Federal Medicaid funds. The functional criteria and verification mechanisms of Section 2 apply here also.

Section 5 would permit State medicaid programs to cover payment of rent or mortgage and repairs for elderly or disabled persons who would otherwise require nursing home care. The amount of payment will be the fraction of the total household represented by the elderly or disabled persons receiving benefits and is subject to a ceiling conforming with current standards for federally assisted housing.

Section 6 establishes within HEW the office of Home Health Patient Ombudsman to assist home health patients receiving Federal benefits. This office will monitor home health programs, assure that patients receive the care to which they are entitled, take appropriate action in expediting complaints, and submit a public annual report.

Section 7 would charge each child over 18 of a recipient of medicaid nursing home or home health assistance up to 5% of the child's taxable income for the period the parent received aid. For example, if a married child with two dependent children earns $15,000 per year and takes standard deductions, he or she would pay less than $500 in any year, while the federal payment might be as high as $10-15,000 per year. The amount paid by the child will be determined on a sliding scale based on income so that an individual earning $4000 in taxable income and a family under $6000 would not have to pay. In no case, regardless of income, will be the contribution exceed the cost of the care. In addition, the bill states that the delivery of benefits is in no way conditional upon the payment of the children. (Section 7 is included in H.R. 4772 and omitted in H.R. 4774.)

Section 8 removes the $10,000,000 limitation in funding authorized under the 1974 H.U.D. Act for demonstration projects for congregrate housing for the elderly, the handicapped, and other groups.

Section 9 requires the same annual audit of medicaid home health agencies and nursing homes now mandated for medicare facilities. This section also requires medicaid home health agencies and nursing homes to utilize cost-related, prudent buyer methods of purchase, so as to reflect reasonable costs. After certification of the cost basis by the State Agency, the Secretary of HEW has the power to revise future reimbursement if necessary so as to reflect reasonable costs. For medicare home health agencies and nursing homes, the Secretary will be required to condet a study of the feasibility of utilizing prudent buyer methods. The results of the study must be reported to the Congress within one year.

Section 10 requires disclosure, for all medicare and medicaid nursing homes and home health aegnices, of any persons with ownership interset in the home or agency, or in the land or building housing the home or agency. This section also requires disclosure, by nursing home or home health agency owners or operators, of any interest in businesses providing goods or services to nursing homes or home health agencies.

Section 11. While it is possible that no additional funding may be necessary. any additional funding required by changes the bill makes in the law would be made up from the general treasury. This procedure will avoid the possibility of either a squeeze on the Mediarce or Social Security trust funds or an increase in premiums for Part B, the social security tax covering part A, deductibles, and/ or coinsurance.

For your use, I am submitting the text of the revised legislation for the record (Appendix One).

ORGANIZATIONS URGING ENACTMENT

Mr. Chairman, I am pleased and proud to list some of the organizations which have been instrumental in drafting this legislation and which have provided their support for the provisions of H.R. 4772 (with Section 7, Child contribution toward parent's care) or 4774 (identical except omitting Section 7):

The National Association of Home Health Agencies, The American Personnel and Guildance Association, the National Cancer Foundation, the American Association of Retired Persons and the National Retired Teachers Association, the National Council for Homemaker-Home Health Aide Services, the National Counicl of Senior Citizens, the American Nurses Association, the National Multiple Sclerosis Society, the American Public Health Association, the United Cerebral Palsy Associations, the American Foundation for the Blind. the American Hospital Association, the National Association of the Physically Handicapped,

the National Association of Social Workers, the American Jewish Congress, the National Association of Counties and many other."

Mr. Chairman, it is long past time for a national commitment to be made to guarantee decent health care for elderly and handicapped. We must make that commitment now. The elderly and disabled, so desperately in need of our concern and help, have long been ignored by our society. Although over 7.5 billion dollars, according to the Social Security Administration, is being spent each year to maintain patients in nursing homes, they are too often ignored once they are there. We, as a society, have ignored the abuses that exist in many nursing homes as a result of some unscrupulous operators who over-charge the elderly, their families, and the government, sell nursing homes at high profits to members of their own families, and then charge the government through Medicaid. We have ignored such abuses until they were dramatically brought to our attention by newsmen's investigations. And, we have ignored the basic question of whether many patients belong in nursing homes at all. The shocking fact is—many of the people who are institutionalized in nursing homes do not belong there at all.

