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structure of OASDI. Perhaps a provision calling for periodic congressional reexamination of the promised benefits with a view to their adaptation to changing needs might be helpful.

The Advisory Council which is authorized in the bill could exercise a constructive influence and help to maintain perspective, and could supply an added element of impartiality and objectivity, in what would be, at best, a difficult administrative task. Not the least important function of such a council, aided perhaps by a larger group of technical advisers, should be to review from time to time the overall utility of the program in the light of evolving medical techniques, and to recommend shifts in emphasis or changes in the statute itself. We believe the Council should be charged specifically with this function, as an added assurance that the program not become static. We sug. gest also a provision to enable the Council to draw on technical advice from outside its own membership.

Having spoken of provisions of the bill that we think could be improved, I should add that there are other provisions that we believe very definitely ought not to be changed, such as those making the benefits available on a service basis, those assuring to beneficiaries freedom of choice among participating hospitals, and those express ing the basic concept that benefits should be provided without a means test.

Summary: The American Hospital Association is convinced that retired aged persons face a pressing problem in financing their hospital care. Without question the introduction of this legislation has not only focused national concern upon the growing problem of the health needs of aged persons, but it has stimulated a great deal of positive action throughout the country in seeking solutions to meeting such needs.

Although much of my testimony has been devoted to suggestions for changes in H.R. 4700, I am prompted to remind the committee that even though all of the changes I have proposed for the bill might be accomplished, we still would be opposed because of the use of the social security system as the mechanism. There is need for further progress in the creation and organization of a system of institutional facilities that will effectively provide the health services that can most economically meet the needs of the aged, without impairing the usefulness of institutions designed to serve the acutely ill patient.

Also, we believe that greater attention should be given to undergirding the present State public assistance programs. If more adequate care was available to persons presently eligible for health benefits under those programs, the need for care of the aged among this public assistance group would be met.

More time is needed for the development of a long-range satisfactory and equitable solution to the problem. We urge a delay in definitive action in the interest of obtaining greater experience in order that we may base final decisions upon the results of experimentation, study and research that is now in process.

Thank you for the opportunity to present our views on H.R. 4700. The staff of the association stands ready to offer any technical assistance your committee may request.

The CHAIRMAN. Dr. Groner, we thank you for bringing to us the thinking of the American Hospital Association on this.

For the benefit of members of the committee who may not know of your operations in Memphis to the extent that Mr. Frazer and others from the area know of them, I want to point out that you are the administrator for one of the very finest hospitals that I know anything about in the country.

Whenever they can, a lot of people from my own State get into your hospital on occasion. I am sure Mr. Baker shares that thought.

We appreciate your coming to the committee.
Are there any questions of Dr. Groner?

Mr. FORAND. Doctor, I appreciate the many suggestions which are included in your statement here. One thing that has struck me rather forcefully is the paragraph on page 6 under the caption, “American Hospital Association Position,” where you say:

The position expressed to the committee last year has been reaffirmed as the position of the American Hospital Association and is in opposition to the use of OASDI mechanism to finance the needs of the aged at this time and therefore, you oppose the bill.

I notice in the copy of the resolution adopted by your association on August 20, 1958, under point 4, which reads:

It is believed that every realistic effort should be made to meet the hospital needs of the retired aged promptly through mechanisms utilizing existing systems of voluntary prepayment. It is conceivable, however, that the use of social security to provide the mechanism to assist in the solution of problems of financing these needs may be necessary ultimately.

In other words, you are not closing the door.

Dr. GRONER. No, sir. We think those two statements are compatible.

Mr. FORAND. You feel that that means a delay but you have not closed the door on that idea ?

Dr. GRONER. We think that more time is needed for these various studies and we doubt that we are in a position to make a statement on the facts which we have at this time. We do feel that in the future more facts will come before us and we hope at that time to be able to make a definite statement on what we think is best for the aged people in our population.

