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AMERICAN HOSPITAL ASSOCIATION,

Washington, D.O., June 29, 1960. Hon. HARRY FLOOD BYRD, Chairman, Senate Finance Committee, Senate Office Building, Washington, D.O.

DEAR SENATOR BYRD: Thank you for your acknowledgment of my letter to you of June 21 in regard to H.R. 12580 and the particular provisions of that bill which would renove the exemption of medical interns from OASDI coverage. I reiterate our hope that your committee will delete these provisions from the bill.

There is one other provision of this bill upon which we would like to comment. This is title VI entitled “Medical Services for the Aged.”

This provision is in accord with two principles long advocated by this association. The first of these is the earmarking of funds to be spent for health services to needy groups, through the method of vendor payments, so that such funds are not administered in competition with funds needed to meet the other necessities of life of such persons. We believe that this approach is likely to improve health planning for the recipients and will prove an important means of encouraging even greater responsibility on the part of the State and local health agencies in relation to the services to be provided. Thus, improvement in the quality of care rendered should result.

This association has also long advocated that recognition be given to the need for financial assistance in meeting the health care costs of many individuals who do not need assistance for their normal expenses of living. This refers to the group usually called the medically indigent. We are pleased that the bill also would provide further Federal matching to States which improve their health care programs for the indigent aged.

We believe that title VI of H.R. 12580 would further encourage States to develop programs making health services available to the medically indigent as well as the indigent among the aged.

We would appreciate your including this letter in the record of your hearings on the bill. Sincerely yours,

KENNETH WILLIAMSON, Associate Director.

AMERICANS FOR DEMOCRATIC ACTION,

Washington, D.C., June 27, 1960. Hon. HARRY FLOOD BYRD, Senate Office Building, Washington, D.C.

DEAR SENATOR BYRD: We write in support of legislation which would utilize the social security system to provide medical insurance for the aged—the principle contained in H.R. 4700, sponsored by Representative Forand, and S. 3503, sponsored by Senator McNamara.

As a group of physicians, our support for the Forand bill is dictated by a belief that social insurance against the costs of illness is in the best interests of the patient and the medical profession, as well as the Nation.

The facts about the inadequate income and huge medical needs of older people have been presented in detail to congressional committees and are well enough known not to need repetition here. It is equally clear that private insurance plans are not, and cannot be, sufficient to meet the requirements of older people as a group. We have had enough experience with these plans to know that the “poor risk” designation of this group leads inevitably to inadequate coverage, exorbitant premiums, cancellation of insurance, or a combination of all three.

The medical and hospital costs of older people can be made self-supporting only if they can be averaged out by level premiums over the adult lives of the insured and the risk distributed as widely as possible. For such a purpose, the OASDI system is uniquely suitable. Use of the social security system is fair and equitable because no person can claim immunity from the need for protection against the infirmities of age, illness, and loss of income.

Legislation proposed by the administration, Senator Javits, and others as an alternative to the Forand approach is inadequate and impracticable. These measures would impose a means test as a prerequisite for coverage and would place a large financing burden on States unable to meet it. The difficulties

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imposed by widely dispersed private administration of the plan and the need to negotiate contracts with a multitude of insurance carriers are overwhelming and unnecessary.

As physicians, we approach this as a problem of health. The prime objective of a health program for any part of the population is to keep people well, out of the hospitals, and to meet their medical needs fully as they arise. Under present conditions of neglect, patients often receive attention only in emergencies when medical treatment may prove least effective and the drain upon the resources of hospitals is a serious threat to the quality and availability of needed services.

In this respect, the hospital coverage provided by the Forand bill, while perhaps a necessary first step, is by no means an adequate solution. If the emphasis is to be upon prerentive medicine, a workable program requires the inclusion of outpatient as well as inpatient services, nursing, and personal services in the home and measures for rehabilitation. Senator McNamara's bill, which places more emphasis on preventive medicine, thus is to be preferred. Investment in such a program would be more than repaid in its contribution to the health and human resources of the Nation.

