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The President in his special health message on January 31, 1955, recommended a broad program of action to meet many of our most pressing health problems. Several bills, including S. 886 and its companion bill H. R. 3458, have been introduced in the Congress to carry out these recommendations: S. 890 provides for extension and strengthening of the water pollution control program; H. R. 3293 provides for an expanded program of medical care for public assistance recipients; and S. 894 and H. R. 3771 provide for a new program to attack the problem of juvenile delinquency.

S. 886 is an omnibus bill consisting of six titles. Title I provides for a program of reinsurance of health services prepayment plans. The reinsurance program has as its purpose the encouragement of private health insurance organizations in the offering of broader benefits and wider coverage. It would particularly emphasize three areas: (a) protection against the high costs of severe or prolonged illness, (b) provision of coverage for individuals and families in rural areas, and (c) provision of coverage relating to home care and physicians office care, as well as hospital care, for individuals and families with average or lower incomes. The bill would authorize the appropriation of not more than $100 million to provide the necessary operating capital. It is anticipated that the program would ultimately be self-supporting from premiums paid by the participating health insurance organizations.

Title II provides for a program of mortgage insurance for construction of health facilities. This program has as its purpose the stimulation of the flow of private credit for the construction of needed health facilities through Government insurance of loans made by private lending institutions, without Federal subsidy. Such insurance would be available for the construction of private hospitals, clinics, nursing homes, and other health facilities. An appropriation of $10 million and such sums as may be necessary thereafter would be authorized for providing the necessary capital for the insurance fund from which the program would be financed. It is expected that premium charges on insured mortgages would maintain the insurance fund on a self-supporting basis.

Title III provides for a 5-year program of grants to States for training of practical nurses, patterned after the present Vocational Education Act of 1946. Appropriations of $2 million for 1956, $3 million for 1957, and $4 million for each of the following 3 fiscal years would be authorized.

Title IV would amend the Public Health Service Act by providing for a program of traineeships for the training of professional nurses for teaching administrative, or supervisory positions and for graduate or specialized training in the several public health specialties.

Titles V and VI also would amend the Public Health Service Act by revising, improving, and simplifying the structure of health grants-in-aid to States. A single grant would replace the present categorical health grants, except that a separate grant for mental health would be authorized for a 5-year period. This and other changes proposed in these titles would permit greater flexibility in the use of Federal funds to meet specific problems of each State.

S. 434 is also an omnibus health bill. It would propose to achieve broader distribution of health services by marked expansion of Federal financial assistance to States and the establishment of a number of new Federal grant programs.

The other two bills, S. 929 and S. 1076, each deal with one program area. S. 929 would provide for a permanent program of grants to States for the training of practical nurses and auxiliary hospital personnel rather than the 5-year practical nurse training proposal in S. 886. S. 1076 would provide for Government loans for the acquisition, construction, and equipping of health facilities to voluntary nonprofit associations offering prepaid health services. Title II of S. 886 provides for Government insurance of private mortgage loans for construction of health facilities rather than direct Federal loans. It also would provide broader coverage than S. 1076.

Enactment of the President's health program would go far toward broadening the distribution and improving the quality of health services without excessive increases in Federal operations or the Federal financial burden. At the same time the program recognizes the primary responsibility of the State and local levels for the health of the community.

Since S. 886 embodies the recommendations outlined in the special message, I am authorized to advise you that its enactment would be in accord with the program of the President and that the Bureau of the Budget recommends enactment of S. 886 in preference to S. 434, S. 929, or S. 1076. Sincerely yours,

DONALD R. BELCHER,

Assistant Director,

Chairman Hill. Now we have Mrs. Hobby. We are delighted to have you here. Will you come around, please, m’am? We would like to have you proceed in your own way.

STATEMENT OF HON. OVETA CULP HOBBY, SECRETARY, DEPART

MENT OF HEALTH, EDUCATION, AND WELFARE, ACCOMPANIED BY DR. ROBERT H. FELIX, DIRECTOR OF THE NATIONAL INSTITUTE OF MENTAL HEALTH; MRS. LUCILE LEONE, CHIEF NURSE OFFICER OF THE PUBLIC HEALTH SERVICE; JAMES H. PEARSON, DIRECTOR OF THE DIVISION OF VOCATIONAL EDUCATION IN THE OFFICE OF EDUCATION; ASSISTANT SECRETARY ROSWELL B. PERKINS; DR. CHESTER S. KEEFER, SPECIAL ASSISTANT FOR HEALTH AND MEDICAL AFFAIRS; AND DR. LEONARD A. SCHEELE, SURGEON GENERAL OF THE PUBLIC HEALTH SERVICE

Secretary HOBBY. Thank you, sir.

