therefore, that we favor the intents of H. R. 7341, the amended H. R. 8149, and the companion bill S. 2758. However, we respectfully submit that the provisions of this pending legislation as written present a serious omission in their complete disregard of the proprietary nursing home. Our thinking and concern regarding the failure to include the proprietary nursing home in planning for extension of the national health program is dictated by three general considerations, namely: 1. What is best for the patient? 2. What is fair and reasonable for the proprietary nursing homes? 3. What is of greatest benefit to the Government in planning the program? Regarding the first point, "What is best for the patient?", we do not believe that the above-mentioned omission serves the patient's best interests. The patient, himself is the basic and primary factor in the consideration of any health program. He must be provided with sufficient and adequate facilities to meet his needs. In order to properly measure these needs, the patient must be described carefully. It is generally agreed that no clear, commonly accepted definition of the nursing home type of patient exists. Such a patient is loosely referred to as chronic, convalescent, infirm, disabled, aged, and long-term-care. The degree of deviation of this group from the so-called acutely ill patient has a wide range, and is determined in great measure by whom may be doing the classifying, where such classification is being made. and the purpose of such classification. Medical, administrative, and economic considerations dictate an overall description of a patient suitable for nursinghome care as being one who, regardless of age, has had complete diagnostic study, a full measure of curative therapy and every advantage of rehabilitation efforts. Except for the convalescent patient, who is defined as a person recovering from an acute illness and expected to regain his former health status, his prognosis for recovery or improvement is scientifically determined to be nil. His medical requirements are finally adjudged to be occasional medical supervision, palliative treatment, and varying amounts of professional and nonprofessional nursing skills. One no longer employs the term "incurable" for this unfortunate patient. But incurable he is a responsibility to the community and to his family. His expected life span may be weeks or it may be years. The question naturally follows: How can we best care for this unfortunate human? He obviously, more than anything else, requires a permanent. placement. Such placement, experts in the field agree, should be in surroundings which simulate home as nearly as possible. These homes should be noninstitutional in size architecture, furnishings, decoration and atmosphere; they should provide unobtrusive professional nursing supervision, and aid in dressing, feeding, bathing, walking, and personal needs. Above all, they should provide the intimate personal contacts so necessary to the helpless. The homes should be so located that they will be readily accessible to relatives, friends, and churches. These are the things that the proprietary nursing homes represent. These are the very advantages that we offer, in contrast to the cold, impersonal, large, institutional facilities of many governmental and nonprofit agencies. The nursing homeowner and proprietor is a community-minded individual with an innate sympathy for the disabled, aged, and helpless. He enrolls in this sement of the medical care team as a matter of choice, and invests his own capital and hard work to back his interest in his profession. From the psychological point of view, it is imperative that the patient be given every opportunity to retain every possible vestige of dignity and selfrespect in his remaining years. In many areas, under present procedure, in proprietary nursing homes, the public-assistance recipient is paid his allotment for room and board directly. He, in turn, pays the nursing home for the care received. Placement of public-assistance recipients in governmental institutions and in many nonprofit institutions eliminates this direct-payment plan. It also takes from the patient the right to choose for himself a place of permanent residence, and choice of personal physician. This in a measure is a reversion to the outmoded concept of the almshouse and poorhouse. Regarding our second point, "What is fair and reasonable for the proprietary nursing homes?", the proprietary nursing homes pioneered in the field of nursing-home care, and led the way out of the dark ages of institutionalized neglect of the chronically ill, infirm, and aged. Private enterprise, as it always has in the past, again led the way. Unfortunately, it is not generally known that most of the proprietary nursing homes did not, and do not, limit their admissions to those able to pay high rates. They admit a great many public-assistance cases at very low