Whereas prepayment through insurance has become a major and an effective method of financing health services; and

Whereas certain groups in our population, particularly the disabled, retired, and aged, are neither eligible nor able to avail themselves of voluntary health insurance: Be it, therefore,

Resolved, That the American Nurses' Association support the extension and the improvement of the contributory social insurance to include health insurance for beneficiaries of old-age, survivors, and disability insurance; and be it further

Resolved, That nursing service, including nursing care in the home, be included as a benefit of any prepaid health insurance program.

The benefits of modern medical science should be available to all citizens of this country. Health services which are essential to social well-being are expensive and likely to become more so in the years ahead. Without insurance protection against the costs of illness, the disabled, retired, and aged must often depend on public relief in times of sickness.

As the number of retired aged in our population increases, a larger and larger financial burden for their medical care will have to be borne by the public. Certainly, insurance coverage against the costs of illness which may occur after retirement, which insurance can be paid for during the working years, would be less costly to the public than tax-supported public relief for health care--a dependency which is distasteful and degrading to citizens of this country.

Insofar as it provides health insurance coverage for beneficiaries of old-age, survivors, and disability insurance, ANĂ supports H.R. 4700. However, we wish to point out that health insurance, particularly for the aged, should be broader than coverage of the costs of hospital, nursing home, and surgical services.

With the increase in experimentation in outpatient clinics and the growth of home-care programs, we believe health insurance should cover such care as well. Home-care programs are particularly useful for the long-term illnesses of the aged, such as heart disease, cancer, arthritis and the cost to the individual of such care should be covered by health insurance.

Coverage also must include nursing care. Nursing is an essential component of modern medical care and must be available if the benefits of medical science are to be provided for the aged and disabled. Beneficiaries of any health insurance should be insured against the costs of needed private duty nursing services no less than they are insured against surgical costs. Coverage also should include public health nursing care in the home as well as nursing home costs.

An indication of the need for coverage of nursing care received by the aged is the amount of such care provided by visiting nurse associations. In the District of Columbia for example, during the first 5 months of this year, 35 percent of the nursing care visits of the Visiting Nurse Association were made to patients over 65 years of age. Yet, according to the 1950 census, persons 65 and older made up only 7 percent of the district population.

A breakdown of cases seen by the Visiting Nurse Association of Houston during 1 week in February 1958, shows that of the 366 nursing visits made, 272 were made to persons 60 years of age and older, and 195 of these were to patients 70 and older.

The Visiting Nurse Service of New York reports that in 1958, persons 65 years of age and older made up 25 percent of the patients

of the VNA of New York and the VNA of Brooklyn. These older patients received half of the 485,000 visits made by the nurses of these two agencies.

We cite these examples merely as an indication of the extent of home nursing care needed by aged persons. We believe such care will increase as more emphasis is placed on home-care programs and care of the chronically ill outside the hospital.

Recognizing the many problems involved, we urge the inclusion of nursing service as a benefit of health insurance for beneficiaries of OASDI. The ANA is, at this time, developing principles which should govern nursing services in prepaid medical care plans which we will be anxious to share with this committee or any administrative agency responsible for such a plan as soon as the statement is completed.

At this time, we wish to call attention to the poor conditions prevalent in nursing homes throughout the country. To provide a means of payment for nursing home care through social insurance will not be enough. All groups concerned with meeting the health needs of the aged in our population must work to raise the levels of care provided in nursing homes, the majority of which are proprietary institutions.

We note that in H.R. 4700 a nursing home to be eligible for payment under OASDI, must be licensed according to the law of the State in which it is located. Unfortunately, in many cases, such State regulation is not adequate to insure safe nursing care in the homes licensed.

Our concern in this matter is obvious, since nursing is the primary and largest service offered by these homes, and the nursing profession is responsible for standards of nursing practice no matter where that practice is carried out.

To protect both the insurance system and the beneficiaries, provisions for payment for nursing home services should clearly define the type of service to be covered. Every precaution should be taken to prevent the financing of substandard institutions through social insurance payments.