Mr. Chairman and members of the committee, the two practical nurse-training proposals under consideration by your committee today—S. 929 and title III of S. 886—are similar in their objectives and approach. They differ, however, in a number of particulars.

Our prepared statement is confined to the objectives and provisions of title III of S. 886, which embodies one of the President's recommendations for legislation to alleviate shortages of health personnel. We will, however, indicate briefly the relationship between this proposal and a related nurse-training proposal contained in title IV of the bill.

Our report on S. 929, which has already been submitted to your committee, summarizes the views of our Department on this alternative proposal.

INCREASING DEMAND FOR NURSING SERVICES

The need for more nursing personnel is serious. Shortages of hospital staff nurses are particularly acute. In a recent survey covering two-thirds of the Nation's 7,000 hospitals, the American Hospital Association found there were 23,000 vacancies for professional staff nurses. In addition, there are shortages of nursing personnel in clinics, doctors' offices, industrial plants, and public health agencies.

The present imbalance between supply and demand is due primarily to the remarkable increases in demands for nursing services that have developed during the last two decades. There are three principal factors responsible for this increasing demand.

The first is the changes that are taking place in the size and composition of our population. Our total population is increasing at an accelerated rate. This in itself increases the demand for nursing services. Furthermore, the acceleration in birth rates and the increasing proportion of persons in the older-age groups have enlarged the two groups with the greatest need for nursing care-the very young and the aged.

Second, all groups in the population are making increased demands on the services of hospitals and other health facilities. This is due partly to the growth and extension of these facilities and partly to increased utilization by our people of the skills and facilities of modern medicine.

The third factor affecting the demand for nursing services is the spectacular advance in medical knowledge. As such knowledge expands and new therapeutic techniques are developed, the responsibilities of both the doctor and the nurse become more complex. The nurse is now a far more important member of the medical team than she ever was before. As a result of these developments, more nursing services are required per patient.

All these factors affecting demand represent continuing trends. There is every reason to believe that these trends will be accelerated in the future.

SUPPLY OF NURSING PERSONNEL

While some progress is being made, the supply of nursing personnel has not kept pace with the rapid growth in demand for nursing services.

Our supply of nursing personnel is composed of two general categories: First, professional nurses and, second, nonprofessional nursing personnel which includes both practical nurses and nursing aides.

Professional nurses, who are also known as registered nurses, constitute the central core of skilled nursing personnel. Their professional preparation consists of at least 3 years of training, including both academic studies and practice in a hospital. They are the staff nurses in hospitals, clinics, and public health agencies. They are also the principal providers of private nursing care—both in the hospital and in private homes. From their ranks are selected the supervisors and administrators of nursing services, as well as the instructional staffs of nursing schools.

At the present time there are about 390,000 professional nurses active in all fields. The total number of active professional nurses is greater today than it ever has been, and the number of graduates from nursing schools is steadily increasing. These increases, however, are barely keeping pace with population growth; they are not adequate to meet the growing per capita demand for nursing services.

Practical nurses are the most highly skilled group in the nonprofessional nurse category. Their training now generally covers a year of preparatory schooling and experience. They can therefore relieve hospital staff nurses of many duties. They are also employed to care for patients in chronic disease hospitals, in nursing homes, and in private homes when the patient's condition does not require professional nursing skills.

There are now more than 100,000 licensed practical nurses, and their number has been steadily increasing. Several factors, however, limit the increase in supply of this type of nonprofessional nursing personnel. I shall discuss these factors in some detail later in my statement.

Nursing aides are usually recruited directly into hospital service without preparatory training. They receive brief training on the job by the professional nursing staff. Because of their limited training they are usually employed only in hospitals and nursing homes where adequate supervision can be provided.

The total number of nursing aides has increased greatly in recent years. About 260,000 are now employed in hospitals. This is the only category of nursing personnel in which the supply appears to be reasonably adequate.

If it please the chairman at this time, I should like to ask Mrs. Leone, chief nurse officer of the Public Health Service, to talk to these two charts.

Chairman Hill. Good. We will be delighted to hear from you.

Mrs. LEONE. Mr. Chairman and members of the committee, these two charts show the supply of nursing personnel and demand for nursing services.

