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I know that the committee will consider your views. Thank you

Nr. LANSTON. You are very gracious. And it is always a pleasure to see the chairman, I may add. .

Mr. SPENCE. If there are no further questions, you may stand aside. Thank you.

Mr. LANSTON. Thank you, sir.

Mr. SPENCE. Our next witness is Dr. Berwyn F. Mattison, executive director of the American Public Health Association.

Identify yourself, Doctor, and you may proceed. STATEMENT OF DR. BERWYN F. MATTISON, EXECUTIVE DIRECTOR,

THE AMERICAN PUBLIC HEALTH ASSOCIATION Dr. MATTISON. Mr. Chairman, and gentlemen.

My name is Berwyn F. Mattison. I am a physician, formerly secretary of health of the State of Pennsylvania, and presently executive director of the American Public Health Association, with headquarters in New York City.

I have a brief statement, Mr. Chairman. May I read the statement ?
Mr. SPENCE. You may read the statement.
Dr. MATTISON. Thank you, sir.
On behalf of the association, may I express our appreciation for the

I opportunity to appear before you and to discuss with you H.R. 5941 and H.R. 5944, identical bills, which would expand the public facility loan program of the Community Facilities Administration and which would make possible loans to public and nonprofit hospitals, to public nursing homes and to municipal facilities for water purification and sewage treatment.

The American Public Health Association is a professional organization of public health workers, totaling approximately 13,000 members from every State in the Union, and representing experienced public health leadership of all disciplines: medical, dental nursing, engineering, sanitation, and other related fields.

We have affiliated organizations in 41 States and with the membership of those affiliates constitute the largest professional public health organization in the world.

а.

SUPPORT OF NURSING HOMES

It is generally accepted that, with the substantial conquest of many of the illnessess of infancy and childhood, more and more of our population can be expected to live into the later years.

Similarly, it is generally accepted that, with so many of the acute diseases of both childhood and adult life well controlled, there will continue to be a proportionately greater number of people suffering from chronic diseases which have not yielded so readily to newer knowledge in medical and sanitary science.

Thus we may expect for some time to come a progressively aging population and an increasing proportion of ills falling in the chronic category. This means more long-term medical care either at home, in the hospital, or in some type of nursing home facility.

It is of interest that the national health survey has reported in 1957–58 an annual average of 6.8 contacts with doctors for persons

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65 years of age and over. This exceeds by 40 percent the average of 5.3 for the entire population.

Similarly and from the same survey, we know that the admission rate to short-stay hospitals is about 20 percent higher for persons aged 65 and over than for the total population.

Another survey carried out more recently by the University of Chicago indicates that, in a 4-week period, 7.4 percent of persons aged 65 and over required some type of personal care at home, including nursing care.

Actually, the figure for females in this age group went as high as 9.1 percent. These figures exclude institutionalized patients and are recorded simply to indicate the tremendous problem involved in providing medical and nursing care to the more elderly segment of our population regardless of where the care is provided.

Meanwhile, it is also widely known that hospital costs have been increasingly rapidly. Fortunately, care of many of the chronic diseases does not require all of the facilities of the modern general hospital, but may be adequately provided by a properly equipped and staffed nursing home or convalescent hospital.

At the end of 1958 the State plans submitted for Hill-Burton Act purposes showed a shortage of 253,000 nursing home beds for the Nation as a whole.

However, these nursing homes or chronic disease hospitals must never become the custodial type institutions that old folks homes or county poor farms were in the past. They must provide safe and sanitary surroundings, properly planned diets recognizing the special nutritional needs of the aged, adequate recreation facilities, and a staff of competent medical and nursing personnel.

