based, or the contribution scale was based. This is really what the task force is gearing itself to determine whether or not the actuaries have taken into consideration all factors and whether or not those factors that were taken into consideration were properly determined.

The CHAIRMAN. The House report defends the future increases in the wage base for purposes of financing the hospital insurance program on the basis that although a safety factor-that is, a fiscally conservative assumption was needed when there was no firm indication of what the actual future cost experience would be: "Now good data are available to the actual current experience, and so such a margin is no longer necessary if adequate reasonable assumptions are adopted as to future trends of unit costs of services and of utilization of services."

Commissioner Ball, the actuarial assumptions have had to be revised every year since the beginning of the medicare program. In fact, they were revised twice in 1969. What makes the House confident that the present cost assumptions will not suffer the same fate?

Mr. BALL. I do not know that I can speak for the House, Mr. Chairman. But I have the same confidence that these are reasonable estimates. Nobody can say over a period like 25 years that it may not be necessary to make changes in them. But there has been a substantial increase in the estimates as relates to how much hospital daily costs are going to increase year by year into the future. To the extent that these estimates now provide over a 10-year period a 110-percent increase, they more than double the hospital daily rate, plus the fact that we have introduced the idea that utilization will increase as well. Now, beyond that, Senator, the way we are proposing to finance the hospital insurance program from here on is to put it on a level basis, raising the rate of 0.6 percent up to 1 percent. If it should turn out that these estimates are by any chance still understated, there is not any doubt but what that 1-percent contribution rate is adequate for many years into the future. The difficulty, if any, would arise only in the latter part of the 25-year period.

So I see no risk in moving to a 1-percent rate as adequate for many years in the future.

POSSIBILITY OF PLACING WELFARE RECIPIENTS IN THE HEALTH CARE FIELD

The CHAIRMAN. We are concerned about finding jobs for welfare recipients. HEW, representing Government health programs, has told us repeatedly of shortages of licensed practical nurses, nurses aides, and assistants of that sort. Specifically, what has HEW done or what can HEW do to involve, train, and place welfare recipients as practical nurses, nurses aides, dietary assistants, and so forth?

Mr. VENEMAN. Actually, Mr. Chairman, this deals with two programs, one of which would be the WIN program and another would be manpower training programs in which the DHEW is involved, along with the Department of Labor. For the most part, whether or not you take a specific welfare recipient and attempt to train him in these areas as the desirable thing to do, depends upon a number of factors. But I think in most of these programs, there are paramedical training courses.

We have another problem. It depends upon the State that you are involved in, too, because many of these positions on a paramedical level

require the ability to pass a State licensing course. Much of this is done. I know in California, in some cases, perhaps not so much welfare recipients, per se, but potential welfare recipients are in programs in the junior colleges and community college system which train them as nurses aides and for other paramedical positions.

The CHAIRMAN. Would you provide for us, in the record, if possible. just how many welfare recipients are involved in these various programs?

Mr. VENEMAN. All right. I think we have to look at it, though, Mr. Chairman, from two perspectives. One would be the number of actual recipients in these kinds or job training programs which would probably, I would suspect, be relatively small. But I think more significant is the potential recipient, one who could very well become the welfare recipient, who moves into a training course of job upgrading, rather than remaining in an unskilled job that might ultimately end up in dependency.

(The information requested follows:)

In the delegated program (1964-1969) Work Experience and Training under Title V of the Economic Opportunity Act, the Department of Health, Education, and Welfare directed particular attention to greater use of paraprofessionals or aides as part of the effort to alleviate manpower shortages in institutional health and related programs with particular emphasis on employment of low income persons. In most projects in this field, classroom training was combined with on-the-job training. The extent of training of personnel as paraprofessionals and aides is illustrated by the following breakdown of Title V projects during one year:

In the health and paramedical field cooperation was enlisted from many sources including two Federal agencies: The Division of Hospitals and the Division o Indian Health in the Public Health Service, and the Veterans' Administration The U.S. Public Health Service hospital in New Orleans, in cooperation with th Title V program, trained and employed medical aides with great success.

