lOTtfilfll REPORT TO SIXTY-FOURTH GENERAL ASSEMBLY SPRINGFIELD, ILLINOIS JUNE 7, 1945 DWIGHT H. GREEN Governor COMMITTEE TO INVESTIGATE CHRONIC DISEASES AMONGJND1GENTS OF THE SIXTY-THIRD GENERAL ASSEMBLY iii tmi in fitpom TO SIXTY-FOURTH GENERAL ASSEMBLY SPRINGFIELD, ILLINOIS JUNE 7, 1945 DWIGHT H. GREEN Governor COMMITTEE TO INVESTIGATE CHRONIC DISEASES AMONG INDIGENTS Established by Act of the Sixty-third General Assembly MEMBERS OF THE COMMITTEE SENATOR ARTHUR J. B1DWILL, Chairman River Forest SENATOR T. MAC DOWNING Macomb SENATOR ALBERT L. SCHWARTZ Chicago (Replacing former Senator J. Will Howell who served the first year) REPRESENTATIVE DAN DINNEEN Decatur REPRESENTATIVE GEORGE G. NOONAN Chicago REPRESENTATIVE WILLIAM ROBISON Carlinville BRIGADIER GENERAL CASSIUS POUST Director, Department of Public Welfare, ex officio Sycamore (Replacing Rodney H. Brandon who served until May 9, 1945) i PERSONS ATTENDING THE PUBLIC HEARINGS HELD IN SPRINGFIELD, ILLINOIS The Reverend John W. Barrett, Chairman, Committee on Legislation and Govern- ment Relations, Illinois Hospital Association. Miss Pearl Bierman, Medical Consultant, Illinois Public Aid Commission. Mr. Willard L. Couch, Assistant Deputy Director, Mental Hygiene Service, Depart- ment of Public Welfare. Mr. Roger K. Frandsen, Assistant Deputy Director, Social Services, Department of Public Welfare. Mr. Raymond M. Hilliard, Public Aid Director, Illinois Public Aid Commission. Miss Anne Hinrichsen, Informational Representative, Illinois Public Aid Commission. Mr. Frank W. Hoover, President, Illinois Hospital Association. Miss Mary Humphrey, Board of Public Welfare Commissioners. Miss Mary-Claire Johnson, Administrative Assistant, Illinois Public Aid Commission. Mr. George J. Klupar, Commissioner of Welfare, City of Chicago. Mr. Lawrence J. Linck, Executive Director, Illinois Commission for Handicapped Children. Mr. Russel! McKay, President, Illinois Convalescent and Nursing Homes Association Mrs. Russell McKay. Miss Edna Nicholson, Director, Central Service for the Chronically 111, Chicago. Mrs. Eleanor F. Proctor, Chief, Division of Standards and Services, Illinois Public Aid Commission. Mr. Robert Rosenbluth, Consultant, Illinois Public Aid Commission. Mr. Edward L. Scheibel, President, Illinois Association of Township Supervisors and County Commissioners. Dr. Conrad Sommer, Deputy Director for Mental Hycjiene Service, Department of Public Welfare. ii TO THE SENATE AND HOUSE OF REPRESENTATIVES SIXTY-FOURTH GENERAL ASSEMBLY STATE OF ILLINOIS The Committee to Investigate Chronic Diseases Among Indigents, which was created by the Sixty-third General Assembly, has the honor of presenting for your consideration the accompanying report of its investigations and findings. The explorations of this Committee have uncovered one of the most serious situations which has confronted Illinois in many years. We have found that Illinois now has approximately 90,000 persons whom chronic disease has reduced to invalid- ism. An additional 270,000 persons are so seriously afflicted with chronic disease or permanent impairments of one kind or another that they also may require spe- cialized services and care from time to time. Yet the facilities presently available for the care of these people are wholly inadequate, many are sub-standard, and in some sections of the State there are no facilities whatsoever. Chronic disease has been called the “insidious modern plague.” Because chronic disease incapacitates for a long period qf time, it is costly and tends to place on society the burden of care for those afflicted. Medicine has become so successful in controlling the frequency and duration of acute diseases that chronic illness has now become the major cause of illness. The rapidly increasing number of older people in the population, due in part to control of acute disease, has greatly added to the prevalence of chronic disease. The Committee has only begun to study the problem. Of particular significance in the testimony presented at the public hearings held by the Committee was the fact that sound planning for care of the chronically ill cannot be restricted to con- sideration of care for the indigent chronically ill. The Committee’s investigations and findings have therefore been broadened to include those able to pay for their care, as well as the indigent. It is hoped that this report may be useful in making further study of the problem and in developing a public policy for the State of Illinois which will improve the facilities for the care and treatment of all persons who are afflicted with chronic illness. The Committee wishes to express its appreciation to the many citizens and or- ganizations who attended the hearings and aided the Committee in assembling the facts upon which this report is based. It also wishes to acknowledge the assistance given by staff members of the Department of Public Welfare and the Illinois Public Aid Commission in preparing the report. Respectfully submitted, THE COMMITTEE TO INVESTIGATE CHRONIC DISEASES AMONG INDIGENTS By Arthur J. Bidwill, Chairman iii CONTENTS Page MEMBERS OF THE COMMITTEE i PERSONS ATTENDING THE PUBLIC HEARINGS HELD IN SPRINGFIELD, ILLINOIS ii TRANSMITTAL TO THE SIXTY-FOURTH GENERAL ASSEMBLY iii NATURE OF CHRONIC DISEASE 1 Origin and Progress of Chronic Disease ..... 1 Diseases Most Frequently Leading to Chronic Invalidism ... 1 Prevalence of Chronic Disease Among Urban Wage Earners . . 2 Control of Chronic Disease: Role of the Family and of Industry . . 3 Ratio of Deaths Due to Chronic Disease ..... 4 Conclusion ......... 5 EXTENT OF CHRONIC ILLNESS IN ILLINOIS .... 6 Estimated Number of Chronic Invalids in Illinois ... 6 Persons Partially Disabled ....... 7 Total Afflicted with Chronic Disease or Permanent Impairment . . 7 Increasing Percentage of Aged Persons in the Total Population . . 8 Extent of Indigency Among Chronic Invalids .... 8 Chronic Invalidism Among Public Aid Recipients ... 9 Conclusion ......... 9 FACILITIES CURRENTLY AVAILABLE FOR CARE OF THE CHRONICALLY ILL 10 Types of Facilities ....... . 10 Hospitals and Related Institutions Registered with the American Medical Association . . . . . 11 Hospitals Not Registered with the American Medical Association . . 13 Non-Registered Nursing Homes and Homes for Convalescent Care 13 Private Homes for the Aged 14 Boarding Homes 15 County Homes and Infirmaries . . . . . . 15 Conclusion ......... 18 STAGES IN RECOGNITION OF THE PROBLEM AS ONE RE- QUIRING JOINT STATE AND COMMUNITY PLANNING . . 20 Action Prior to 1900: State Institutions for Special Groups . . 20 Non-Institutional Care Prior to 1900 ..... 20 Development of State Facilities: 1900-1943 .... 20 Recognition of the Problem in its Entirety . . . . 21 Conversion of County Homes into Facilities for the Chronically 111: The Rennick-Laughlin Bills of 1945 ..... 22 CONTENTS Chicago’s Central Service for the Chronically 111 24 Development of Facilities in Homes for the Aged ... 24 Illinois Convalescent and Nursing Homes Association ... 24 Regulation of Nursing Homes ...... 24 FACTORS REQUIRING PARTICULAR STUDY IN CONNECTION WITH PLANNING FUTURE ACTION 25 Types of Facilities Needed to Achieve Maximum Rehabilitation of Patients ...... 