rates. Many of these patients are incontinent, bedridden, and totally helpless. They have been overcrowding the facilities of general hospitals, occupying the beds badly needed for the acutely ill. The average cost of the care in the general hospital is about $18 per day, or almost $550 per month. In spite of this fact, in spite of the substantial savings made possible in the proprietary nursing homes, it is these very nursing homes which are ignored and omitted in legislation which purports to expand the health program of the Nation. Bill S. 2758 proposes aid for the public and nonprofit agencies but not for the proprietary group. Nonprofit agencies admit patients who are able to pay their way, those who pay their way partially, and those who require total assistance from public and private agencies. In return for the designation of “nonprofit,” these agencies are given the benefit of tax exemptions, the right to go to the community for soliciting of funds, and of course, a sizable sum of money from tax funds. Just as the nonprofit institutions, we, the proprietary nursing homes, admit people who are able to pay their way, people who can partially pay their way, and people for whom private and governmental agencies have assumed responsibility. The unhappy difference is that we have no tax exemptions, no right of fund solicitation, and no recourse to tax funds in charitable institution budgets. Ours is a very, very difficult role. We are a recognized member of the medical care team in the total medical care program, locally, state-wide and nationally, yet for some reason, which we believe is purely an oversight, no mention is made in S. 2758 of the proprietary nursing home. If enacted into law in its present form, this bill will result in the closing of the great majority of proprietary nursing homes. We wish to stress one final point in our consideration of what is fair and reasonable in considering this legislation in relation to the proprietary nursing homes. It seems to us that in the exclusion of our agency from the benefits of this legislation, we are asked to face a type of unfair competition which is completely foreign to the basic principle of free enterprise and private initiative so frequently and so ably expressed by our executive and legislative leaders. Regarding our third point, "What is of greatest benefit to the Government in planning this program?", we submit that in all program planning it is axiomatic that existing agencies and facilities be utilized. Ths constitutes sound reasoning. The experience and the structure is there. Much time and expense can be saved, and there is much to be gained by making use of the existing proprietary nursing home. In testimony before the Committee on Interstate and Foreign Commerce, in the House of Representatives, it was stated that the per-bed construction cost in the Government planned nursing homes would be $8,000. As we have already pointed out in our statistics on investments, private enterprise is presently supplying the same facilities at a cost of less than $4,000 per bed. Careful thought and consideration should be given to any group, be they designated "proprietary" or "nonprofit," which can produce for governmental use equivalent facilities at less than half the cost as shown in the Government survey. We again wish to emphasize that the disruption of a profession cannot help but result in both individual and corporate tax losses to the Government and cannot be disregarded. STATEMENT OF MELVIN A. CASE, VICE PRESIDENT, NATIONAL ASSOCIATION OF REGIS TERED NURSING HOMES, INC. By name is Melvin A. Case. I am vice president of the National Association of Registered Nursing Homes, Inc., and vice president of the New York State Nursing Home Association, Inc., both of these associations are composed of proprietary nursing home owners and operators. I am in full accord with the testimony made by other members of our association and the other associations of nursing homes. I would like to make a point of the financial and economical status of proprietary nursing homes. During the hearings on H. R. 7341, it has been testified that there are 20,000 nursing homes in the United States. Assuming for this discussion the figure of 20,000 nursing homes, it is important to note the following: the average capital investment per nursing home is conservatively set at $60,000. The total estimated investment, therefore, is $1,200 million. The average nursing home has a bed capacity of 25, providing therefore, an approximate total of 500,000 beds. For the care of its guests, under present standards, each nursing home employs, roughly speaking, one person for every three patients, or in round numbers a total of 170,000 persons. The average weekly salary of such employees is about $50.00, or about $8,500,000 weekly. The sum total of these figures cannot help but impress you with the fact that we who address you on S. 2758 today