The situation with respect to skilled nursing home facilities presents problems of a different order. Unlike our general hospitals, home nursing and home care programs, the great majority of nursing homes are operated on a proprietary basis and the level of care is generally inadequate. The Senate Subcommittee on Problems of the Aged and Aging, in its report of February 1960, outlined some of the major criticisms of the present level of nursing home care in the United States as follows:

1. Physical plants and equipment are substandard and outmoded. 2. Home operators often lack proper qualification to assure the provision of proper service.

3. Nursing personnel lack proper experience and training to supervise or to render skilled nursing care.

4. Types of services provided are too limited to meet the needs of patients.

5. Management of the patients in nursing homes by physicians is either lacking or inadequate.

6. Licensure standards differ greatly and are either too low or are not being enforced because of the practical problem of finding a place to put the patient.

7. Licensure agencies lack sufficient personnel to do a really effective job of inspection and consultation work even where standards exist.

8. The "storage-bin" philosophy still prevails in spirit or in fact in most nursing homes.

The report of the Senate subcommittee comes to the following conclusion:

This is the discouraging picture of nursing homes and their patients painted by knowledeable people in the year 1959. One cannot see this picture as often as did the subcommittee without wondering for how many people-too well to die but too disabled to live independently or with their families-the future holds only needless relegation to such a limbo here on earth and whether that society which has created the situation has a responsibility for corrective action.

As of January 1, 1961, there were approximately 326,000 beds in skilled nursing homes, but more than two-fifths of these were nonacceptable. The acceptable beds were so classified only on the basis of avoidance of fire and health hazards. Considerations of adequacy of staff and quality of services did not enter into this definition of acceptability. The States have estimated a need for approximately 448,000 beds in nursing homes providing skilled care; this would provide about 21⁄2 beds per thousand population. According to the Senate subcommittee report, this

would appear to be a conservative figure based on a 1957 study in which inquiries to physicians produced an estimated need of 4 beds per 1,000 population if ability to pay or shortages of facilities no longer limited an individual's ability to receive care.

If this latter estimate is correct, we need over 700,000 skilled nursing home beds in this country.

We now have about 181,000 acceptable beds-acceptable only on the basis of avoidance of fire or health hazards. Only a small proportion of these are truly acceptable in terms of providing anything approaching adequate skilled nursing home care.

Our experience indicates that, in general, substandard care is provided in proprietary nursing homes. It is unfortunate but true that

the less service provided, the greater the profit. In contrast, progressive, patient-centered care is usually provided in nonprofit or public nursing homes. It was this situation which led our association, after considerate deliberation, to urge in 1958 support for construction of nonprofit nursing homes.

The APHA is deeply concerned with the possible impact of H.R. 4222 on this situation. As now written, the bill's provision of payment for skilled nursing home care may well have the effect of perpetuating the present inadequacies in the quality of such care. We have reviewed carefully the definition of a skilled nursing facility outlined in H.R. 4222, and we do not consider that it will exclude low-quality facilities. On the contrary, past experience indicates that there will be a great expansion in the number of these inadequate and unsatisfactory nursing homes in an attempt by individual proprietors to cash in on the new funds without worrying unduly about the adequacy of the service which is being provided. In all conscience, the APHA believes that this danger must be pointed out in order to prevent what is now a national disgrace the condition of American nursing homes-from becoming a firmly intrenched national scandal.

One possible alternative would be to delete from the bill all payment for skilled nursing home care. This has the drawback that such care is an important segment of the total health services required by the aged. The other alternative is to include in the definition of a skilled nursing facility the same criterion proposed in H.R. 4222 for a home health agency, namely: "An agency which is a public agency, or a private nonprofit organization exempt from Federal income taxation under section 501 of the Internal Revenue Code of 1954." Although this would have the disadvantage that only a portion of the present beds would be eligible for payment under the program, the disadvantage is more apparent than real, since most of the remaining beds cannot really be said to provide adequate skilled nursing home care. In any event, we believe that the financing of care in substandard nursing homes would not only be a disservice to the aged ill and a misrepresentation of the results intended but would freeze into this Nation's armament against disease and suffering an ineffective and inefficient component. We must, therefore, urge the strongest possible safeguards relative to nursing home care.