25 Proper Location and Coordination of Facilities .... 26 Methods of Financing Care for Indigent Persons .... 26 Summary of Fundamental Questions to be Considered ... 27 CURRENT LEGISLATION ON THE CHRONICALLY ILL . . 29 Conversion of County Homes into Facilities for the Chronically 111: Rennick-Laughlin Bills (S.B. 210, 212, 213, 534) ... 29 Aid to Persons Afflicted with Cancer or Tumor ... 29 Care for the Tubercular ....... 29 Extension of Facilities for Physically Handicapped Children (H.B. 412: Van der Vries, Edwards, and Prusinski) 30 Regulation of Hospitals and Related Institutions ... 30 Legislative Commissions to Continue Study of Medical Care Problems 31 LIST OF TABLES No. Page I Estimated Number of Chronic Invalids in Illinois ... 6 II Estimated Number of Persons in Illinois with Chronic Disease or Permanent Impairment ....... 7 III Registered Hospital Facilities in Illinois During 1944, By Type of Service , . . . . . , 12 IV Registered Hospital Facilities in Illinois During 1944, By Type of Management . . . . . . 13 V Number of Nursing Homes in Illinois Admitting Patients from Public Aid Rolls as of March 1945, Distributed According to Usual Monthly Rate for Bed Patient . . . . . 14 VI Private Institutions for the Aged in Illinois Admitting Public Aid Recipients, as of May 1945 15 VII Potential Facilities for Care of the Chronically 111 Represented by County Homes in Operation in Illinois, as of March 1945 . . 16 NATURE OF CHRONIC DISEASE Chronic invalids have been defined as those “persons who have been, or are likely to be, incapacitated by disease for a period of at least three months, that is, unable to follow the daily routine of the average normal person, and whose incapacity will probably continue for an indefinite period.” (Jhe Challenge of Chronic Diseases by Doctors Boas and Michelson). Affliction with a chronic disease is too often considered as part of the “penalty” of growing old. Only in recent years has there been recognition of the fact that “something can be done about it” and that chronic disease is not limited to aged people but can strike children, young adults and the middle aged as well. Actually, “Aging is a physiological and pathological, not solely a chronological process.”1 Origin and Progress of Chronic Disease Dr. Ernest P. Boas has described the origin and incapacitating nature of chronic diseases as follows: “Chronic diseases are for the most part obscure in origin, although a number of the infectious diseases, in particular, tuberculosis, syphilis, and the several forms of rheumatism are responsible for much chronic disability. Among the many diseases of unknown origin the most important are dis- eases of the heart, arteries, kidneys and liver, organic affections of the nervous system, mental disorders, cancer, non-tuberculous diseases of the lungs such as asthma, the various forms of rheumatism, diabetes mellitus and other disturbances of the glands of internal secretion or of metabolism. “Physical incapacity arising from these diseases is at first insignificant but gradually assumes ever greater proportions. In the earlier stages of his illness the subject of a chronic disease is ambulant and able to work, but gradually he becomes more and more disabled and eventually becomes an invalid . . Diseases Most Frequently Leading to Chronic Invalidism In testimony presented before a public hearing of the Committee to Investigate Chronic Diseases Among Indigents, Miss Edna Nicholson, Director of the Central Service for the Chronically 111 of Chicago, reported concerning the diseases which most frequently lead to chronic invalidism. Miss Nicholson said: “Of the physical conditions responsible for invalidism, rheumatism and arthritis account for the largest single group of patients. These conditions are followed closely, in point of numbers of patients, by heart diseases. There are almost 10,000 people in Illinois who are invalids as a result of rheumatism or arthritis, and almost that many who are invalided by heart disease. These are in addition to many times these numbers of people who suffer some degree of pain and handicap as a result of these conditions 17he Unseen Plague—Chronic Disease by Doctor Ernest P. Boas, p. 50. 27he Vnseen Plague—Chronic Disease by Doctor Ernest P. Boas, p. 4. 1 but are not completely disabled by them. Tuberculosis patients in their own homes make up the third largest group of invalids; this does not include the large numbers suffering from tuberculosis and confined to institutions. “Arteriosclerosis and high blood pressure, including cerebral hemor- rhage and resulting paralyses, account for the next largest number of in- valids. These conditions are followed in frequency by diabetes; kidney disorders; cancer and other tumors,- and a long list of other chronic diseases. “Blindness, deafness, orthopedic handicaps and other physical impair- ments as distinguished from disease, account for another large group of partial or permanent invalids. In addition, many persons are disabled as a result of nervous and mental conditions which are not acute but which reveal ‘senility,’ ‘forgetfulness,’ and mild mental confusions.” Prevalence of Chronic Disease Among Urban Wage Earners Important information concerning the prevalence of chronic disease among urban wage earners is given in the December 16, 1944 issue of 7he Journal of the American A/ledical Association which summarized the “Findings of the Study of Chronic Disease in the Eastern Health District of Baltimore.” This study indicates that 90 persons per thousand in an urban wage earning population are affected with chronic disease and that families having an afflicted member tend to require from three to four times as much medical care as other families. These facts are significant in planning the distribution of facilities for treat- ment of the chronically ill. They also point to problems which will arise in planning for meeting the costs of care. For this reason the summary of the Baltimore find- ings, as given in 7he Journal of the American AAedical Association, is quoted here in its entirety: “The Eastern Health District of Baltimore, which comprises two city wards containing about 11,000 white families and 2,800 colored house- holds, was chosen for a five year survey of chronic illness.1 This was con- sidered reasonably representative of the type of locality in which an urban wage earning population lives. “The following chronic diseases were included: manifest mental dis- orders, psychoneuroses, psychopathic and personality or behavior dis- orders,- heart disease or hypertension,- arthritis,- diabetes,- varicose veins,- gallbladder disease; peptic ulcer,- chronic nephritis,- cancer,- rheumatic fever,- tuberculosis, and syphilis. Out of each thousand persons in the pop- ulation of 5 years of age and older there were 32 cases of hypertension or heart disease, 18 cases of manifest and subclinical mental disorders, 16 cases of arthritis, 7 cases of rheumatic fever, 6 cases of diabetes and 11 cases of other chronic conditions. This resulted in a total prevalence of these chronic illnesses of 90 per thousand of population. “Families chosen because of a case of chronic disease showed an ex- cess rate of illness among its members as compared with the other family groups. The rate of physician visits for these patients with chronic disease was 2,375 per thousand of population, or slightly more than two visits per person annually. The rate of clinic visits was 1,517 per thousand, giving a Downes, Jean.: Findings of the Study of Chronic Disease in the Eastern Health District of Balti- more, Milbank Memorial Fund Quart. 