The scope of the training in the health field in the training of paraprofessiona aides is illustrated by the following Title V assignments in one year: 175 chil care and nursery aides, 27 family day care aides, 242 homemaker service aides and more than 500 health aides. Trainees learned skills as surgical technicians nursing assistants, therapy aides, dietary aides, pharmacy assistants and labora tory assistants.

According to information made available by the Department of Labor, ther were approximately 2,300 public welfare recipients provided MDTA training i the health field during fiscal year 1969. The training included professiona nurses, nurse's aides, licensed practical nurses and orderlies.

Many WIN Program trainees (AFDC) are co-mingled in Department of Labo regular manpower programs. Therefore, data are not available on the numbe of WIN trainees assigned to training in the health field.

(The following table shows data on employed WIN trainees :)

WIN employed terminees in health occupations1

DOT major occupational grouping

Percent of employed trainees

Occupations in medicine and health, n.e.c., e.g. medical or dental assistants, technicians, therapists_

Attendants, hospitals, morgues and related health service, e.g. nurse's aids and orderlies_

Occupations in social and welfare work, e.g. case aid, program aid, group work

2

6

2

1 Based on reports for 4,788 employed WIN terminees processed through January 1970. Source: U.S. Department of Labor Manpower Administration, Office of Manpower Management, Data Systems, July 24, 1970.

The CHAIRMAN. The nursing home associations testified last month that they had reasonably good success in taking some of these people and putting them to work in nursing homes, and believe that there is a considerable potential in that area. So if they can be used to provide service in that connection, it seems to me that in that regard, one of your programs can help the other program.

Mr. VENEMAN. I think this is the service deal that lends itself to these kinds of people. However, I do want to reiterate that as you do get into the more skilled jobs, you do run into that licensing barrier. Mr. Newman, I think could add a little bit to that.

Mr. NEWMAN. Mr. Chairman, I would like to comment with regard to the medicaid program. The concern that you have expressed about the use of so-called nonprofessionals is directly stated in the statute authorizing the medicaid program. The statute directs us to attempt in those States in which it is feasible to use nonprofessionals in the administration of this program. We have just begun, as the result of the reorganization of the Medical Services Administration, to encourage the use of medicaid in innovative health delivery programs which would encourage use of nonprofessionals and develop community aids who can begin to fill roles in delivering health services. We have begun.

The CHAIRMAN. Well, in those areas, if you have had personal experience, you will know that when you have someone in your family who is very ill, it is just amazing how difficult it is to get someone with any competence at all, just to help or sit with a person who is very ill. Oftentimes, relatives are willing to pay whatever it takes to provide help, but they just can't get it. Yet we have all these people over here by the thousands who are drawing money and apparently are not capable of doing anything. All you are talking about in many cases is somebody to sit with the sick person and to call for the registered nurse or call for the doctor if the person takes a turn for the worse.

Now, a lot of these people who are drawing welfare money can be trained to do that kind of work. It seems to me that with the shortage of people to help in this area, one program should complement the other. You are paying money on the one hand for people who are doing nothing and on the other hand, we are trying to provide care which is very difficult to obtain because there are no people to do the work. It seems to me that one hand should help wash the other. Maybe we can get some results.

Now, some of these programs interrelate. We just passed an amendment the other day to put more money in to try to provide sanitation, water, sewage in communities that have never had it in the history of

this country, and some of those communities are more than a hundred years old. It would be better, rather than paying money under a family assistance plan, if we had that man out there working, putting water into people's homes and providing for sanitation and sewage treatment rather than to have nothing to show for it.

While in some respects, one takes the view that this program has nothing to do with that one, many times, they do. I would hope that we could relate them insofar as possible.

Mr. VENEMAN. Mr. Chairman, I would agree that this kind of program, if it should pass, would open up job opportunities. But there is the requirement requiring prevailing wage rates in certain skills. I think, as these job opportunities open, job opportunity programs dealing with welfare recipients should be geared to the kind of job that is available. So if that community was in fact putting in a water supply system and there was additional manpower needed, I would hope that the training program would be geared to provide that kind of labor from the potential public assistance market area.

