aiding those who need hospital service before an accurate evaluation can be determined as to the efficacy of such legislation as H.R. 4222.

Traditionally, the Nation's hospitals have served a vital community purpose and they have been able to perform this function in an atmosphere of community control. This has permitted hospitals to operate in a manner responsive to the needs of the community.

It is true that many elderly patients are without funds to provide themselves with necessary health services, including hospitalization. But it is also true that this is the case with persons of all age groups.

To meet this need, various agencies become involved, according to the degree of responsibility. First, there is the responsibility of the individual himself. There then follows the responsibility of the family, then the community, through established philanthropic organizations, city and county governments, then the State government, and then the responsibility of the Federal Government. This chronology must be maintained if our society subscribes to the principle of decreasing priority of responsibility in direct ratio to the ascendancy of level of government.

The approach offered by H.R. 4222 reverses this chronology. It places with the Federal Government the first order of priority for supplying the needs of American citizens and, to this extent, is an abrupt reversal of and departure from the traditional concept of individual and community responsibility to and for those who are unable to supply their own needs. This is the same philosophy basic in the concept of the welfare state which holds that social welfare responsibility must be vested solely with the Central Government to the denial of the responsibilities and prerogatives of the individual, community philanthropic agencies, and lower levels of government.

Further examination must be made of the immediate and long-range effects which H.R. 4222 would have on the operation of hospitals. This bill provides that an agency of the Federal Government shall be invested with the authority to set standards and to regulate costs of hospitals which would participate in the program. Such a provision could and would have far-reaching and detrimental effect on hospital care in this Nation. It would mean that hospitals could no longer be responsive to the needs of the communities which they servecommunities whose needs differ widely with respect to their cultural, economic, and ethnic environments. It would result in hospitals operating under a uniform system of regulation administered by the Central Government which would tend to reduce the level of service rendered to a drastic degree.

Coupled with this danger is the fact that built into H.R. 4222 are those pressures which work toward expansion of the program, both with respect to age groups and services. It is not only conceivable but likely that these pressures would be exerted ultimately to include total medical services for persons of every age. This factor in itself is worthy of the most careful consideration by those who must make the decision as to whether H.R. 4222 should be enacted.

To further support its position, the Tennessee Hospital Association wishes to enumerate briefly some of those programs already in existence in Tennessee which are fulfilling the need which H.R. 4222 purports to do. These include:

1. The Tennessee indigent hospitalization program, administered by the Tennessee Department of Public Health. This program provides hospitalization to persons of all age groups who are found to be in need of hospitalization and not able to afford the cost.

2. The Tennessee welfare hospital assistance program. This program operates under the provisions of the old-age assistance program and provides hospitalization and nursing home care for OAA recipients.

3. The Kerr-Mills law medical aid to the aged program. When this program is implemented August 1, 1961, it will provide hospitalization and necessary drugs to persons over 65 who are not recipients of OAA but are unable to afford the cost of such hospitalization and drugs.

It is noteworthy that the physicians of Tennessee, through their State medical association, have further enhanced the effectiveness of these programs through their having agreed to make no charge to the State or local governments for services rendered to persons receiving aid from these programs.

It is not possible to enumerate the many voluntary philanthropic activities of church groups and other organizations which are also contributing to the care of elderly persons. It must also be stated that these organizations are not only willing to continue these activities and to expand them, they are not com

plaining that the cost of such activities is accentuating their financial difficulties. The Tennesse Hospital Association believes that the need for providing health care for the elderly is being met in Tennessee, and that no further legislation by the Congress is required at this time. The Tennessee Hospital Association also believes that passage of such legislation as H.R. 4222 would set in motion those forces which would result in the gradual deterioration of medical care in the United States through the substitution of quantitative rather than qualitative health service.

JUNE 22, 1961.

Mr. IKARD. Miss Helen Hall.

JAMES E. FERGUSON,

President, Tennessee Hospital Association.

Miss Hall, will you please identify yourself for the purposes of the record and you are recognized.

STATEMENT OF HELEN HALL, HONORARY PRESIDENT OF THE NATIONAL FEDERATION OF SETTLEMENTS AND NEIGHBORHOOD CENTERS

Miss HALL. Yes, sir. I am Helen Hall and I am director of the Henry Street Settlement on the Lower East Side of New York City. Today I am speaking for the National Federation of Settlements and Neighborhood Centers, a national organization of some 270 settlements and neighborhood centers located in 90 urban communities across the country.