22:337 (Oct.) 1944. 1 total of about four visits per person annually. The same population group had an additional 2.5 visits per person for illness not related to the chronic disorder. Patients with chronic disease, therefore, had from three to four times as much medical care (measured by the number of visits from a physi- cian !) as did the other members of their families and the general population studied. Persons in the 381 ‘Chronic disease families’ formed 26 per cent of the total observed population, had 54 per cent of the total illnesses and received about 50 per cent of the medical care for illness given to the total population. Persons from these few families also constituted al- most 40 per cent of the persons hospitalized during the second year of the morbidity study. “This interesting report again emphasizes the necessity for sound fundamental studies of the need for and cost of medical care in differently constituted groups. A large part of the medical care problem is the control of the housing, dietary and other environmental factors which affect the development of chronic disease. From the information presented it could be deduced that any plan to spread the cost of medical care over the entire population studied would mean that a comparatively small group and one perhaps especially liable to chronic illness would receive a disproportionate share of the benefits.” Control of Chronic Disease: Role of the Family and of Industry Dr. Herman L. Kretschmer of Chicago and President of the American Medical Association reports the intensive study now being given to “The Problem of the Chronically 111 Patient” in the April 21, 1945 issue of Jhe Journal of the American Medical Association. His comments concerning prevention of chronic disease and the role to be played by the family and industry in reducing its disabling effects are pertinent to the investigations of this Committee. Dr. Kretschmer says: “Prevention is and should be the first consideration in treatment. Prevention of chronic illness begins with health education on proper per- sonal hygiene, right living and suitable diet, with particular emphasis placed on the importance of an annual physical examination. This often re- veals foci of infection, such as infected tonsils and teeth, which can then be removed long before the arthritis or hypertension begins. “The family has an important role in the care of the chronically ill. The patient’s invalidism is too often created or increased as much by the attitude of his family and friends as by the physical condition itself. Friends and relatives in their sympathy for the patient’s ill fortune may know of no other way to offer help than to shelter and overprotect the patient to the point where his spirit may develop handicaps more severe than those which cripple his body. “We are living in an era in which many think first of institutions and of governmental aid; what burdens the individual cannot carry, Washing- ton is asked to underwrite. The family spirit has diminished. A change of attitude must take place—that the glory of youth too will vanish and that the young person has an obligation to the other members of his family. We have become so institutionally minded for almost every kind of medical and social problem that we are apt to lose sight of the fact that a label on bricks and mortar does not mean a magical solution of the problem. 3 “Industry too has an important role to play in this problem. Careful con- sideration should be given to the aging; and effort must be made to place the older worker in a position commensurate with his capacities so that he may feel that he is taking part in production, thereby retaining his self respect. He should not be shunted off into an inconsequential position when he still is able to perform productive work. “Certainly for those patients for whom any significant degree of rehabilitation can be anticipated, active steps must be taken to restore independence and self reliance as fully and as rapidly as possible. This is of fundamental importance not only to the patient and his family but to society, and efforts must be made as fast as possible to provide the additional facilities and services needed in our communities to accom- plish this. “Management of these patients depends in part on the severity and in part on the type of illness. A certain number of them can be managed as ambulatory patients in the home, with visiting nurse and medical services. When a patient has to be hospitalized, hospitalization should be continued until he can return to his home. “For the aged who are fairly active physically and mentally and are still continuing with their work, it has already been mentioned how their mental attitude and morale are sustained if they are given employment. “Those who are fairly normal mentally but are physically disabled and dependent, medical service which is palliative should be given so that they may not suffer needlessly. Commitment to an institution should be deferred as long as possible, as the home accords them the happiest surroundings and their usefulness can be maintained by giving them some light duties to perform. These people, if committed to an institution, soon become help- less old men and women, because mental changes are hastened by the shifting of the environment. “The group which needs either skilled nursing care or intensive medi- cal treatment can be confined to a hospital designed for this purpose. “For those who are completely helpless and permanently incapacitated, domiciliary care is all they need.” Ratio of Deaths Due to Chronic Disease Changes which have occurred as a result of advances in medical science and public health over the last fifty years have sharply reduced the number of deaths caused by acute infectious diseases. The effect of this prolongation of the life span of the population was commented on by Miss Edna Nicholson1 as follows: “The almost miraculous reduction in the number of deaths caused by the acute infectious diseases—such as typhoid fever, diphtheria, small- pox, pneumonia, etc.— has meant that persons who otherwise would have died as a result of these acute conditions are, instead, living longer and are being made helpless for long periods of time preceding death by arthritis, heart disease, high blood pressure and ‘strokes,’ kidney disturbances, or cancer. testimony by Miss Edna Nicholson, Director, Central Service for the Chronically. Ill, Institute of Medicine of Chicago, Public Hearing held at Springfield, Illinois, April 10. 