represent a large financial stake in the American economy. We have never asked for subsidies, and we have carried a tax burden through the years, growing because of the pride we have in our work and the interest we have in our patients. Hon. WILLIAM A. PURTELL, Chairman, Subcommittee on Health, STATE OF CONNECTICUT, Senate Committees on Labor and Public Welfare DEAR SENATOR PURTELL: It has come to our attention that your committee is holding hearings on the Wolverton Amendment to the Hill-Burton Act. It is our desire to give you a brief outline of the present nursing home (chronic and convalescent hospital, Connecticut General Statutes, Sec. 1545c, Sanitary Code Regulation 200) situation in Connecticut and the anticipated value of Federal funds to aid in construction of such facilities. There is attached hereto a brief statement in which these facts are set forth. Sincerely yours, STANLEY H. OSBORN, BRIEF OUTLINE OF THE CHRONIC AND CONVALESCENT HOSPITAL SITUATION IN CONNECTICUT Chronic and Convalescent Hospitals (occasionally called nursing homes) In Connecticut at this time, we have a total of 201 institutions providing 5,660 beds for the care of the chronically ill. These may be classified as follows: 1 Chronic disease hospitals: 1. St. Luke's Hospital, Greenwich (nonprofit corporation); 2. Hillside Home and Hospital, Bridgeport (city); 3. Masonic Home and Hospital, Wallingford (fraternal); 4. New Britain Memorial Hospital, New Britain (nonprofit); (partially commission on care and treatment of chronically ill aged and infirm); 5. Hospital of Commission on Care and Treatment of Chronically Ill, Aged and Infirm, Rocky Hill (State); 6. Newington Home and Hospital, Newington (nonprofit corporation). Other Government and nonprofit: 1. Odd Fellows Home, Groton (fraternal); 2. Children's Center, Hamden (nonprofit corporation); 3. Notre Dame Convalescent Home, Norwalk (church); 4. Jefferson House. Hartford (nonprofit corporation); 5. Hebrew Home for the Aged, Hartford (nonprofit corporation); 6. Howood House, Hartford (nonprofit corporation); 7. Curtis Home Infirmary, Meriden (nonprofit corpo ration); 8. Hillside Home Infirmary, New London (city); 9. Nathaniel Witherell Hospital, Greenwich (city); 10. McCook Memorial Hospital, Chronic Unit, Hartford (City). In Connecticut, nursing homes are legally chronic and convalescent hospitals. On December 13, 1953, the occupancy rates of these institutions were as follows: Government and nonprofit, 90 percent occupancy; proprietary, 94 percent occupancy. DOMICILIARY HOMES FOR AGED In addition to the above, we have approximately 50 nonprofit domiciliary homes for the aged (mostly endowed). Many of these undertake to care for their aged residents for the remainder of their lives, but some do not have an acceptable infirmary unit because existing buildings do not meet the requirements of the Connecticut fire-safety code for nursing homes. It is anticipated that the Wolverton amendment funds, if available, will in Connecticut be used largely to meet this important need. It is understood that, if the Wolverton amendment is passed, Connecticut will receive approximately $70,000 per year for construction of nonprofit nursing homes.1 At the minimum rate of participation-33% percent-this would mean about $200,000 of such construction or, at the estimated cost of $8,000 per bed, 25 additional beds per year. SUMMARY We estimate that (1) there will be an increase from 1952 to 1967 of 19.7 percent in Connecticut residents over 65 years of age; (2) the occupancy rate of existing facilities is now very high, 90 to 94 percent; (3) it is already difficult and in some areas impossible to find much-needed beds. The objectives of the Connecticut licensing agency-State department of health-is to stimulate the provision of good facilities and personnel for the care of the chronically ill at the lowest cost compatible with its standards. This agency is not concerned with the type of sponsorship. It works with existing institutions toward constant improvement of standards of care. It makes an effort to guide prospective new operators in regard to local bed need and the establishment and maintenance of a good institution, whether the prospective institution be proprietary or nonprofit. The very fine work which has been and is being done by proprietary nursing homes in Connecticut is very well recognized. Connecticut is proud of its high standards of care and even prouder of its continuing efforts to improve these standards. Re S. 2758. Hon. WILLIAM A. PURTELL, WASHINGTON, D. C., March 19, 1954. Chairman, Subcommittee on Health, Committee on Labor and Public Welfare, DEAR MR. PURTELL: S. 2758, amending the Hill-Burton Act, defines hospitals and related facilities as those in which patient care is under the supervision of "persons licensed to practice medicine in the State." That language might be interpreted to disqualify osteopathic applicants in