While I am officially representing the National Federation of Settlements and the people in these other neighborhoods, I feel that I especially represent the men and women of my Henry Street neighborhood with whom I have been closely associated for the past 27 years. And especially again a group of 350 men and women all over 65, calling themselves the Good Companions and meeting at Henry Street, who have given me a concentrated education in the kind of problems older people are facing today. I am, of course, Mr. Chairman, representing the patient today and what I think we all feel in the settlements is what they want. I am glad to see, in looking at the list of people that are speaking, that you have some of the people themselves coming to speak to you.

I will not dwell on the statistics of the aging population with which this committee is necessarily familiar. What I would like to do in a very few minutes is to give you some idea of what we see at firsthand as the reasons why the provisions of this proposal are so vastly important to the people among whom we work, important not only to men and women over 65 themselves, but to the responsible members of their families.

Increased longevity is of course basic to the problem. When I first started to work in a settlement neighborhood in Philadelphia nearly 40 years ago, my older neighbors formed a much smaller proportion of the community and the dependent and ill years were so much shorter. There were not so many older people living alone and their difficulties were more often a part of a total family situation. However, when the depression came on and older workers were so often the first to be laid off their total lack of resources stood out sharply against the backdrop of the depression years. And too, as disastrous as being out a job was to heads of families, and to younger men and women, at least they could make a living again when jobs were to be

had, while older people were through for good, and totally dependent. They became an economic burden to their families or their communities, all of which added immeasurably to their misery. It was against this experience that old age and survivors insurance was planned.

However, I was on the President's Advisory Council to the Committee on Economic Security before the passage of the Social Security Act, and I can remember the dire predictions of its opponents of those days against its every provision. Since then, one of the most rewarding experiences of living in a neighborhood such as mine, has been to see at firsthand its protections as they have worked out in the lives of my neighbors. Few of its opponents of yesterday would want today to risk the ups and downs of our economy, without the cushioning effect of insurance payments as they go into the homes of the recipients and come back into the community as sustaining purchase power.

The insurance principle is basic to American life and we subscribe to it as the most self-respecting way of protecting ourselves against dependency and against disasters of all kinds. But, while few would question that old age and survivors insurance has increased the security and dignity of millions of older people, when this same principle is applied to the hazards of health everything seems to change.

Old shibboleths, such as "free choice of doctor," "doctor and patient relationship," obscure any reasonable understanding of what this bill provides. To put it in its simplest terms, as I understand it, it does not supply the services of private physicians. It supplies hospital care, nursing, and other care in the patient's home, care in nursing homes, and outpatient diagnostic services all with time limitations, and some deductible stipulations and all through already established local channels. Making it possible for the recipient to save for these services, through a payroll deduction, and making those services something to count upon, is where the difference comes in.

Let us consider the doctor-patient relationship as a practical consideration not because it should be discussed in the light of this proposal, as it does not apply, but because it is being brought up again at this time. Some years ago, the settlements made a study of doctorpatient relationships among their neighborhood people and we found that only one-third of the families at that time had what could possibly be thought of as a family doctor and in the one-third, the relationship was often pretty ephemeral. They went, as they do today, largely to clinics, and to hospitals where they are treated by the doctor on duty at the time, or in an emergency, the doctor on the ambulance or the doctor in the accident ward. Without insurance, we should face the fact that the doctor-patient relationship must rest primarily on the patient's ability to pay at the time he is taken ill. It is only in the middle and upper income brackets that the choice can be unfettered.

This bill has also been called Government medicine although its providers of services are largely private, or city or State as the case is today-certainly not largely Federal. But in all the controversy, the fact is often overlooked that some of our best medicine seems to be practiced in the Veterans' Administration. I, myself, served with the Red Cross in the First and Second World Wars and, right after the First World War for a time with the Army itself in the Philippines and China establishing service clubs for enlisted men-4 years.

all told-and I had occasion numerous times to use some excellent medical care supplied by the Army.

After all, President Eisenhower himself, from West Point to the Presidency and on, has been the recipient of what is often referred to derogatively as state medicine. I have always failed to understand why the passage of money between doctor and patient enhances the relationship especially if the payment is an unbearable burden on the patient. In this case, the doctor must feel less free to continue treatment or, like so many doctors, continues without charge. This is uncomfortable for the patient and most unfair to the doctor. But unfair or not, we know that doctors are doing this all over the country. I know of no other profession which by its nature puts this kind of pressure on its practitioners.