4 “Seventy-five years ago 14 of every 15 deaths which occurred in the United States were due to diseases which struck swiftly, and came to an end with only short periods of illness preceding death. In only one case of every 15 was death caused by a condition which brought with it a long period of invalidism preceding death. Today these so-called 'chronic’ condi- tions account for one of every two deaths, and the full effects of the shift in the nature of diseases causing death is only beginning to be evident. The greatest advances in the control of the acute infectious diseases have come within the last 25 years—some within the last 5 or 10—and the full effect of these advances has yet to be felt.” Conclusion Chronic disease has been described by The Surgeon General of the United States Public Health Service as “the nation’s number 1 health problem.” The full effect of the change in the nature of diseases causing death is only beginning to be evident. It is apparent that this change will require increased attention by the med- ical profession and by hospital management which have in the past given major emphasis to acute illnesses. It is also apparent that chronic disease carries with it serious social and economic implications. These will require immediate and careful study, in order that a public policy may be formulated which will keep to a minimum the economic and social losses attendant upon prolonged illness. 5 EXTENT OF CHRONIC ILLNESS IN ILLINOIS According to a recent study made by the Illinois Public Aid Commission, there are at present in Illinois approximately 90,000 persons who are chronic invalids. These constitute 1.14 per cent of the population of Illinois as of the 1940 census. The Public Aid Commission’s data are shown in Table I below, by age groups. Table I. Estimated Number of Chronic Invalids in Illinois® Age Groups Total Population Chronic Invalids Per Cent of Age Group Number All Ages 7,898,000 1.14 90,200 Under 5 547,000 .17 900 5-14 1,161,000 .26 3,000 15-24 1,361,000 .38 5,200 25-34 1,327,000 .49 6,500 35-44 1,193,000 .94 11,200 45-54 1,055,000 1.42 15,000 55-64 686,000 2.51 17,200 65-74 400,000 4.81 19,200 75 and Over 168,000 7.20 12,000 aTable derived primarily from application of National Health Survey figures (Bulletin 6, 1935-1936, Appendix Table C, p. 14, “Invalids per thousand pop- ulation according to age”). These figures were applied to the same age groups in Illinois, as reported in the 1940 census, and slightly modified by original studies. While it is seen that two-thirds of the chronic invalids are under 65 years of age as against only one-third 65 or over, other studies indicate that from the stand- point of those requiring public care, approximately 60 per cent are under 65 years of age and 40 per cent are in the older group. In large part, this is due to the pro- gressive severity of the invalidism as age increases, and further to the factor that as persons grow older, those who may have previously cared for them in the home may have died or are no longer able to provide needed care. In developing a coordinated plan to provide for chronic invalids in Illinois, it is important to remember that only one-third of the estimated chronic invalids are 65 years of age or over. Those who are 65 or over, if indigent, may have the costs of chronic illness met through the State’s Old Age Pension program. Most chronic invalids, however, are middle aged, the largest number falling within the age groups between 45 and 65 years. For this group, should indigency accompany chronic ill- ness, facilities for meeting the costs of needed care are more restricted than they are for chronic invalids 65 years of age or over. 6 Persons Partially Disabled In addition to the 90,000 persons in Illinois who are now chronic invalids, it is estimated that there are over fifteen times as many who, in varying degrees and at various times, may need some specialized services. These additional numbers represent persons who are afflicted with chronic disease or permanent impairment. The majority of these are not handicapped to the extent that they cannot take care of themselves under normal circumstances. Various estimates have been made as to the percentage of these whose handicap may become serious enough to interfere with self-care or normal adjustment in life. The Public Aid Commission study estimates that approximately 270,000 periodically may require special services or care. Total Afflicted With Chronic Disease or Permanent Impairment It is estimated that there are 1,483,000 persons or 18.8 per cent of the 1940 population of Illinois, who at the present time are either chronic invalids or afflicted with chronic disease or physical impairment’ which may lead to chronic invalidism. These are shown by age groups in Table II below. Table II. Estimated Number of Persons in Illinois with Chronic Disease or Permanent Impairment" Age Groups Total Population Persons with Chronic Disease or Permanent Impairment Per Cent of Age Group Number All Ages 7,898,000 18.8b 1,483,000 Under 5 547,000 3.4 18,700 5-14 1,161,000 6.8 79,300 15-24 1,361,000 8.3 112,800 25-34 1,327,000 15.9 211,200 35-44 1,193,000 22.1 263,600 45-54 1,055,000 27.3 288,300 55-64 686,000 34.4 236,100 65-74 400,000 46.7 186,800 75 and Over 168,000 51.4 86,200 aTable derived primarily from application of National Health Survey figures (Bulletin 6, 1935-1936, Appendix Table B, p. 14, “Persons per thousand popula- tion reported to have chronic disease or permanent impairment, according to age, and for total population for the entire United States.”) These figures were applied to the same groups in Illinois, as reported in the 1940 census. 6The National Health Survey found 17.7 per cent of the total population af- flicted with chronic disease or permanent impairment but the percentages for each age grouping, when applied to the Illinois population resulted in a slightly larger overall percentage. Table II differs from Table I in that it includes all persons afflicted by chronic disease or permanent impairment, while Table I is limited to those whose affliction is so serious that chronic invalidism exists. In comparing the two it will be noted that six per cent of the total number of sufferers have been classified as chronic invalids. In the older age groups, however, this percentage is greater. 7 Increasing Percentage of Aged Persons in the Total Population The National Health Survey made during 1935-1936 found that one-half of all persons 65 years of age and over suffered from chronic diseases. This fact be- comes particularly important since the percentage of older people in the total pop- ulation is rapidly increasing. The National Industrial Conference Board in its “Economic Almanac” for 1943-44 estimated the increase in the aged population as follows: Year Population 65 and Over— Per Cent of Total Population 1940 6.8 1950 8.0 1960 10.1 1970 11.9 1980 3 14.4 While it is true that all old people are not sick, the largest number of chronic invalids being middle aged, it is the older group of chronically ill persons Vho particularly need facilities for care outside their own homes. Children and young adults who are chronically ill more frequently remain in their own homes. As age increases, the possibility of care in the home decreases. Parents and other members of the family who have been caring for the invalid grow old and become unable to continue care of the patient. Although a little more than one-third of all chronic invalids are 65 years of age and