I think medicare should be made more comprehensive, an immediate step that could be taken, for example, would be to fully fund part B of medicare under general revenue financing. I think that is one thing that could be done. I think medicare could very much be incorporated into a national health insurance program when such a program is finally enacted.

There is legislation before the Congress that speaks to this.

My only concern would be that in moving from what is really now a very large-scale type program, the title XVIII program, to a national health insurance program, that that movement is accompanied by no loss of benefits to older.

I certainly think that most of the people who have introduced legislation to establish a national health insurance program, particularly one that involves the administration by the Social Security Administration, envisions this.

Mr. CORNELL. I would gather, also, from what you have said that you find that State agencies supervising nursing homes have not been very adequate.

Mr. BECHILL. I have very strong feelings on that that they have not done the job.

I do not blame the State agencies, themselves. I think the relationships that have been developed over the years

Let me just back up a minute, if I might, on this one point.

I think we can expend a lot of time trying to find out who are the culprits who are responsible for the present state we find so far as nursing homes are concerned and the laxity in inspection and enforcement. I think that responsibility is shared by a whole line of people over the years. I don't think it was done willfully or with any intent, necessarily. I think it has involved people like myself who have served at the State and Federal levels in official positions of responsibility. I think it has involved members of legislatures who have discussed nursing homes largely in terms of fiscal rather than human

concerns.

I think it has involved organizations that have largely been concerned with their own self-interest and profit and proprietory gain rather than the welfare of human beings.

I could go on.

Mr. CORNELL. Are you aware in my home State there is supervision there under the Lieutenant Governor?

Mr. BECHILL. Yes; I am.

I think again the ombudsman program, something of this order, is a splendid effort by State government.

Again, I would like to see some direct help given to a consumer. There are times that the official bureaucracy at either the Federal or State level, no matter what their intent, finds it a hard thing to respond sometimes to complaints.

I would just like to see us have some experience in trying to give some bona fide organizations an opportunity to be this third force to see that the laws and enforcement of those laws are what is intended. I think that there is a splendid organization in Detroit, Mich., the Citizens for Better Care, Inc., of Detroit, that has pioneered in this area. They are not the only organization but they have been very effective in opening up the decisionmaking and records and the

manner in which nursing homes and homes for the aged and other care facilities are administered under public scrutiny.

They have been able, as a result, to effect some change in that particular State.

I think we have had a closed system of decisionmaking between government and providers that somehow we have just got to alter if you are really going to get any improvement in this situation. Mr. CORNELL. Thank you.

Mr. BRADEMAS. Mr. Beard.

Mr. BEARD. I was very happy to hear your remarks in this area. I want to assure you that in Rhode Island, with the help of the elderly, we have managed in the past to have monthly inspections. I hope that maybe we can do the same thing nationally.

I think it is an area that is tremendously neglected. For many of the people it is a problem for them. You can't put it in terms of dollars and cents.

I want to assure you that, from my point of view-as a matter of fact, I probably arrived here because of that issue-I will try to do what I can to solve that problem.

Mr. BRADEMAS. Mr. Miller.

Mr. MILLER. First of all, I thank you for your remarks. They are very sincere and I appreciate the frankness with which you address yourself to some of the conflicts that exist in the administration of some of the programs.

In your remarks you talk about the tilt, due to the funding through medicare and medicaid, toward institutional programs of care for the elderly.

Would you mind explaining that?

Mr. BECHILL. I think what I was referring to here, Mr. Miller, was the percentage of the total dollar expenditures for medicare that have largely gone into two items, which have to do essentially with inpatient hospital care and the principal item that I am concerned with is the very low percentage under the medicare program, and I might add under the title XIX medicare program, that goes for the payment of home health services.

I believe the Senate Committee on Aging has had extensive studies on this subject.

The present expenditure of the total has been less than 1 percent of the medicare dollar going for home health aid.

What we have is a situation in which the premium is placed on providing protection in institutions. I am saying I think we need a better balance than that so that there are ways in which home health services can be made more readily available to older people and more choice be made available to older people and the families.

Mr. MILLER. Those services also present, I think, some of the same problems that we see in the shoddy operation of nursing homes.

In California we have had rather inadequate proprietory operations. If you believe we ought to commit more money, and I am in agreement with you, to home health services, how do we keep out of the trap we have fallen into with nursing homes to make sure that the person is not getting ripped off in his own home?

Mr. BECHILL. I was aware of the problem that was developing in California, Mr. Miller, on a large scale. I also wish I had an express answer on how to deal with it.

48-087-75-10

Mr. MILLER. Do you envision the same type of consumer patient licensing?

Mr. BECHILL. Well, I would, personally-of course, my biases are quite clear. I, personally, would like to see the bulk of home health services being provided under private auspices or by private nonprofit agencies that have had a demonstrated experience in this area, and there are many.

