PRESIDENT'S HEALTH RECOMMENDATIONS AND

RELATED MEASURES

MONDAY, APRIL 5, 1954

UNITED STATES SENATE,

COMMITTEE ON LABOR AND PUBLIC WELFARE,

SUBCOMMITTEE ON HEALTH, Washington, D. C. The subcommittee met at 10 a. m., pursuant to recess, in room P-63, Capitol, Senator William A. Purtell, chairman of the subcommittee, presiding.

Present: Senators Purtell (chairman of the subcommittee), Goldwater, and Hill.

Also present: Roy E. James, staff director; Melvin W. Sneed and William G. Reidy, professional staff members.

Senator PURTELL. Our hearing is on the vocational rehabilitation recommendations of the President, and our first witness is Mr. E. B. Whitten, executive director of the National Rehabilitation Association. You have a prepared statement, and do you wish that incorporated in the record and then make a summary, or is it your desire to read the complete statement? It is rather lengthy, but if you wish to read it, you may.

STATEMENT OF E. B. WHITTEN, EXECUTIVE DIRECTOR, NATIONAL REHABILITATION ASSOCIATION

Mr. WHITTEN. No, Mr. Chairman; I would prefer that the statement be filed for the record, and I shall speak from some notes and try to conform to the time limit that has been given.

Senator PURTELL. It is so ordered.

(The written statement of Mr. E. B. Whitten is as follows:)

STATEMENT OF E. B. WHITTEN, EXECUTIVE DIRECTOR, NATIONAL REHABILITATION ASSOCIATION

The National Rehabilitation Association is a private, nonprofit corporation organized in 1925 to promote the rehabilitation of the handicapped and the professional advancement of rehabilitation workers. It has been in active existence continuously since that time and has grown from an organization of less than 100 individuals to its present membership of over 14,000. The National Rehabilitation Association was the chief sponsor of the Barden-La Follette amendments to the Vocational Rehabilitation Act, which was passed in 1943, and for several years has been urging State and Federal legislation to make the rehabilitation efforts of private and governmental agencies more effective. The 14,000 members of the association are almost equally divided between professionals in the field, that is, rehabilitation counselors, therapists, physicians, etc., and lay people who recognize the human and economic values of rehabilitation and seek to promote them through membership in the association. Its

interests is in all of the disabled and in all areas of the rehabilitation process. The National Rehabilitation Association is the publisher of the Journal of Rehabilitation with a circulation of over 16,000.

SCOPE OF THE REHABILITATION PROBLEM

For a number of years, the Office of Vocational Rehabilitation stated that 7 of each 1,000 of the general population suffered disability to the extent that rehabilitation services were needed. More recent estimates indicate that this figure was much too low. Studies of the incidents of disability that this committee will be interested in include the 1949 survey of disability conducted by the Office of Vocational Rehabilitation with the aid of the Census Bureau, and the 1936 National Health Survey. Several other valuable studies are included in volume 3 of A Report to the President by the President's Committee on the Health Needs of the Nation.

When considered collectively, these studies indicate that about 2 million adults are disabled to the extent that they need rehabilitation services of some kind and that about 300,000 are so badly disabled that sheltered working conditions are needed for them. They also indicate that about 250,000 people are added anually to this total by accident and disease. Since the numbers needing rehabilitations services are so much greater than can be helped by present personnel and facilities in public and private rehabilitation agencies, it is little wonder that the exact number of the severely disabled is a rather academic question to many who work in this field.

PRESENT STATUS OF REHABILITATION

At present, the efforts of the State-Federal rehabilitation program are resulting in the rehabilitation of 65,000 persons annually. This number would not be possible without the assistance of personnel and funds from private sources. In addition, a sizable number of individuals are rehabilitated by private rehabilitation agencies without getting on the public rehabilitation rolls. The number of such individuals is impossible to ascertain but it is probably not over 35,000 annually. It is safe to assume that from all sources not much over 100,000 persons are being rehabilitated annually of the 250,000 who become disabled. The remaining 150,000 are either relegated to the human scrap heap completely or they are performing in menial capacities at far less than their potential.

