative costs. When you say compared with nursing homes, however, you have to qualify, as you indicated earlier, what kind of nursing home you indicate.

Senator RANDOLPH. I do realize that.

Mr. WILLIAMSON. I believe we can give you some information for the record.

Senator RANDOLPH. That will be helpful

Senator MCNAMARA. We would like to have that for the record, if you have the figures.

Mr. WILLIAMSON. We will get it for you.

Senator CLARK. May I ask one more question, Mr. Chairman?
Senator MCNAMARA. Senator Clark.

Senator CLARK. Senator Randolph raised this question about nursing homes, and over in the Banking and Currency Committee we are presently considering the extent to which aid should be given to proprietary nursing homes for housing, rehabilitation, and rebuilding purposes. Their witnesses were in the other day and I thought they were quite impressive on the basis that they could give pretty adequate care for the aged at a good deal lower cost than the same care could take place in a hospital. I am wondering if you would agree with that?

Mr. WILLIAMSON. Yes; no doubt about that. I think the average cost that came out the last year, just the other day, in the general hospital was over $29 a day. In the nursing home I hear it is around $7 a day, or $8 or $9. You can get a good level of nursing home care. However, most of the nursing homes, many in the country, goes down to around $2 or $3 a day, and you get what you pay for.

Senator CLARK. Even at that very low level it probably meets State requirements for adequacy, does it not? I mean they are not running bootleg institutions?

Mr. WILLIAMSON. No. They must be approved by the State.

That is one of the reasons, Senator, in the bill over in the Banking Committee that you referred to we have recommended strongly to the committee that the Federal Government do what it can do to insure adequate standards by putting in that bill requirements that the State have a respectable level of standards for such care.

Senator CLARK. Yes. I think you are quite right.
Senator MCNAMARA. Thank you.

Mr. WILLIAMSON. Thank you.

STATEMENT OF JULIA C. THOMPSON, WASHINGTON REPRESENTATIVE, AMERICAN NURSES' ASSOCIATION

Senator MCNAMARA. Our next organization we will hear from is the American Nurses' Association, Julia C. Thompson, Washington representative.

We are happy to have you here, Miss Thompson. And do you have a prepared statement that does not seem too long? Is it your plan to insert it in the record at this point and summarize it?

Miss THOMPSON. I would like to read most of the statement. I have a few paragraphs which I will summarize and I have a few statements that I would like to add to it which occurred to me as the testimony was given this morning, Senator.

Senator MCNAMARA. Your entire statement will appear in the record at this point.

(The prepared statement of Miss Thompson follows:)

PREPARED STATEMENT OF JULIA C. THOMPSON, WASHINGTON REPRESENTATIVE, AMERICAN NURSES' ASSOCIATION

The American Nurses' Association welcomes this opportunity to discuss with this committee problems of the aged which come within the scope of the association's activities. We realize, of course, that the subject of your inquiry includes many social and economic problems. One of the major ones, we believe, is that of the health care for the aged and it is to certain aspects of this problem that we will confine our comments.

It is generally agreed that the health problems of persons 65 years of age and over are serious ones, since it is the long-term and chronic diseases to which this group is most subject. The increasing number of aged persons in our population and the fact that persons of this age usually are less able to pay the costs of such illness, of course, add to our concern with this problem.

The American Nurses' Association believe that this committee would find it worth while to study the possibilities and needs for the expansion, improvement, and extension of methods of providing health care to aged persons in their homes as a partial solution of their needs. We realize, of course, that there is a need for more hospital facilities, but we believe that more hospital beds alone is not a solution for the health problems of persons 65 or older.

Another area which must receive attention in our efforts to provide adequate health care for this group is the very serious situation now existing in many so-called nursing homes. A marked improvement in standards of care must be made if these facilities are to serve their purpose in meeting needs of our aged population for nursing care.

Public health nursing agencies are finding that more and more of their visits to patients are made to aged persons with long-term illnesses. We mention this not only because it indicates a need for such service, but to point out that the only method of providing such service, by and large today, is through visiting nurse services, which exist mainly in the large urban areas. Small urban centers and rural areas have few facilities for the care of patients at home. In a few instances such service is supplied by local health departments, and there is evidence of a trend in this direction although we cannot support this statistically. We do know that in 1957 there were 807 local nonofficial public health agencies in this country. Local nonofficial agencies usually are visiting nurse services which are not supported by public funds. There were also 97 local combination agencies. These are local health departments which usually include a visiting nurse service.

In reports of a number of visiting nurse associations to the National League for Nursing, we find that a large number of nursing visits are made to patients in the older age brackets. In 1958, the Detroit Visiting Nurse Association reported that 16.4 percent of its patients were 65 years of age or over. The Visiting Nurse Service of Rochester and Monroe County, N.Y., has studied the age range of their patients and found that in 1950, 34 percent were over 65; in 1954, 39 percent; and in 1958, 44 percent, and these patients received 52.7 percent of the total visits made. The VNA of New York reported that in 1958, 25 percent of their patients were 65 or older and this group received 50 percent of the visits.

In its 1958 annual report, the Chicago VNA states: "Our records reflect an ever-changing health picture in the community. The senior citizen is receiving most of the nursing care; 71,822 visits were made to patients over 65 years of age. This is 38 percent of our total visits. Fifty-seven percent of our visits went to patients over 45 years of age. Most of these are patients who have some form of crippling disease which requires long-term nursing care. In addition to the physical problem, these people have many social, nutritional, and emotional needs. The problems of this group of the population are partially the result of the change in attitudes and institutional patterns of society.