have been increased opportunities for those doctors not imbued with high ethical standards to make money unscrupulously or to follow easy rather than constructive patterns of treatment.

The large amount being paid for medical services today does not necessarily result in the best use of facilities or in high-quality care.

Commercial insurance companies say quality of care is not their business. They are probably right.

But we think the medical professions might well take more responsibility themselves in eliminating substandard care and securing widespread adoption of constructive practices. We think the doctors especially should take responsibility for promoting a more adequate supply of well-trained medical students and other professional personnel in view of the vast and increasing demand for good services.

Government programs that involve payment for medical care inevitably affect pattern of care.

Your committee may well want to consider various methods of shaping a health benefits bill so that the resulting program will move in the direction of furthering high-quality care. We would look favorably on strengthening the power of the Secretary gradually to improve standards that would have to be met by hospitals and nursing homes if their services are to be paid for out of the trust fund. Such regulations should of course be arrived at after consultation with an advisory council of professional people and on the basis of standards developed by doctors and other members of the medical professions. Another possibility would be to encourage hospital practices, such as the use of evaluation committees, in order to speed return of patients to their homes or to less expensive institutions.

You will be told that the provision of health benefits contemplated in the Forand bill would lead to abuses. Now we would be the last to deny that the possibility of abuse exists in a health insurance program. To do so would be to disregard our vast experience with many types of insurance now in operation. The problem is how to direct the insurance program in a manner to encourage the development of constructive patterns that will prove of benefit to the people covered. This is not easy, but it is definitely possible. It will take the most careful social engineering. We of organized labor pledge our complete cooperation to this effort. We will gladly work with representatives of other groups including the hospital administrators and the medical profession in the development of standards and procedures designed to guarantee the highest quality of care under the program.

Existing or potential deficiencies in the services for which the Government would meet the costs should not be permitted to delay providing the Federal health benefits the aged so urgently need. Lack of ability to pay for medical bills ought not be the determining factor in the amount of medical care received. Yet today, for many of the aged, lack of financial resources results in health care that is too little and too late.

EXPLORATION OF ADDITIONAL TYPES OF BENEFITS

H.R. 4700 follows patterns established by most private group plans of paying for surgical care as well as hospitalization. It adds skilled nursing home care following hospitalization to encourage use of less expensive facilities.

The key benefit of the three is the one for hospital care. Payments for such care are included in most existing insurance, and hospital bills loom large in many severe or chronic illnesses of the aged.

Hospitalization is, however, only one element in the complex pattern of good health care. The latter includes at least the following elements:

Preventive care, with early and effective diagnosis.

Readily available, continuing care for acute and chronic diseases alike, including the services of doctors and nurses, necessary drugs, and therapy.

Advice and assistance with maintaining independent self-care and with speedy rehabilitation after illness.

The last few years have seen increased experimentation under private insurance with the coverage of various forms of care that are good in themselves and also keep down the costs of hospitalization. We have discussed with experts in the field various possible combinations of benefits that would achieve these purposes.

Your committee last year asked the Department of Health, Education, and Welfare to explore hospital and nursing home care.

We recommend that you now consider two additional types of benefits that might be combined with others to provide a valuable pattern for the aged and other beneficiaries. While more comprehensive benefits will be recommended by some, the ones we are proposing have two advantages. They can be dealt with according to reasonably well-established procedures, and they would make a very real contribution to the care of the aged without leading to additional costs beyond those which your committee might want to consider at this time.

Two additional types of benefits are: (1) Payment for certain types of diagnostic care in outpatient departments of hospitals; (2) payment for care by visiting nurses in the patients' homes.

Diagnostic benefits

A

Diagnostic benefits would support early diagnosis and preventive care. patient's physician could prescribe essential tests, such as electrocardiograms or X-rays, without having to put the patient in the hospital and without being concerned as to whether he could pay the cost. Serious illness could thus be caught at an early stage.

The bill might specify some of the types of diagnostic care for which payment would be made, leaving the addition of other types to later recommendations by the advisory council. You might consider permitting nonprofit clinics other than the outpatient departments of hospitals to be paid for providing such diagnostic

care.

Home nursing benefits

The home nursing care we have in mind would be provided by professional nurses and organized through a responsible agency, such as a visiting nurses' association, a hospital, or a local health department. Many communities already make such professional home nursing care available. Many people much prefer being at home and recover faster there. Costs are much lower than in institutions.

Demonstration projects

We likewise recommend that you consider the value of a new program of Federal grants for demonstration projects on methods of promoting the speedy return of the aged to self-care and home care.

Very dramatic examples exist here and abroad of what can be accomplished toward these goals. Care consciously directed toward minimizing the amount of hospitalization of the aged has resulted in much shorter hospital stays, more effective use of hospital beds, and remarkable success in avoiding chronic invalidism.

The inclusion in a committee bill of a limited authorization for grants for such demonstration projects would help to emphasize your committee's concern with the development and application of methods that will both promote health and independence and minimize institutional care.

