The concern and leadership of the Committee on Ways and Means for improving the health and welfare of all Americans is well known to all of us and much appreciated. We welcome the opportunity to submit our point of view with respect to the necessity for initiating a program of health care benefits.

We feel close to you in this matter because our work, too, represents unselfish, humanitarian concerns for people. Historically you find our profession among the social security pioneers in America. Many of the organizations which testify have our members in their midst. We are proud that several of the commissioners of security security have been and are members of our profession as are many of the personnel in the Department of Health, Education, and Welfare.

Our association has long had among its goals of public social policy statements on social insurance and health. I would like to ask that these two policy statements, which were approved at our delegate assembly in May 1958, be included as part of my statement.

With respect to our policy statement on social insurance, included among the recommendations is the following: "Included in this system should be provision for medical services to covered persons and their dependents."

In our statement on health, we indicate as follows: "A comprehensive national health program, which will assure full health care to all individuals by apply ing the principles of group payment and tax support or the principles of compulsory national health insurance to a total range of health measures, is endorsed and the development of such a program recommended."

From this last excerpt from the health statement, it is obvious that we do not believe that the bill (H.R. 4700) being considered by this committee goes far enough, and we hold that a national health insurance system is not only desirable but is possible to achieve.

Alternatives to hospital and nursing home care are available. We will not suggest them here. The American Public Welfare Association which appears before you tomorrow will propose amendments to H.R. 4700. Many of our members are in APWA and on the committee that drafted the proposals.

On the broad question of health insurance these are the facts as we understand them.

Voluntary hospital insurance, according to December 1958 preliminary estimates, covered 121 million people, 70 percent of our population.

However, less than half of our older citizens have any kind of health insurance. As you know from the study made for your committee by the Department of Health, Education, and Welfare, older people use two and a half times as much general hospital care as those under 65. Income for this group is lower than for the rest of the population. Proportionally more people over 65 rely on public assistance or free care than any other age groups. Many of these are self-sustaining for all necessities of life except medical care. They have profound and rightful objection to a means test for medical care, particularly when it can be provided through insurance.

This report also revealed that persons with health insurance enter hospitals more frequently but have more short duration stays than those who are uninsured.

Persons with insurance go in early for treatment or diagnosis; persons without insurance include many "uninsurables" and those who postpone care until need is overwhelming.

In Pennsylvania, where naturally I am most familiar with facts with respect to medical care needs of the aged, almost 10 percent of the total population or about 1 million persons are over 65 years of age. As a group, these people not only have the highest costs for medical care but are least able to pay for it. A major factor in the high costs of medical care for aged people is hospitalization. Older people have more illnesses and disabilities than those in the prime of life. Injuries due to accidents are often more serious; older bones break more easily and heal more slowly. The result is that people over 65 years of age need to go into hospitals more often and stay longer when admitted.

A number of efforts have been made in Pennsylvania to cope with the problem of medical care needs of the aged, but the solutions have been less than satisfactory. The General Assembly of Pennsylvania, for example, provides $28.5 million in subsidies to hospitals for "free care." This amount may possibly be increased. However, the subsidies at best pay about one-half of the cost of this so-called free care. The hospitals make up the other half as best they can. This presents, we know, a very serious problem to hospitals in Pennsyl

vania; so serious, in fact, that some chests and united funds are considering discontinuing their support of hospitals because of the unrealistic financial burden placed upon them.

An arrangement, therefore, that would permit the costs of hospitalization of older persons to be pooled over all wage earners through the social security system might insure, first, that such care would be made available, and secondly, would relieve the State of Pennsylvania and its municipalities and voluntary groups of increasingly difficult and almost impossible problems of financing such medical care.

We have studied the arguments against extension of OASDI to health care. We cannot agree with them. The patient's free choice of hospital or physician is not curtailed. It is not a free service. It does not have to reduce the quality of care. It will not discourage medical education, research or advancement. It is not socialized medicine. It is not a system of regimenting doctors or bringing them under bureaucratic control.

