another patient who needs hospital care as distinguished from a nursing home hospitalization. COUNSEL. Then you foresee that this study would be designed primarily to determine ways and means and feasibility of utilizing facilities outside the VA system for the care of nursing care patients? Mr. HUGHES. Yes; and working out procedures and arrangements within the community, within the home community of the veteran for handling the problems of this sort. COUNSEL. You do not see any hope of this resulting in any greater utilization in the VA system of nursing care patients as a result of this study? Mr. HUGHES. We certainly do not see the study as leading to the establishment of either VA nursing homes or of payments to nonservice-connected veterans for nursing home care. COUNSEL. That is all. Mr. EVERETT. Mr. Meadows. Mr. ROBERTS. No questions. Mr. EVERETT. Mr. Roberts, any questions? Mr. ROBERTS. No questions. Mr. EVERETT. Mr. Schadeberg, any questions? However, I think the record should show I agree with the Bureau of the Budget that our first responsibility should be with the serviceconnected veterans and I am certainly 100 percent in agreement and I think the record should also show I am diametrically opposed to the Bureau of the Budget on this particular matter, but I would like to thank Mr. Hughes for being so forthright and perfectly clear in stating his position. I think it was a very forthright statement. Mr. EVERETT. Thank you, Mr. Hughes; we certainly enjoyed having you and thank you again for coming. Mr. HUGHES. Thank you, Mr. Chairman. Mr. EVERETT. The committee will meet at 10 o'clock tomorrow morning. (Whereupon, the subcommittee adjourned at 11:10 a.m. to reconvene at 10 a.m. Thursday, May 16, 1963.) INTERMEDIATE CARE FACILITIES THURSDAY, MAY 16, 1963 HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON INTERMEDIATE CARE OF THE COMMITTEE ON VETERANS' AFFAIRS, Washington, D.C. The subcommittee met at 10 a.m., pursuant to recess, in room 356, House Office Building, Hon. Robert A. Everett (chairman of the subcommittee) presiding. Mr. EVERETT. The subcommittee will come to order. We are happy to have with us this morning Dr. Jack C. Haldeman, Chief of the Division of Hospital and Medical Facilities, Bureau of State Services of the U.S. Public Health Service. He is here in response to my letter to Secretary Celebrezze, and we are happy to have him present the views of his Department. Dr. Haldeman was recently given the highest award of the Department of Health, Education, and Welfare; namely, its distinguished service medal in recognition of his outstanding contribution and service throughout his entire career in the Public Health Service, but with particular reference to his activities under the Hill-Burton Act, not only involving construction, but also the development of a research and demonstration project. He is unusually well qualified to present the views of his Department and we congratulate him on this high honor and look forward to receiving his testimony today. STATEMENT OF JACK C. HALDEMAN, M.D., ASSISTANT SURGEON GENERAL, AND CHIEF, DIVISION OF HOSPITAL AND MEDICAL FACILITIES, BUREAU OF STATE SERVICES, U.S. PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Dr. HALDEMAN. Thank you Mr. Chairman. Mr. Chairman and members of the subcommittee, I believe that I can best contribute to the subcommittee's consideration of the nursing home problem by placing in perspective the need and demand for longterm-care facilities, and the current and proposed programs of Federal aid in this field. Public concern with the problem of health care for the elderly has greatly intensified in the past decade. As the number of older persons in our population continues to increase, and the medical and nursing needs of this group have been identified, the availability or unavailability of resources to care for the chronically ill and aging has been brought into sharp focus. In many instances, the problems are just now being isolated and identified, and in other areas considerable progress has been made. Everyone concerned, however, recognizes that a formidable job lies ahead if our aged population is to be given the care and attention which they deserve. Our aged population now totals 17.3 million persons and is increasing at the rate of over 1,000 a day. More than 600,000 were in institutions at the time of the 1960 census, and of those not institutionalized or living with their spouse, about half were living alone or with nonrelatives. Many of the elderly have low incomes, and the resources they have may be strained by higher than average medical care costs. As age increases, the impact of chronic illness becomes more severe. More than 21⁄2 times the days of disability are reported for older persons than for those under 65. Hospitalization is more frequent and the hospital stay is longer. NURSING HOMES AND RELATED FACILITIES In a brief span of years, rapid developments have taken place in the provisions of nonhospital facilities for the chronically ill and aging. In 1961, according to a Public Health Service inventory, some 23,000 such facilities with a resident capacity for 592,800 persons, including 362,200 skilled nursing home beds, were providing nursing and supporting services to the aged and chronically ill-a 32-percent increase in capacity since 1954. Since 1954, skilled nursing care homes have increased from 7,000 to 9,700 and the total bed capacity has nearly doubled. Among the States, the supply of long-term-care beds varies widely. The 5 States best supplied have a ratio of 48.4 beds per 1,000 elderly, while the 5 States which are least well supplied have a ratio of only 9 beds per 1,000 elderly. It is estimated that, to bring all States to the level of the 5 highest States, over 500,000 additional long-termcare beds would be required. Ownership and size: In terms of ownership, publicly owned facilities are the largest with an average of 61 beds. The smallest homes are under proprietary ownership, their average number of beds being 24. Approximately 87 percent of the skilled nursing homes are owned by proprietary interests. Although accounting for nearly 9 out of 10 homes, the proprietary homes provide little more than 7 out of 10 beds. The size of skilled nursing care homes ranges from small establishments of fewer than 10 beds to large facilities of 500 beds and over. The majority are