Present rehabilitation efforts are not evenly distributed with respect to the variety of disabilities suffered by the handicapped. For instance, considerable progress has been made in the rehabilitation of the amputee, the blind, and the deaf, but the rehabilitation of the mentally retarded, the mentally ill, the epileptics, the cerebral palsied, etc., is almost in its infancy. The number of persons with these disabilities rehabilitated each year, when considered in the light of the number of persons possessing such disabilities, is significant proof of this fact. We might add that to our knowledge there is no one particular type of disabled individuals which is receiving completely adequate rehabilitation services.

In recent years, much knowledge has been gained with respect to the methods and techniques for rehabilitating many of the handicapped who were once considered not feasible for rehabilitation. The pioneering work of such institutions as the Institute for the Crippled and Disabled and the Institute of Physical Medicine and Rehabilitation, both in New York City, the Woodrow Wilson Rehabilitation Center of Fisherville, Va., and others have been notable in this respect.

Almost always, services in such institutions is expensive. It is not unusual that several thousand dollars be spent on one case. With funds of public and private rehabilitation agencies extremely limited, many individuals are not being sent to such centers who could profit from the many services that are available.. This situation, in turn, makes communities very cautious about establishing such facilities, although they know handicapped people needing such services are available.

Neither Congress nor the States, apparently have realistically considered how rehabilitation for all of the severely handicapped can be financed. It is significant that a number of our largest and most effective rehabilitation centers could not have been established or at least could not have reached their present state of development without the revenue from the United Mine Workers Welfare and Retirement Fund, which had the money to rehabilitate crippled miners and has: not hesitated to use it.

HISTORY OF THE STATE-FEDERAL REHABILITATION PROGRAM

Efforts of the Federal Government to rehabilitate handicapped civilians began with the passage of the Vocational Rehabilitation Act in 1920. Before that time, a few States had demonstrated the possibilities of vocational rehabilitation. The act of 1920 was inspired by the Veterans' Administration Act which had been passed in 1918. Services, at first, were limited to individuals injured in industry. The program continued from 1920 to 1943 with meager appropriations, limiting its services principally to vocational training and counseling services. The Barden-La Follette amendments of 1943 broadened the scope of services and enabled the program to expand rapidly during the war years and immediately after. In order to make a handicapped person employable, a rehabilitation agency may now make available medical and psychological diagnosis, hospitalization and surgery, training supplies, placement equipment, and counseling services throughout the rehabilitation process. Approximately 1,500 professional workers now serve 200,000 persons annually, rehabilitating 65,000 each year. Reports from the Office of Vocational Rehabilitation, which will undoubtedly be made available to this committee, will indicate how the State-Federal program has grown in the number of persons rehabilitated and in the type and variety of services offered. Such reports also show the source from which cases are referred to the State agencies, the types of disabilities that are served and in what numbers, and the types of jobs into which these people are rehabilitated. Most significant, we think, is that these figures indicate that the philosophy of the State agencies is to serve all types of the handicapped, so far as their personnel and facilities will permit, and that each year shows a higher percentage than the year before of the number of cases which could be considered most severely handicapped,

RESPONSIBILITY OF THE FEDERAL GOVERNMENT FOR REHABILITATION

The Federal Government has long been concerned with the problem of disability in the country, but up to date most of its expenditures have been in public assistance for the handicapped rather than in rehabilitation. For instance, the Federal Government is participating in $140 million being paid annually to 140,000 disabled breadwinners of 370,000 dependent children; it is participating in the payment of $92 million to 159,000 permanently and totally disabled adults; it is contributing $63 million being paid to 98,000 needy blind. It is estimated that without something substantial being done to rehabilitate the persons who might be classified as "permanently and totally disabled” under this new category of public assistance that total expenditures may reach $300 million or $400 inillion annually. The greatest amount that the Federal Government has ever appropriated for rehabilitation of the handicapped is $23 million which has been made available for the 1953-54 fiscal year. Inasmuch as the values of rehabilitation in increasing the available manpower and production and in reducing dependency are well known, it seems axiomatic that the Federal Government does have a concern for the rehabilitation of the handicapped people of this Nation. It also appears that it has a responsibility to do more in the future to assist in the rehabilitation of the handicapped people than it has done in the past. Any other course would seem to be very shortsighted at this time.