We are opposed to extension of public assistance grants and governmental subsidies as a method of meeting health needs. Purchases of medical care by OASDI beneficiaries are regarded as consumer expenditures, not governmental expenditures. It seems so logical to meet the expanding need in this way rather than to extend tax support surrounded by all the uncertainties of local government.

Tax support is highly developed for mental and tuberculosis care. Why? Because a long time ago citizens decided that their Government had to take over the responsibility. No one objected because no one else could bear the burden. Care was too expensive for the average man. Government, in fact, entered what was a profitless area for the medical practitioner.

Should our approach to general medical care be direct Government intervention? For the medically indigent, including the OASDI beneficiary, this is an increasing reality.

We forget that the first compulsory insurance system in the world was American. The Congress in 1798 set up and operated health insurance for seamen-The Marine Hospital Service. Stopped in 1884, it began with deducting from wages until in 1905 the system became tax-supported. Health insurance was replaced by wholly tax-supported medical care. When we examine the ever increasing number of OASDI beneficiaries who get public assistance grants and a major number get their medical care paid for by tax funds, we must recognize as spurious the "socialized medicine bogey." Certainly, payment of medical care out of governmental tax funds is less desirable within our "way of life" than the purchase of medical care by beneficiaries with OASDI insurance funds.

We would like your committee to consider seriously the following suggestions before reaching its final decision:

1. Do not think of hospital and nursing home care as the sole methods for meeting the health needs of aged persons.

2. In listing the institutions and agencies to receive Federal assistance, do not exclude facilities operated by State and local governments.

3. Provide for the setting and maintaining of proper standards in the facilities your committee decides should receive payment.

4. Establish safeguards around your determinations of reasonable costs for hospital and nursing care to be paid out of insurance funds.

Again, I appreciate very much this opportunity to present the point of view of the National Association of Social Workers to this committee. As I indicated earlier, Dr. Charles I. Schottland will now present his statement to the committee.

NATIONAL ASSOCIATION OF SOCIAL WORKERS,
New York, N.Y.

EXCERPT FROM "GOALS OF PUBLIC SOCIAL POLICY" (ADOPTED BY DELEGATE ASSEMBLY, MAY 1958)

Modern industrial organization, with its dependence on a money economy, creates special economic hazards for those individuals who are either unable to work or for whom work is not available. The best way to prevent economic need due to loss of earning power is to supplement a full-employment economy

with an adequate system of social insurance. Social insurance is a form of group saving under Government auspices which assures money payments on a predetermined scale or other stipulated benefits to insured individuals and, in some instances, to their dependents, when their income from employment is cut off for reasons beyond their personal control.

Under our American system, social insurance coverage is related to individual employment; contributions are made by and/or on behalf of the individual worker; his benefit rights are based on such contributions; and the level of his benefits is related to his previous earnings. Such a system safeguards the clear-cut entitlement of beneficiaries and provides an objective method of relating benefits both to individual wage scales and to national productivity. Even though a governmental contribution to the system as a whole, or in behalf of individuals, such as exists in many other countries might someday prove economically desirable, the safeguarding principle of individual entitlement remains the essential value of social insurance.

The objective

The total system of social insurance, in order to fulfill its social purpose in American life, should protect all workers and their dependents against the major economic hazards of modern life and should provide benefits adequate to maintain a reasonable standard of living commensurate with the Nation's productive capacity and sense of social justice.

To this end the following are recommended: Recommendations

1. A comprehensive program.-All workers, including civilian and military personnel, governmental and railroad employees, and self-employed persons, should be protected by a single system against loss of income due to retirement, premature death, and permanent disability. Included in this system should be provision for medical services to covered persons and their dependents. Supplemental systems to provide more adequate protection should be encouraged, and benefits of those now protected under separate systems should be maintained at least at present levels through supplementary payments such as now exist in many private industry plans. Wage earners and salaried persons should also be protected against loss of income due to unemployment and temporary disability.