The situation of older people in the United States today has not only been changed by their longevity and hence increasing numbers in the population, but for better or worse, Americans have become increasingly mobile. The tendency of younger families has been to move to other neighborhoods or other parts of the country, while older people often prefer to stay where they feel at home. Often the move does not or cannot include grandparents. Public housing and urban renewal and the trend to the suburbs, all play a part in the mobility of city families. While mobility is on the increase today it also is part of the American tradition to seek your fortune by moving, dating from covered wagon days to the automobile and the trailer. Of course today part of the moving is due to the difficulty in finding a home. Large families have a desperate time to find quarters in New York, and I am told, in many of the larger cities.

The increase in the birth rate after World War II has played its part. Perhaps the youngest members have had to take the place of the older members when it came to finding a large enough home. This does not necessarily mean indifference to the welfare of the older members of the families. I know of countless daughters who have stayed in my neighborhood instead of moving to the suburbs so that they could care for their old parents. Others who come back two or three times a week, from another neighborhood, to clean and shop for their mothers or fathers. However, the fact remains that there are many old people living alone-some of them liking the independence of it and others half dead with loneliness. In other words, the family has become decentralized and it is more difficult to mobilize them for emergencies and, of course, for long-term care. To come back to the "good companions" and some of the things they, and many others, have made clear to me. One is that "old age insurance" is universally preferred to being on "welfare," which means relief, and that they want health needs to be a part of social security rather than a relief measure. This, it seems to me, stems from many of the qualities we like to associate with Americans.

First: It is more self-respecting-it is theirs by right of having contributed toward it. They do not have to go through anything humiliating to get it. The process of a means test is considered humiliating, no matter how skillfully and humanely it is carried out. Second: Their children and relatives if they have any, have to be involved in the means test and this can be very bitter for countless reasons, many of which I have listened to over the years. It may, to their mind, be taking money away from grandchildren, if their married

children have to pay for their illness. It may mean approaching relatives long since estranged. A thousand different humble, generous, or perhaps poor reasons make a means test hated and to be avoided by the self-respecting.

One of our neighbors should have a cataract removed from her eye. She has been told that it might cost a total of $1,000. She and her husband both have social security, but they have no savings. If she had the operation she would have to get it through medical assistance to the aged and that would mean that her son would have to be investigated. The son is a geologist just starting his career, and they are very proud of him and know he cares for them. She will not let him know. They will not have him handicapped at this moment, and she puts the needed operation off until he can get a start. Perhaps not wise but very understandable.

A few days ago one of our "good companions" had a dizzy spell in the street, falling off the curb. She cut her face and was bleeding badly when I saw her. Her neighbors were busily trying to help her when a young police officer came up. He wanted her name and address and then wanted to know her nearest relative. "My son," she said proudly. The officer asked for him name and address. "I don't give you that," she said firmly. "He is in California. He is a good son to me and I don't want him worried because his mama has a little fall." And that's all the officer got, badger as he did.

More of the reasons why children are not always able to be the resources that it is often thought they should be, are suggested in excerpts from the stories of older peoples' health needs, collected by the National Federal of Settlements from different parts of the country.

For instance, Mr. Allen is 79 and bedridden after a stroke in 1957. His wife has varicose veins and many other health problems. They own their own home, for which they paid $3,500 in 1922. The taxes are $68 per year. Their combined social security is $126 a month and Mr. Allen has a pension from his firm of $47.50 per month, giving them an income of $183.50. This they managed on until sickness caught up with them.

The notations as to their children are as follows:

Son: 38 years old, married, has four children. He suffered a nervous breakdown last summer and was off work several months. Daughter: married, her husband has been an invalid for 10 years. She does housework outside the home to keep the family going.

Mr. and Mrs. Benson live on a combined social security grant of $99. They own a six-room house and live in three rooms. A couple who look after them have the other three rooms free. They could manage without help until both of them became ill and health problems mounted up. Mr. Benson is 81 and has had heart attacks. His wife needs radium treatments and has many other health needs. It is a long story but they did not need to ask for relief until the health problems overcame them.

The notation on their children are as follows:

Mrs. Benson has a married son by her first marriage who has 13 children. He is working but has had two cancer operations.

Mrs. Benson's married daughter, by her first husband, lives in Wooster, Ohio, is divorced, and has four children.