carry out what is a great national need?" it would be in this skilled. nursing home area.

Mr. BAILEY. You spoke of the training of nurses. How expensive would that training be? Would you turn out registered nurses, or would you turn out nurses capable of taking care of the aged? Where is the shortage?

Mr. COHEN. Well, let me say first, Mr. Chairman, there is a tremendous overall shortage of nurses. In order to find out what ought to be done, we appointed a panel at the President's request of nurses and other public groups to study this whole problem of nursing shortage. They will be completing their report this fall, and we will probably submit to the Congress next year a program for nursing education, in order to overcome this shortage.

I would say that as far as the aging are concerned, one of the greatest areas of shortage in the nursing field is what we call visiting nurses. Visiting nurses, through local visiting nurse associations, are able to come into the home of the older person, once a day, three times a week, once a week, to enable the elderly persons to get their medical care without having to go into an institution or a hospital, and in this particular area, the visiting nurse service, offers

Mr. BAILEY. Outpatient service?

Mr. COHEN. Well, outpatient service usually, yes, outpatient in the sense that it is not in the hospital. Because everything must be done to give the patient as much medical care, out of the hospital, that is, in the outpatient department of a hospital or in their home, if we are not going to just have to build tremendous institutions in the future, which will be so costly, and which will take up very much needed professional personnel. So I would say that this report that we are going to make next year on nursing education is not only of importance to everybody in the community, but particularly to the aged. The reason for that is that the volume of hospital service used by people 65 and over is approximately two and one-half to three times as much as that used by people under the age of 65.

Of course, that is the reason why hospital care is such a big issue at the present time. With hospital costs going up about 5 to 7 percent a year, and with the aged requiring nearly three times as much hospital care as younger people, the obvious problem of providing for this care is a very great issue.

But we do have, as you say, a tremendous shortage of nurses, and this is one of the things that we think will be very high on our priority next year as far as medical education is concerned.

Perhaps most of that legislation will go to the House Interstate and Foreign Commerce Committee, and perhaps will not be looked upon as a Federal aid to education proposal.

Mr. BAILEY. But there is a bill there before them now, isn't there, for H.R. 4999?

Mr. COHEN. Yes, sir, 4999. That, however, only encompasses physicians, dentists, and schools of public health, because we had not completed this nursing survey in time for that bill, but I do think that is the next priority.

Mr. BAILEY. It was my pleasure last night to address the State convention of osteopaths, and they had not acted, but they had prepared a resolution recommending immediate action on the part of the Gov

ernment in the field of aged and aging, and the most pleasant thing about it that I saw was that in their resolution, they said they thought it was best to leave the financing of it to the Congress.

Now proceed with your regular presentation.

Mr. COHEN. Thank you.

The Community Health Services and Facilities Act, recommended by the President and passed last year, has as one of its major purposes the improvement of the out-of-hospital health services for older people. In addition to doubling the grants for nursing-home construction, this act authorized almost $10 million specifically for the improvement of out-of-hospital medical services for older people.

We are cooperating with the States in implementing the Kerr-Mills law passed by Congress in 1960. We have urged the States to take full advantage of the provisions of the law wherever they can do so. In March, 86,192 persons were receiving payments under the medical assistance to the aged (MAA) provisions of the Kerr-Mills law. Mr. BAILEY. What was that number again?

Mr. COHEN. Eighty-six thousand.

Mr. BAILEY. That is in the Nation as a whole?

Mr. COHEN. In the Nation as a whole, except that that involved approximately 20-some States. That is, not all States were yet implementing the Kerr-Mills bill.

Mr. BAILEY. Doctor, if you have the information at your fingertips, would you mind commenting on the experience over in my State of West Virginia?

Mr. COHEN. Yes, I happen to be familiar with your West Virginia. Mr. BAILEY. We were one of the States that tried to put through this program, I believe. At the Commission last night, someone had the information there, there were 9,000-out of the 173,000 people in the State over 65-there were only 9,000 receiving treatment under that Kerr-Mills bill.

