go to pay for services to well-to-do and rich people who need no such help.

The Kerr-Mills program will take care of any services needed by the poor, the disabled, or the sick. Already the social security program proposes to levy a very heavy taxation which should not be increased just to furnish a handout to all above 65 years

of age. A majority of those over 65 are more able to help themselves than any other age group. A large percent of them have stocks and bonds, social security benefits, bank savings, pensions, health insurance, a home, reduced living expenses, prosperous children, State health assistance, and many other assets.

The Kerr-Mills program selects the needy, whereas, H.R. 4222 is for everybody covered by social security and the Railroad Retirement Act, whether they are in need or not.

(3) Centralization of Federal control rather than State initiative: Virtually every sovereign State has its own health and welfare program. The States have their charity hospitals, free nursing care, and homes for the aged, which are adapted to their own local needs and which are controlled by the people who live within these varying environments.

One blanket measure covering the whole of the 50 States could not possibly meet the local situations equally when the situations differ so widely.

The Kerr-Mills program awards Federal aid to the individual States and allows the States to adapt this aid to their own local needs.

I deeply appreciate the validity of public aid exercised and controlled at the level of the local community in providing food, shelter, clothing, hospitalization, medical care, and nursing facilities for those who actually need such assistance-not necessarily for every person over 65 years of age.

(4) Destruction of certain well-established health programs already in useful operation: There are certain well-established health programs already in operation which H.R. 4222 inevitably will hamper. We have health insurance, possibilities through Blue Shield-Blue Cross and the like, which are available and are financially attainable for the greater percentage of citizens over 65.

The Kerr-Mills law supplements voluntary health insurance and is as flexible as the varying needs of our citizens over 65.

State programs for health and welfare would necessarily be dangerously affected by H.R. 4222. The skill and efficient work of our physicians would be curbed to a serious extent if they had to give less attention to those actually in need while taking care of multitudes who would come to them without any serious ailment.

I, therefore, respectfully voice my opposition to the enactment of H.R. 4222 because I believe it would be detrimental to the personalities of the senior citizens, because it would be enormously expensive to the taxpayer, because it would be difficult to operate efficiently at the local level and because it would destroy some of our well-established methods of care of the aged and indigent.

Mr. Chairman, I thank you for the privilege of appearing before your committee.

The CHAIRMAN. Dr. Leavell, we thank you, sir, for coming to the committee to give us the benefit of your thinking on this matter.

We appreciate the fact that Mr. Williams brought you to the committee and introduced you.

Are there any questions? Thank you, sir.

The committee, without objection, will recess until 2 o'clock this afternoon.

(Whereupon, at 12:35 p.m., the subcommittee recessed to reconvene at 2 p.m., the same day.)

AFTERNOON SESSION

The CHAIRMAN. Our next witness is Miss Thompson.

If you will identify yourself for the record by giving us your name, address, and capacity in which you appear, we will appreciate it.

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

Miss THOMPSON. Mr. Chairman, I am Julia C. Thompson, Washington representative of the American Nurses' Association.

The CHAIRMAN. We recall your previous appearance before the committee, Miss Thompson. We welcome you back. We are glad to have you with us.

Miss THOMPSON. The American Nurses' Association is the national organization of over 171,000 registered professional nurses in 54 constituent State and territorial associations. As one of the professional groups deeply concerned with providing health care for the American people and as the largest single group of professional persons giving that care, we welcome this opportunity to present our views on the proposal before this committee.

In the interest of society at large, and in the interest of its members, the American Nurses' Association has supported the Social Security Act and extensions and improvements in the contributory social insurance system. We appear here today to support the principle of inclusion of health insurance benefits for the beneficiaries of the oldage, survivors, and disability insurance under the social security mechanism for covered, retired members.

The ANA adopted this position at its biennial convention in 1958, and reaffirmed the stand at the biennial convention in 1960. Because there have been questions about ANA's stand on this legislation, we have prepared a summary of the actions taken by the ANA on the issue of compulsory health insurance since the subject became a topic of congressional concern. This summary is attached to our statement and we request that it be included in the record of hearings, along with the testimony on the legislation.

(The statement referred to follows:)

SUMMARY OF AMERICAN NURSES' ASSOCIATION'S ACTION ON SOCIAL SECURITY

MEASURES

The American Nurses' Association has demonstrated an interest in and concern for provision of health services, as well as the giving of nursing care, since it was organized in 1896. As early as 1936, the association began studying and formulating principles relating to the inclusion of nursing service in any prepaid health plans, whether the plans were voluntary or compulsory. At the biennial convention in 1946, the first "Tentative Statement of Functions of the Joint Committee of the American Nurses' Association and the National Organi

695

zation for Public Health Nursing on Nursing in Prepayment Health Plans" was adopted by the house of delegates.