The great advantage to our second approach, that is, to limit payment to nonprofit and public nursing homes, is that it would provide a secure financial base for the encouragement of general hospitals, religious and fraternal organizations, and official agencies in local communities to expand existing skilled nursing home facilities and, even more important, to construct new faciilties with the aid of HillBurton funds. If this were done, H.R. 4222 could make a very significant contribution to the elevation of standards of nursing home care in this country, since the hope for such elevation of standards lies primarily in the expansion of voluntary nonprofit and public institutions. The latter cannot be accomplished unless, in addition to Hill-Burton funds for construction, there is assurance of adequate financial support for operation. Inclusion of payment for skilled nursing home care in nonprofit and public institutions would therefore have a very important effect in improving the quality of nursing home services available to our senior citizens.

76123 0-61-pt. 1- 31

The APHA wishes also to record its view that the imposition of deductibles will prove harmful to the health of aged persons. While there is some doubt that such deductibles will keep the costs of the program down-they may actually have the paradoxical effect of increasing costs-and the need for conserving funds can be met far more effectively by excluding payment for unsatisfactory nursing home care, our main concern is the effect of deductibles on meeting health needs. We believe that the deductibles proposed in H.R. 4222 will deter many older persons from seeking health care when needed, and the result will be the postponement of care until illness is far advanced. No barrier should be allowed between the patient and needed medical care. This will make even more difficult the timely application of health measures designed to prevent complications and disability and halt the further progress of disease. From the standpoint of the health of the aged public, therefore, we urge removal of the provisions for deductibles in the proposed legislation. Finally, the APHA wishes to emphasize that while H.R. 4222 specifies certain standards for the health benefits, it does so on a national basis. Because of the considerable variation around the country in standards of hospital and other types of care, the most likely effect of national standards alone would be toward mediocrity. The program would have to set minimal standards in order to be feasible in the States where standards of care are low as well as the States where standards are high.

Also, while H.R. 4222 specifies a considerable range of benefits including home care, it would be highly desirable in each State to plan for the development of services. Such planning should be concerned not only with the simple availability of services but should aim toward continuity of care and other desirable features designed to improve the quality of health services for the aged. The favorable effect of such planning can be seen in the hospital planning and construction program, the Hill-Burton program, whereby many States have moved far in the direction of rational development of facilities for health care.

To assure the highest attainable quality of health services, H.R. 4222 should provide that the Secretary of Health, Education, and Welfare contract with the State health agencies to develop a State health plan for the aged, including as requirements:

1. Standards at least equal to the Federal standards. Where State standards are higher, these shall prevail.

2. Assurances for continuity of care within the range of services available, with emphasis on early, preventive, and rehabilitative care. 3. Improvement in the organization and coordination of services. 4. Appropriate utilization of medical schools and related professional health training resources within the State.

5. An informational program for the public in the wise use of service benefits.

6. Coordination of planning for the development of health facilities.

7. Public and professional representation on all advisory bodies. As contemplated by H.R. 4222 and even with such a provision, the Federal Government would, of course, retain ultimate authority; it would set minimum standards and operate the program in any State failing to submit an approved plan. The entire cost would be borne

by the Federal social insurance trust fund and the States would enter into the program only on the basis of a contract approved by the Secretary of Health, Education, and Welfare.

A broader contract of the sort outlined above would be far preferable to the limited type of contract now provided in H.R. 4222. Such a broader requirement on the State health agencies would go a long way towards achieving better quality of health care for the aged in every part of the country.

The American Public Health Association appreciates this opportunity to bring these recommendations to the attention of this committee. We respectfully urge their favorable consideration.

Mr. KING. Thank you, Dr. Terris.

Doctor, I note the resolve of your organization that the American Public Health Association supports the appropriate proposals to provide paid-up insurance for health service required by aged persons. Doctor, is the American Public Health Association aware of any workable proposal to provide paidup health insurance for health services required by aged persons other than the use of the social security mechanism?

Dr. TERRIS. We are aware that various proposals have been made. Our organization has not taken a position with respect to the proposals which have been made.