over, about one-half of all invalids needing care outside their own homes are over 65. Extent of Indigency Among Chronic Invalids An estimate of the extent of indigency among chronic invalids in Illinois was given by Miss Edna Nicholson of the Chicago Central Service for the Chronically 111. In her report before the Public Hearing in Springfield on April 10, 1945 Miss Nicholson said: “For purposes of planning facilities for care of the chronically ill in Illinois, it can safely be estimated that there are 25,000 to 30,000 invalids in the state who are now in need of some financial help in meeting the costs of adequate care, or will be within the immediate future; and that if there should be a sharp decline in employment and wages this number would be considerably increased. “This does not mean that institutional facilities must be provided for all of these persons. About a half—possibly as many as two-thirds of them— can, and will prefer to, remain with their families in their own homes. For many of these old age pensions will provide the only help they need. For others, help may be provided through other forms of public assistance, or to some extent through private philanthropy. “There are about 10,000 to 15,000 invalids, however, who are indigent and who cannot be cared for in their own homes, either because they have no homes and families or because the necessary arrangements for their care cannot be made in their homes. To this group should be added at least 20,000 more invalids who also need care outside of their own homes but who are able to pay for their care from their own or their families’ re- sources. For these persons homes offering personal care and nursing serv- ices must be made available. 8 “To summarize: conservative estimates indicate that, in addition to care provided for invalids by their families in their own homes, facilities are needed in nursing homes and institutions for the care of 35,000 to 40,000 invalids in Illinois, of whom about 25,000 are already in need of financial assistance or will be as soon as the present high levels of employment and wages begin to decline.” Chronic Invalidism Among Public Aid Recipients The percentage of chronic invalidism among those currently receiving public aid is estimated to be 87 per cent greater than it is among those earning over $1,000 a year. This is readily understandable since the factor of chronic illness has often produced or contributed largely to the need for public aid. Among Old Age Pension recipients it is estimated that there are 7,000 chronic invalids. There is no exact information as to the number of chronic invalids on the present poor relief rolls in Illinois. However, the majority of the 52,949 persons who were receiving relief in May 1945 were classified as unemployable. In this group will be found many hiiddle-aged persons afflicted with chronic disease or suffering from physical impairment. Of the persons at present residing in county homes in the State, it is estimated that 80 per cent are in need of continuing nursing service and care. Conclusion All of the factors enumerated above point to the increasing seriousness of the problem of chronic illness. They indicate that chronic invalidism is not confined to the aged or to any one group alone; nor is it confined to the indigent. While the problem of chronic illness bears more heavily on the poor than on others, it is im- portant to keep in mind the fact that the indigent chronically ill constitute only one part of a very large group of invalids in Illinois, all of whom are urgently in need of more and better facilities for care. 9 FACILITIES CURRENTLY AVAILABLE IN ILLINOIS FOR CARE OF THE CHRONICALLY ILL As brought out in the previous section of this report, testimony presented to this Committee indicates that Illinois now has approximately 90,000 chronic invalids and an estimated 270,000 additional persons so seriously afflicted with chronic dis- ease or physical impairment that they also may require from time to time hospital or nursing service more extensive than that which can be provided by relatives or friends at home. At the present time there is no complete census concerning the number and bed capacity of hospitals, sanataria, nursing homes, or other institutions in Illinois which offer facilities for care of the sick and, in particular, for the chronically ill or physically impaired who require care outside of their own homes. The fact that the present laws of Illinois do not require licensing of hospitals and related institu- tions makes unavailable at a central point in the State complete information con- cerning hospital and nursing facilities. The partial information available, however, would indicate that existing facilities are both insufficient and so unequally dis- tributed as to present a serious problem in providing care to all ill persons who need access to them, especially the chronically ill. Types of Facilities Facilities currently available for care of the chronically ill are of the following types: HOSPITALS AND RELATED INSTITUTIONS. Federal Hospitals (for Veterans). State Hospitals (for the Mentally III). State Schools and Institutions (for the Blind, the Deaf and Mentally Defective). State Hospitals for Special Types of Illness (Venereal Disease, Eye and Ear). General Hospitals (Mainly Restricted to the Acutely 111). Tuberculosis Sanitaria. County Homes and Infirmaries. Homes for the Aged. Nursing Homes and Homes for Convalescent Care. Boarding Homes. HOME NURSING AND HOUSEKEEPING SERVICES. In a few communities hospital and institutional facilities are supple- mented by visiting nurse services and housekeeping services which pro- vide nursing or housekeeping services to the chronically ill who remain in their own homes. The best available information indicates that housekeep- ing service is available only in the City of Chicago where it is provided by the Chicago Home for the Friendless, by the Jewish Social Service Bureau, and by the Chicago Welfare Administration. The Visiting Nurse Association has established services in only 21 coun- munities, those chiefly metropolitan centers. Information available to the 10 Illinois Public Aid Commission three years ago indicated that the Visiting Nurse Association had as of that time services in Alton, Aurora, Chicago, Danville, Decatur, East Moline, East St. Louis, Elgin, Evanston, Galesburg, Joliet, Kewanee, LaSalle, Marseilles, Moline, Ottawa, Peoria, Quincy, Rock- ford, Rock Island and Springfield. Hospitals and Related Institutions1 Registered with The American Medical Association Although by no means restricted to the chronically ill nor, on the other hand, indicative of the total number of facilities available in Illinois for care of the sick, information collected by the American Medical Association for the year ending September 30, 1944 concerning hospitals and related institutions registered with that Association points to the inadequacy of existing facilities for hospital and nurs- ing care, both in terms of bed capacity and distribution so as to provide ready access to patients throughout the State. Obviously, all of the beds in the hospitals or related institutions registered with the American Medical Association are not available to the chronically ill. It may be assumed for example, that most of the beds in the hospitals classified as general hospitals are reserved for the acutely ill. Furthermore, seventeen of these hospitals are operated by the Federal Government for the benefit of servicemen or veterans only. Others are operated by county or city governmental units and ad- mission is in general restricted to the indigent. Information concerning the 327 hospital facilities registered with The American Medical Association is shown in Tables III and IV on the following pages. Table III classifies these facilities by type of service; Table IV classifies them by type of control. 