In presenting this report, the chairman of the committee said, "We [as a committee] believe in this principle of prepayment, but we think it is up to the consumer to decide just how it is to be managed." 1

This same committee stated in its report that "it reaffirms its recommendations presented at the 1944 biennial, namely, that 'the committee favors the expansion of prepayment health insurance plans with provision for nursing service, including nursing care in the home. It believes that, in addition to voluntary effort, governmental assistance is necessary for obtaining adequate distribution of health services.' " 2

The ANA has always supported the old-age, survivors, and disability insurance program, and for the first time in 1948 included a plank in its platform which reads: "Extension of social security benefits for nurses as part of society's obligation to the profession." Since that time, there has always been a plank in the platform which calls upon the association to support the extension and improvement of the Social Security Act.

3

Due to continued and determined efforts of the ANA, private duty nurses were the first self-employed group to be brought under social security in 1950. At the same time, nurse employees of nonprofit organizations could also receive coverage if the employer elected coverage.

Because nurses were subjected to considerable harassment by some of their medical colleagues, the need for a unified stand resulted in the following resolution being adopted by the delegates at the biennial convention in 1952:

"Whereas the American Nurses Association in its 1952 platform has reiterated the policy adopted in 1950 of 'promoting the inclusion of nursing benefits in prepaid health and medical care plans'; and

"Whereas significant developments have occurred since 1950 in our efforts to provide health protection for the American people, as evidenced by the fact that 21 States now have committees on nursing in medical care plans; and

"Whereas another significant development has been the introduction by several large insurance companies of a new medical care insurance policy which includes as one of its benefits the services of registered nurses; and

"Whereas American nurses desire to remain free to provide nursing service in any prepaid health and medical care plan the American people adopt: Be it, therefore,

"Resolved, That this house of delegates reaffirm the principle that registered nurses shall, without fear or favor, enjoy their rights and privileges as individual citizens to express their views and to make decisions regarding any prepaid health and medical care plan which is consistent with the basic American Nurses Association policy of promoting and improving nursing care for the American people."

The platform of the American Nurses Association has included a statement supporting the extension and improvement of the social security system since its inception. This statement could be interpreted to cover any improvements of the act. However, in 1957, when former Representative Aime Forand introduced legislation to include health care benefits under social security for retired beneficiaries, the committee on legislation believed that this issue needed special consideration because of its controversial nature. As a result, the committee recommended that the resolution adopted in 1952 be reconsidered. After approval by the board of directors, a special research person was engaged to gather information pro and con for use by the committee in its deliberations. In March of 1958, the committee on legislation recommended that the ANA support the principle of inclusion of medical and health care benefits under social security for retired and disabled workers. The committee also recommended that, if the board of directors approved the recommendation, the issue be placed on the agenda for the convention. The recommendation was approved and following board action, State nurses associations were notified that the subject would be State associations were sent the presented to the house of delegates in June. same background material that was studied by the committee to prepare the delegates for discussion.

1 American Nurses' Association proceedings, vol. I, House of Delegates 35th Biennial Convention, Sept. 22-27, 1946, p. 115.

2 Ibid., p. 113.

2 American Nurses' Association Proceedings, vol. I, House of Delegates 36th Biennial Convention, May 31-June 4, 1948, p. 17.

4 American Nurses' Association Proceedings, vol. I, House of Delegates 38th Convention, June 16-20, 1952, pp. 126-127.

The following resolution was approved by an overwhelming vote of the delegates, and on June 30, 1958, the ANA testified in favor of the principle embodied in the resolution:

"Whereas necessary health services should be available to all people in this country without regard to their ability to purchase; and

"Whereas prepayment through insurance has become a major and an effective method of financing health services; and

"Whereas certain groups in our population, particularly the disabled, retired, and aged, are neither eligible nor able to avail themselves of voluntary health insurance: Be it, therefore,

"Resolved, That the American Nurses Association support the extension and improvement of the contributory social insurance to include health insurance for beneficiaries of old-age, survivors, and disability insurance; and be it further "Resolved, That nursing services, included nursing care in the home, be included as a benefit of any prepaid health insurance program."

During the 2-year interval between conventions, individual nurses and the constituent State nurses associations of the ANA were again subjected to considerable pressure by members of the American Medical Association. At the convention in 1960, a resolution was brought before the house of delegates by one State nurses association asking that the ANA change its position in support of the principle included in the resolution of 1958. However, the house of delegates reaffirmed the 1958 position by an overwhelming majority of the 1,200 voting delegates, with less than 50 dissenting votes.