We welcome the Forand-McNamara measures as a useful first step in meeting a paramount problem of our society, and we urge you to work for their passage. We feel confident that Congress will not permit itself to be immobilized by slogans which were outdated when social security became a fact a quarter of a century ago.

Sincerely yours,
Herbert K. Abrams, M.D., Medical Director, Union Health Service,

Inc., Chicago, Ill. ; E. M. Bluestone, M.D., New York, NY; Morris
Brand, M.D., Medical Director, Sidney Hillman Health Center,
New York, N.Y.; Allan M. Butler, M.D., Professor of Pediatrics,
Harvard Medical School, Chief of Children's Medical Service,
Massachusetts General Hospital, Boston, Mass. ; Martha M. Eliot,
M.D., Professor of Maternal and Child Health, Emerita, Harvard
Srhool of Public Health, Cambridge, Mass. ; Frank F. Furstenberg,
M.D., Medical Director, Outnatient Department, Sinai Hospital of
Baltimore, Md.; Palmer H. Futcher, M.D., Baltimore, Md.;
Franz Goldman, M.D., Associate Professor of Medical Care,
Emeritus, Harvard School of Public Health, New York, N.Y.;
Alan F. Guttmacher, M.D., Obstetrician & Gynecologist-in-Chief,
the Mount Sinai Hospital, New York; Manfred Guttmacher, M.D.,
Chief Psychiatrist, Supreme Court Bench, Baltimore, Md.; Ursula
M. Hober, M.D., Chief, Department of General Practice, Woman's
Hospital, Philadelphia, Pa.; Philip M. LeCompte, M.D., Path-
ologist, Faulkner Hospital, Clinical Assistant Professor, Harvard
Medical School, Boston, Mass.; Louis Leiter, M.D., Chief of Medi-
cine, Montefiore Hospital, New York, N.Y., Edward C. Mazique,
M.D., President, National Medical Association, Washington, D.C.;
Raymond C. McKay, M.D., Associate Clinical Professor of Medi-
cine, Western Reserve University, Cleveland, Ohio ; James Howard
Means, M.D., Professor Emeritus, Harvard Medical School, former
Chief of Medical Services, Massachusetts General Hospital,
Boston, Mass.; Frederick D. Mott, M.D., Executive Director,
Community Health Association, Detroit, Mich. ; Milton I. Roemer,
M.D., Associate Professor of Administrative Medicine, Cornell
University, Ithaca, N.Y.; Leonard S. Rosenfeld, M.D., Metropoli-
tan Hospital, Detroit, Mich. ; William A. Sawyer, M.D., Medical
Consultant, International Association of Machinists, Washington,
D C.; Alfred S. Schwartz, M.D., Clayton, Mo.; George Silver, M.D.,
Chief of Social Medicine, Montefiore Hospital, New York, N.Y.;
Benjamin Spock, M.D., Professor of Child Development, Western
Reserve University, Cleveland, Ohio; Park J. White, M.D., St.
Louis, Mo.; Ernst Wolff, Senior Pediatrician, Mount Zion Hospi-
tal, San Francisco, Calif.; Harry Zimmerman, M.D., Chief of
Pathology, Montefiore Hospital, New York, N.Y.; Martin
Cherkasky, M.D., Director, Montefiore Hospital, New York, N.Y.;
Rirhard L. Riley, M.D., Baltimore, Md. ; Albert I. Mendeloff, M.D.,
Baltimore, Md.

BELLAIRE, OHIO, June 29, 1960. HARRY BYRD, Chairman, Senate Finance Committee, Washington, D.C.:

Would like to appear before committee to testify for health care for aged through contributory social security system. If committee schedule too busy for me to be heard would like this wire read into record.

Dr. MURRAY B. HUNTER, Bellaire Clinic.