We believe that the term "nursing home" should apply only to that facility which provides skilled nursing care on a 24-hour basis under the supervision of a profesisonal nurse. When a nursing home offers intensive and complicated nursing care, requiring professional skill and judgment, it must be prepared to employ professional nurses to give such service. We urge your careful consideration of the type of nursing home care which is to be covered by social insurance.

Insurance protection against the financial hazards of illness in retirement is not now available to the majority of those persons who need it. Neither voluntary nonprofit nor commercial insurance programs offer the needed protection at the cost and method of payment possible for those living on a limited retirement income. Extension of the most universally held insurance, the old-age, survivors and disability insurance, would appear to be the most feasible method of providing this coverage.

This committee must have a great deal of data from many sources on the need for health insurance for our growing aged population. However, I would like to mention the situation which employees face

in the hospital industry, in which the largest group of our professional nurses are employed.

American hospitals employ a total of approximately 1.3 million workers. This is more than major industries such as basic steel, automobile and interstate railroads. More than one-half of these workers are employed in nongovernmental hospitals

During 1956 and 1957 the Bureau of Labor Statistics conducted a study of "Salaries and Supplementary Benefits in Private Hospitals" in 16 metropolitan areas covering 400,000 full-time hospital employees. At the time of the study, fewer than half of these employees were covered by pension plans other than OASDI. In one city, the number of employees covered by retirement plans in which the hospital participated was as low as 212 percent.

This situation, coupled with the well-known fact that salaries in hospitals are low, means that the majority of these employees will be dependent, after retirement, on OASDI benefits for their income. With the low wages prevalent in the hospital industry and many nonprofessional workers earning less than the Federal minimum, these employees cannot save for retirement and will not be able to pay for health insurance after their retirement.

I wish to thank the committee for this opportunity to present the views of the American Nurses' Association on the extension and improvement of the Social Security Act. The ANA will be happy to furnish any additional information within the scope of its activities which the committee wishes to have.

Mr. FORAND. Thank you, Miss Thompson, for coming before the committee and giving us the views of the American Nurses Association. Now may I ask you if your members in approving the principles of the Forand bill did so because of their experience regarding the reaction of patients to the fact that they were unable to pay their medical services and that operated as a sort of barrier and interfered with their recovery?

Miss THOMPSON. I would believe that that would be true, because of the close association that nurses have with their patients and also with the experience that the nurses have in public health agencies in which they visit in the home, where they find persons who are not seeking or do not have medical care because they do not have the money to procure it.

Another element which enters into this is the relatively low income. of nurses and they, too, have a fear of needing some kind of protection when they get to retirement age.

Mr. FORAND. In your opinion, are all the people who need skilled nursing care getting it today?

Miss THOMPSON. I believe not. I am quite sure that in the nursing homes they are not receiving that care. I know that there are many hospitals who feel that they need more nurses on their staffs. Mr. FORAND. There is definitely a shortage of nurses too.

Miss THOMPSON. That is correct.

Mr. FORAND. I found that out when my wife was in the hospital 8 months ago.

Miss THOMPSON. We are trying to increase that too.

Mr. FORAND. I want to commend the nurses who are working. I found that there are any number of them who cannot put in full time

because of family reasons and yet work by the day, 1, 2, or 3 days a week. I am told by some hospitals that if it were not for that type of willing worker they would not be able to operate the hospitals. I know others who, instead of working an 8-hour shift, are working 12 hours to help fill the need.

Thank you very much for the information you have given us.
The CHAIRMAN. Any further questions of Miss Thompson?

Mr. ALGER. Miss Thompson, you are aware I am sure of the testimony that was presented to us that members of the medical profession and the gentleman just before you of the American Hospital Association testified to us that medical care and hospital care have been provided people even though they are unable to pay it. You are aware of that statement made to us?

Miss THOMPSON. Yes.

Mr. ALGER. Now is there any danger or is there any uncertainty or concern in your mind that by too hastily adopting Federal compulsion we might limit, delay, or even stop the growth of voluntary plans?

Miss THOMPSON. I think I might answer your question this way, in saying that our major concern is providing health services for people and that as we study this issue and look at it from all sides we have found that there is no way in which certain groups in our population can now receive insurance coverage and that this method at this time seems to be the most feasible one.

Would that answer your question?