Bearing these considerations in mind, the American Public Health Association at its 86th annual meeting in St. Louis, Mo., October 30, 1958, passed the following resolution:

Whereas there is a nationwide shortage of adequate facilities for the care of the chronically ill, and

Whereas achievement of effective health services for the chronically ill re quires the development of nursing home facilities operated where feasible as parts of, or in close affiliation with, approved hospitals, therefore be it

Resolved, That the American Public Health Association :

1. Urge State and local health departments to take such steps as may be necessary to raise the standards of nursing home care through establishment and enforcement of adequate licensure laws and through the provision of professional consultation services to nursing homes ;

2. Recommend that State and local health departments encourage the construction of suitable facilities for nursing homes and homes for the aged under the auspices of, or in affiliation with, approved hospitals;

3. Support proposals for provision of Federal aid through grants or loans for the construction of nonprofit nursing homes and homes for the aged which will meet State standards and such Federal standards as may be conditions for recepit of Federal aid ;

4. Encourage further efforts by insurance plans to develop extended benefit programs for patients who need care in a nursing home and other types of long-term care.

You will note particularly paragraph No. 3, which specifically supports proposals for Federal grants or loans for the construction of nonprofit nursing homes.

We believe that the assurance of good quality service should be paramount in any extension of nursing home facilities.

Extension of these facilities without adequate safeguards for the quality of the service provided might well end in fiery holocausts or the physical, mental and emotional deterioration of patients cared for by such additional institutions.

To prevent this, it is extremely desirable that, in addition to qualifications (A) and' (B) under paragraph 5. of section 205(a), there be specific provision that the facility qualifying for a Federal loan must meet standards of construction and operation satisfactory to the Public Health Service.

In many instances, such standards have been established through action of the various States.

a

MODERNIZATION OF METROPOLITAN HOSPITAL FACILITIES

The operation of the Hill-Burton program over the past several years has greatly encouraged the construction and operation of more adequate hospital facilities in rural areas.

However, its provisions have not been sufficient to take care of the more recent problems growing out of population movements from urban to exurban areas.

The obsolescence of some urban and suburban hospital facilities and the need for expansion of others requires some action such as that provided under the bills being discussed today.

Here the quality of care provided by any such renovation or extension of a facility is safeguarded by the provision included under paragraph (4) under section 202(b) providing that no assistance be extended involving an increase in beds unless the project is in conformity with the applicable State plan under section 623 of the Public Health Service Act.

We feel that with these safeguards the additional loan program thus provided would be of considerable help in making available adequate numbers of modernized hospital facilities to the population of many rapidly growing metropolitan areas.

GRANTS FOR WATER TREATMENT PLANTS AND SEWAGE TREATMENT PLANTS

The American Public Health Association went on record in 1958 as supporting an amendment to Public Law 660 to increase the total amount of authorized and appropriated moneys for sewage treatment.

This recognition of the need for more help to municipalities constructing sewage treatment facilities is paralleled by a recognition of the need for help in constructing modern water purification plants.

Here, too, the provisions of the new bills under discussion would appear to be highly desirable providing again that safeguards as to the technical quality of the facilities being constructed be included in the act.

Both with regard to water purification and sewage treatment the technical problems of assuring a safe water supply on one hand, and protection against stream pollution on the other, are becoming more and more difficult.

This is because of new industrial processes which are continually introducing different chemicals and physical pollutants into the effluents from their plants, as well as to the new hazard of radioactive materials appearing in the effluents of plants utilizing nuclear energy in one form or another.

This increasing complexity makes imperative the most careful screening of the plans of any contemplated water treatment or sewage treatment plant prior to authorization of a Federal loan for that purpose.

It would seem therefore that the bill should specifically provide for participation by the Public Health Service in the review of any applications for Federal grants for either of these purposes.

As a single example of the need for additional Federal help in the construction of sewage treatment facilities, let me quote the requests for grants from one State for the fiscal year 1958–59, amounting to something in excess of $1,600,000, with only 40 percent of that amount being available under the current provisions of Public Law 660.

Even if that law is amended to increase the amount of grants available, the need would still exist in many communities for the kind of help in securing loans or selling bonds which would be provided by these bills.

