Senator LONG. You mentioned that some of the hospitals having a chronic department or division were competing with some of the private homes. Is there too much of a conflict there? Is there a need for both of those services? Or, if we had-most of the hospitals are crowded, general hospitals-if we had more nursing homes, would that relieve the condition in the general hospitals?

Mr. CHASTAIN. It would not only do this but it would cut the cost to the patient or the patient's family tremendously. In most instances, in the hospital, in the first place, they aren't concerned with the care of the elderly person like we are to begin with. They are more interested from the standpoint of a person comes in, she has a baby, they have been able to use their clinical facilities, X-ray et cetera, and the patient is gone. They don't have the time nor the training to give to these older people.

Mr. Chairman, these are human beings, and when we take the dignity of them being an individual away from them then you have nothing, and in nursing homes, even in our out-State areas where they lack proper training, they have something to give to these older people that you don't find in the cold atmosphere of a hospital.

Senator LONG. What types of recreation do you have in these nursing homes? Are these persons able to enjoy any types of recreation? Mr. CHASTAIN. Well, of course, there is a definite lack of recreational aspects to this program. Many of the nursing homes are able to, of course, they have radio, television, they have parties of different kinds, birthday parties, these are all important to older people. In my particular nursing home I have a bus that I take my people for rides and they go to Shaws Garden in St. Louis and they go to Grants Farm. A lot of the other nursing homes, of course, have other areas that they are able to work in. They make things, crocheting, things like this, where they are able to. Ceramics is something else that is quite interesting and the older people seem to take to this sort of thing.

Senator LONG. We have been told at some of our hearings that some of the homes have very definite programs of rehabilitation. Some of the doctors have told us that that is one of the important aspects of treatment and care of these patients. Do any of our homes in Missouri have any programs of that kind?

Mr. CHASTAIN. I would say yes, Mr. Chairman, that many of our homes do have a set program of rehabilitation. You find it perhaps more in your newer type homes where they have the facilities built in rather than a makeshift type thing that some of the older homes have to use. But whether it is in the new installation or the old installation, the important thing is to keep this older person interested in something so that they don't just sit and wait for the meal and then wait until time to go to bed. The thing that is interesting to one older person may not interest another older person at all, so you have to delve around until you find the thing that this particular person responds to and this is where our training in nursing homes comes in as being important.

Senator LONG. It is very important that they do keep some interest in something?

Mr. CHASTAIN. That is right, sir.

Senator LONG. Thank you, Mr. Chastain.

Mr. CHASTAIN. Thank you, sir, and it has been an honor to be here.

Senator LONG. Our next witness is Dr. John P. Ferguson, president of the Greene County Medical Society.

Doctor, it is pretty cold in here. I am afraid you are going to have some patients before the day is over.

STATEMENT OF DR. JOHN P. FERGUSON, PRESIDENT, GREENE COUNTY MEDICAL SOCIETY

Dr. FERGUSON. Senator Long, Congressman Hall, members of the staff, since you have so kindly introduced me I will go right on from there.

I have been a resident of Springfield all my life and a practicing physician here in Springfield for approximately fifteen and a half years. This year, in addition to serving my patients in this area, I have had the privilege of acting as president of the Greene County Medical Society, so it is in behalf of not only myself but of the doctors of this area who are members of the Greene County Medical Society that I want to express my appreciation to you and the committee for this opportunity of presenting this brief statement. I am going to reiterate some of the things that have been said to date, and I feel that they are important enough to go over them very briefly.

As you have heard from other witnesses, we feel that the nursing home picture here in Missouri, and in our area of the State, is particularly a very bright picture. We have, to repeat again, 17,830 licensed nursing home beds available in Missouri, and, according to the more recent statistics from the department of health, approximately 16,000, or 90 percent, of these beds are occupied. Likewise, you have heard that the average charge for nursing home care in Missouri is $100 a month at the present time.

