bill for the people over 65 when they leave the plant, or over 70 or over 72. We have seen local unions themselves out of their own treasury say: "We will pay part of it if the employer will pay part of it." But this is not the answer. We need the Forand bill, and we need higher social security payments because the cost of medical and hospital care and housing is growing every day. And there is one thing else that I referred to in my brief statement here and that is that is that we think older people ought to be given an opportunity to work as long as they want to work. I think one of the greatest mistakes we are making is establishing the principle that people must retire at a given age, because there are some people who at 55 are as old as someone at 70. And I have seen some people who chronologically may be 70, yet are physically as young as some at 55 years of age. And I think it a mistake to waste the talent when you consider that we can no longer have nuclear and atomic wars. Wars are out of the question. You can no longer have wars to kill off some of the unemployed as was done in the past. We are going to have more and more people around who are going to grow older and older. We are going to have a real problem, not only of taking care of people when they are old but of finding employment for people both young and old. In the textile industry, in the last 10 years, over 400,000 jobs have disappeared, not by automation, but by mechanization and by technology. I wonder what is going to happen when automation begins to hit the textile industry. And because the textile industry is an old industry we find that the older people, suffer more. First, very few receive severance pay when the mills liquidate, secondly, no opportunity to be retrained to go to another job, and thirdly, no opportunity to move to another area.

And if they do not have the money or someone to help them with the wherewithal these people are left on the scrap heap. In one particular town, Passaic, N.J., I saw three plants liquidated. Botany Woolens, Fortsmann Woolens, and Gera Mills, which between them had 11,500 workers. These mills are out of there, and thousands of men women over 50 cannot find work.

Senator CLARK. I do not want to interrupt you and I am keenly conscious of the very real problems of the textile industry, but we have just got to get down to what you can tell us about the problems of the aged and aging.

EMPLOYMENT

Mr. STETIN. Let me add this: The 5 million people we had unemployed in the past 4 years have lost to this country $100 billion in production and consumption that we could have had.

You ask the question: "Where are we going to get the money?" and I say to you that we have got to find a system whereby our people are fully employed and working and if we have that we will have the money to supply the low-cost housing for the aged. We will have the money to supply the medical care and the hospital care that is needed for the older people. And I say that is a problem. I say to you, sir, that the 30-hour and the 35-hour week must be a part of this problem because if we are going to have everybody employed we simply must say to everybody, "You are going to work less.

Not some work 48 and some not work at all and this is part and parcel of this particular problem.

I just want to conclude with one additional statement.

As the witnesses who will follow will tell you the hospital and surgical bills that many of them pay are so large as to be almost unbelievable. It is only clear that the other older workers, those without the coverage of hospitalization or Blue Cross, when they go out of work would either be quite unable to pay such bills or would be forced to liquidate their lifelong savings.

On the other hand, I, as a person, am also concerned with maintaining a proper level of community services and realize that hospitals, too, are faced with a terrible squeeze. The aged who cannot pay hospital bills as a group are the principal source of hospital deficits. If the hospitals come out for the Forand bill, as they should, and finally will be forced to do, they come under attack from the American Medical Association, the insurance companies' lobby and some of the conservative figures who would like to continue to play Lady Bountiful. Let me say very frankly on behalf of the people who still stay at work and pay into Blue Cross that it would be possible to improve their average scale of benefits if the hospital deficits now caused by the inability of the aged to pay did not have to be based on those still drawing a paycheck when work is available.

The trade union movement is concerned with working out a much closer working relationship with the hospitals and with the medical organizations.

Senator CLARK. Thank you very much, Mr. Stetin, for a most interesting, stimulating, and controversial statement. I am sure if I turned the medical profession loose on you we would be here all afternoon. I do not dare to.

And so in a very arbitrary way, I am going to say thank you very much. The panel is dismissed.

We are an hour and 10 minutes behind and I have been trying to speed this hearing up.