Mr. ALGER. I appreciate what you say. I want you to know that it is possible that some of us believe that there might be even a greater benefit to our entire Nation by relying on community services plus the voluntary programs. I do appreciate your testimony.

Do you feel there is any inequity at all in proposing a compulsory tax on many people who won't want this type of service and yet would have to pay for it?

Miss THOMPSON. Mr. Alger, I believe that the majority of people are now making some contribution through taxes which supply public assistance and medical care to persons, so I don't see there would be any great problem there.

Mr. ALGER. This would involve additional and new taxes.

Miss THOMPSON. But as we increase the coverage for health care under this program we could cut down the public assistance, the money that is used for medical care under public assistance.

Mr. ALGER. You understand what I am asking. We are going to force people to pay for this. Many will not want it but they will be forced to pay. Does that seem at all inequitable to you?

Miss THOMPSON. No. I don't think I would make a comment similar to the one that Mr. Cohen made earlier this afternoon; that in many employment situations you are faced with certain factors or conditions of employment which will take certain amounts of money out of your salary whether you wish it to be taken out or not. That is one of the conditions of employment.

Mr. ALGER. Thank you.

The CHAIRMAN. Any further questions of Miss Thompson?

Again we thank you for bringing to the committee the views of the American Nurses Association.

Miss THOMPSON. Thank you, Mr. Chairman.

The CHAIRMAN. Our next witnesses are Dr. Besdine and Dr. Friedrich.

Will you gentlemen identify yourselves for the record by giving your names and address and capacity in which you appear?

STATEMENT OF BERNARD J. CONWAY, SECRETARY, COUNCIL ON LEGISLATION, AMERICAN DENTAL ASSOCIATION

Mr. CONWAY. I am Bernard J. Conway, Chicago, Ill. I am secretary of the American Dental Association Council on Legislation.

Dr. Besdine, because of sickness beyond his control, is unable to be here this afternoon. I request, Mr. Chairman, that his statement be inserted in the record at this point.

The CHAIRMAN. Without objection, it will be included in the record at this point.

(Dr. Besdine's statement follows:)

STATEMENT OF THE AMERICAN DENTAL ASSOCIATION

On H.R. 4700, a bill to provide hospitalization and surgical benefits under the O.A.S.I. title of the Social Security Act before the Committee on Ways and Means, U.S. House of Representatives

Mr. Chairman, members of the committee, I am Dr. Matthew Besdine of Brooklyn, N.Y. I am a member of the American Dental Association's Council on Legislation. With me are Dr. R. H. Friedrich, secretary of the Association's Council on Dental Health, and Mr. Bernard J. Conway, secretary of the association's council on legislation.

We are here today to present the American Dental Association's views on H.R. 4700 which has as its purpose the inclusion of health care benefits within the O.A.S.I. title of the Social Security Act. The American Dental Association believes firmly in and has adopted as a part of its official policy the principle that "dental care should be available to all regardless of income or geographic location." Over the years, and to an ever-increasing extent during the last two decades, the majority of the programs and activities of the association and its State and local subdivisions have been dedicated to the accomplishment of this objective.

The dental profession is fully aware of the dental care problems not only of aged people but of people in other segments of the population as well. Organized dentistry is working vigorously, as are other voluntary organizations, to find the solutions for these problems.

At the present time there is no assurance that the introduction of a drastic and irreversible system of federally sponsored health care such as that proposed in H.R. 4700 will produce the desired result. On the contrary, there is much evidence that it will not. Much additional exploration is needed before the Government will be justified in embarking upon a venture so costly and so uncertain. This is not to say that the American Dental Association is opposed to all forms of Government participation in programs to increase the availability of health care. In the field of dental health, the association supports vigorously many Government programs. At the same time, it is believed that the primary responsibility should be left to private individuals and agencies.

The association's house of delegates last year adopted a statement of policy for specific application to H.R. 4700 and similar bills, a copy of which is offered for the record. This policy recognizes that there are areas in which the Government has a responsibility to act and others in which it is justified in acting to provide health care or financial support of health care for certain segments of the population. These segments include, of course, military personnel, veterans, and others toward whom the Government bears a special responsibility or a special relationship. Also included are the needy, whether or not they are among the aged. Beyond this, the association is convinced, the Government should not go.