The number of beds is likewise increasing. In 1957 it was estimated that there were 15,500 beds available in comparison to the 17,830 beds available today, or an increase of 2,330 beds. This has been about an average annual increase of 583 beds over the past 4 years. The total number of nursing home guests is likewise increasing, of course, and they have increased by approximately 450 a year. In 1957 prior to the passage of the Missouri nursing home inspection and licensing law there were 14,200 residences as compared to the 16,000 today.

Likewise, you have been told and know that every licensed home in Missouri has supervised medical care and the division of health is spending approximately $200,000 annually for the education and the instruction of these nursing home proprietors, and likewise, hopes to by those means to improve the standards of patient care. Of the nursing homes in the State 98 percent of all the beds are privately owned or operated and only 2 percent of the beds are operated by the State and county governments. Of this 2 percent, two of the homes are located here in Springfield and operated by our county court without State or Federal assistance. These are certainly model homes and, as we like to brag on our own community, show what we can do on a local level.

It is our belief that the nursing home picture in Missouri as to cost does not indicate a need for Federal intervention into this aspect as is outlined in proposals currently under consideration by Congress. It is not our position that nursing home care here in Missouri is perfect, but it is our position that the rate of progress being made in Missouri will more than keep up with the need and demand for nursing home services if the current rate of progress continues.

It is worthy to note also that there are 13 licensed nursing homes here in our county with 736 beds. The average cost per bed in this district per patient per month is $92.43 per month. I feel, however, that the most important thing that I have to present to you here as a witness today is a recent analysis made by a local general hospital of all of its unpaid bills, and this survey covers a period of the first 11 months of 1961. For the purposes of this study the patients were broken down into 5 age groups, 0 to 18, 19 to 21, 22 to 45, 46 to 64, and 65 and over. I will not read the table as such because you have it before you in your statement, except to point out that if you will note that the age group of 65 and over shows the best record of payment of any of the 5 age groupings in this study. The percentage of the people of 65 and over, there were only 15 percent of them who had unpaid bills in this 11-month period. This is in quite complete contrast to a double figure of those who, in the 0 to 21 age group, where there were, of course, approximately 30 to 31 percent of unpaid bills in this 11-month period.

To put it another way, this immediately illustrates the ability of the over 65 age group to meet their own responsibilities, and again, by age grouping, the percentage in the next table, and I will not read it word for word, the percentage of total billings paid and the total billings not paid, the results are shown. Again you will notice that the largest percentage of billing was in the 65 and over age group, but here again the greatest amount collected of people who paid their bills was in the 65 age group and over. Only 13 percent of those of 65 and over remain unpaid. This, of course, is in contrast to the 27 to 29 percent in the 0 to 21 age group. So we feel that by and large the people over 65 pay their bills better than any other segment of our population, and I think a great number of our merchants will verify this fact, not only in health care but in economics as well in the community.

(The table referred to follows:)

As a physician engaged in the practice of medicine I feel that we are not up here to debate a great issue of socialized medicine or anything of the sort. I feel that we are here to urge you and your committee to reject social security as an appropriate mechanism for providing proper health services to older people. I think we have done a very excellent job in the State of Missouri and I am proud of the way that Missouri is performing.

I would like to submit three fundamental reasons for my own particular position in feeling as I do. I feel that, first-and this is a restatement of some of the things that you have also heard—that to provide health benefits as distinct from cash payments to social security reccipients is a sort of affront, you might say, to the dignity and independence of this very large group of older people.

If benefits need to be increased to provide an adequate living standard in retirement, let them be increased, but let our older people receive more money, if Congress believes this is necessary, then let our senior citizens take care of themselves as free citizens. Older people, as you have likewise heard, do not want to be segregated from the rest of us and they do not want to be cared for directly by Government services.

