the committee set forth in bills that witnesses could comment on. And, of course, we expect that whatever the committee does will look like none of the bills that are actually introduced. I find there is some good in all the bills I have read. We appreciate your appearance this morning. Mr. Duncan. Mr. DUNCAN. I would like to welcome Mr. Bell and also Mr. Balitsaris who is from my hometown. How many members do you have in your association? Mr. BELL. We have approximately 7,200 nursing homes in the American Nursing Home Association. They must be a member of a State nursing home association to be a member of our association and there are approximately 23,000 homes in the Nation, according to some figures, but I think it is important to recognize that we represent slightly over half of all of the beds in the country, over 500,000 in the 23,000 homes. Mr. DUNCAN. Does that include profit and nonprofit? Mr. BELL. Yes, sir; our association represents proprietary and nonproprietary. Mr. DUNCAN. How many beds are in the not-for-profit hospitals class? Mr. BELL. In our association approximately 15 percent are nonproprietary and I am told that is about the same proportion that exists in the country out of the 1 million beds. Mr. DUNCAN. I didn't understand you. Mr. BELL. About 15 percent are nonproprietary. Mr. DUNCAN. Thank you for your fine statement. I know it will be helpful. The CHAIRMAN. Mr. Brotzman. Mr. BROTZMAN. I also wanted to welcome Mr. Bell to the committee and his assistant and tell you that your organization works quite well out in our State. I have a lot of contact with your representatives there, particularly Mr. Harrison, the executive director. He was talking to me about the problems of our senior citizens and I was quite impressed with your testimony on nutritional services. I know this is a problem that really effects most of our senior citizens. We probably don't talk about it enough, but I think one of the reasons they do suffer reversals in their health is that they don't eat properly. I want to compliment you on bringing that to the committee's attention again. Mr. BELL. We know that nutrition of the elderly is important in nursing homes. We know it is also a subject of great controversy. Mr. BROTZMAN. That is true, it is. Mr. BELL. On the one hand, I recently saw a headline of where we were accused of killing the patients with kindness because we served sugar in their coffee and the elderly should have a reduction on intake. On the other hand, we are criticized because we don't serve sugar with the coffee. I think the point we would like to make is with the assistance of the dietitians required in the Government programs, we are committed to providing nutritious healthy meals and it is true, I think, that we will continue to be subjected to criticism until the authorities themselves can decide who will determine what an elderly person can eat. The CHAIRMAN. Any further questions? If not, again we thank both of you for your appearance. Next is the representative of the American Public Health Association, Dr. Miller. We welcome you to the committee, Dr. Miller. You are recognized, sir. STATEMENT OF DR. C. ARDEN MILLER, PRESIDENT-ELECT, AMERICAN PUBLIC HEALTH ASSOCIATION Dr. MILLER. Thank you, Mr. Chairman. I am Arden Miller, professor in the School of Public Health at the University of North Carolina. Our association has a membership of about 50,000 people, including those who are members by virtue of membership in the affiliated organizations in the various 50 States. The membership is made up of nurses, physicians, sanitarians, and a growing number of consumers and professionals representing the outpatient field. We have prepared testimony at some length. We will submit that independently. The CHAIRMAN. Without objection that will be included at the end of your oral statement. Dr. MILLER. Thank you. That statement includes a policy statement approved by the governing council of the American Health Association bringing out some nine points in relation to health services. It is those nine points the association used to assess the effectiveness of any national health insurance proposal. We have not been involved in either the preparation of individual proposals or endorsement of individual proposals, but rather in advocating principles that should attach to any that are inactive. The written testimony further identifies three major issues for detailed consideration. These relate, one, to the great potential for public disservice by vesting in the private sector control over the funds and processes of national health insurance; two, the false assumptions that are identified with requiring that patients share directly in the costs of medical care; and, three, the great advantages that accrue from using health insurance as a device to guarantee delivery of essential preventive health care to all Americans. It is the latter point I will address exclusively in my oral comment, that is a program of preventive services in national health insurance. You are well aware of the inadequacies of preventive measures involving large numbers of Americans. This includes immunization of children, prenatal care, dental care, and early detection and treatment of visual defects, hypertension in adults, and cancer in the reproductive tract of women. The correction of these inadequacies, in our view, should be incorporated in a program of national health insurance. The incorporation of a scheme, a package, of preventive benefits for all age groups it seems to us is dependent on excluding copayment requirements for all preventive services. It is also dependent on a combined package for all age groups and a large number of health conditions. The package, I think for purposes of illustration, can be best identified by outpatient health care services for mothers and children. Such a package would include prenatal care, obstetric and midwifery services, homemaking assistance, and mothercraft, postnatal care for mother and infant, family planning services, well-child and development checkups, routine immunizations and anticipatory guidance, preschool screening and school health services, including a mandate to treat and correct identified defects; genetic counseling; and sickness care to treat children not reached by private medical care programs even when they are subsidized through insurance provisions. The total population, as well, must have included among the preventive service extended to them on a first dollar basis: 1. Home health services, including payment for homemakers, nurses, podiatrists, and other providers for the disabled, aged, and chronically ill. Expensive hospitalization would hereby be diminished. 