Mr. FORAND. I am a member of the corporation of three different hospitals and I can appreciate the headaches and the trials and tribulations which are faced by the administrators of hospitals. Would the member hospitals not now receive funds under the Hill-Burton funds?

Dr. GRONER. Yes, many hospitals receive funds under the HillBurton Act.

Mr. FORAND. Do you feel there is excessive control by the Federal Government under this act?

Dr. GRONER. I think there have been instances of control. By and large, I think it has been a good program.

Mr. FORAND. Why then, does the organization feel that there might be excessive controls by the Government under H.R. 4700 when they are accepting the funds under the Hill-Burton Act?

Dr. GRONER. The provisions for accepting the funds under the two are a little different, Mr. Forand.

Mr. FORAND. Because of that difference, you feel you should hold out!

Dr. GRONER. I think the three inherent dangers which we mentioned under this bill could jeopardize the quality of hospital care to a much greater extent than the provisions under Hill-Burton jeopardize the care.

Mr. FORAND. Is my memory serving me correctly when I think that just a few years ago the hospital association was looking for direct appropriations of Treasury funds to help meet the deficits? Dr. GRONER. I am not familiar with that.

Mr. WILLIAMSON. You are correct. We did have a proposal by which Federal and State Governments would match funds combined with a premium paid by the individual for voluntary health insurance, the Federal-State participation to assume that part of the premium recognized or representing the greatly increased utilization of hospitals by the aged. We did have such a proposal.

Mr. FORAND. For the puropose of the record, will you identify yourself, please?

Mr. WILLIAMSON. My name is in the statement. Kenneth Williamson, associate director of the American Hospital Association.

Mr. FORAND. Would you have an informed guess or you may have figures in your own organization as a result of a poll of your membership showing the number of your members who are in favor of H.R. 4700 as against those who are opposed to it, say 20 percent, 50 percent or what?

Dr. GRONER. We do not have a poll, but I think our policy probably reflects the views of members as well as any national organization can. We come from every area of the United States and every State in the Union. Delegates are elected by the members in that State.

Next week again we are meeting with a group of them to get their reaction. That involves every section of the country.

Mr. FORAND. Do you have even a rough guess as to how they would be divided on this question?

Dr. GRONER. I would be afraid to hazard a guess. I do think this action of the house of delegates reflects the feeling of the members of our association.

Mr. FORAND. I am not trying to put you on the spot. I thought you might have that information.

Dr. GRONER. I understand that and I am not trying to dodge the question.

Mr. FORAND. I think that is all I have to ask right now.
Are there any questions?

Mr. BAKER. Dr. Groner, do you have any figure or statistics whether accurate or fairly accruate, to show what percentage of patients, as of now, pay for hospital services out of some form of health insurance or out of their own resources?

Dr. GRONER. I could get those figures for you. It is between 70 and 76 percent.

Mr. BAKER. Those pay out of insurance funds? Dr. GRONER. Yes, sir; 70 to 76 percent. Mr. BAKER. That is roughly three-quarters. Dr. GRONER. Yes, sir. Mr. BAKER. They pay out of some form of voluntary insurance ? Dr. GRONER. Yes, sir; either Blue Cross or other commercial type of insurance.

Mr. BAKER. Someone gave the figures the other day that three people out of four have it.

Dr. GRONER. I do not want to mislead you. These are people who are covered, but not necessarily that the bills are paid in full.

Mr. BAKER. I meant, of the individual patient; roughly threefourths of them do pay out of some form of insurance plan.

Dr. GRONER. Yes, sir.

Mr. ALGER. I was interested in pages 7, 8, and 9. The three reasons you gave for feeling that this bill would have a bad effect-and you mentioned first an irrevocable step; and second, the fact such abuse might result from the bill; and third, that the program might then almost necessarily be extended to all others.

I want to commend you for this because I have the uneasy feeling that when we members recognize the problem--and there are many problems we have to solve we immediately think if we pass a Federal law this will automatically solve the problem.