small, however, averaging about 25 beds, and usually are more than 80 percent occupied. Hospital affiliation: Studies by the Public Health Service in 1958 and 1959 revealed the need for closer relationships between hospitals and nursing homes. Demonstration projects of hospital-nursing home affiliation, undertaken as a result of these studies, gave concrete evidence that such arrangements can be effectively carried out. Moreover, these arrangements provide mutual benefits to both types of institutions in areas of administration, service, personnel training, and community effort. Operating costs and charges: Data available from various State and local surveys of nursing homes show a wide spread in operating costs per patient-day. Staffing, size of facility, level of care provided, and economic status of the area are among the factors which influence costs. Dietary and nursing service costs, based on studies in two States, account for about half of total operating costs. Monthly charges, as would be expected, also vary widely. A study of nearly 2,700 homes in 13 States indicated that charges increase with the size of a facility and with the severity of the patient's condition. LICENSURE PROGRAMS All States and territories, excluding Guam and the Virgin Islands, license nursing homes. All States, except Alabama, Guam, Puerto Rico, South Carolina, and the Virgin Islands, also license homes for the aged. A wide variation exists, however, among the standards which are applied in each State. A State which has a network of high quality nursing homes is in a position to apply high standards of maintenance and operation. The application of the same standards, however, in a State with large numbers of low quality nursing homes would close a high proportion of these homes, and deprive many needy aged persons of the security associated with those facilities providing only board, room, and some degree of personal care. For these reasons, many State officials, who are vitally interested in raising the standards of nursing home care in their State, find themselves hooked on the horns of a licensure dilemma. CHARACTERISTICS OF NURSING HOME PATIENTS Certain basic facts regarding the characteristics of patients in nursing homes can be obtained from studies made in this area. The very elderly predominate among nursing home patients. Their average age is in the neighborhood of 80 years. The majority have some heart or circulatory condition and a significant proportion have had fractures, in most cases of the hips. Two out of every 10 are confined to bed and only 5 out of 10 can walk alone, sometimes helped by a cane or crutch. More than half have periods in which they are mentally confused. In general, they have been patients in the home for a year or longer. Although determination of the level of care reported as needed by nursing home patients is highly subjective, studies have indicated that a substantial number of patients may require less than skilled nursing care. This is not to imply that they should not be in the nursing home, but it is indicative of the diverse nature of services provided by these facilities, ranging from strictly boarding care to skilled nursing services. FEDERAL AID PROGRAMS-PUBLIC ASSISTANCE PROGRAMS Public assistance funds aid in the payment of care for many nursing home patients. Although State and local public welfare agencies, traditionally, have made provision for some medical care to indigent persons, it was not until fairly recent years that the Federal Govern ment assumed a role in providing general medical care for the needy. Today, nursing home care is one of the medical services for which there is Federal sharing in State expenditures for assistance programs under the Social Security Act. During fiscal year 1962, vendor payments for medical care of old-age assistance recipients totaled $350.7 million, an increase of $56.6 million from the preceding year. Identified payments for nursing home care represented 33 percent of all vendor payments. Inpatient hospital care represented 34 percent. Mr. EVERETT. Doctor, under the Kerr-Mills bill you are paying the States for nursing care in helping these older people? Dr. HALDEMAN. Yes. Under the Kerr-Mills bill there were two provisions, one which I will speak to in a minute, but it also had a provision for increasing the vendor payments under the old-age assistance program as well as creating the new category for medical assistance for the aged. Mr. EVERETT. Did you have something before the Kerr-Mills bill? Dr. HALDEMAN. Under the public assistance program there was a program for medical care for the aged. The Kerr-Mills bill expanded this. Mr. EVERETT. Before the Kerr-Mills bill was passed, did every State participate in that program? Dr. HALDEMAN. I am not sure but my impression is that every State did not. Under Kerr-Mills only about 29 States have taken advantage of the provision of the Kerr-Mills bill which would provide for the new category for medical assistance for the aged. Mr. EVERETT. Will you furnish that for the record, the States that did participate in the old-age assistance and also the States that are now participating under Kerr-Mills. Dr. HALDEMAN. I would be glad to. Twenty-nine States and territories are now participating in the medical assistance for aged program. Forty-three States and territories were providing assistance under the medical portion of OAA (old-age assistance) prior to Kerr-Mills. Mr. ROBERTS. Doctor, actually some of the States that are not participating in the Kerr-Mills bill have legislatures meeting, and the reason they did not participate is that their legislatures have not met since the Kerr-Mills bill. Dr. HALDEMAN. I think that is correct. I know there are a number of States that have not enacted Kerr-Mills legislation that are in the process of doing so. Mr. ROBERTS. If you had that information-those that are in process-in your report, it would be helpful to put it in so we can see whether they are actually trying to take advantage of it. Dr. HALDEMAN. I will supply it for the record. (The information requested follows:) Seven States have had enabling legislation passed and in five other States the enabling legislation has been introduced. Mr. EVERETT. Mr. Secrest? Mr. SECREST. No questions. Mr. EVERETT. Mr. Patterson? COUNSEL. I wonder if the doctor could give us the scale of benefits by State. |