AMERICAN NURSES' ASSOCIATION, INC.,

New York, N.Y., June 24, 1960. Hon. HARRY FLOOD BYRD, Chairman, Committee on Finance, U.S. Senate, Washington, D.C.

DEAR SENATOR BYRD: In 1958, the House of Delegates of the American Nurses' Association, recognizing that certain groups in our population, the aged, retired, and disabled, do not have lequate pro ion against the financial hazards of illness, adopted a position supporting the extension of the social security system to include health insurance coverage for these beneficiaries of the program. In May of this year, in convention, the house of delegates emphatically reaffirmed this position.

In 1958 and 1959, ANA testified on bills sponsored by Representative Forand (Democrat, Rhode Island), approving in principal the proposals in these bills but pointing out the need for including nursing benefits under social insurance and calling attention to the lack of standards for nursing homes and effective regulations to insure safe care. A copy of our 1959 testimony is attached to this letter and we request that both be included in the hearings you are conducting.

We have been gratified that recent proposals introduced in the Senate have included nursing benefits and diagnostic, preventive, and rehabilitation services. We are also pleased that legislators are aware that the quality of care in nursing homes needs to be upgraded substantially.

In taking the position in support to the extension of social security to include health insurance coverage, the ANA indicated its concern for the health needs and related financial problems of many millions of Americans and its recognition that nurses have small incomes and on retirement will also be faced with the problem of maintaining a decent standard of living and securing needed medical care services.

We believe that using the social security mechanism to solve the problem of financing health care is more reasonable, dignified, and appealing to the people of this country than a solution that requires the States to participate in what is another, and very limited, program of public assistance. Sincerely yours,

Mrs. JUDITH G. WHITAKER, R.N.,

Executive Secretary.

STATEMENT OF JULIA C. THOMPSON, WASHINGTON REPRESENTATIVE, AMERICAN

NURSES' ASSOCIATION The American Nurses' Association is the national organization of over 190,000 registered professional nurses in 54 constituent State and territorial associations. As one of the professional groups deeply concerned with providing health care for the American people and as the largest single group of professional persons giving that care, we welcome this opportunity to present our views on the proposal before this committee.

In the interest of society at large and in the interest of its members, the American Nurses' Association has supported the Social Security Act and extensions and improvements in the contributory social insurance which it provides. In 1956, the ANA supported the eligibility of insured individuals over 50 years of age for disability benefits and at the same time supported the proposals for lowering the retirement age limit for women to 60.

The American Nurses' Association now supports the extension of contributory social insurance to provide health insurance benefits for the beneficiaries of oldage, survivors, and disability insurance. The position of the ANA on the measure before you can best be stated by reading to you a resolution, approved by the ANA House of Delegates at its convention in June 1958 :

Whereas necessary health services should be available to all people in this country without regard to their ability to purchase; and

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: Therefore be it

Resolved, That the American Nurses' Association support the extension and 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 tarsupported public relief for health care-a dependency which is distasteful and degrading for citizens of this country.

Insofar as it provides health insurance coverage for beneficiaries of old-age, survivors and disability insurance, ANA 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 homeçare 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 slows that of the 366 nursing visits made, 272 were 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 Visiting Nurse Association of New York and the Visiting Nurse Association 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 serivces in prepaid medical care plans which we will he 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 professional 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 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 1,300,000 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 QASDI. In one city, the number of employees covered by retirement plans in which the hospital participated was as low as 242 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.

ASSOCIATION OF CASUALTY & SURETY COMPANIES,

New York, N.Y., June 24, 1960. Re H.R. 12580, duplication of workmen's compensation and social security dis

ability benefits.
Hon. HARRY F. BYRD,
U.S. Senator, Senate Office Building,
Washington, D.C.

DEAR SENATOR BYRD: The above captioned bill would, among many other amendments to the Social Security Act, considerably increase the area of duplication of social security benefits and workmen's compensation. On behalf of our

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