To provide the means to match the needs of the elderly to the care available is challenging. For years the nursing home has been the dumping ground for the senior citizens with whom our society cannot cope. You are aware of the situation, which I know from visiting nursing homes myself is all too often the case, of patients blankly staring at a television set with nothing else to do. Even excellent nursing homes, and there are many, give the entering patient the depressing feeling that this will be the end of his or her life.

According to New York State Health Department data collated by the Federation of Jewish Philanthropies, the average nursing home patient in New York City lives only fifteen months after entering. I believe that this is as much caused by a wrenching away from family and friends and a loss of the will to live as it is by deteriorating health.

Representative Claude Pepper and I have joined Senator Frank Moss in the introduction of 49 bills to require more stringent contro's over the nursing home industry, to provide training of additional persons specializing in the care of the elderly, and to support expansion of home health services for the elderly. H.R. 4772 and 4774, The National Home Health Care Act, is central to this effort. ESTIMATES OF PERSONS UNNECESSARILY INSTITUTIONALIZED BECAUSE OF THE LACK OF ALTERNATIVES

There is no reason why an elderly or disabled person should be institutionalized if it is not necessary. There is no reason to compromise his or her dignity and independence. The numbers of elderly and disabled who would benefit by such alternatives who are now forced to seek institutionalization, whether in hospital or a nursing home only because of a lack of these alternatives-are astounding. A study done for HEW in January of this year cites figures showing that as many as 144,000 to 260,000 or 14 to 26 percent of the nation's 1,070,000 nursing home patients may be I quote "unnecessarily maintained in an institutoinal environment." And the Levinson Gerontological Institute reports that 40 percent could live at home.

Such a state of affairs is tragic, for no matter how well maintained a nursing home may be, the effect of entering one upon the patient is to create a state of depression. There is a major inconsistency in the current Medicare/Medicaid law. in that the alternative of part-time health care in the home setting, for those who do not require the full range of services of a nursing home, far cheaper than institutionalization, is not generally available.

ESTIMATES OF PERSONS UNNECESSARILY INSTITUTIONALIZED BECAUSE OF THE LACK A 1971 study by the Levinson Gerontological Policy Institute, Brandeis University, estimated that more than 1.7 million elderly would benefit from home health care. This estimate included individuals who were confined to their homes for some measureable physical illness, injury, or handicap, or who were severely limited in movement and mobility as well as those persons in nursing homes and other long-term institutions who could be expected to live at home if alternative services were provided. This estimate was reduced from an estimate of 3 million potentially eligible persons.

The estimated costs of home care were limited in the study to persons over 65 years of age since the most extensive data was available on the severity of

disability of those individuals. Homebound persons were assumed to need more visits per week than those "having trouble getting around". The total estimated annual costs nationwide were $736,360,000 based upon 1,563,400 total potentially eligible persons (of which 625,000 were homebound and 938,000 had trouble getting around"). The authors of the study felt that as much as $500,000,000 of this projected sum could be secured from payments made for unnecessary institutional care. This estimate was intended only as a "ball-park" figure. It could be altered by changing the number of visits, the length of visits, the hourly wage of providers, or the number of persons eligible.

A 1974 study by the University of Minnesota School of Public Affairs developed cost figures for maintaining non-institutionalized patients at home, including not only the cost of home health medical visits, but all other resources necessary to maintain the individual, such as nursing services, food, housing and utilities, so as to come closet to paralleling the cost breakdown for nursing homes.

The study found that home care is less expensive for all individuals except those of high disability. For people with low disability, regardless of living arrangement (the study found that it is cheaper to care for persons living at home but not living alone), care was found to be significantly less expensive in their home than at even the lowest level of institutional care: $158.02 per month home health care for a person living with someone compared to $276.80 for ICF (intermediate Care) Nursing homes; and $239.06 home care for someone living alone compared to $276.80 for ICF care.

In New York City, home health programs-averaging from $180 to $600 per month depending on the level of care-cost substantially less than the $15,000 to $20,000 per year or $1,500 per month or $50 per day it takes to place a patient in a nursing home. These figures are for New York City, but there would be comparable savings across the country.