We will hear next from our next panel of witnesses, Mrs. Celia R. Moss, director of the home care program of the Montefiore Hospital in Pittsburgh; Mrs. Lilly E. Naylon, president of the Pennsylvania Nurses Association of Harrisburg; Mrs. Alice K. de Benneville, executive director of the Visiting Nurse Association of Allegheny County; and Dr. Sidney Cobb, associate professor of the Graduate School of Public Health of the University of Pittsburgh. I think Mr. Sidney Bergman is here instead of Mrs. Celia Moss.

I think in view of what we have been saying about the nursing profession and nursing homes, that I will ask Mrs. Naylon to start. Your prepared statement will be made a part of the record at this point, Mrs. Naylon. Please proceed.

(The prepared statement of Mrs. Naylon follows:)

PREPARED STATEMENT OF LILLY E. NAYLON, PRESIDENT, PENNSYLVANIA NURSES

ASSOCIATION

The Pennsylvania Nurses Association welcomes this opportunity to discuss with this subcommittee problems of the aged which come within the scope of the association's activities. We recognize that the subject of your inquiry includes many social and economic problems. One of the major concerns, we believe, is that of the health care for the aged and it is to this aspect of the problem that we will confine our remarks.

The PNA, a constituent of the American Nurses Association, is an organization for the advancement of nursing governed and supported by 17,000 licensed

professional nurses of Pennsylvania. It serves to promote good patient care by fostering high standards of nurse practice and promoting the welfare of nurses. The association works with appropriate groups to meet the total health and nursing needs of Pennsylvania in both normal times and those of emergency and disaster. Another of its important functions centers around promoting measures to insure adequate nursing service within the Commonwealth, including nursing benefits in prepaid health and medical care plans.

Sickness and old age go hand in hand for many people. A report from the 13 public hearings held by the Governor's committee on aging in 1958 shows that approximately 4 of every 100 men and women 60 and over spent last night in an institution because they were sick or couldn't cope with the daily trials of living. 14,000 were in county homes.

10,000 plus were in mental hospitals.

7,500 were in general hospitals.

21,000 were in nursing homes, convalescent homes, or homes for the aged. However, fewer older people use general hospital care than do the general population; about 7 percent of the old folks spend some time in a hospital as against 11 percent of the general population. But, when they go they stay longer, more than twice as long, on the average. In Pennsylvania 14 of every 100 older people who are out of institutions suffer from a long-term disabling illness. The increasing numbers of aged persons in our population and the fact that persons of this age usually are less able to pay the costs of such illness, of course, add to our concern with this problem. Studies show that persons 65 and over who go to the hospital spend 66 percent more than the general population, 62 percent more for medicines and 30 percent more for physicians' services. Special surveys show that among the old folks, medical care and drugs are the unmet needs most frequently mentioned.

There is not State-assistance program of nonhospital care for persons who have sufficient funds to support themselves as long as they are well but who cannot meet their medical needs. These are medically indigent. Regardless of how acutely are the individual's needs, medical care short of hospitalization cannot be had if he has an individual income of $64 per month. Private hospital insurance plans are not enough: national estimates indicate that only 25 percent of the people 65 and over are covered by Blue Cross or other types of hospital insurance.

What about facilities for the chronically ill in Pennsylvania? The 1957 State Hospital Plan for Pennsylvania indicates that there are 3,869 existing acceptable chronic disease hospital facility beds; needed, 7,263. The 1957 State Hospital Plan for Pennsylvania indicates that there are in the State 5,056 suitable nursing home care beds (includes private, public, and nonprofit facilities). Pennsylvania requires 22,264 such beds; it now has 23 percent of the total it needs.