2. Contributions and benefits.-The level and scope of contributions and benefits provided by this system should reflect rising wage levels, national productivity, and an increasing standard of living.

3. Protection against disability.—A major need in the present system of social insurance is more adequate protection against loss of income due to disability. All steps should continue to be taken moving toward an adequate comprehensive Federal system of insurance protection against loss of earnings due to disability, both temporary and long term. Protection should be provided against all disability and illness, whether work connected or due to other causes Present Federal protection against permanent and total disability should be extended to all insured workers without age limitation; should include dependents' benefits and provide for the payment from the insurance system of rehabilitation costs of insured disabled persons. Pending development of a broader Federal program which includes temporary disability insurance, those States which choose to extend such protection to their citizens as an interim measure should provide for administration by a public agency to assure accountability for tax funds, and benefit payments should be adequate in amount and duration to maintain reasonable income levels.

4. Dependents' benefits.—In all situations covered by social insurance, dependents' benefits should include persons who are actually dependent upon the insured worker. In addition to those now eligible this would broaden the coverage of surviving widows, the younger wives of retired workers, and the dependents of persons receiving disability insurance.

5. Deferred retirement.-Measures should be taken to encourage the employment of workers who are able and eager to work beyond the age at which they become eligible for retirement benefits, including the payment of higher benefits following deferred retirement.

6. A stronger unemployment insurance program.-A single Federal system of unemployment insurance covering all workers is a desirable ultimate objective. Pending the achievement of such a Federal system the State programs should be improved in the following ways: (a) all who work for wages should be pro

44432-59- -11

tected; (b) benefit levels should be increased to reflect increases in the wage level; (c) benefit periods should be extended to meet realistic unemployment situations as they exist in many localities; (d) restrictive disqualification provisions should be eliminated; and (e) "experience rating" provisions should be abolished and provisions made for appropriate contribution adjustments on a flat-rate basis.

In addition to changes in State laws to accomplish these ends, changes should be made in the standards contained in the Federal law to raise the benefit level, extend the duration of benefits, extend coverage to all employed workers, and stipulate that supplementation of unemployment compensation payments through employer-employee wage guarantee agreements be permitted.

7. A stronger workmen's compensation program.-A single Federal system of workmen's compensation covering all workers and operated on a social insurance basis is a desirable ultimate objective. Pending the achievement of such a Federal system, existing programs should be improved in the following ways: (a) all who work for wages should be protected; (b) benefit levels should be increased to reflect increases in the wage level; (c) the duration of benefits should be extended to cover the entire duration of disability or dependency; (d) all occupational accidents and diseases should be covered; (e) adequate authority should be given for the issuance of safety and health regulations; and (f) the administration and financing of the program should be handled by a public agency to assure accountability for tax funds, economy and efficiency of administration, and payment of adequate benefits promptly when due.

The problem

III. HEALTH

Advancing medical science brings mankind constantly closer to the possibility of achieving the goal set forth in the World Health Organization charter: "Enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, or economic and social condition." Good health is defined in this same document as a "state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."

At the same time these very advances in medical knowledge and practice create new problems both for individuals and for society. For many individuals the problems involved in securing and paying for needed medical care present an insurmountable obstacle to the achievement of optimum health, while the organization, administration, and distribution of health services present challenging problems for a society as a whole. Moreover, the complexity of modern life itself tends to create or aggravate certain health problems, including those which involve mental or other psychogenic illness or distress. No unresolved problems are more costly to society than those in the field of health, whether the cost is measured in personal suffering or incapacity, economic loss, family burdens, or continuing world tension.

