Senator MUSKIE. I would like to send down to you, in case you have not seen it, Mr. Cruikshank's testimony of yesterday and, particularly, the tables, which I would like to have you or your people look at.

Now, what Mr. Cruikshank has tried to do here is to reflect the impact of the administration's proposal upon hospital bills, taking into account medical and hospital services.

To use the language in his statement, he says table 1-there are three tables there-shows the out-of-pocket costs under the existing Medicare program for covered medical and hospital services by size of medical service bills and number of days in hospital at $110 per day.

[The tables referred to appear in part 8, Barriers to Health Care for Older Americans, pp. 678-683.]

Now, of course, using these tables, one can pull out illustrative examples of what might be the impact of CHIP compared to Medicare. For example, using table 1 with a medical services bill of $200 and a 20-day hospital stay, the amount that the patient would pay would be $172 under Medicare.

Going down to table 2, that same patient would pay $560 under CHIP which-from table 3-represents an increase of 225.6 percent. This would be for patients with $5,250 of income or more as the tables do not include income testing.

Now, one can find the other side of the picture, too, in this table and I am certainly not going to ask you to respond with an instant analysis of these three tables but I would like to bring them to your attention and then if your technical people want to provide us with an analysis of these tables. I would be delighted to have it because they were put in the record yesterday.

I thought that we ought to have a response and, obviously, you are going to look at it from a different perspective than the people who prepared it.

COST-SHARING-INCOME RELATED

Secretary WEINBERGER. We certainly would, be happy to look at them. I think, in this connection, that they are not income related is completely accurate and I think in that connection, it is very important to bear in mind the 1972 census shows the median income for those over 65 is $2,520 so the income related cost-sharing that is in our bill provides very substantial benefits and very substantial differences from these figures, which assume that everybody under these tables has an income of $7,000 or probably more. There is quite a gap between those tables and what would be required under CHIP and we can get a lot of hypothetical cases and put them before you that show that payments under the CHIP program would be less. Senator MUSKIE. It might be possible for you to construct tables comparable to these for the other two income levels?

Secretary WEINBERGER. There are several income levels but we could try to do that.

[Subsequent to the hearing the Department of HEW submitted comments on the statement of Nelson Cruikshank, president, National

Council of Senior Citizens; and Bert Seidman, director of Social Security, AFL-CIO. Submitted by Frank E. Samuel, Jr., Deputy Assistant Secretary for Legislation (Health). See appendix 1, items 3 and 4, pps. 949, 962.]

Senator MUSKIE. There are five in all but those that are income tested or income qualified, are three.

Secretary WEINBERGER. It is important, I think, Mr. Chairman, to bear in mind that there is a great advantage to the elderly, many of whom have very low income, to have a program in which there is a scale or a sliding scale of payments relating to income and, therefore, getting it within the income ability of people over 65 to pay and, at the same time, there is a tremendous benefit also to enabling them to spread their payments over as long as they wish for whatever amount they may actually owe.

The other point I was endeavoring to make to Senator Percy before he left is the fact that materially the cost of the first few days of hospitalization is something that is budgetable, is planned for in many situations and can be handled.

It is the long continuations, the catastrophic feature, that cannot be provided for by anyone and that is the thing that is not covered now and would be covered under our program but we will be glad to comment on these specific tables and construct some more accurate ones, as we believe they would be on an income related basis.

Senator MUSKIE. All right, it is difficult to bounce an illustrative example back and forth across this table. I can bring up a horror story and you can bring up some.

Secretary WEINBERGER. We have two for every one, sir, if you would like us to spend all morning going over it.

Senator MUSKIE. You can study our example and we can study yours but frankly, what I want to get a picture of is exactly what Senator Percy was talking about. This is the reason I found these charts useful although they might not present the whole picture.

I want to know what the impact is on Medicare patients in the average hospital stay as shown in chart 5.* This will give us the picture of the tradeoff.

Secretary WEINBERGER. I would like to emphasize once more if I could, Senator, the fact that a great deal of the hospitalization at the present time is influenced by the design of the Medicare system and we cannot assume, from all of those black bars, that all of those days of hospitalization, 5 days, and so on, were either necessary or the best method of treatment in many cases. In too many cases it is ordered by the doctor because it is there and this is the thing we do have to keep in mind in the design of any health insurance program. Senator MUSKIE. I agree with that and that gets me to another point. I would agree with you that one of the reasons hospitalization constitutes something like 60 percent of the health care costs of the elderly is because there is unnecessary utilization of hospital care and I have been an ardent advocate of home health care as a substitute. The administration's plan would cut that, cut it from 100 days

See chart 5, p. 902.

Secretary WEINBERGER. No, sir.

Senator MUSKIE. I mean visits, not days. This chart which we have here suggests that the visits would be cut from 200 to 100 and that there would be a coinsurance feature added that does not exist

now.

Secretary WEINBERGER. What you need, Senator, is another chart that shows you the incidence of home visits and the vast proportion of those are under 100 visits per year and that is why we cover that proportion up to and including 100 visits, rather than 200 visits.

Senator MUSKIE. Mr. Secretary, I see I have about 2 minutes to get to the floor to cast a vote. I will try to be right back and I will try not to hold you too long.

Secretary WEINBERGER. All right, sir.

[A brief recess was taken at this point.]

AFTER RECESS

Senator MUSKIE. The committee will be in order. Mr. Secretary, I understand you have another appointment?

Secretary WEINBERGER. I do, but we will stay as long as possible. Senator MUSKIE. There are a lot of interesting questions I would like to pursue but I do not think that they are such as would justify on my intruding on your schedule.