The Pennsylvania Nurses Association believes that this committee would find it worthwhile to study the possibilities and needs for expansion, improvement, and extension of methods of providing health care to aged persons in their homes as a partial solution of their needs. We realize that there is a demand for more hospital and nursing home facilities, and we believe that more beds alone is not a solution for the health problems of persons 65 or older. High on the list of program needs in Pennsylvania is extension of home medical care programs that will keep people out of hosiptals, as well as additional facilities for care through nursing homes and county homes. In one of the largest counties in the State populationwise (Allegheny County) there is no public-supported county home to provide custodial care for those older persons who are in need of this type of structured security during the twilight period of their lives. The need for rehabilitation centers for older folks is paramount. Too few get the benefit of rehabilitation and physical restoration services; i.e., if rehabilitation were started at the beginning of their illness many would be restored following a stroke. Financial support is needed also for low-cost clinics for the aged.

Another area which must receive attention in our efforts to provide adequate health care for this group is the very serious situation now existing in many so-called nursing homes. A marked improvement in standards of care must be met if these facilities are to serve their purpose in meeting needs of our aged population for nursing care.

Public health nursing agencies are finding that more and more of their visits to patients are made to aged persons with long-term illnesses. In Pennsylvania many visiting nurses associations report over 70 percent of the visiting nurse service calls are for the aging, but we need more nurses prepared to serve people in their own homes. How can one visiting nurse serve a population of 20,000?

We mention this not only because it indicates a need for such service but to point out that the only method of providing such service, by and large today, is through visting nurse services, which exist mainly in large urban areas. Small urban centers and rural areas have few facilities for the care of the patients at home. In many counties there are no organized facilities to care for the ill and disabled. In a few instances such service is supplied by the local or State health department. We do know that there are 86 local nonofficial public health agencies in Pennsylvania. There are visiting nurses associations which are not supported by public funds. There are two combination nursing services where the local health department and the Visiting Nurses Association jointly provide total care for their patients. These are located in two populous centers and are confined to a small segment of the population within these urban areas. Statistics in Pennsylvania show the need for visiting nurse service is constantly increasing. A major portion of all VNA calls are for people 60 and over.

The Pennsylvania Nurses Association believes that nursing service should be an integral part of any prepaid medical care plan whether under governmental or voluntary auspices. The American Nurses Association (ANA) has a committee at work on guiding principles for the inclusion of nursing benefits in such plans. The inclusion of both private duty and public health nursing services as a benefit of health care plans would do much to make home nursing care more readily available to the aged. Since visiting nurse services provide nursing care without cost where there is inability on the part of the patient to pay for it, and visits to aged patients appear to be increasing, payment through insurance coverage would help meet the cost of additional personnel to extend such service now limited by the present income of these agencies. The ANA recently testified before the House Ways and Means Committee in favor of providing health insurance coverage to OASI beneficiaries. This decision was made by the ANA House of Delegates at its June 1958 convention.

The most frequent and important services provided by home-care programs are beside nursing and health-care teaching, which constitute two major facets of nursing care in the home. Other important direct services which should be included are: Homemaker services, social casework, occupational and physical therapy, and nutrition. Home-care programs benefit all groups in the population, but they are particularly suited to meeting many of the health care needs of the aged. Along with the suggestion that this committee study the need for increasing and expanding care in the home goes the full realization that today personnel shortages in the health professions, particularly nursing, make this difficult. However, we believe much of the total health care needed by our elderly citizens could be safely given in their homes and should be given there by teams of workers covering the medical and paramedical services essential for such care.

There has been a great deal of emphasis on the need for building additional hospital and nursing home facilities. There are several Federal grant programs to provide financial assistance in this area. However, we believe not enough attention has been paid to the need for personnel to staff such facilities. Additional buildings and beds without qualified health personnel are useless.

As we view the participation of the nursing profession in caring for the aged, we find that many of the problems which now face the profession in providing nursing care for all people are highlighted. Care of the aged is affected by the critical shortage of qualified professional practitioners, by poor utilization of professional nursing skills, by the need for expansion of educational facilities, and by the continuing need to upgrade standards of nursing care. The ANA is working in all of these areas in addition to its efforts to improve conditions so that nurses themselves will be secure when they reach the age of 65.