We went into it in a large way, but it sort of fell on its face. If you have got some information, I would like to have it.

Mr. COHEN. Yes. Let me give you the national figures, and then relate it to West Virginia, if you like.

Mr. BAILEY. That is fine.

Mr. COHEN. In March of this year, which is the latest figures that are available, 86,192 persons were receiving payments under the medical assistance to the aged provisions of the Kerr-Mills law in the States that had such programs. Payments for these recipients totaled in March $17.5 million.

Almost three-fourths of all of the recipients in the country in March and seven-eighths of the payments were in four States, New York, Massachusetts, California, and Michigan.

Now West Virginia, for March, paid 7,571 recipients, out of this: 86,000. The total payments were $377,937, and the average payment was $49.92.

Now my first comment would be that the thing that is interesting here in West Virginia is that their average payment of roughly $50 is: quite different from the average payment in the Nation as a whole,, which is about $200. I cannot offhand, without going into it in more detail

Mr. BAILEY. We were unable to finance the State's part of the program. That is why it fell on its face, I think.

Mr. COHEN. Yes, there was a period of time in there when the program was not in operation because of these financial difficulties.

Since the program started, from October through February, there were 34,862 cases opened in West Virginia.

Mr. BAILEY. Now that is down to approximately 7,000.

Mr. COHEN. Well, I would not say it is down. Thirty-four thousand is the cumulative figures for the whole period. A person may have only drawn for a month or two, but there were 34,862.

Mr. BAILEY. Now Doctor, right at that point, how could those people be reached through Federal assistance? There will be a certain part of them not covered by social security. Should the King-Anderson bill be approved, about 83 percent of these elderly people will fall under the provisions of social security. Will that Kerr-Mills bill or some other similar legislation have to remain in existence to handle these people who are not under social security?

Mr. COHEN. Yes, sir. The position of the King-Anderson bill is not that the Kerr-Mills bill should be repealed. It is that with the passage of the insurance provisions, the Kerr-Mills bill will narrow down to where it will be a supplement to take care of two kinds of problems: the individuals who are covered under the King-Anderson bill, but for which types of medical services are not payable under King-Anderson; let us say drugs, as an example. Drugs are not taken care of under the King-Anderson bill, and the Kerr-Mills bill would still take care of them, or for individuals who are not covered at all.

So I would say that looking at it from the standpoint, let us say, of West Virginia and some of the other States which are having a very heavy financial burden in handling the problem now, they could do a much better job for this smaller group of people if 85 percent of the burden were taken over by the King-Anderson bill.

So the King-Anderson bill does not provide for repeal or modification of the Kerr-Mills bill, but rather assumes that it will become a second line of defense, rather than the first line of defense which it is now. In my opinion, that is the reason why most of the other States have not even taken advantage of it at all, because of the very heavy fiscal burden that it places upon them, particularly at a time when they are under very heavy burden to raise funds for education. I have talked to Governor after Governor, and the dilemma that he faces in his tax program is that he has got these very heavy demands because of the influx of the students in education, and he has got this tremendously increasing aging population. He is trying to figure out how he is going to meet both of these financial burdens simultaneously. Now one of the things that we can do-and I feel strongly about this, because I think it will ease the ability of the States and localities to meet the education problem-is to finance more of this health insurance cost through the social security system, and that ought to make it a lot easier for many of the State legislatures and the Governors to do a beter job in financing education costs.

Mr. BRADEMAS. I must say, Mr. Chairman, I find it astonishing that some people can contend that Kerr-Mills is meeting the problem of paying for hospitalization and health costs, across the country, when you say that seven-eighths of the payments are going into-or seven-eighths of the money, is that right?

Mr. COHEN. I said three-fourths of the recipients and seven-eighths of the payments are in these four States.

Mr. BRADEMAS. Seven-eighths of the payments are going into four States.