We recommend strongly that your committee either undertake its own study of the desirability and feasibility of providing diagnostic and home nursing benefits as part of the OASDI programs, or that it ask the Department of Health, Education, and Welfare to make such a study, reporting not later than January 1, 1960.

No further study is required on the need for Federal health benefits under the old-age, survivors, and disability insurance program. But we realize that the committee may want further exploration of alternative administrative procedures and of the best methods of accomplishing the goal of making good health care available to the aged on a reasonable basis.

THE APPROPRIATE ROLE OF GOVERNMENT

The Federal Government has long been concerned with health problems. The U.S. Public Health Service traces its beginning back to 1798 when the new National Government assumed responsibility for hospitals for seamen. Tremendous contributions have been made to research as well as actual care of sick people by the National Institutes of Health, the veterans' hospitals, the military hospitals, the maternal and child welfare programs, the emergency medical and infant care program of World War II, and medicare program.

When those opposed to proposals such as those in H.R. 4700 express fear that the Federal Government cannot properly administer health benefits for the aged, let us remember that the American Medical Association and the life insurance companies and others followed a similar line back in 1935 with respect

to our social security program. They said it would be impossible for the Federal Government to administer old-age benefits and keep wage records for so many people. This was "socialism"-and it would mean "dog tags" for every citizen, threatening everyone's independence.

A similar cry was raised in 1956, which the Congress wisely discounted in enacting disability benefits. You will recall that the Eisenhower administration opposed that measure and fought it vigorously, yet today this same administration boasts of the accomplishments under this part of the social security program. We believe that the evidence on the inevitable shortcomings of private insurance amply indicates the need for Federal action. The problem is not whether the Federal Government can constructively administer health benefits for the aged and other beneficiaries but, rather, what are the best methods by which it can once again provide a channel for the American people to do together what they cannot do for themselves individually.

The Forand bill has many wise provisions that should allay fears of Government controls. It provides for an advisory council to be consulted in the development of regulations under the general powers given to the Secretary of Health, Education, and Welfare. Such an advisory council would presumably be supplemented where necessary by direct consultation with spokesmen for such organizations as the American Medical Association, the American Hospital Association, and the American Nurses' Association.

The bill also permits the Secretary to make use of voluntary nonprofit organizations to the extent that he determines "that such utilization will contribute to the effective and economical administration of this section." The organizations utilized might be some of the present Blue Cross associations, for example, or possibly a new group established by the hospitals. This provision should appeal to persons who honestly believe private groups can better run programs of this kind than the Government can.

The program would not impose one pattern nor provide services directly. It would merely pay for the costs of care rendered by a wide variety of institutions, owned and run by many types of groups or by private doctors. Group practice prepayment plans, such as cooperatives and labor-health centers, could be utilized by patients, as could any providers of services who were willing to accept the obligations and standards of the program.

The bill does not give the Federal Government authority to tell doctors how to carry on their medical practice. In the case of hospitals, it contains the following paragraph:

"No supervision or control over the details of administration or operation, or over the selection, tenure, or compensation of personnel, shall be exercised under the authority of this section over any hospital or nursing home which has entered into an agreement under this section."

The major responsibility for developing standards should continue to rest with the various health professions, including the hospital administrators. But insofar as they are not able to fulfill their responsibility alone, the Federal Government may need to backstop their efforts with specifications for the care it purchases just as it now draws up specifications before it buys drugs or hospital beds. It is tragic that the leaders of the American Medical Association seek to fight the Forand bill through a public relations campaign instead of helping us to explore constructive methods of meeting the need toward which the bill is directed. The AMA has had a way of turning to public relations people and expending millions on them instead of discharging fully its responsibility for advancing the quality of care.

Spokesmen for the American Medical Association last year told your committee that "any Federal supervision of medicine and hospital care is socialization." On questioning, they explained that the various veterans' programs fell within the definition of socialized medicine, and also the armed services' medical care program. Workmen's compensation programs, they stated, do so "to a certain extent also." The Federal disability insurance program was considered very definitely to be leaning toward socialized medicine. (Ways and Means Committee, "Hearings on Social Security Legislation," June 1958, pp. 900902.)

If all these programs are properly designated as socialized medicine, then not only the camel's nose but at least part of his hump is now within the tent. Close to half of all hospital care in this country is financed from tax sources, in addition to many other programs already mentioned. Rather than indulging in slogans, we believe it desirable to evaluate specific procedures in terms of clear-cut need, common experience, and prospective benefits.

The trend for decades has been in the direction of growing community interest in health programs, translated into various types of government action. The public interest, expressed through government, is bound to keep on increasing as more and more people add good health care to their standard of living. In many States the insurance commissioners are directly involved because of their responsibility for passing upon increases in rates by groups like Blue Cross. The commissioners are finding that they must look into types of expenditures, methods of determining rates, and even representation on Blue Cross boards, in order to carry out their functions properly.