Since that time, the pressures on nurses who are members of the ANA have been increased and repeated efforts have been made to influence State associations to repudiate the action taken by the ANA. However, eivedence to date indicates that nurses believe firmly in the position taken by their professional association. Their concern is based on making nursing service available to all who need their care.

The ANA testified before your committee in favor of including health insurance benefits to retired beneficiaries of the OASDI in 1958 and 1959. Our primary reason is stated very succinctly in the resolution adopted at both conventions. The resolution states:

Whereas necessary health services should be available to all people in this country without regard to their ability to purchase; and

Whereas prepayment through insurance has become a major and an effective method of financing health services; and

Whereas certain groups in our population, particularly the disabled, retired, and aged, are neither eligible nor able to avail themselves of voluntary health insurance: Be it therefore

Resolved, That the American Nurses Association support the extension and improvement of the contributory social insurance to include health insurance for beneficiaries of old-age, survivors, and disability insurance; and be it further Resolved, That nursing services, including nursing care in the home, be included as a benefit of any prepaid health insurance program.

Nurses, also, have a need for this kind of security. The average annual salary for a staff nurse in a hospital is $3,800 ("Facts About Nursing," 1960 ed., pp. 119-128). This group of nurses comprises over 60 percent of the total employed ("Facts About Nursing," 1960 ed., p. 8, table 1). Most hospitals provide social security coverage but only a small percentage have any other retirement plans for their employees ("Facts About Nursing." 1960 ed., pp. 119-128).

Private duty nurses, who are independent contractors, are the next largest group ("Facts About Nursing," 1960 ed., p. 8, table 1). According to a survey in November 1959, the average fee for an 8-hour day is $16. If the nurse works 20 days a month, which was the average for this survey, she can earn $336 per month. She has no paid sick leave, retirement plans, paid vacation, or other benefits commonly available to the employed worker, and she pays all of her own social security. Forty-six percent of those surveyed dependen on this in

come for their own support and the support of others ("Facts About Nursing," 1960 ed., pp. 128-132).

The third largest group of practicing nurses are employed in physicians' and dentists' offices; and according to a 1958 survey of employment conditions among office nurses, their average monthly income is $300. Almost half of the nurses surveyed reported there were no formal provisions for sick leave and about 19 percent stated they did not reveive any paid sick leave ("Facts About Nursing," 1960 ed., pp. 154-160). Social security coverage is not compulsory for hospital employers. Only 5 percent were covered by retirement plans other than social security for which their employers paid part or all of the premium.

These three groups comprise about 86 percent of the nurse force in active practice. It is obvious with the present high cost of living that this large group with marginal incomes cannot save enough to meet all of the exigencies of their retirement, particularly the cost of protracted or catastrophic illnesses. Neither can they, with limited incomes, assume the financial burden of long illnesses of dependents.

There are certain portions of the bill on which we would comment and recommend changes or clarification. We would seriously question the language under section 1603 (b) (1), page 7, beginning with line 22 which states

(1) Nursing care provided by or under the supervision of a registered professional nurse or provided by or under the supervision of a licensed practical

nurse.

The word "or" implies that the services of either a professional or a practical nurse is acceptable. The practical nurse cannot function in place of a professional nurse. The laws governing nursing practice in most States would prohibit the practical nurse from performing nursing functions without the supervision of a professional nurse. Also, the short-term training of a practical nurse, usually 9 to 12 months, would preclude her ever acting in a supervisory capacity. The ANA, in its statement of standards for nursing care in nursing homes, lists what we believe are minimum requirements for providing safe nursing care. A copy of this statement is attached to the testimony and I would request that this also be included in the record as part of our testimony.

The CHAIRMAN. Without objection, it will be. (The statement referred to follows:)

STATEMENT OF STANDARDS FOR NURSING CARE IN NURSING HOMES

(Adopted August 5, 1960)

The American Nurses Association recognizes the urgent need to meet the major and growing problems of the great number of the aged and chronically ill patients in our country. The U.S. Public Health Service has informed us that 450,000 of these patients are now in 25,000 nursing homes, and that the number of both patients and nursing homes is steadily increasing. A special committee of the American Nurses Association reviewed the publications of other national organizations that are concerned not only with the availability of nursing care facilities but also with the quality of care being given in these institutions. The American Nurses Association concurs with the 1960 report of the U.S. Senate Subcommittee on Problems of the Aged and Aging, in which the subcommittee stated the solutions of the problems are the joint responsibility of all organizations and individuals in the United States.