We seriously question the feasibility of the Federal Government's contracting directly for the medical, hospital, and nursing home care of OASI beneficiaries, but we do wish to commend the efforts being made in Congress by its Members to assist our aging population and recognize that such legislation as has been introduced is a sincere effort to meet the increasing needs of elderly people.

However, we believe that the economic status of the individual should be the basis of determining need; that free choice of facility within the framework of our licensing laws and within the category of need should be assured; that determination of price for care should be on the State or local rather than national level; that the manner in which such funds are dispensed should be left to the discretion of the States; and that some sort of participation on the part of States would be desirable for the proper administration of such a program for the medically indigent.

As a parting thought which has to do with reducing the burden of high costs of medical care for the aged, we urge each member of this committee to look over carefully that portion of the housing bill S. 57 which provides for FHA insured loans to nursing homes. Passage of this type of legislation will assist materially in providing more modern and efficient nursing homes which are accepted as the logical care facility for our aged and chronically ill.

As evidence of savings in medical care costs existing even today, we call your attention to the broad differential in cost between nursing home care and hospital care. Most surveys show a comparison of $6 per day for nursing home care as against $24 per day for hospital

care.

A large majority of the people over 65 who need care in a medical facility are as well cared for in a nursing home as in a hospital, and more utilization of nursing homes in most cases will make the dollars we spend go four times as far.

In the event the housing bill carrying the FHA loan insurance feature for nursing home construction, which I just referred to a moment ago, fails to be enacted into law, our association will be asking Congress to enact this feature as a separate bill. We ask you as Congressmen to assist in the enactment of such legislation since it bears heavily on the problem before you even though it will not be referred to your committee.

Mr. Chairman, we are grateful for the opportunity to appear before this committee and I thank you for myself, Mrs. Rogers, Mr. Bateman, and the American Nursing Home Association membership.

The CHAIRMAN. We thank you for bringing to us the views of the American Nursing Home Association. We are pleased to have Mrs. Rogers and Mr. Bateman accompany you to the witness stand. Are there any question of these witnesses?

Mr. FORAND. On page 2 of your statement you say that your organization has been working very closely with other professional organizations and as a result there was formed a national joint council to improve the health care of the aged.

Mr. MUSTIN. Yes, sir.

Mr. FORAND. Are you aware of the fact that the joint council was instituted to try to beat down or prevent the Forand bill from becoming law?

Mr. MUSTIN. I am not aware of that.

Mr. FORAND. I am making you aware of it right now.

All the members of the joint council to improve the health care of the aged are proprietary in nature except the American Hospital Association. You know that, do you not?

Mr. MUSTIN. Yes, sir; principally so.

Mr. FORAND. We have heard about overcrowding and unsanitary conditions in nursing homes. Does your association establish standards for membership in the association?

Mr. MUSTIN. We do not establish nationally one set of standards, at least we have not done so to date. In each State the State determines the qualifications for which licenses are issued. In the past we have gone on the basis of license. However, we are now in the process of looking into standards and classification with the idea of making some difference between the levels of care afforded by the individual nursing homes.

Mr. FORAND. How far do these go toward insuring good quality of medical care?

Mr. MUSTIN. I think it goes very far. I think the nursing homes individually and as an associate have made more progress in the few short years that we have been recognized as a medical facility than perhaps any other medical organization in past history. We have made wonderful progress as can be attested by doctors and health organizations.

Mr. FORAND. When States license nursing homes, their standards if any generally that relates to the safety and overcrowding and not the medical care, is that correct?

Mr. MUSTIN. No, sir.

Mr. FORAND. I wish you would give the committee some information on that point.

Mr. MUSTIN. It encompasses safety standards and sanitation, but it also encompasses medical care. In a nursing home, we not only have the duty of taking care of that person with regard to room and board, but we also must furnish a total nursing care, in fact, a total stewardship of that person so that actually the building itself is merely a means to the end. The care given in nursing homes is our principal object in view.

Mr. FORAND. Is that provided by practical nurses or registered nurses?

