Summary: Discusses eligibility for OAA payments in public institutions, Recommends expansion of program to pay for care in nursing homes.
The following text is an excerpt from a 1948 report of the Advisory Council on Social Security which resulted in major changes in the Social Security legislation in 1950. This excerpt explains why the Old Age Assistance program in 1935 excluded payments to individuals in public institutions, and recommended that OAA be expanded to be made available to public institutions that provide medical, rather than domiciliary, care. It also recommended expanding assistance payments to pay for care in nursing homes, and creating a system of state oversight of nursing homes.
Recommendation 4. Care of the Aged in Medical Institutions
The Federal Government should participate in payments made to or for the care of old-age-assistance recipients living in public medical institutions other than mental hospitals. Payments in excess of the regular $60 maximum made to recipients living in public or private institutions or made by the public-assistance agency directly to these institutions for the care of aged recipients should be included as a part of medical-care expenditures under recommendation 3, page 112**. To receive Federal funds to assist aged persons in medical institutions under either public or private auspices, a State should be required to establish and maintain adequate minimum standards for the facilities and for the care of persons living in these facilities. These standards should be subject to approval by the Social Security Administration.
Many recipients of old-age assistance suffer from chronic ailments and some of these conditions require prolonged treatment in medical institutions. Private institutions and commercial nursing homes with charges within the financial reach of recipients of old-age assistance do not have sufficient capacity to provide for all recipients need- in care in medical institutions. In some communities, public medical institutions could care for these aged persons if the Federal Government were to bear a share of the cost. Moreover, if Federal funds were available for this purpose, communities would be stimulated to develop additional facilities for the care of chronically ill persons and to improve the quality of care in such facilities.
Care for aged and chronically ill persons is a growing problem and in the opinion of the Council is a Federal concern. Today more than 350,000 recipients of old-age assistance are bedridden or are so infirm as to require considerable help in eating, dressing, and getting about indoors. Of them, about 50,000 are living in commercial boarding or nursing homes or private institutions. Some of these persons living in such homes or institutions are getting very unsatisfactory care. Of those living in their own homes or with others, many need prolonged treatment in medical institutions.
As the number of aged persons in the population grows, the number needing nursing-home and other services for the chronically ill will also rise. Since the passage of the original Social Security Act, the number of persons aged 65 and over has increased from about 8,000,000 to nearly 11,000,000. In another 25 years there will probably be almost twice as many aged persons in the United States as there are today.
Care of chronically ill persons in medical institutions is necessarily expensive. A needy person without ‘some additional resources can- not obtain satisfactory care with an assistance payment limited to $50 a month. In Connecticut in 1946, for example, the average cost of nursing-home care for the aged was $118 a month.
We believe, therefore, that the Federal Government should participate in monthly amounts in excess of $50 paid to old-age-assistance recipients living in medical institutions, including commercial nursing homes meeting prescribed standards, and should participate also in payments made by the State or local agency directly to such institutions for the care of aged recipients. Such expenditures should be classified as medical-care costs and should be included in the aver- age monthly maximum recommended for medical care in recommendation 3 (p.112).** Thus the Federal Government would share in individual payments beyond the regular maximum, but total Federal expenditures for medical care, including care of aged persons living in private or public medical institutions, would be limited to a monthly average of $6 per recipient for the program as a whole.
In writing the Social Security Act, Congress prohibited Federal participation in payments to persons living in public institutions. In so doing, it sought wisely, we believe, to discourage care of needy persons in almshouses. In many localities in the Nation, persons unable to support themselves previously had no choice but to go to the almshouse. We believe that it would be desirable to continue for the present to prohibit Federal sharing in assistance to recipients of old-age assistance in public domiciliary institutions. This recommendation therefore is limited to medical institutions. Although some States have developed public homes supplying a very high quality of care, there is still danger that in other States, Federal participation in the cost of domiciliary care would encourage the continuance or return of the almshouse. Safeguards should be imposed by statute and by regulations of the Social Security Administration to preclude the use of the old-fashioned “poor house ”for recipients of old-age assistance. Safeguards would also be needed to protect the rights of recipients to live where they choose, without pressure to live in institutions if they do not wish to do so.
At present the Social Security Act does not require States giving assistance to persons living in private institutions or nursing homes to establish any standards for the operation of such facilities. Some of the private institutions and nursing homes in which recipients are living offer a very poor quality of care and do not properly protect the health and safety of the recipients. We believe that, as a condition of eligibility for Federal funds, a State aiding needy aged persons in public and private medical institutions and commercial nursing homes should be required to have an authority or authorities that would establish and maintain adequate minimum standards for institutional facilities, and for the care of aged persons living in these facilities. The Social Security Administration should, before approving the standards established by a State, assure itself that the recipients of old-age assistance residing in private and public medical institutions and commercial nursing homes will receive adequate medical and nursing services and that their safety will be adequately protected. For institutions, both private and public, to be considered as medical institutions under this recommendation, the institutions should maintain and operate facilities for the diagnosis, treatment, or care of persons suffering from illness, injury, or deformity, and be devoted primarily to furnishing medical or nursing service.
It is estimated that the additional annual cost to the Federal Government under this recommendation would range from a low of $20,000,000 to a high of $32,000,000.These amounts have been included as part of the estimated cost for medical care under recommendation 3 (p.112).**
* The Federal Government now shares in money payments to aged individuals living in private institutions, but it does not share in aid to persons who are living in public institutions, unless they are receiving only temporary medical care. Persons in public mental hospitals would not generally be competent to handle their own payments and are therefore excluded from this recommendation.
** Author's note: "Recommendation 3 on page 112" was a general recommendation to provide medical care to recipients of Old Age Assistance.
Advisory Council on Social Security, Recommendations for Social Security Legislation: The Reports of the Advisory Council on Social Security to the Senate Committee on Finance. 80th Congress 2nd Session, Document NO. 208, 1948.