The objective

Governmental health policy and programs should assure to every individual, whatever his age or circumstance, full access to the benefits of existing medical knowledge and the most rapid possible advance in the scope of that knowledge. Operating and research programs alike should be directed toward (a) the promotion of positive health for all; (b) the prevention, treatment, and control of illness and disability; (c) the restoration of those affected by illness or disability to a maximum of normal living; and (d) the more effective organization, staffing, financing, and administration of health services. All governmental and community health programs must be such as to promote and protect the qualitative and quantitative adequacy of personal and community health service, with provision for continuity of care and attention to the social aspects of medical need. In the years immediately ahead these objectives must be pursued through a variety of interrelated measures, both governmental and voluntary, looking toward the achievement of a comprehensive health program which will assure full health care to all.

To achieve these ends the following recommendations are made: Recommendations

1. National health program.-A comprehensive national health program, which will assure full health care to all individuals by applying the principles

of group payment and tax support or the principles of compulsory national health insurance to a total range of health measures, is endorsed and the development of such a program recommended.

2. Organization of health services.-There is need at the present time for wide and varied experimentation in new or better adapted methods of organizing and paying for personal health services. These should receive governmental support and encouragement to the extent that public accountability for tax funds permits. Among such developments are the following: (a) extension of the benefits of various sickness insurance plans; (b) the promotion of group practice prepayment plans covering a broad range of health services; (c) new developments in the role of the hospital, including broadened outpatient services, home care, affiliated nursing homes, foster care, regional clinic services, and rehabilitation services; (d) other community programs for providing health services on a specialized or coordinated basis; (e) extension of principle of Government purchase of health services from community resources meeting acceptable standards; and (f) coordination of services and planning to permit optimum use of health facilities.

3. Public health structure.-All levels of government and all areas of the country should be served by a network of public health agencies with adequate authority, staff, and financing to administer basic health programs. Provision should be made also for health planning on a regional and interdepartmental basis.

4. Special groups. A special measure of responsibility has been assumed by Government for meeting the health needs of certain groups in the population. These include members of the Armed Forces and their dependents, veterans, Government employees, merchant seamen, Indians, children, and expectant mothers, persons with communicable diseases, the mentally ill and persons recovering from or threatened by mental illness, children and adults with physi cal handicaps, and persons dependent for their livelihood on public assistance. Full financial support should be extended to programs for these groups and the principle extended, where appropriate, to other groups of special vulnerability. In addition the following specific recommendations are made:

A. Mothers and children: Health services for mothers and children should include: prenatal, obstetrical, and postnatal care; well-child clinics; immunization; remedial and other services for the physically and mentally handicapped; school health services; child and family guidance centers; nursing service, social services, and preventive programs.

B. Older persons: Provisions should be made to assure that the medical needs of older people will be met through their inclusion in voluntary insurance plans, extension of the social insurance principle, or special governmental programs to meet particular needs.

C. The Armed Forces: The program of medical care for dependents of members of the Armed Forces should be broadened to provide a full range of health services.

D. Noninstitutional care for the chronically ill: Supervised noninstitutional care in their own or foster homes should be provided for persons recovering from mental or physical illness or suffering from long-term illness not requiring full hospital care.

E. Persons financially dependent on public resources: Public welfare agencies, in cooperation where appropriate with public health agencies, should have sufficient authority and financing to purchase or, in some instances, to provide medical care on an adequate basis for all needy persons to whom it is not otherwise currently available, including those otherwise self-supporting persons who are unable to meet the cost of necessary medical care.

F. Preventive mental health services: In addition to improved State services for mentally ill and mentally retarded, emphasis should be placed on State and local support of and planning for preventive mental health services.

5. Standards.-The standards of medical and related health care under both private and governmental auspices should be developed and maintained at the highest level through all appropriate measures, including licensing, standardsetting, and consultation. There is particular need at this time for improvement in the standards of facilities for long-term care, especially nursing homes and facilities for convalescent care.

6. Coordination.-All possible measures should be undertaken to effect coordination of health programs in order to assure complete health care to individuals and a well-rounded community program. Coordinating mechanisms to