Mr. MUSTIN. I believe every State in the Union requires that a nursing home must have a licensed nurse. In some States a nursing home is permitted to engage licensed practical nurses, that is, a person who has had about 13 months of training. In some States the nursing homes are required to have a registered nurse. In some of the States in the Union the nursing homes are required to have continuous registered nurse supervision around the clock every minute of the year, which is something that a good many hospitals have not been able

to meet.

Mr. FORAND. Different States have different standards?

Mr. MUSTIN. Yes, sir; different States have different standards. Mr. CURTIS. I want to commend your association for appearing here and testifying on the bill and also I want to express appreciation for the work your association has been engaged in to my knowledge in

improving these standards. In my own State of Missouri they now regard our nursing home law as somewhat of a model, is that not true? Mr. MUSTIN. Yes, sir.

Mr. CURTIS. I know the work your people did in trying to help bring

that about.

Incidentally, in this housing bill that you refer to, if that were enacted that would go a long way toward improving the standards, would it not, inasmuch as it is geared to do these things?

Mr. MUSTIN. Yes, it would, Congressman.

Mr. CURTIS. On the economics, I notice on page 6 where you cite the figure of $6 a day to $24 a day, the bulk of our nursing homes are renovated, older buildings, many times multistoried mansions. I understand that a nursing home designed for one floor as a nursing home facility is considerably less costly, than one of these renovated, multistoried buildings, and if we did have modern, up-to-date nursing home facilities that that $6 per day average could be cut considerably. Am I correct in that?

Mr. MUSTIN. That is correct, because 2 years ago we built a modern 1-floor nursing home using SPÁ funds.

Mr. CURTIS. Do you have any estimate of the differential in cost between the multistoried as compared to the more modern facility design for nursing homes?

Mr. MUSTIN. No, sir; I have not made any effort to get such figures. I had no idea you would be interested in those figures.

Mr. CURTIS. I would appreciate it if you would obtain such figures. I have heard estimates. One gentleman told me that he could cut his costs to one-third. I do not know if that is so, but I can imagine the differential in personnel needs where you have to move the patients from story to story would be considerable. I think such

figures would be valuable.

You are familiar with the report of the Department of Health, Education, and Welfare of April 3, 1959, are you not? It is on hospitalization insurance for OASI benefits.

Mr. MUSTIN. No, sir, I am not familiar with it.

Mr. CURTIS. I would appreciate it if your organization and all organizations who are going to testify before us would evaluate that report and supply the committee with their opinion as to how accurate and how well done the report is in the areas in which they are particularly familiar. I think that information would be of considerable value to the committee.

Mr. FORAND (presiding). Are there any further questions?

Mr. KNOX. Mr. Mustin, I was interested in your statement which reveals the differential costs between the different nursing homes and the hospital care.

Then, in reference to the qustion of relief that those hospitals would receive if nursing homes became a national project, what percentage of those who are now hospitalized could be housed in nursing homes with adequate care?

Mr. MUSTIN. That is a question that would require a long answer, sir, because there are a number of kinds of hospitals.

Let me illustrate one point. In the States where the social security and old-age assistance payments are the rule, we find upon examination, that a substantial number of persons in the State mental institu

tions are merely senescent. The States do not pay enough and the counties do not pay enough and they gravitate into the homes for the insane. In fact, the doctor who was in charge in Tennessee told me one person in three at that time did not need the services of a mental institution.

Since that time, they have passed a law which does not permit them to take anyone over 65 unless they are purely psychotic.

As to the number of persons in general hospitals who perhaps stay a little longer, that would be hard to determine. It would depend a great deal upon the facilities in a particular State, whether or not they had adequate nursing home facilities, and it would also depend a great deal upon a working relation and liaison between the nursing homes, the hospitals, and the dctors so those people would be cognizant of the fact that nursing care could be made for their people who did not require the specialized services of a hospital.

I would suspect that there would not be a larger percentage but a lot of money could be saved by transferring people from high-cost beds to nursing-home beds.

