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 needing 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 cannot 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 average monthly maximum recommended for medical care in recommendation 3. 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.

5. Federal funds should not be available for any public assistance program in which the State imposes residence requirements as a condition of eligibility for assistance, except that States should be allowed to impose a 1-year residence requirement for old-age assistance

The Social Security Act provides that a State plan for old-age assistance or aid to the blind may not require, as a condition of eligibility, residence in a State for more than 5 of the 9 years immediately preceding application and 1 continuous year before filing

7 One member of the Council felt that States should be allowed to impose up to a 5-year-residence requirement in the old-age-assistance program.

the application. For aid to dependent children, the maximum requirement for the child is 1 year of residence immediately preceding application, or, if the child is less than a year old, birth in the State and continuous residence by the mother in the State for 1 year preceding the birth.

In old-age assistance, of the 51 jurisdictions with federally approved plans, 27 have a 5-year residence requirement. Three States require residence within the State for 3 years, 1 for 2 years, and 16 for 1 year. Four States (Kentucky, New York, Rhode Island, and Utah) have no residence requirement imposed by statute or regulation.

In aid to the blind, of the 47 jurisdictions receiving Federal funds, 21 have a 5-year requirement; 2 require 3 years; 2 require 2 years; 17 require 1 year; and 5 have no requirement. The five States with no requirement are Mississippi and the four listed above as having no residence requirement for old-age assistance. Many other States waive the residence requirement in aid to the blind for applicants who become blind while residing in the State.

In aid to dependent children, of the 50 jurisdictions with approved plans, 8 States have no residence requirement: Alabama, Georgia, Kentucky, Mississippi, New York, Rhode Island, Wisconsin, and Utah. The others have a 1-year requirement. (See appendix A, table 15.)

In general assistance, which is financed solely from State and local funds, there is of course no Federal requirement and practice varies widely. Legal settlement in the community as well as State residence is often required. The settlement requirement not only makes it necessary for the applicant to have resided in the community for a specified period of time, but may require him and all members of his family to have been self-supporting, or at least not to have been dependent on public funds for support during any part of such time. In communities with such a rule, the receipt of any amount of public aid during a qualifying period prevents the recipient and his family from gaining legal settlement and thereby from becoming eligible for continuing assistance.

Under one State law, if the local public assistance office believes that a newcomer to a community may not retain his job and may need assistance, he may receive a "notice to depart." Such notices disqualify the person for general assistance for 2 years, and the notice is subject to renewal.

Residence and settlement laws result in unwarranted hardship for needy persons, not only because these laws are sometimes invoked by welfare administrators for the purpose of "shipping back" needy persons to the communities where they "belong," but also because persons often lose their residence and settlement in the State in which they once had such status before they can acquire it in another. They "belong" nowhere under the statutes of the respective States.

In our society, mobility of population is essential. Individuals should be free to move where jobs are available and if, as a result of illness or other misfortune, they become needy, they should not be

denied assistance because they have crossed State or county lines. We believe that residence and settlement provisions are socially ALL unjustifiable.

In the programs for aid to dependent children and aid to the blind, immediate steps should be taken to require the States to abolish residence requirements. Elsewhere in this report we have recommended that the Federal Government participate in the costs of a State-Federal general assistance program to aid those persons to whom no other means of support is available. We believe that it is essential, if such a program is to fulfill its purpose, that the States be prohibited from imposing any residence or other artificial barriers to eligibility for general assistance.

We recognize, however, that the States into which older persons move because of favorable climate and which have relatively adequate assistance for the aged, fear increased financial liability if residence requirements should be eliminated entirely for old-age assistance. Therefore, we have recommended that the States be authorized to impose, if they desire, a residence requirement of not more than 1 year for old-age assistance.

6. A commission should be appointed to study current child health and welfare needs and to review the programs operating under title! of the Social Security Act relating to maternal and child health services, services for crippled children, and child welfare services. The commission should make recommendations as to the proper scope of these services and the responsibilities that should be assumed by the Federal and State Governments, respectively More fully to meet the needs of children in two important areas, the Council has recommended increased insurance protection for children under old-age and survivors insurance and has recommended also that the Federal share in payments for aid to dependent children be made comparable to that in payments to needy aged and needy blind persons.

In addition, the Council received information on further needs of children which, the Council believes, would require direct health and welfare services rather than the cash payments with which it has been primarily concerned. Accordingly, the Council recommends appointment of a special commission which should include specialists in child health and welfare services to appraise currently unmet needs of children and to determine how these needs may best be met. Consideration should be given to such questions as: What constitute the essential features of an adequate maternal and child health program and an adequate child welfare program? Should necessary and welfare services be provided to all children and mothers or should they be limited to those whose families cannot afford to pay for the services? Is the present scope of maternal and child health and welfare services sufficiently broad or should new services be instituted? Should new or expanded services be supplied by govern mental agencies, by voluntary agencies, or by both acting together?

health

According to information supplied to the Council by the Children's Bureau, many children are now in great need of health and welfare services for whom such services are not available or are wholly inadequate. Among the health needs which that Bureau feels are most urgent are those arising from

(1) Inadequate health services for both mothers and children; these services are lacking in many areas, particularly in rural communities.

(2) Rheumatic fever; some 500,000 children are suffering from rheumatic fever.

(3) Premature birth; some 150,000 infants are born prematurely each year.

(4) Lack of dental care; some 20,000,000 children are in urgent need of dental attention.

(5) Cerebral palsy; between 100,000 and 160,000 children have cerebral palsy.

(6) Physical and mental defects; many children of school age lack provision for medical examinations and for the correction of handicapping conditions found.

(7) Inadequate supply of professional personnel; nearly all parts of the United States lack a sufficient number of pediatricians, public-health nurses, and medical social workers to provide adequate health services for children.

Among the welfare services which the Bureau feels are most urgent are those arising from the lack of

(1) Adequate boarding home care for children in need of such care 60,000 children are now receiving care in boarding homes under public auspices, and many communities have insufficient funds to provide adequate care.

(2) Proper detention or temporary shelter care for childrensome 300,000 children annually receive detention care, a large proportion under very unfavorable circumstances.

(3) Facilities and services for the day care of children of working mothers; approximately 2,000,000 women with children under 10 years of age were in the labor force in February 1946.

(4) A sufficient number of child welfare workers and other qualified personnel in many parts of the country, particularly rural areas.

Unmet health and welfare needs among children are of the gravest consequences to the Nation. Such needs, if ignored too long, may necessitate more expensive and less effective treatment later. If child health and welfare services meet these needs promptly and constructively, however, incalculable gains in physical strength and efficiency, in personal adjustment, family solidarity, vocational aptitude, and more satisfying and useful lives can be realized. The Council believes that, after extended inquiry, a commission such as that suggested here would be able to formulate farseeing plans on which may be built a sound long-range program for the Nation's children.