Mr. KING. That is all, Doctor Terris.
Thank you again.

Dr. TERRIS. Thank you, Mr. Chairman.

Mr. KING. Dr. Lawrence and Dr. Fineberg.

Mr. DEROUNIAN. I might point out that these two members of the medical profession come from my neighboring county of Queens. They are outstanding in their relative field, and I know what they have to say has a great deal of merit. I am happy to welcome them. Mr. KING. Thank you.

Mr. KEOGH. Mr. Chairman, may I have the record to note that the gentlemen come from my neighboring county of Queens, and I join in the sentiments expressed by Representative Derounian.

Mr. KING. Very well.

Mr. MASON. They come pretty well recommended from both sides of this committee.

Mr. KEOGH. This, Mr. Chairman, I would prefer to have off the record at the moment.

(Discussion off the record.)

Mr. KING. We are back on the record now. You may be seated, gentlemen, and proceed with your statement.

STATEMENTS OF GEORGE J. LAWRENCE, JR., M.D., CHAIRMAN, COMMITTEE ON FEDERAL LEGISLATION; AND HENRY L. FINEBERG, M.D., EXECUTIVE VICE PRESIDENT, ON BEHALF OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK

Dr. LAWRENCE. Mr. Chairman and members of the committee, my name is George J. Lawrence, Jr. I am a physician engaged in the practice of obstetrics and gynecology in Flushing, N.Y. I am also chairman of the Committee on Federal Legislation of the Medical Society of the State of New York. I am accompanied by Henry L.

Fineberg, M.D., who is executive vice president of the Medical Society of the State of New York. Up to a few months ago Dr. Fineberg was the first deputy commissioner of the department of hospitals of the city of New York. I am here today to voice the vigorous and unalterable opposition of our organization, the largest State medical society of physicians in the United States, with a membership of 25,500 doctors, to the proposed law, H.R. 4222.

Opposition to H.R. 4222: I wish to make the position of the Medical Society of the State of New York clear. As its official representative, I advise this committee that our State medical society maintains that not enough evidence has been presented to show that the enactment of the proposed law, H.R. 4222, is necessary in New York State. On the contrary, there is much evidence for the contention that such a law in New York State is not needed and will not provide better medical care for persons over 65 years of age.

Incorporate 1959 statement: In order to save the time of this committee, our State Medical Society respectfully requests that the evidence submitted on July 17, 1959, before this committee by Renato J. Azzari, M.D., be incorporated in this testimony as far as applicable. The reason for this request is that the same basic reasons for opposing H.R. 4700, known at that time as the Foran bill, applies to our objections to the present bill, H.R. 4222.

Kerr-Mills law: The State Medical Society in New York should also like to call to the attention of the committee that as a result of the hearings held in 1959, Congress enacted what is known today as the Kerr-Mills law, which was initiated by this committee. The society therefore respectfully submits that in view of the time and considered deliberations given by Congress to this law and particularly by this committee, that this new law be given ample opportunity to prove its worth before any further legislation is enacted. I, therefore, respect fully request that incorporated also in this testimony is a resolution adopted by the Medical Society of the State of New York embodying in brief form the basic reasons for its opposition to the proposed law H.R. 4222.

New York statement: The Medical Society of the State of New York also calls to the attention of the committee the report of the New York State Committee of One Hundred for the 1961 White House Conference on Aging entitled "The Added Years." In chapter 2, entitled "Health and Medical Care," recommendation 34 states:

It is recommended that all States take necessary steps promptly to utilize Federal funds recently made available for medical care under the old-age assistance programs and for the medically indigent aged.

This recommendation specifically advocated implementation of the Kerr-Mills law by all States in the Union.

A copy of "The Added Years" is attached. This report spells out in detail the many progressive projects now being carried out in the State of New York to meet the needs of the aged.

Basic contention: The basic contention of the Medical Society of the State of New York is that the voluntary method is the best one for solving problems of financing health care. The ultimate objective is the best care for all who need it, regardless of age. The Medical Society of the State of New York contends that when age is the criterion, and not need, the next step will be to cover other age groups.