Secondly, not only is the social security mechanism not wanted in this connection, it is plainly, to me, not the appropriate or economical means to achieve the stated goal. Everyone of us will agree, I am sure, that there is a place for Federal assistance to the aged people or persons who lack the resources to maintain a decent living standard and they do need some help in certain instances to pay for health care. It emphatically does not follow that to give direct service to all the older people regardless of need makes any sense whatever.

Third, and finally, following the social security approach could mean only the progressive adding of services and, inevitably, the extension of health services to other age groups until it supplants entirely the present vigorous system of voluntary and private mechanisms for prepayment of health care. I believe these are mechanisms that have grown as America has grown and that they are in the best tradition of our country.

With those remarks, Senator, I will conclude, and if you have any questions, I will try my best to answer them.

Senator LONG. Doctor, thank you very much.

Let me say to you and to our audience here, as I have said to these meetings before, some of the last part of your statement was dealing with the proposed King-Anderson bill, tying the particular program to social security. Technically that problem is not before this committee. Recommendations were made to the Congress last year and such legislation is now pending before the Finance Committee of the Senate and the Ways and Means Committee of the House. Although we have had some discussion of it, it is one of the subjects the senior citizens will more than likely discuss this afternoon.

We may have disagreements on the problem but I want to say to you and the other doctors, there is no one more bitterly opposed to socialized medicine than I am or would be. There is a difference of views sometimes as to what is socialized medicine, as I am sure you can understand. I don't want to go into detail in discussing that problem with you. As I say, technically it is not before the committee, but it is great, too, as I have said before, that you can come

to meetings of this kind and you can have different views. It is just like various different religions, we are all trying to get to Heaven, but we may take different routes.

There are two or three questions I would like to ask you about your statement that might be better clarified for the record.

I notice over on page 2 you mention that the nursing home picture in Missouri does not need Federal aid. I am very much interested in this problem in Missouri and I think our State government has made great progress since the disastrous fire in Warrenton. I have no information that Federal intervention has been proposed; that any such plans are true. Can you elaborate on that statement?

Dr. FERGUSON. It has been my feeling, maybe more than any actual information on such, that in any hearing by any Senate committee on any subject that there is a possibility that there might be the desire of the Federal Government to, by its mere hearing on such a problem, as we are having here today, nursing homes, to consider possible assistance to such nursing homes in Missouri or any other State.

Senator LONG. Under the general hospital bill for assistance and under our general housing and FHA program, it has been set up, and I believe in 1959 it was expanded, and the last Congress increased it and made it more liberal. That is the only information I had.

Dr. FERGUSON. I am thinking of additional control, sir, additional help.

Senator LONG. Doctor, in this particular area in the seventh district specifically, do you know whether or not there is sufficient nursing home beds? Of course, that's our main subject here today. Now, do you know whether there are sufficient beds in this district?

Dr. FERGUSON. I am not an authority on nursing home beds in this particular area. I am more conversant with the situation here in Greene County. Our district health officer, who is here in the audience, would be much better a man to answer that than I.

Senator LONG. There are five counties in the district where they have no homes. I was wondering if it branched further than that. Maybe we can get that from one of the other doctors.

Thank you very much, doctor, for your statement.

Dr. FERGUSON. Thank you, Senator.

Senator LONG. Dr. Kenneth Knabb, representing the Missouri Academy of General Practice.

STATEMENT OF DR. KENNETH E. KNABB, REPRESENTING THE MISSOURI ACADEMY OF GENERAL PRACTICE

Dr. KNABB. Senator Long, Congressman Hall, members of the staff, I am Kenneth Knabb, a resident of Springfield, Mo., where I have been a practicing family physician for the past 16 years. I appear before you today as a representative of the Missouri Academy of General Practice.

In behalf of the 600 physicians who represent the Missouri Academy of General Practice, I want to thank you for the opportunity of appearing here today and presenting this brief statement. As a family physician, taking care of all ages of patients in all groups, including those over 65, I would like to state that the financial problems of my patients are not set by the age in which they are in. I take care of these patients in all ages, including those who can pay nothing.