The American Hospital Association has repeatedly gone on record to the effect that "retired aged persons face a pressing problem in financing their hospital care" and that "Federal legislation will be necessary to solve the problem satisfactorily." Undoubtedly spokesmen for the AHA will give you the complete statement adopted by its House of Delegates in August 1958. These repre

sentatives will also of course explain its misgivings about the specific bill before the committee.

We shall examine with open minds any alternative proposals for Federal action which the American Hospital Association or others may make.

Through the years, a variety of plans have been suggested for utilizing Federal funds for health care of the aged. Some have been shaped in the hope of avoiding any close contacts between the Federal Government and the hospitals. But is it not probable that any form of Federal action likely to be developed and adopted by the Congress will have to carry safeguards concerned with honest and efficient use of funds and the maintenance of at least minimum standards of service?

THE AGED DESERVE ACTION NOW

The men and women who are in their declining years today have earned a better deal than they are getting. They have lived through a very difficult period, characterized by a series of depressions, two world wars, and tremendous changes in economic and social conditions. It is no wonder if many of them have not been able to provide individually for incomes in their years of retirement that are adequate to pay for steeply increased medical costs as well as other higher-priced necessities.

We realize that it may be impossible to secure action this year by both the House of Representatives and the Senate. But surely the Congress should not wait beyond next year. The problems of the aged are acute. As it has long been said, justice delayed is justice denied. It is even more true that health delayed is health denied.

We appreciate the many pressing problems with which your committee must deal. But we strongly recommend that you plan to complete your study of these issues, including such additional hearings as may be necessary not later than early 1960 so that the Senate too will be able to act on the measure next year.

Mr. CRUIKSHANK. The printed record of the House hearings will contain much valuable testimony in support of health benefits by distinguished members of the health professions, by authorities in the field of social security, and by spokesmen for welfare groups, cooperatives, and organizations of consumers.

Convincing evidence was presented showing that many aged persons are not getting the medical services they need and that hospitals and other facilities are in difficult financial straits which will become more acute in the months ahead. Many witnesses besides our own labor people explained that public assistance is not an adequate method of meeting the health needs of the great majority of the aged who do not want to be considered indigent and who do not meet the very harsh requirements of many State and local public assistance programs.

The feasibility of administering Federal health benefits as part of the old-age, survivors, and disability insurance program was attested to by Mr. Charles I. Schottland, former Commissioner of Social Security, appointed by President Eisenhower, as well as by Mr. Arthur J. Altmeyer, who for years served in this position under Demo

cratic Presidents.

No convincing evidence was produced to support the claim of commercial insurance companies that they could do the job so that Federal action was unnecessary. Future projections of growth were not substantiated by facts. One spokesman for the insurance industry said the chart on page 44 of the Department of Health, Education, and Welfare report on "Hospitalization Insurance for OASDI Beneficiaries" needed correction because preliminary figures, which showed a downturn in the proportion of the population covered by voluntary health insurance in 1958, had been superseded. The industry, he said, was rapidly expanding its coverage. But, although he did not say so at the time, the revised figures of the Health Insurance Council confirm the 1958 downturn, though reducing it slightly. At the end of 1957, the proportion of the population owning some kind of voluntary health insurance was 72 percent. At the end of 1958, the proportion had fallen to 71 percent, and it was still 71 percent on June 1, 1959, or about what it had been at the end of 1956.

This flattening out of the curve for the entire population casts grave doubts on the predictions as to growth in coverage of the aged which insurance company spokesmen presented to your committee.

In spite of the evidence presented, opponents of Federal health benefits continue to argue that the aged are now getting adequate medical care. Your committee can clarify the actual situation by detailed investigation and publicity on conditions in nursing homes, public hospitals, and other institutions for the aged. The quality and adequacy of care as well as its theoretical availability are of course important.

3. New legislation and expanded appropriations are needed to speed the construction of housing, hospitals, nursing homes, clinics, and other community facilities. In some cases, special provisions for the aged may be desirable, as in the housing bill recently vetoed by the President. But to a considerable extent young and old alike share a common dependence upon effective communitywide action to eliminate slums and enable local areas to keep up with rapid changes in their population.

Without expansion of educational facilities of all kinds, many communities will shortly be experiencing still more intense shortages of specialized personnel trained to provide counseling, medical care, therapy, and rehabilitation.

4. Through improved labor legislation, older workers can be aided to have the benefits of unionism and decent wages and working conditions.

Constructive amendment of the Taft-Hartley Act and the Fair Labor Standards Act can be especially helpful to persons approaching retirement. Many are found in the industries where long hours and low wages still prevail and where employer hostility still crushes efforts to organize unions for self-protection.

The workers in such occupations who are now young will reach old age with a far better chance to be healthy, self-supporting, and self-reliant if they are permitted to share in the many improvements which unions can obtain for their members.

Just as aged persons today are living at a level far below their capacities, so our Nation is performing at a needlessly low level of production.

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