1The term “related institution,” as used by the American Medical Association, means "infirmaries, nursing homes, and other institutions designed to give certain medical and nursing care in an ethical and acceptable manner, without giving a full hospital service.” (7he Journal of the American Medical Association, March 31, 1945, p. 786.) 11 Table III. Registered Hospital Facilities in Illinois During 1944, By Type of Management0 Number of Number Average Per Cent Type of Service Hospitals of Beds Occupancy Occupancy ALL TYPES 327 101,342 81,774 80.7 General6 218 44,701 31,052 69.5 Nervous and Mental 30 45,799 42,980 93.8 Tuberculosis® 32 4,360 3,425 78.6 Maternity 6 574 326 56.8 Industrial 2 85 44 51.8 Eye, Ear, Nose, Throatd.. 2 225 108 48.0 Children’s 3 382 203 53.1 Orthopedic 4 220 121 55.0 Isolation 2 456 62 13.6 Convalescent and Rest®.... 14 564 361 64.0 Hospital Departments of In- stitutions 12 3,506 2,689 76.7 All Other Hospitals 2 470 403 84.1 “Data for Illinois assembled by the Illinois Public Aid Commission from article entitled “Hospital Service in the United States” published in the March 31, 1945 issue of 7he Journal of the American Medical Association. Above figures are from pages 776-778. Data are limited to hospitals and re- lated institutions registered by the American Medical Association according to standards adopted by that Association. All Illinois hospitals and related institutions are not registered. Data were reported for the 12 months ended September 30, 1944. 50 of these general hospitals, or 23 per cent, are located in Chicago and Cook County. cThese tuberculosis sanitaria were distributed among 24 counties, concentrating in the northern and central portions of the State. There are only three regis- tered tuberculosis sanitaria in the southern part of the State. Twenty of the sanitaria are operated by -county governments; three by city governments; one by city and county together; one by the Veteran’s Administration; and the remainder by non-profit associations. dBoth of these are in Chicago. eAll but two of these are in Cook County. 12 Table IV. Registered Hospital Facilities in Illinois During 1944, By Type of Management® Number of Type of Control Hospitals Number of Beds Average Per Cent Occupancy Occupancy ALL TYPES ..327 101,342 81,774 80.7 GOVERNMENTAL .. .. 88 74,893 61,283 81.8 1. Federal .. 17 19,341 11,987 62.0 2. State .. 22 43,760 40,660 92.9 3. County .. 27 8,313 6,222 74.8 4. City .. 21 3,355 2,312 68.9 5. City-County .. 1 124 102 82.3 NON-PROFIT ..191 24,224 18,928 78.1 1. Church Related.... .. 89 13,065 10,457 80.0 2. Non-Profit Ass’n.. .102 11,159 8,471 75.9 PROPRIETARY .. 48 2,225 1,563 70.2 1. Individual and Partnership .. 33 980 669 68.3 2. Corporation ... 15 1,245 894 71.8 “Data for Illinois assembled by Illinois Public Aid Commission from article entitled “Hospital Service in the United States” published in the March 31, 1945 issue of 7be Journal of the American 'Medical Association. Above figures are from pages 774-776. See Table III, footnote “a” concerning limitations of these data. Hospitals Not Registered with The American Medical Association Complete information is not available as to the number of hospitals established in Illinois but not registered with the American Medical Association. The only in- formation available is that known to the Illinois Public Aid Commission concerning non registered hospitals giving care to public aid recipients. As of May 1945, there were 15 such hospitals outside of Cook County, ex- clusive of non-registered infirmaries in County Homes. No information is available concerning the bed capacity and average occupancy of these 15 non-registered hospitals. No information is available concerning non-registered hospitals in the City of Chicago. Comparing the number of registered hospitals with those listed in the classified telephone directory, it may be estimated that there are at least 15 non- registered hospitals in the City of Chicago. Non-Registered Nursing Homes and Homes for Convalescent Care Complete information for this type of facility is likewise not available, except for information in possession of the Public Aid Commission concerning such homes willing to give care to public aid recipients at rates agreed upon between the homes and the Commission. As of March 1945 the Public Aid Commission authorized nursing home care for public aid recipients in 163 convalescent and nursing homes, of which only seven were registered with the American Medical Association. The distribution of these homes between Cook County and counties other than 13 Cook and by the usual monthly rate charged for a bed patient is shown in the following table: Table V. Number of Nursing Homes in Illinois Admitting Patients from Public Aid Rolls as of March 1945, Distributed According to Usual Monthly Rate for Bed Patient® Number of Homes, by Usual Monthly Rate for Bed Patient^ Total Lower than Number $40 or $100 or of Homes $40-$60 $61-$79 $80-$89 $90-$99 Over Total State 163c 64 ,31 13 23 32 Cook County .... 84 19 20 7 17 21 Other Counties 79d 45 11 6 6 11 oTable prepared by the Illinois Public Aid Commission, bln accordance with a policy adopted in September 1944, the Commission pays a maximum of $60 per month for bed patients; $50 to $59 per month for seroi-ambulant patients; and $40 to $49 per month for ambulant patients. Homes included in this table which charge in excess of $60 per month for bed patients are, however, caring for ambulant or semi-ambulant patients at Com- mission rates. In a few instances, they have accepted bed patients at the Commission rate, although their usual monthly rate is higher. cExact information concerning the bed capacity of these homes is not avail- able but it is estimated that they contain approximately 3,500 beds, 1,400 in Cook County and 2,100 in the other counties. The long waiting lists indi- cated that occupancy is 100 per cent. dFifty-one of the counties outside of Cook have no nursing homes admitting public aid recipients. In 29 of these counties there is only one nursing home which will admit public aid recipients. Private Homes for the Aged1 Since chronic illness tends to afflict the middle-aged and the aged more fre- quently than children and adults, homes for the aged represent an important po- tential resource in planning for care of the chronically ill who cannot be cared for in their own homes. % There are about 80 private institutions for the aged in the State. These homes are supported by fraternal, religious, or national groups. Of these, 49 have admitted