Particularly in those communities in depressed areas where their borrowing power is severely limited, the construction of new or modernized water and sewage treatment facilities may be difficult indeed.

In these instances the kind of help offered them by Public Law 660 is quite insufficient to initiate the actual construction of facilities. Provision of Federal loans under proper safeguards would be most helpful in these depressed areas.

In summary, it is my opinion that H.R. 5941 and H.R. 5944 should be amended to provide implementation of the expanded loan program through the U.S. Public Health Service in order to provide reasonably uniform and adequate safeguards to the health of the people who would be served by the expanded facilities made possible.

With that provision, I am sure that the additional funds thus made available for the construction of nursing homes, of hospitals and of water and sewage treatment plants could present a very significant contribution to meeting our health problems during the years just ahead.

Mr. Chairman, that is the end of my prepared statement. There are two or three comments which I should like to make, however, in view of some of the things which I have heard said this morning.

The chairman mentioned a few moments ago the need for water and sewage treatment plants in smaller population areas. I should like to add my personal experience in this regard.

I served in Pennsylvania for 3 years, up until about a year ago, as secretary of health, and I can think of several examples, but I will mention only one—the Wyoming Valley area of Pennsylvania, which is the area near Wilkes-Barre-a mining area which was experiencing, and is still experiencing difficult times.

In community after community in the Wyoming Valley, the health department attempted to secure the construction of proper sewage treatment plants, only to find that although the communities were willing, they had bumped their heads against the ceiling of their borrowing power in one fashion or another, and simply couldn't provide the necessary facilities.

And, gentlemen, this got to be a vicious circle, because in this particular area they were trying desperately to get new industry to come in, and we had several experiences, where new industry actually came to the Wyoming Valley, looked the situation over, and when they found that there was not adequate municipal water, and that there was not adequate sewage treatment, decided that they would go elsewhere.

I think this is an extremely important aspect of the help which would be provided by the bill now under consideration.

Now, with regard to the need for nursing home beds, we in the American Public Health Association, have done no national survey as to the need. I did mention the number of beds appearing in the State plans under the Hill-Burton Act—about a quarter of a million.

I would like to point out that the American Public Health Association is doing surveys, health surveys, in communities, every year. At one of the recent ones, which is still going on, in Bridgeport, Conn., the survey director told me just a few days ago that the nursing homes up there exhibited a peculiar phenomenon. In the higher cost beds, there were always a few available with either no waiting or only a short waiting period. But in the homes with medium or lower cost beds, there was always difficulty in getting a bed. People were waiting many months to get into these lower cost nursing homes.

I think it is just one more indication that there is a very real and pressing need for this type of facility which will increase gradually as our population increases in the older age brackets.

I think we could say that there is a definite need for more low-cost nursing home beds, particularly those closely related to general hospitals, or out-patient departments.

I would like to leave just one other thought with you, and that is that the whole provision of care for the chronically ill, like everything else, I guess, is not simple, and there are a series of facilities which can and should be considered when we talk about that problem.

First of all, you have your general hospital with its whole gamut of modern facilities for surgery and all kinds of diagnostic and treatment facilities.

Within that particular galaxy you have what is now coming to be known as progressive care, where in a general hospital you can start off with a complete care using all of these facilities, you can move then to another unit where less elaborate faciilties are available and therefore a lower per day cost, and from that you can move to an ambulatory or more or less self-service, cafeteria-type of service within the same hospital.

But this is just the first kind of institution. Below that, you have the nursing home, with complete or a fairly complete range of facilities. You have the boarding home with an infirmary. You have the boarding home without any infirmary facilities. You have home nursing care, which is being supplied in more and more communities. And then you have the homemakers service, where no nursing care is necessary providing you can get someone to come in who is skilled in taking some of the chores off the arthritic or other partially incapacitated adult.

My only point in bringing this up is that we need more nursing homes of different types, and the definition of nursing home is going to be extremely important. And this is one more reason why there should be screening by the Public Health Service of any such grants,

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