Speaking for myself, I assure you that we will take very seriously the specific proposals you have made in your statement.

I just have two questions to ask you before I yield to my colleagues. You talked about the current weaknesses with respect to enforcement of nursing home standards.

Do you think the situation would be much improved if the Federal Government were to assume full responsibility for inspection and monitoring of nursing homes that receive funds under title VIII and XIX?

Mr. BECHILL. I have heard that proposal presented before and, historically, it has always been rejected because, historically, the licensing and inspection responsibility in this area and a number of others has rested with the States.

Frankly, Mr. Chairman, I am not very sanguine, despite the efforts that have been made in the last 2 or 3 years for there to be any marked improvement in the licensing and inspection of nursing homes. I don't reach that conclusion very easily. This is why I suggested that we bring a third force into the scene, the consumer, in a somewhat organized way.

In my own person judgment, and I think it would be opposed very strenuously as probably not very feasible to come down this way, but we now expend $12 billion-plus, or more, in the medicare program, almost $8 billion in medicaid, the level of licensing and inspection that has been available to various State agencies has only afforded minimal kinds of protection to older people.

I think it is time for the Federal Government to consider seriously the assumption of this responsibility directly even though I realize the cost that will be involved administratively. I think it is intolerable that we have permitted these conditions to exist, considering the vast expenditures of public funds under those two titles over the past several years.

Mr. BRADEMAS. I appreciate that response.

One might find that public moneys could be saved and services improved if there were some relatively modest involvement in some really effective form of inspection and monitoring.

Just one other question.

Do you think older persons would be better served if RSVP and foster grandparents were administered by the Administration on Aging in closer conjunction with title III and title VII!

Mr. BECHILL. Mr. Chairman, I always have favored a strong StateFederal Administration on Aging as possible.

When the title VI program of the Older Americans Act was repealed and amended as part of the Domestic Volunteer Act, I believe, at that time I was quite impressed with the leadership of the ACTION program and their views toward the foster grandparent and the RSVP program.

Frankly, on a very personal basis, I would prefer to see those two programs because of their identity returned to the Administration on Aging.

But I do have to point out, Mr. Chairman, that that is a personal opinion. It is not based on any close study. I am very concerned that a program, for example, that I was very strong about, the foster grandparent program, is not moved, is not submerged as a result of its now being part of the ACTION agency.

We have talked about going backward in many respects in this legislation. It would seem to me that there is still a major need that the foster grandparent program and RSVP program can fulfill in a person-to-person support of services.

Several years ago, I think other witnesses before this committee testified to their support for a major expansion of the foster grandparent program. I still believe that we could easily have a program that would involve upward of 100,000 older people and still not meet some of the needs that exist in some of the programs in the institutions serving children.

Mr. BRADEMAS. Thank you very much.

Mr. Cornell.

Mr. CORNELL. One of the things I particularly noted about your statement, Mr. Bechill, is the fact that you emphasize the idea of health care to the elderly.

While I know some of us are not specifically familiar with the Older Americans Act, I did appreciate that you made reference to medicare.

I find in my area many of the people, the elderly, tell me that the greatest financial burden that they have is the cost of medical care. Not only, of course, the nursing home aspect but the fact that medicare does not cover outpatient drugs. For that reason, I have publicly supported a national health security program that will absorb medicare and would, of course, be very comprehensive in its treatment. Do you have any opinion on this?

Mr. BECHILL. Medicare, in my view, is one of the finest pieces of social legislation ever enacted by the Congress of the United States in any century.

I don't think that, despite the criticisms of the program, that we are ever going to go backward on that principle as set forth in the act.

I think the principal problem with medicare at the moment is that it has not been expanded to cover some of the still regular and intermittent costs like drugs. That is what I meant in my written testimony, sir, by still having a number of imperfections.

I think that there are a number of areas in medicare that I hope the Congress will examine in the next year or two with the point of attempting to improve because I think the original intent of the law has not been as effective as it might have been because of the rise in general of medicare prices.

I think there is now information to suggest that we are now covering less of the dollar spent for medical care by older people under medicare now than was the case even a few years ago. I think we have to look at that program seriously.

Mr. CORNELL. I believe that out-of-pocket expenses now paid by the people under medicare is greater than the elderly paid on the average for medical care prior to 1965.

One gentleman called me shortly before I came to Washington and pointed out that he and his wife are paying $13.40 for medicaid, I believe it was, a month and he had to purchase outpatient medication that cost him hundreds of dollars.

But I gather from what you say that you feel the best thing as far as the elderly are concerned is to make medicare more comprehensive and not have it absorbed by general national health care programs. I say both things.

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.

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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.]