public aid recipients for care. Information is available only for the 49 which have admitted public aid recipients. This is summarized on the following page. The information given here represents a summary of a report of May 4, 1945 of the Illinois Public Aid Commission entitled “Private Institutional Policy—Chronic Care.” 14 Table VI. Private Institutions for the Aged in Illinois Admitting Public Aid Recipients, as of May 1945 Number of Institutions Number Now Having Chronic Care Facilities Range of Average Number of Residents Total State 49 8 6 to 263 Cook County 21 5 10 to 263° Other Counties 28 3 6 to 146b aThe smallest is the Home for Aged Colored People; the largest, the Chicago Home for Incurables. £>The smallest is Jacob’s Horae in Lee County; the largest, St. Vincent’s Home in Adams County. The homes in counties other than Cook are distributed among 22 counties. There is a growing trend among these institutions toward the development of facilities for caring for chronically ill persons. The Chicago Home for Incurables has always cared for chronic patients. Such facilities have more recently been de- veloped by the Home for Aged Jews, the Orthodox Jewish Home, Rosary Hill Con- valescent Home, and St. Ann’s Home in Cook County and by St. Joseph’s Hos- pital in Adams County, the I.O.O.F. Home in Coles County and the Eastern Star Sanitorium in Macon County. It is expected that such facilities will be developed in more of the institutions of this type as the problem of the chronically ill receives increasing attention and as equitable bases of payment for care in such institutions are developed in co- ordination with payment rates for other types of facilities. Boarding Homes No information is available concerning the number of such homes in the State which include among their residents many of the less serious cases of chronic ill- ness. In the opinion of the Illinois Public Aid Commission, many of the homes now designated as “nursing homes” are really only boarding homes. In the absence of state licensing provisions proper classification cannot be made. County Homes and Infirmaries Before the full problem of chronic disease and chronic invalidism came to be recognized, many assumed that public aid in its modern form, especially Old Age Pensions and other types of “social security,” would completely depopulate the traditional “county poor farms” and remove all reasons for their continued main- tenance. It has therefore been a matter of much surprise to many when they have realized that county homes and infirmaries continue to operate in Illinois, that they have been depopulated but not completely depopulated, and that in many areas of the State they represent the only facility for chronic invalids, especially older people who have developed peculiarities or irritabilities which make adjustment elsewhere diffi- cult. Furthermore, in a number of instances, these county homes have been found to offer nursing services far superior to those offered in neighboring unlicensed and unsupervised “private nursing homes.” As of March 1945, there were 72 county homes in operation in Illinois. Many 15 counties had discontinued operation of such homes during the years following 1935 when Illinois enacted its first Old Age Pension Act. While it is true that there is no use for the old type "poor house” under pres- ent day conditions, the existing 72 county homes still in operation represent a po- tential resource for care of the chronically ill. Information concerning these 72 county homes is given in the table below. Table VII. Potential Facilities for Care of the Chronically 111 Represented by County Homes in Operation in Illinois as of March 1945“ County Capacity Number of Inmates as of November 25, 1944 Per Cent Occupancy November 1944 ALL COUNTIES .. ....7,264 4,303 59.2 Adams .... 75 32 42.7 Brown .... 15 3 20.0 Bureau .... 100 42 42.0 Calhoun .... 25 3 12.0 Carroll .... 31 26 83.9 Cass .... 18 8 44.4 Champaign6 .... 100 41 41.0 Clark .... 13 4 30.8 Coles .... 40 20 50.0 Cook—(Infirmary only) b ....2,780 2,239 80.5 Crawford .... 30 7 23.3 De Kalb .... 80 47 58.8 De Witt .... 30 12 40.0 Douglas® Du Page .... 47 47 100.0 Edgar .... 20 2 10.0 Edwards .... 12 1 8.3 Effingham .... 24 1 4.2 Fayette .... 25 13 52.0 Ford .... 35 11 31.4 Franklin .... 21 12 57.1 Fulton .... 60 32 53.3 Greene .... 20 7 35.0 Hamilton 8 6 75.0 Hancock .... 40 28 70.0 Henderson .... 20 2 10.0 Henry .... 80 20 25.0 Iroquois ... 60 16 26.7 Jackson .... 15 6 40.0 Jersey .... 25 3 12.0 (Continued on Following Page) 16 Table VII. Potential Facilities for Care of the Chronically 111 Represented by County Homes in Operation in Illinois as of March 1945“ (Continued from Preceding Page) County Capacity Number of Inmates as of November 25, 1944 Per Cent Occupancy November, 1944 Jo Daviess 10 2 20.0 Kane 190 127 66.8 Kankakee 60 21 35.0 Knox 100 39 39.0 Lake5 90 66 73.3 La Salle 275 130 47.3 Lawrence 50 3 6.0 Lee 49 25 51.0 Livingston 70 39 55.7 Logan 40 6 15.0 McDonough 60 11 18.3 McHenry 85 60 70.6 McLean 120 40 33.3 Macon 100 60 60.0 Macoupin 68 28 41.2 Madison 130 97 74.6 Menard 26 26 100.0 Mercer 40 15 37.5 Monroe 30 23 76.7 Montgomery .... 25 12 48.0 Morgan 76 10 13.2 Moultrie 15 9 60.0 Ogle 53 36 67.9 Peoria 270 82 30.4 Piatt 50 8 16.0 Putnam 15 2 13.3 Randolph 25 9 36.0 Rock Island 80 38 47.5 St. Clair* 300 159 53.0 Saline 16 5 31.3 Schuyler 30 7 23.3 Scott 25 3 12.0 Shelby 25 6 24.0 Stephenson 90 25 27.8 Vermilion 137 100 73.0 (Continued on Following Page) 17 Table VII. Potential Facilities for Care of the Chronically 111 Represented by County Homes in Operation in Illinois as of March 1945® County Capacity Number of Inmates as of November 25, 1944 Per Cent Occupancy November 1944 Warren 100 23 23.0 Wayne 14 5 35.7 White too 8 8.0 Whiteside 65 25 38.5 Will 91 90 98.9 Williamson 12 9 75.0 Winnebago6 176 114 64.8 Woodford 32 9 28.1 (Continued from Preceding Page) “Table derived from Illinois Public Aid Commission report entitled “The Status of County Homes in Illinois as of November 25, 1944,” adjusted to exclude County Homes which were discontinued after November 1944. hThe hospital facilities of these four county homes are registered by the American Medical Association. cThe Douglas County Home was discontinued March 1, 1945 and leased to an individual as a grain farm. It had a capacity of 21 inmates. In November 1944, it had three inmates in residence. Douglas County, however, maintains a hospital separate from the County Home. This hospital with a capacity of 40 and an average occupancy of 27 is registered by the American Medical Association. dThe Lake County General Hospital is maintained separately from the Lake County Home. The Lake County General Hospital is registered by the Amer- ican Medical Association. In an earlier study made by the Illinois Public Aid Commission in March 1944, when 83 county homes were in operation, the following estimate was made of their adaptability for conversion into homes for care of the chronically ill: 27 Adaptable with minor renovation. 23 Adaptable with substantial renovation. (County homes in this group are of masonry construction and are equipped with plumbing and central heating, but floor layouts and other features of design may require modification to provide suitable facilities for the care of the chronically ill). 