You might want to finish responding to my last question and I might have one or two more before your next commitment.

Secretary WEINBERGER. I have forgotten what it was?

Senator MUSKIE. It was a question about the apparent reduction in home health benefits.

Secretary WEINBERGER. Yes. We believe from our examination of the facts we have that 100 covered visits would cover the great bulk of all of the cases.

I share with you the feeling that home health care is frequently preferable to hospitalization and we believe that the 100 covered visits that we have would take care of the great bulk of the situations rather than the 200 which are rarely utilized, if at all, under the present coverage.

Senator MUSKIE. Well, it is my impression--and I would like your experts or yourself to comment-that one of the reasons why home health benefits are not utilized more is because of the restrictive way in which the law is now written. Is that true?

HOME HEALTH CARE UNDER CHIP

Secretary WEINBERGER. I would not be able to speak to that. I think the home health care we are talking about under the Comprehensive Health Insurance Plan is quite different than the visits covered at the moment.

Commissioner CARDWELL. I think most people would agree there are economic disincentives under the present arrangement. On the other side, there is an area of great unknown-the consequences of an open-ended approach to home health and third-party financing,

could probably be incalculable at this point. We would urge some caution in thinking through on that.

I think the idea here was that the approach to coverage would be essentially the same. One could argue over the difference between the 200 visits and the 100 visits and find an issue.

Senator MUSKIE. You have raised an interesting point. Are you saying that the administration's program would loosen up the criteria or eligibility?

Commissioner CARDWELL. No, we are saying the criteria for eligibility and the general philosophy about the role of third-party financing, under an insurance approach, are essentially the same. We are not changing that philosophy and so the only real issue we see is the one you have drawn: the comparison of 100 visits versus 200 a year.

Senator MUSKIE. I agree the number of visits may, in a sense, be the result rather than the cause of a problem here if the home health care program is too narrowly based in terms of eligibility and encouragement to use it. What we are talking about is the importance of reducing the use of hospitalization for problems that could be solved in other ways. Since we all seem to be philosophically attuned to the notion of home health care, the question is: Should not we provide in legislation such as my bill, S. 2690, for a liberalization of the program in order to provide a stimulus for its use and to reduce reliance on hospitalization? That is really the issue. I am simply trying to define it.

Secretary WEINBERGER. Senator, I guess the question is whether a relaxation or stimulation of its use would occur in place of hospitalization or would occur in cases where it was not required, even in and for itself. If you had unlimited home health care and, assuming you could get someone to make house calls, you would have a possibility of a very substantial use in situations where it was not required.

I think what Mr. Cardwell is saying is that there should be some restrictions and some restraints on it because no one knows what opening it up would do, again, in the way of overloading the system and depriving people who might be more in need, or entirely in need, from getting the care-the kind of care they might not get if people who did not need it were overusing it. I think that is the basic problem we have got.

Senator MUSKIE. I wish you would look at S. 2690 and give us your comments. You should still be subject to physician's supervision under S. 2690.

Commissioner FLEMMING. Senator, I just noted in the Secretary's statement, on long-term care, where we do have that area under intensive study, not only with respect to its health dimensions but with respect to its income security features and social services, that home health services would be encompassed within the framework of that work and looking at the question of institutionalization versus the home health side where, as noted, we are siding with you philosophically on the issue.

HOMEMAKERS SERVICES DEMONSTRATION PROJECTS

Senator MUSKIE. Well, section 222 of the Social Security Amendments of 1972 provided for demonstration projects to test the value of homemakers services as a Medicare postoperative benefit. One of the objectives would be to determine if such coverage would reduce long range cost by reducing the lengths of stay in hospitals and skilled nursing facilities and I understand the demonstrations have not yet begun. On February 12, I addressed a letter to Dr. Charles Edwards on this subject.

I have not yet received a reply and I look forward to receiving one if you could expedite that.

Secretary WEINBERGER. What is the date of your letter?

Senator MUSKIE. February 12 and I will include that in the record and a reply.

Secretary WEINBERGER. We will get that back to you; that is too long for you to wait.

Senator MUSKIE. I have waited longer.

Secretary WEINBERGER. I feel we should get our mail answered as quickly as possible and congressional mail has a high priority. Senator MUSKIE. I do not want to be too critical on that point; I might discover my own staff has waited that long to answer mail. A point Mr. Glasser made yesterday, and I quote from his testimony the following:

Eye examinations, development of visual care, eyeglasses, ear examinations, and hearing aids are covered under the administration's proposal; the children up to age 13 but the major problems of vision care and hearing and major need of eyeglasses and hearing aids are not among children, it is among the elderly. My questions are; first, is that an accurate statement? And second, if it is, where will the needy aged go for their noncovered items which will no longer be provided by Medicaid?

Secretary WEINBERGER. I think the reason for the emphasis on well-child care and the other services mentioned is that the greatest benefits we can get in the preventive field will result from providing such services to children in that general age group. In that age group, you have accomplished a very substantial advance on existing preventive medicine. With respect to persons over 65, we

Senator MUSKIE. Mr. Secretary, I think you must be in league with the floor here. There is another vote to which I must go. Secretary WEINBERGER. That is the first time anyone has accused me of having any power on the floor of the Senate.

Senator MUSKIE. You ought to reexamine your resources.

Secretary WEINBERGER. I will not hold you. I will complete that answer in writing, if you wish.

Senator MUSKIE. There is one other question I would like to put and have your answer in the record. Then there are some other specific questions we would like to submit. You have said in your statement several times that the total increase in Federal spending for the aged will be approximately $1.8 billion?

Secretary WEINBERGER. Yes, sir.

See appendix 1, item 2, p. 948.