I have received hundreds of letters from health providers, providing case after case of patients who were or could be kept out of institutions by home health care. These letters have kept me and my staff quite busy! I'm pleased to have the opportunity to relate some of what they say, and they are poignant. Here's what the Visiting Nurse Association of Eau Claire, Wisconsin wrote on July 30, 1975: "Our agency has a caseload averaging 100 patients per month. Of these 69% are over 65 years of age.

"Twelve of these chronic homecare patients, who otherwise would be in an institution, account for 30 visits per week. Our cost per visit is $16.20. Could 12 persons be supported in an institution for $486 per week?

"Three of these 12 patients have only their small income to help pay for their care, which is custodial care not covered by Medicare."

The Visiting Nurse Association of Greater St. Louis, Missouri related a local hospital administrator's comments in the Journal of the American Hospital Association:

"If I am correct in my contention that without our home care program many home patients would have been cared for in a hospital or at least in a skilled nursing home, then our program currently (1972) is saving the community taxpayer and the premium payer about $1,000,000 a year. If each hospital in St. Louis had an effective home care program, we could obviate $200,000,000 in capital construction and could reduce annual health care operating expenses by $20,000,000 or more."

H.R. 4772 and 4774 provides that hospitals may be reimbursed for such home health programs.

The Mercer Health Center of Bluefield, West Virginia writes (August 15, 1975):

"Assuming that the average daily cost of one day's stay in a hospital is only $50.00, our agency has cut the cost by one-half. For the 2,666 home visits in 19741975, this would mean a savings of $66,650.00 without even estimating the cost of the continued daily hospital stay.

"Of the 271 patients who received Home Health services during 1974-1975, approximately 200 would have needed to be in nursing homes and/or hospitals if no Home Health services were available."

The former President of the Appalachian Regional Hospitals writes (August 15, 1975) that, after initiating a comprehensive home care program, "Our hospital length of stay rate (as well as our occupancy) dropped markedly."

The Visiting Nurse Association of Western Westmoreland County, Pennsylvania writes (July 29, 1975) of a case example:

"(3) A 92 year old female lives alone. She has a neurogenic bladder which necessitates a suprapubic catheter which has to be irrigated three times a week to keep it patent. This patient is clear mentally and very independent. We feel certain that if our services were not available she would have to be institutionalized."

The Library of Congress has estimated that, by the legislation I am proposing, because of the use of home health by patients that would otherwise be in Skilled and Intermediate Care Facilities, "Net savings would be an estimated $200 million," although additional persons utilizing the expanded home health benefits provided could nullify the cost savings.

The Congressional Budget Office is currently preparing a fiscal impact estimate of the legislation. I will provide this to the Committee as soon as it is completed. At my request, the General Accounting Office researched literature in the home health field to obtain cost data. In a letter of September 17, 1975, GAO reported: "Thirty-two publications and documents were reviewed which relate to home health care, of which 20 dealt with the costs of home health care as compared to costs of alternative services. Of the 20, 19 presented data which supported the proposition that home health care can be less expensive under some circumstances than alternative institutional care."

Where home health care would conceivably be more expensive would primarily be for patients of high debility. To guarantee that the cost to the government will not be exorbitant for a patient, my legislation provides for alternative care through Medicare/Medicaid not to exceed in government funds the cost of skilled nursing home care. In the rare case where the home care would be more than institutionalization, the patient can either pay the difference himself or be institutionalized. Thus, patients would be given the choice, at no additional cost to the government.

For the Committee's use, I am supplying for the Record the list of studies and publications reviewed by GAO (Appendix 2).

Even if the expense of home health care approached nursing home costs, which it will not, I believe that home health would be worthwhile, if only because of the positive impact upon the patient.

Mr. Chairman, I am aware that the Committee's jurisdiction in home health care relates to Medicare, and I have emphasized in my statement those portions of my bill which I believe to be badly needed medicare amendments. These include expanding the number of home health visits allowed, removing the term "skilled" from the requirement to receive home health care, allowing reimbursement for homemaker and other supportive services, requiring disclosure of interests by home health agencies, and creating a Home Health Patient Ombudsman to monitor these programs. I expect other provisions relating to medicaid to be the subject of hearings in another committee.