Before this committee-and in your testimony—you answered the gentleman from Rhode Island that more time is needed. I know sometimes we get impatient and want to solve these problems, forgetting that if we pass a Federal law it may not change the time schedule at all.

My quesion is, Do you not believe that a solution can be found just as quickly without the passage of this bill through voluntary programs if we continue to apply the same effort that is being applied by those who believe we ought to have this Federal insurance?

Dr. GRONER. I believe, Congressman Alger, that the voluntary system has made tremendous strides. I am quite encouraged over what it has done in the past 12 months. I think we said in our testimony that this bill has stimulated it.

I think it is entitled to an opportunity to see what it can do.

Mr. ALGER. And the voluntary programs may very well solve the problems that need to be solved ?

Dr. GRONER. Yes, sir.

Mr. ALGER. I do not think, from the witnesses I have heard this week here, that we have been given any proof at all that people are not getting medical attention for lack of money. In fact, I am learning to the contrary.

Are you aware of many cases of people who are refused hospital care or medical service because of their lack of ability to pay?

Dr. GRONER. I am not aware of such.
Mr. ALGER. And you represent the hospital folks?
Dr. GRONER. Yes, sir.

Mr. ALGER. Let me ask you something else. What recourse would the hospitals have if the social security administration refused to certify them or refused to grant them payments under this bill?

Dr. GRONER. This is obviously one of our real concerns. I know of no recourse under this bill. I do not know whether it is even taken care of in this bill at all in that respect.

Mr. ALGER. This could have a serious financial effect.
Dr. GRONER. Yes, sir; as medical care has in some instances.

Mr. ALGER. You mention in your statement the Federal Government acting as the arbiter of costs, on page 17. Is it not true that the Federal Government, necessarily by this bill, will have to become

arbiter of all expenses in medicine with respect to doctors' fees, medicines, hospital fees, and so forth?

Dr. GRONER. This is one of our points; and, obviously, they are going to be budgeting the matter of costs, which we think, undoubtedly, would affect the quality of care.

We think they would have to supervise costs. We think they would have the obligation to do it and this would in turn result in a lessening of quality of care.

Mr. ÅLGER. That is as compared to the voluntary arrangement as now enjoyed ?

Dr. GRONER. I would like to add one word to what I said a moment ago. I do feel that providing insurance would add to the utilization. Mr. ALGER. And is added to it? Dr. GRONER. Yes, sir; in the retired age group. Mr. ALGER. Thank you, Mr. Chairman. Mr. FORAND (presiding). Are there any further questions? If not, we thank you very much. The next witness is Miss Julia C. Thompson. Will you come forward, please?

For the purpose of the record, will you give your name, address, and the capacity in which you appear?



Miss THOMPSON. I am Julia Thompson, Washington representative of the American Nurses' Association. The American Nurses' Association is the national organization of over 190,000 registered professional nurses in 54 constituent State and Territorial associations.

Mr. FORAND. You are recognized for 15 minutes.

Miss THOMPSON. The American Nurses' Association is the national organization of over 190,000 registered professional nurses in 54 constituent State and Territorial associations. As one of the professional groups deeply concerned with providing health care for the American people and as the largest single group of professional persons giving that care, we welcome this opportunity to present our views on the proposal before this committee.

In the interest of society at large, and in the interest of its members, the American Nurses' Association has supported the Social Security Act and extensions and improvements in the contributory social insurance which it provides. In 1956, the ANA supported the eligibility of insured individuals over 50 years of age for disability benefits and at the same time supported the proposals for lowering the retirement age limit for women to 60.

The American Nurses' Association now supports the extension of contributory social insurance to provide health insurance benefits for the beneficiaries of old-age, survivors, and disability insurance. The position of the ANA on the measure before you can best be stated by reading to you a resolution, approved by the ANA house of delegates at its ocnvention in June 1958:

Whereas necessary health services should be available to all people in this country without regard to their ability to purchase; and

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