(The two charts referred to appear at pp. 40 and 41 in the prepared statement.)

Mrs. LEONE. This chart-nursing personnel—shows one portion of the total supply, that portion employed by 5,000 general hospitals. Not included on that chart are the nurses employed in the chronicdisease hospitals, nursing homes, doctors' offices, and public health and other fields of employment.

The total number of nurses employed in those 5,000 hospitals is 392,000; 201,000 are professional nurses shown in blue on the chart; 190,000 are nonprofessional nurses shown in green on the chart.

The chart also shows how the nursing personnel are apportioned among the various types of jobs in these hospitals. Eight thousand of the professional nurses are directors of nursing services in hospitals; 19,000 of them are supervisors who are in charge of the nursing service of one department of a hospital, the obstetric department, the surgical department, and the like.

Each of these departments is divided into two or more wards.

Thirty-one thousand of these professional nurses are head nurses, each one in charge of a ward, with from 20 to 50 patients on it; 143,000 professional nurses are staff nurses who care for the patients in those wards.

The nonprofessional nursing personnel are of two main types; 41,000 of them are practical nurses who assist the staff nurses in the care of patients; 150,000 of them are nursing aides who perform similar nursing tasks.

Chairman Hill. Are the nursing aides on your chart all regularly paid aides? We do have voluntary aides.

Mrs. LEONE. Those are all paid aides.
Chairman Hill. They are the regular ones?

Mrs. LEONE. Yes. Professional nurses in these three categories here direct the services, the activities of all of these other personnel. Mrs. Hobby will have a word to say later about improving the managerial skills of these nurses, so that these services will go farther.

Today we are addressing ourselves to practical nurses. This bar will show

you how small the number of practical nurses is that these hospitals can secure to help with the important job of the professional nurse in caring for patients.

This chart will explain some of the increases in demand for nursing services.

In 1930, 6 million people entered general hospitals in this country. These 5 figures represent the ratio, 5 per every 100 of our population admitted to general hospitals during that year.

Now, in 1954, 18 million people were admitted to hospitals, that is, general hospitals. And these figures represent the ratio—11 out of every 100 of our population who were admitted to a hospital in 1954. Of course, this does not mean that more people were sick in 1954. It means that more people used health facilities, and that there were more health facilities available for their use.

In 1930, the medical and health knowledge called for, and the supply of nursing personnel provided 1 professional nurse for each 6 patients in general hospitals.

In 1954, 2 professional nurses for each 6 patients in general hospitals. Actually, more nurses were needed here, but their positions were vacant.

The major reason for this increased requirement per capita or per patient is the advance in medical science and medical knowledge.

More than twice as many people in proportion seeking care, and more than twice the amount of care per patient required for each one of them

There are then three major reasons for the increase in demands: (1) the increase in population itself; (2) the increased utilization of health facilities; (3) the advances in medicine which called for more nursing personnel per patient.

Chairman Hill. We certainly want to thank you, Mrs. Leone. Those charts tell a lot. You may proceed.

Secretary Hobby. In view of existing shortages and of increasing demands for nursing services, it is apparent that action is needed along two general lines: First, we must increase the total number of nursing personnel. Second, we must utilize all available nursing personnel more effectively.

APPROACHES TO INCREASING THE NURSE SUPPLY

Title III is directed toward increasing the supply of nursing personnel through the training of additional practical nurses. We believe that this approach offers the greatest promise of immediate and longterm results. We also believe it is the approach through which the Federal Government can most effectively participate.

We are aware of the related need for maintaining and expanding our present supply of professional nurses and nursing aids. We do not believe, however, that Federal assistance can be as productive in the recruitment or training of these two categories of nursing personnel.

In the case of professional nurses, it is doubtful whether Federal assistance could add significantly to the energetic recruitment campaigns now being conducted by nursing and hospital associations. Enrollment figures for professional nursing schools indicate that the proportion of high school graduates interested in nursing as a career has not varied significantly in the last decade. Therefore, except for recruitment programs for special emergency needs—such as the cadet nurse program in World War II—we should not rely on Federal recruitment programs or training inducements to increase the supply of professional nurses.

In the case of nursing aids, there is no evidence of any general shortage of recruits. Furthermore, since nursing aids are trained on the job, without preemployment schooling, no specialized training programs or facilities are necessary. The principal requirement is nurse personnel on the hospital staff qualified in on-the-job training techniques. Through the efforts of State vocational education agencies, supplemented by instructor training programs sponsored by

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