Mr. Chairman, I believe that the Committee will find. as I have, that it is irrational to force thousands of persons to accept institutionalization if they can be helped through home health care. I believe that the passage of the National Home Health Care Act, H.R. 4772 and 4774, will correct this inju stice to our nation's elderly and handicapped.

APPENDIX 1

[H.R. 9829, 94th Cong., 1st sess.]

A BILL To amend part B of title XVIII of the Social Security Act to broaden the coverage of home health services under the supplementary medical insurance program and remove the 100-visit limitation presently applicable thereto, and to eliminate the requirement that an individual need skilled nursing care in order to qualify for such services, to amend part A of such title to liberalize the coverage of post-hospital home health services thereunder, to amend title XIX of such Act to require the inclusion of home health services in a State's medicaid program and to permit payments of housing costs under such a program for elderly persons who would otherwise require nursing home care, to require contributions by adult children toward their parents' nursing and home health care expenses under the medicaid program. to provide expanded Federal funding for congregate housing for the displaced and the elderly, and for other purposes Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled. That this Act may be cited as the "National Home Health Care Act of 1975".

HOME HEALTH CARE UNDER SUPPLEMENTARY MEDICAL INSURANCE PROGRAM

SEC. 2. (a) Section 1832(a)(2)(A) of the Social Security Act is amended by striking out "for up to 100 visits during a calendar year".

(b) Section 1834 of such Act is amended to read as follows:

"CONDITIONS AND LIMITATIONS APPLICABLE TO HOME HEALTH SERVICES

"SEC. 1934. (a) Payment under this title may be made for home health services furnished an individual who is determined under regulations to be receiving such services wholly or partly as an alternative to institutional care, during any calendar year or other period specified by the Secretary, only if it is detemined (in accordance with regulations) that the total amount of such payments is less than the total amount of the payments which would be made under this title during that year or period for the corresponding services (and) related care) furnished such individual if he or she were receiving such services in the form of (or as a part of) skilled nursing facility care.

"(b) In determining for purposes of this title whether an individual may receive payment for home health services, the Secretary shall make certain that the need of such individual is assessed and shall assure referral to the appropriate level of care.

"(c) The Secretary shall within 90 days after the date of the enactment of this subsection promulgate such regulations as may be necessary to carry out this section, and such regulations shall be periodically reviewed and revised thereafter in the light of experience under this subsection.

"(d) As used in this section and in sections 1814 (a) (2) (D) and 1835 (a), the term 'institutional care' means care in a hospital, skilled nursing facility, or intermediate care facility.".

(c) Section 1835(a) (2) (A) of such Act is amended to read as follows:

"(A) in the case of home health services, such services are or were required because (i) the individual is or was confined to his home (except when receiving items and services referred to in section 1961 (m) (7)) and needed (on an intermittent basis) nursing care or any of the other items or services referred to in section 1861 (m), or (ii) the individual needed such services as an alternative to institutional care; and a plan for furnishing such services to such individual has been established and is periodically reviewed by a physician;".

(d) Section 1835 (a) of such Act is further amended by adding at the end thereof the following new sentences: "In the case of home health services, the initial recertification required by paragraph (2) where the services involved are furnished over a period of time (and any reevaluation of the individual's need for institutional care) shall be made, within 30 days after the physician's original certification with respect to such services (or need), by a panel of at least three health providers (which shall include at least one physician, and may include one or more social workers, nurses, psychiatrists, psychoanalysts, and other qualified specialists) appointed in such manner as may be approved by the Secretary; and such panel shall thereafter review the need for and level of the individual's home health care at least twice each year (four times each year whenever feasible) so long as he or she is receiving (or claiming entitlement to have payment made for) such care. A finding by such panel that the initial certification or a previous recertification was erroneous or unjustified may be considered for all of the purposes of this title to be a determination of the Secretary (with respect to the items or services involved) under section 1862 (d).".

(e) (1) (A) Section 1861 (m) (4) of such Act is amended by inserting "or homemaker" after "home health aide".

(B) Section 1861 (m) of such Act is further amended by adding at the end thereof the following new paragraphs:

"For purpose of paragraph (4), services of a home health aide include (in addition to other services normally provided by a home health aide) any of the following, performed under the supervision of the appropriate health professional: physical therapy, occupational guidance and therapy, nutritional guidance, family and personal counseling (including the provision of information concerning senior centers (as defined in title V of the Older American