STATE-FEDERAL PROGRAM OF REHABILITATION MUST BE MAINTAINED Continued progress in the rehabilitation of the handicapped, in our judgment, depends upon the following factors:

1. The State-Federal program of rehabilitation must be maintained and strengthened. Almost everyone intimately acquainted with the work of the State agencies recognizes that they are doing a good job with what they have to work with, but few of them are staffed and financed to do anywhere near what is expected of them. Since it is unrealistic to assume that the private rehabilitation agencies are going to be able to handle the burdens of rehabilitation by themselvs, and since it appears that the demand for rehabilitation services is going to increase rather than decrease, it appears inevitable that the State-Federal program of rehabilitation must remain the heart of the Nation's effort to rehabilitate the handicapped. The State-Federal program carries rehabilitation into every crossroads in the country. In many areas, in whole States, in fact, the rehabilitation counselor of the State-Federal pro

His

gram is the case finder, counselor, psychologist, and placement agent. knowledge of people and facilities enables him to do well an almost unbelievably difficult job. If rehabilitation is to move forward as we all hope it will, there must be more well-trained rehabilitation counselors and they must be given the tools to enable them to work more effectively.

In bills sponsored by the National Rehabilitation Association and now before this committee, we are making some suggestions with respect to amendments to the present State-Federal rehabilitation program which will remove certain restrictions that we believe serve to retard the progress of rehabilitation. They are in substantial agreement with similar proposals found in S. 2759. The problem is, however, fundamentally, one of money, and, of course, the personnel and services that money can make available.

Another reason that we feel that the Federal Government can afford to be liberal in financing vocational rehabilitation is that it is a pioneer program in so many respects. Although there has been a rehabilitation program since 1920, it is only in recent year that the potentialities for many of the severely handicapped have been realized. Important as the dividends of the present program may be, they are small, indeed, in comparison with the possibilities. For instance, the No. 1 problem of disability in this country is mental illness. It affects more people and costs taxpayers more money than any other disability. Medical science is making wonderful strides in curing mental illness. Mental health authorities agree that rehabilitation following definitive treatment is a must, if most desirable results are to be obtained. Yet, the rehabilitation of this group is in its infancy. Some States are hardly touching it at all. The Federal Government could profitably spend $10 million per year, matched or unmatched by the States, to encourage a determined effort to rehabilitate the mentally ill. The same might be said for other large groups that are hardly affected by rehabilitation as yet.

In our judgment, it will be many years before the Federal Government can assume that it has done its part to promote rehabilitation and consider a stabilization of the program.

REHABILITATION CENTERS

2. In the second place, progress in rehabilitation will, to a considerable extent, depend upon the availability of rehabilitation facilities wherein the severely handicapped may be rehabilitated. The rehabilitation center is such an

institution.

Reduced to its simplest terms, a rehabilitation center is a place where the various members of the rehabilitation team, physician, therapist, counselor, social worker, appliance fitter, etc., can cooperate in the practice of their special skills in the rehabilitation of the handicapped. All of us can remember when the fitting of an artificial limb, a relatively simple procedure in a rehabilitation center was a matter of great difficulty. The poor amputee was pushed from counselor, to physician, to limbmaker, until he was dizzy. If the limb didn't fit, the limbmaker blamed it on the physician for not having the stump in good condition, the physician was likely to blame the situation upon the limbmaker and the amputee was lost in the shuffle. As a result, surveys of the use of artificial limbs revealed that a high percentage of them were not being used at all. This team approach to the rehabilitation of the amputee has cleared up this problem to a great degree. Some types of the severely handicapped, the paraplegics for instance, need the services of the rehabilitation center even worse than the amputees, if this is conceivable.