Mr. KNOX. Relative to the hospital building program which was built with Hill-Burton funds and whether or not the provisions for the Federal participation in the homes for the aged such as is contained in the housing bill, will it bring any actual relief to the general hospitals as far as additional bed space is concerned? I understand hospitals are expanding at rapid pace so far as bed space is concerned. Mr. MUSTIN. As you know, since 1954 there have been provisions for sums of money, passed in the millions of dollars, to build nonprofit and other public nursing homes under Hill-Burton auspices.

In some instances those are built by counties and nonprofit organizations and some by hospitals and in other instances as directly connected to hospitals. There has been a substantial number of beds built through this process since the law became effective in August of 1954. Mr. Knox. Did I understand you to state that there have been some Hill-Burton funds made available for nursing homes?

Mr. MUSTIN. Yes, sir.

Mr. CURTIS. I think that about 90 percent of those in nursing homes are in proprietary homes.

Mr. MUSTIN. Seventy-one percent.

Mr. CURTIS. Seventy-one percent are in the proprietary?

Mr. FORAND. Thank you for your appearance, Mr. Mustin, and those who accompanied you.

The next witness is Mr. Reuben Johnson.

For the purposes of the record, will you identify yourself by name, address and the capacity in which you appear?

STATEMENT OF REUBEN JOHNSON, COORDINATOR, NATIONAL FARMERS UNION

Mr. JOHNSON. Thank you, Mr. Chairman.

I am Reuben Johnson, coordinator of legislative services, National Farmers Union. My address here in Washington is 1404 New York Avenue.

The CHAIRMAN. We are pleased to have you with us and you are recognized, sir, for 10 minutes.

Mr. JOHNSON. Thank you very much, Congressman Mills.

It is a pleasure to be afforded an opportunity to appear before this distinguished committee of the House in support of H.R. 4700.

The rising cost of medical care, especially hospital care, over the last several years has become a major concern of all citizens, whatever their age. But it is of greatest interest to those among us who have reached the age of retirement and who live on fixed and declining monthly incomes. The average such person has been found to use about 211⁄2 times as much hospital care as the average for persons under age 65.

Through medical research, better trained doctors and nurses, and better health facilities, generally, we have increased quite substantially life expectancy in the United States. Both the number and proportion of persons over 65 in the population are increasing.

Of the 5.84 million farm operators in 1940, 828,000, or about 14 percent, were 65 or more years of age. By 1954 the number of farm operators was 4.69 million, with 779,000, or 16.6 percent, age 65 or more. The average age of farm operators in 1940 was 48 years compared with 49.6 years in 1954.1

The man on the street today would probably guess Florida and California to have the highest percentage of population age 65 or more. California, with 8.3 percent of its population 65 or over, is surpassed by Arkansas, Connecticut, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Vermont, Washington, West Virginia, and Wisconsin.

Florida, with 10.1 percent of its population age 65 or more is surpassed by Arkansas, Iowa, Maine, Massachusetts, Missouri, Nebraska, New Hampshire, Oklahoma, Rhode Island, and Vermont.

The above figures indicate why there is an increase in the interest of farmers in geriatrics. In this connection, it is expected that the 1960 census will show an even greater percent of farm operators age 65 or more, and a further increase in the average age of farm operators. Losses from the farm in recent years have been greatest among the beginning and younger farmers not able to stay in business and pay off heavy capital debt.

In the years ahead, it is inevitable that a larger proportion of persons age 65 or more will have to rely on public assistance for payment of their medical bills. Private insurance is costly and premiums must be continued into the retirement years when income is low and declining. Many of the aged will not be able to pay for the kind of coverage they need during the period when they need it most. Limiting coverage under private plans and lowering the cost to the aged still leaves the bulk of the problem unsolved.

In this connection, I might add that National Farmers Union operates privately a program of health insurance. In spite of this fact, delegates to national conventions continue to emphasize the need for programs of the type which H.R. 4700 provides.

1 Number farm operators and average age based on 1954 Census of Agriculture, vol. II, p. 82.