2. Periodic examination of all adult women for early signs of cancer of the breast and the cervix. Less than half of adult women are now tested by Papanicolau smears, even though the experience of more than two decades suggests that the tragic consequences of advanced cancer of the cervix could be nearly eliminated by routine testing. 3. Periodic examination and early treatment for hypertension. 4. Preventive mental health services and family counseling. National health insurance in the view of the association should not only eliminate financial barriers to these preventive services, but should carry a commitment on the part of Government to all Americans if they are not otherwise provided. We believe these services will be effective if maintained. We also believe they will be cost effective in lowering hospital rates and reducing the expense and incidence of catastrophic illness. Many of these services will be rendered by private physicians who can be compensated under public health insurance provisions. Many services will also be rendered by other providers and they, too, will be compensated under the same provisions. Some people in some circumstances, however, will not be reached by the full spectrum of preventive services except through direct public service programs. For these people, Government must become the provider of last resort. For all people, Government must become the guarantor of health and for the services necessary to maintain it. A program of national health insurance should take steps to provide that guarantee with respect to all public health services. The APHA favors reducing health care service costs including diminished use of hospitals, not by creating barriers to health service, but by redence removal of these barriers causes unreasonable use of preventive dence removal of these barriers causes unreasonable use of preventive care. When medical care became free in Quebec, for example, the patients who the doctors thought would seek medical care without reasonable cost rose only 1.1 percent to 1.9 percent. And for those who it was felt should have sought medical care earlier, it fell. In recent years, Congress has enacted some new programs related to health services with the stipulation that they function "without interfering with patterns of professional practice." National health insurance could be enacted with this same restraint and all our present inadequacies and inequities in medical care might be perpetuated and entrenched, probably with a larger pricetag. 36-221 074 - 3 I think it is necessary that we increase government commitments in order to guarantee the delivery of health services to people whose health is at the greatest risk. The nature of that guarantee is critical. There is little evidence to indicate more money spent for traditional programs will increase health services to the large segments of our society who are at greatest risk of poor health. Experience under titles XVIII and XIX indicate substantial barriers in addition to high cost stand between people and the health care they require. Something more than money is needed. The need includes setting standards for monitoring, for compliance and directly providing the services not otherwise provided. The services must be supplied in ways acceptable to sensitive ethnic groups, welfare recipients, et cetera. We must provide from the Federal level those essential services that private and local mechanisms even with financial inducements fail to provide. Our Nation has ample experience to demonstrate how health services can be extended to serve hard-to-reach people in hard-to-reach places. Persistent problems indicate not our inability to cope, but our great commitment to the problem. Government must do more. The place to begin is a national health insurance program that guarantees the delivery of appropriate comprehensive health care to all Americans. [The prepared statement follows:] TESTIMONY OF THE AMERICAN PUBLIC HEALTH ASSOCIATION ON NATIONAL HEALTH INSURANCE TO THE COMMITTEE ON WAYS AND MEANS JUNE 7, 1974 In recent years, national health insurance has been of growing interest and concern to the American people. This has been reflected in Congress through the proliferation of legislative proposals that have offered a broad spectrum of approaches to providing means of financing and reorganizing health services. During this period, the APHA has monitored activity, both within Congress and in the private sector, concerning national health insurance. Through its members who represent the broad spectrum of health and healthrelated disciplines, the Association has developed a set of criteria by which to measure the various proposals' effectiveness in meeting the health needs of our nation's citizens. In discussing these criteria, it is helpful to view them within the context of the activities and mission of the Association. Although APHA members are involved in a variety of activities in the public health arena, they are. bonded together through their shared concern for the public's welfare a concern that transcends either economic or professional motives. Our professional prerogatives are not vested. in the status quo. We do not constitute an "industry" which feels threatened by programs that place the public good ahead of private gain. We have had no role in the preparation of any single proposal now being considered by this Committee; rather, our concern is with the development of a workable system of health care to meet the needs of people. We have, rather, chosen to develop these standards as bench marks by which we can judge all the proposals and their ultimate effects on the American health service system. We hope that they will be equally helpful to you in your efforts to sift through the wide variety of proposals before you, and in synthesizing the best features contained therein into a system which will best meet our nation's health needs. To resolve the widely recognized crisis in our country's health care system, the American Public Health Association recommends a national health care program to include democratically constituted policy-making bodies with a majority of consumer members at every level of administration, and with: (2069) |