The Federal Government has already demonstrated its interest in helping States to finance a hospital-construction program. It is not too much to expect that the Federal Government should now concern itself with assisting the States in the establishment of rehabilitation centers which can do so much to assist in the rehabilitation of the 2 million severely handicapped people of this country.

SHELTERED WORKSHOPS

3. In the third place, the expansion of workshop facilities for the severely handicapped will be of great assistance in assuring forward progress in rehabilitation.

Despite the progress in rehabilitation, there remain many people, 300,000 it has been estimated, who are too severely disabled to be placed in competitive employment. With respect to these people, this question must be answered. Shall they

be left idle and helpless in their homes or in tax-supported institutions, or shall they be given the opportunity to work to whatever degree they are able? From the standpoint of economics, the rehabilitation of this group is not as profitable as the rehabilitation of those who can take their place in competitive employment. They do not earn as much. They do not pay as much in taxes. The sheltered shops which we are suggesting for such individuals are not moneymaking institutions, in fact, they may lose considerable sums at times. It is usually necessary to have some sponsoring agency in the community which is willing to take the responsibility for such deficits as may exist.

On the other side of the picture, a considerable number of people who are employed in sheltered workshops develop to the extent that they can move out to other employment.

The human values are self-evident. We cannot allow human beings to be cast aside just because they cannot produce at normal rates. The respect we have for human dignity in this country demands that we give every citizen an opportunity to do his best.

Incidentally, in the management of sheltered workshops, care must be exercised to see that they do not become filled with people who could make a living elsewhere. Careful planning and firm administration are necessary to prevent such a situation from arising.

PERSONNEL FOR REHABILITATION

4. Fourth, it is axiomatic that rehabilitation work cannot be done unless there are people to do the work. At the present time, there is a great shortage of personnel in practically all professional areas of rehabilitation. Rehabilitation is unique in that there is no one profession whose members are trained to do a complete rehabilitation job. The successful rehabilitation of the severely handicapped depends upon the combined efforts of the physician, the physical therapist, occupational therapist, nurse, vocational counselor, and numbers of other professional people with equally specialized skills. In practically all of these areas, there are serious shortages. In any program designed to advance rehabilitation in the immediate future, provision must be made for recruiting and training professional workers.

RESTRICTIONS IN PRESENT VOCATIONAL REHABILITATION ACT

5. Fifth, there are certain restrictions which should be removed from the Vocational Rehabilitation Act in order to allow the State agencies to do a more complete job of rehabilitating the handicapped of the various States. For instance, an arbitrary limitation of 90 days hospitalization for any one disability mitigates against the rehabilitation of the severely handicapped who may require a longer period of hospitalization. The removal of this restrictive language would in no way endanger the basic operation of the program and would undoubtedly enable many of the severely handicapped persons now being denied service an opportunity to be rehabilitated.

The present law has also been interpreted so as to mean that Federal funds cannot be used to reimburse State agencies for personal services in connection with the management and supervision of homebound or other small-business enterprises. Neither can Federal funds be used to stock inventory for such business enterprises. A clear-cut statement in the law authorizing the agencies to render such services would be extremely helpful.

PRINCIPLES THAT SHOULD GOVERN FEDERAL PARTICIPATION IN A PROGRAM OF VOCATIONAL-REHABILITATION CENTERS AND SHELTERED WORKSHOPS

In our judgment, the following principles should prevail in a program of Federal assistance to the States for the purpose of establishing rehabilitation centers and sheltered workshops.

1. Federal financial participation should be based upon the needs of the States for assistance. We recommended the formula used to distribute funds under the Hill-Burton Construction Act.

2. Funds should be available to State governmental units and to private nonprofit corporations.

3. Preference for services in rehabilitation centers and workshops established with Federal assistance should be given to persons referred by the vocationalrehabilitation divisions, crippled-children services, workmen's compensation com