Mr. COHEN. Well, the situation, Mr. Brademas, is even worse than that.

Let us take New York. About 40 percent of all the cases opened in New York were simply transfers from the regular old-age assistance caseload, so that while that is fine-I mean, they are getting the assistance even at that, 60 percent of it were not really new types of cases. In Massachusetts, two-thirds of the cases opened came from the oldage assistance rolls, for whom there was already under the existing law a provision for the financing of it. So not only was a major part of this money going in those four States, but a major part of it was simply reshifting from the existing program to Kerr-Mills.

I think the need is so great that the situation will continue to increase. I would be glad to put into the record this table which shows month by month what happened under Kerr-Mills, from its inception, when it first started with about 12,000 recipients, to 86,000. I think it will increase in the future, simply because there is no other alternative at the present time.

Mr. BAILEY. With no objection, we will ask you to submit that for inclusion in the record.

(The document referred to follows:)

Number of States reporting and number of recipients of and total payments for medical assistance for the aged in each month, October 1960–March 1962

1 Number of recipients are persons on whose behalf payments were made during the report month to suppliers of medical services.

Source: Bureau of Family Services.

Mr. BAILEY. Now, Doctor, I am not going to interrupt you any more, Go ahead.

Mr. COHEN. No, sir; I am perfectly happy, Mr. Chairman, for your interrupting at any time.

I now turn to the question of housing.

Providing the kind of living environment that will enable our older people to live comfortably, vigorously, and in dignity has for

some time been of great concern to the Federal Government. This administration has put a high priority on such a goal. At the request of the President, the last session of the Congress passed the Housing Act of 1961, which very definitely and specifically increased and enlarged the aid which the Federal Government could give in support of construction of housing particularly designed to meet the unique requirements of our senior citizens. A new Office of Housing for Senior Citizens has been established in the Office of the Administrator of the Housing and Home Finance Agency. This serves as a coordinating center and central referral for the programs of the agency affecting senior citizens of three different income groups.

The low-rent public housing program serves older people in the low-income group. Of all the persons living in federally aided public housing, 123,000 are 62 years of age or older.

The housing program for senior citizens of moderate income took a major spurt in 1961. Loans approved and reserved at the beginning of that year totaled only $5 million. At the end of the year it had risen to $37 million, or 7 times as great as it was the first of the year. The special program of mortgage insurance under FHA on liberal terms serves senior citizens in a wide income range. At the end of December 1961, 12,430 units of rental housing for older people had been built and applications for mortgage insurance to build another 15,000 units were pending.

Now turning to welfare, through the old-age assistance provisions of the Social Security Act, the Federal Government helps States to provide funds to take care of minimum basic needs of many our aged people.

There are about 214 million aged persons now on old-age assistance. Although they receive assistance, they maintain the right to manage their own affairs and the right to participate in family and community life. The welfare bill which is pending in this session of Congress will improve the status of our older citizens because it is designed to help retain and improve their capability for self-care and to reduce dependency.

The Public Welfare Amendments of 1962 (H.R. 10606), as passed by the House recently, and now pending in the Senate Finance Committee, would authorize 75 percent Federal matching in all public assistance titles for certain services, specified by the Secretary of Health, Education, and Welfare, designed to enable individuals to retain capability of self-care and to reduce dependency. Under this provision 75 percent matching would be allowed for training of personnel who are employed or who are preparing to work in State or local welfare agencies. I cannot emphasize too much that particular provision because, as you know, one of our greatest difficulties is finding trained people to work with these old-age public assistance recipients. The new bill would make permanent the authorization, already in the Social Security Act, for Federal funds to increase the number of trained people for work in the public assistance program.

Another important provision of the new bill would permit waiver of some of the State plan requirements in order to facilitate demonstration projects and experiments to improve the operation of the old-age assistance program.

The number of persons 45 years of age and over rehabilitated under the Office of Vocational Rehabilitation program has increased 31%