three-fourths of the States. We, therefore, respectfully request that the bill be amended, on page 13, after line 22, to add the following: "(p) The term 'persons licensed to practice medicine in the State' includes licensed doctors of osteopathy within the scope of their practice as defined by State law." As an alternative, amend the bill to conform with the amendments of section 631 of the Public Health Service Act as contained in H. R. 8149 as it passed the House. Doctors of osteopathy are licensed in all the States. They are expressly “licensed to practice medicine" in about one-fourth of the States. Generally, they are licensed to practice osteopathy and surgery. Four out of five osteopathic hospital projects which have received or are receiving Hill-Burton construction funds are located in States licensing the practice of osteopathy and surgery. American Osteopathic Association records list 386 osteopathic hospitals with upward of 12,000 total beds in the United States. A Brookings Institution survey, published in 1952, based on reports from 91 osteopathic hospitals, showed 183,462 admissions, with 1,238,312 days of care. The nonprofit hospitals received 69 percent of the admissions and provided 64 percent of the total days of care. The general hospital accounted for the great majority of all use of osteopathic hospitals. 1 In Connecticut, nursing homes are legally chronic and convalescent hospitals. The American Osteopathic Association supported the Hill-Burton Act when it was before this committee in 1946, and favors implementing the President's January 18 health message for broadening that act. Very truly yours, LAWRENCE L. GOURLEY, Legal Counsel, American Osteopathic Association. Hon. H. ALEXANDER SMITH, THE AMERICAN INSTITUTE OF ARCHITECTS, Chairman, Committee on Labor and Public Welfare, MY DEAR SENATOR SMITH: The American Institute of Architects is in favor of the administration's recommendation to amend the hospital survey and construction provisions of the Public Health Service Act, as proposed in S. 2758. As private citizens we recognize our Government's responsibility and the role that it should play in helping communities to meet vast unfilled needs in the medical field. We acknowledge that many of these have been seriously neglected. It is in the public interest to extend the program as proposed. As architects, we have considerable knowledge of the present hospital survey and construction program. Because of our experience with the workings of that program, we believe that any extension of Federal assistance in the medical field should follow the pattern established under the earlier act. Therefore, if it is possible, we should like to have the attached statement appear in the record of the hearings on S. 2758, held by your committee. Very sincerely, EDMUND R. PURVES, Executive Director. STATEMENT ON S. 2758 The American Institute of Architects, the national professional association representing nearly 10,000 American architects, endorses the proposed amendments to the hospital survey and construction provisions and the Public Health Service Act, as proposed in S. 2758. The Institute has had more than a passing interest and knowledge of the hospital survey and construction program, having backed the initial legislation in 1946. To the architect, the philosophy of this act and its administration represents an outstanding example of how cooperation between a Federal agency and private enterprise may be achieved. As President Eisenhower has pointed out, there are vast needs for facilities for the diagnosis and treatment of ambulatory patients, for the chronically ill, for rehabilitation, and for nursing homes. It is apparent that these needs will not be met without Federal contributions to supplement available local funds. If such Federal aid is to be authorized for these additional medical facilities, we should like to be assured that the program will be well planned and administered. We believe that passage of S. 2758 will accomplish this objective, through following the highly successful pattern of the earlier act. We, therefore, should like to go on record as in favor of the bill. Hon. H. ALEXANDER SMITH, AMERICAN NURSES' ASSOCIATION, INC. Chairman, Senate Committee on Labor and Public Welfare, Senate Office Building, Washington, D. C. DEAR MR. SMITH: The American Nurses' Association, an organization of registered professional nurses, with a membership of 170,000 nurses in 53 constituent State and Territorial associations, wishes to record an opinion on legislative proposals to expand health services which are now before your committee. We note that you are now conducting hearings on S. 2758 and H. R. 8149-bills "to amend the hospital survey and construction provisions of the Public Health Service Act to provide assistance to the States for surveying the need for diagnostic or treatment centers, for hospitals, for the chronically ill and impaired, |