Again, in the case of the home health services, I would see the need for licensing of their activities and proper inspection activities.

But, I, also, to be consistent, would feel there ought to be strong consumer representation in their administration to avoid some of the abuses I am aware have developed in California and other States as we have seen the large-scale influence on entrepreneurial operations in this field.

Mr. MILLER. Thank you very much.

Mr. BRADEMAS. Mr. Bechill, again we want to thank you very much for a splendid statement.

We appreciate your coming to testify.

The subcommittee is adjourned until tomorrow morning at 10 o'clock.

[Whereupon, at 12:57 p.m., the subcommittee recessed, to reconvene at 10 a.m., Friday, January 31, 1975.]

4

COMPREHENSIVE OLDER AMERICANS

SERVICES

AMENDMENTS OF 1973 AND RELATED PROGRAMS

FRIDAY, JANUARY 31, 1975

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON SELECT EDUCATION,

OF THE COMMITTEE ON EDUCATION AND LABOR,

Washington, D.C. The subcommittee met at 10:05, pursuant to call, in room 2175, Rayburn House Office Building, Hon. John Brademas (chairman of the subcommittee), presiding.

Present: Representatives Meeds, Lehman, Cornell, Beard, Miller, Hall, Jeffords, and Pressler.

Staff members present: Jack G. Duncan, counsel; Robert Agee, staff assistant; and Charles W. Radcliffe, minority counsel.

Mr. BRADEMAS. The Subcommittee on Select Education will come to order for the purpose of further hearings on the operation of the programs authorized by the Older Americans Services Amendments of

1973.

The Chair wants only to observe that this legislation is of great importance to Americans in their later years and that the Chair for one is determined to act expeditiously to extend these important programs in order that the older persons in our society can be assured that the social services, nutrition programs, public service employment and volunteer opportunities supported by this legislation will be continued without interruption.

The Chair will also observe that there appears to be some disagreement developing with respect to the direction in which the Federal Government should move.

Yesterday the subcommittee heard from representatives of the administration who told us that we should lower the amounts authorized for title III of the act, that we should restrict the amounts authorized for research and training, and that we should drop the authority of the Commissioner of Aging to conduct housing and transportation programs for the elderly.

I think I also detected a warning in the testimony of the administration that we should anticipate a presidential message shortly urging that Congress defer and/or rescind some of the 1975 funds already appropriated for older Americans programs.

On the other hand, we heard from the distinguished chairman of the Committee on Education and Labor, Mr. Perkins, who declared that we should not only continue these important programs but vastly expand them.

( 139 )

Today we have appearing before the subcommittee a distinguished list of public witnesses who will give us their views on the effectiveness of the programs supported by the amendments of 1973 and offer any suggestions for change.

Our first witnesses today are Harry F. Walker, executive director of the Commission on Aging, Maryland president of the National Association of State Units on Aging, accompanied by Louise Gerrard, executive director of the West Virginia Commission on Aging who is the first vice president of the National Association of State Units on Aging.

STATEMENT OF HARRY F. WALKER, EXECUTIVE DIRECTOR, COMMISSION ON AGING; MARYLAND PRESIDENT, NATIONAL ASSOCIATION OF STATE UNITS ON AGING, ACCOMPANIED BY LOUISE GERRARD, FIRST VICE PRESIDENT OF THE NATIONAL ASSOCIATION OF STATE UNITS ON AGING, AND PAUL HENDRICK, EXECUTIVE DIRECTOR OF THE NEW HAMPSHIRE COUNCIL ON AGING

Mr. WALKER. Mr. Chairman, I would like also to introduce Paul Hendrick, executive director of the New Hampshire Council on Aging, member of our legislative committee.

Mr. BRADEMAS. The Chair might interrupt to say that as we have a very large number of witnesses it will be helpful to the extent possible if witnesses will try to summarize the main points that they wish to make and their testimony will be included as if read in its entirety in the record.

Mr. WALKER. Mr. Chairman, the testimony we are presenting today is based on our discussion with a number of State executives in the last several years.

Because key provisions of the Older Americans Act are relatively new, it is too early to evaluate some parts of the program. There is no question, however, that the Older Americans Act legislation is filling a void in services available to the older men and women of our country.

Our suggestions and comments today are aimed at strengthening some provisions and clarifying others, all with the central focus, as expressed in the act, of assisting our older people to secure equal opportunity to the full and free enjoyment of life.

TITLE III

In general, State units on aging support the area agency on aging concept as offering a practical vehicle for bringing services to older adults at the local level, while also serving as a means of generating grassroots support for aging programs.

Because these AAA's are barely 1-year old and are still in the process of evolving into mature units, we do not recommend changes in the legislation relating to them.

We are aware that area agencies are being asked to do a great many things with budgets that often are incongruously small. In some States, these area agencies are one- or two-person operations, yet they carry formidable responsibilities.