The CHAIRMAN. We need people handling a program like that who know how to make it work, rather than people who know how to keep it from working.

Senator Anderson once made a statement; he said if an administrator wants to make a program work, he can usually find a way to make it work. If he does not want to make it work, he can find a thousand reasons why it will not work. He really needs some good administrators.

Mr. VENEMAN. What we are working up against, though, are barriers placed in the statutes, either at the State or Federal level.

The CHAIRMAN. That is something we want to try to do something about. I hope you will help us with it. I am going to introduce a proposal to try to provide day care for these children, try to make it available throughout this entire country.

One of the big obstacles that we have to overcome in that regard is that in all these communities they perceive that such standards would stand in the way of providing day-care services.

Mr. VENEMAN. And make it impossible for certain people to assist in it. I think Governor Williams of Mississippi participated in that recently.

The CHAIRMAN. We will set our own standards, and as long as they comply with the standards we set, our law will prevail over the local law. We are not going to try to help these people on the one hand and then find that they are trying to pass laws to keep it from working on the other. If you want it to work, do whatever is necessary to give it a chance.

How many billions of dollars in new medicare payroll taxes would be imposed in calendar 1971 under this bill? That is, how many billions of medicare taxes would you get under present law in 1971, and how many billions under the bill? Would that be 4.1 in 1971?

Mr. VENEMAN. Additional income of $4.1 billion would be correct for the hospital insurance program for 1971.

The CHAIRMAN. And how many billions of medicare taxes would you get under present law, in 1971?

Mr. BALL. Present law income would be about $6 billion.

The CHAIRMAN. That is what I estimated. How many billions under the bill?

Mr. BALL. We are talking of income now.

Mr. VENEMAN. Wait a minute. Are you in the hospital insurance side, Mr. Chairman?

The CHAIRMAN. Yes.

HOSPITAL TAX EXEMPTIONS

Mr. VENEMAN. Good; then we are on the same wavelength.

The CHAIRMAN. The House version of the tax reform law had a condition removing the requirement that with the addition of tax exemptions, hospitals provide free or below-cost care to the extent of their financial ability. The Senate deleted that provision, preferring to consider the matter when they took up medicare this year.

The Senate concern was that without the present requirement of tax exemption, hospitals might claim that medicare and medicaid paid less than their costs, and might refuse to take or might limit their admissions of medicare and medicaid patients.

Additionally, large numbers of poor people, including those on general welfare assistance, might also be denied or limited in access to the necessary hospital care.

The National Governors' Conference agreed with and supported the Senate action. What is the position of the Department of HEW on this issue?

Mr. VENEMAN. I am not sure that we have taken a position on that particular issue, Mr. Chairman. I do not think there has been a departmental position. If you would like us to review the proposal, we shall be happy to do that and place the Department's position in the record.*

CARE FOR MIGRANT WORKERS IN COMMUNITY HOSPITALS

The CHAIRMAN. What is your experience with treating migrant workers in community hospitals?

Mr. VENEMAN. It varies. I think that perhaps Mr. Newman can speak to that question better than I. I can speak to it from personal experience in California, which has a system of county hospitals.

For the most part, in California the counties care for migrant farmworkers in public facilities regardless of the duration of their stay, the amount of time they have been in the county, or anything else.

I am sure that experience in caring for migrants varies from State to State, and I shall ask Mr. Newman to answer the question more generally.

The CHAIRMAN. Would that be the case if they were purely charity patients?

Mr. NEWMAN. Yes, Mr. Chairman. A significant problem in the medicaid program is that eligibility is determined at the State level, and as you know, eligibility for cash assistance is often the only determinant for medicaid eligibility. Migrants are often shut out of medicaid because they are not eligible for cash assistance.

The CHAIRMAN. Here is a list of questions Senator Gore sent to me. I think I shall ask a few of them and then I shall submit them and you can respond for the record to the rest of them.**

*At presstime, Sept. 3, 1970, the material referred to had not been received from the Department. See app. B.