In caring for the patient with long-term illnesses, nurses must have knowledge of the physiological, emotional, social, and economic factors that affect him particularly when the patient is aged. The patient must be seen in relation to his family and community, and knowledge of community facilities and resources is necessary to meet the patient's economic, social, and spiritual needs. It has been estimated that one-third of the nursing positions today should be filled by nurses with broad preparation attained through collegiate study and holding college degrees. This group includes the staff positions in public health nursing. However, our most recent figures (1956) show that only 8.5 percent of

practicing nurses have such preparation. A 1958 statement by the PNA points out that Pennsylvania is currently preparing 3 percent of its nurses in collegiate schools which is markedly below the national level of 15 precent.

If we are to increase the number of professional nurses qualified for these positions, we must have additional facilities, faculty and scholarship assistance for nursing students in colleges and universities. We hope that Congress will consider the need for funds to assist nurses in their collegiate preparation at the baccalaureate level. In the last session of Congress, Pennsylvania Nurses Association supported and urged passage of H.R. 1251 (Green, Democrat, of Oregon) and S. 1118 (Humphrey, Democrat, of Minnesota). Because of the lack of facilities and scholarships in collegiate schools of nursing, we are losing potential candidates for the profession. Expansion of educational programs for nursing in colleges and universities is impossible without immediate and substantial Federal aid.

Another very serious deterrent to expanding and improving nursing education and to improving standards of practice is the serious shortage of qualified teachers, administrators, and supervisors. We are very pleased that a 5-year extension of the traineeships providing for nurses preparing for such positions which was established under the Health Amendments Act of 1956 was approved by Congress recently. Part of this program includes traineeships for public health personnel of which nurses are a part.

If we are to come near to meeting the present demands for nursing, let alone prepare for the future, public funds must be made available in support of nursing education at least to the same extent that it supports education for other essential professional services. There must also be increasing appropriations of public funds for research in nursing. All of the profession's efforts to improve nursing practice and to foster proper utilization of nursing skills depend upon enlarging our knowledge of the scientific bases of patient care, and upon our ability to experiment in finding ways to best utilize the skills of the various categories of nursing personnel.

Many programs of the ANA and PNA are directed toward improvement of patient care through improvement of the contribution of nurses to that care. Our work on defining functions and setting standards of practice, our efforts to advance nursing education and the utilization of nursing skills, are all conducted in the light of the major health problems of the Nation, including the problems of the aged.

Just as the ANA works closely with the National Federation of Licensed Practical Nurses in its efforts to improve practical nursing and increase the number of licensed practical nurses the PNA works with the Licensed Practical Nurse Association of Pennsylvania in an effort to strengthen nursing service to the citizens of Pennsylvania. The trained practical nurse plays an important part in nursing services for the aged where she can perform many of the simple acts of care, and thus relieve the professional nurse for those functions which require greater judgment and specialized skill.

A major concern of our State association is the continuing improvement of licensure designed to protect the public from unsafe practices in nursing through the establishment of minimum legal requirements for nursing practice. In recent years, the profession has had to work hard to maintain such protection for the public and the qualified nurse. Our State legislature moves with great care when they are asked to lower the legal standards of nursing. Rather than lowering the standards for nursing, State governments must move to raise the standards of the institutions in which patients are cared for. Much needs to be done, especially to upgrade the regulations of the convalescent and/or nursing home.

Nursing is the largest and most complex of the health professions and its services are vital to the prevention and treatment of disease and injury in any age group. Our special concern for the problems of the aged is manifest in all that is done to improve nursing service for the public.

On behalf of the Pennsylvania Nurses Association, I would like to thank the committee for this opportunity to appear and present our views on this subject. The Pennsylvania Nurses Association will be pleased to assist this committee in any way possible.