30 Not adaptable. 3 Available information does not justify opinion as to adaptability. 83 Total Conclusion The information given above concerning facilities currently available in Illinois for care of the chronically ill would indicate that future study should be directed toward the following possibilities for establishing additional facilities for the chron- ically ill and for co-ordinating all types of facilities so as to assure adequate care and service to all residents of the State of Illinois who are afflicted with chronic disease or permanent impairment: 18 1. The possibility of setting aside more beds in general hospitals for pa- tients who are chronically ill, or of establishing infirmary facilities in connection with general hospitals. 2. The possibility of converting County Homes which can be so converted into homes for the infirm and chronically ill, with proper regard to con- struction, sanitation, and general hygiene so as to safeguard the health, safety, and comfort of the patients.1 3. The possibility of establishing additional tuberculosis sanataria, with attention to their proper distribution so as to provide ready access to tubercular patients in all parts of the State.2 4. The possibility of establishing additional infirmary facilities in private institutions for the aged. 5. The possibility of establishing additional private nursing homes and homes for convalescent care, under competent management and with proper standards, licensed, and supervised by a state agency or by local governments in conformity with state standards.3 6. The possibility of establishing additional home nursing and housekeep- ing services. The need for continued study of the problem of the chronically ill is obvious. This should be accomplished through extension of the present legislative Committee, enlarged so as to include, ex officio, representatives of all State agencies directly concerned with the problem.4 1This recommendation has already been acted on by the Sixty-fourth General Assembly which passed the Rennick-Laughlin Bills, Senate Bills 210, 212, 213, and 534. These Bills have been signed by Gov- ernor Dwight H. Green, The importance of these Bills as representing a major step in developing facilities for the chronically ill, is discussed in a later section of this report. 2Senate Bills 47 and 48, House Bill 325, and House Joint Resolution 29 of the Sixty-fourth General Assembly have reference to care for the tubercular. 3This recommendation has already been acted upon by the Sixty-fourth General Assembly which has under consideration three bills pertaining to the licensing of hospitals, nursing homes, and related institutions. These Bills are Senate Bill 373 and House Bills 252 and 103. Senate Bill 373 is the most comprehensive of the three Bills. These Bills are discussed in more detail in a later section of this report. 4The Sixty-fourth General Assembly has before it for consideration Senate Bill 436 which would accomplish this recommendation with specific reference to the chronically ill. It also has before it for consideration Senate Bill 336, which pertains to the more general subject of the hospitalization and medical needs of the State. Both of these Bills are discussed in a later section of this report. 19 STAGES IN RECOGNITION OF THE PROBLEM AS ONE REQUIRING JOINT STATE AND COMMUNITY PLANNING Action Prior to 1900: State Institutions for Special Groups In Illinois, as elsewhere, the first chronic illness to receive recognition as re- quiring special action by the State as well as local communities was that of mental illness and mental defect. Provision was made for care of such persons in State hos- pitals for the mentally ill, of which there are now eleven,1 and the two institution- schools for the mentally defective at Dixon and Lincoln. For the blind, a school was established at Jacksonville (1849) and an Industrial Home in Chicago (1887). A school for the deaf was established at Jacksonville (1839). Non-Institutional Care Prior to 1900 Early indication that action by the State would not be limited to the operation of state institutions for those requiring custodial care, is found in the “Act to reg- ulate the state charitable institutions,” etc., approved April 15, 1875. This Act included provision for a “charitable Eye and Ear Infirmary.” The object of this infirmary was defined as that of providing “gratuitous board and medical and surgical treatment for all indigent residents of Illinois, who are afflicted with the dis- eases of the eye or ear.”2 The name of this infirmary, which is located in Chicago, was changed by the General Assembly in 1923 to “The Illinois Eye and Ear In- firmary” and admission to its facilities was no longer limited to those “of absolute inability to pay charges for board or treatment.”3 Development of State Facilities: 1900-1943 Legislation having a bearing on specific aspects of chronic disease or physical impairment enacted by the General Assembly of Illinois between 1900 and 1943 is listed below, in chronological order: 1911—Visitation and Instruction of the Adult Blind (June 7, 1911). Surgical Institute for Children Gune 6, 1911), 1913—Colony for Epileptics (May 27, 1913). 1919—Rehabilitation of Physically Handicapped Persons (June 28, 1919). Segregation and Treatment of Diseased Persons (June 28, 1919). ’Counting the Illinois Security Hospital at Menard (for the insane convicted of crimes) and the Veterans Rehabilitation Center established in Chicago in 1944. The nine basic state hospitals for the mentally ill are located at Alton, Anna, Dunning, East Moline, Elgin, Jacksonville, Kankakee, Manteno and Peoria. Illinois Revised Statutes 1943, Ch. 23, Par. 44. 3Jbid., Ch. 23, Pars. 70a and 71. 20 1921—Rehabilitation of Injured Persons (June 28, 1921). The title of this act was amended June 16, 1943 to “An Act in relation to vocational rehabilitation of disabled persons.” 1931—Illinois Research and Educational Hospitals (July 3, 1931)®. 1933—Physically Handicapped Children (June 30, 1933). 1937—Tuberculosis Sanitarium Districts (May 21, 1937). 1941—Committee to Investigate Chronic Diseases Among Indigents (July 17, 1941). 1943—Cancer and Tumor Relief (May 12, 1943). Committee to Investigate Chronic Diseases Among Indigents (July 22, 1943). Recognition of the Problem in its Entirety The first recognition of the problem of chronic illness in its entirety, came with the establishment of the legislative committees in 1941 and 1943. The 1941 com- mittee was hampered in its work by the impact of the war on all activities in the State. It was therefore continued in 1943 by Act (S.B. 551) of the Sixty-third General Assembly. The duties of the present committee were defined as follows in the Act cre- ating it: “The Committee shall have the following duties: 1. To make a complete and thorough survey of the number of per- sons in Illinois in indigent circumstances who are afflicted with chronic diseases not already provided for in existing State institutions, and who re- quire hospital care at public expense. 2. To determine and recommend the location or locations for institu- tions to administer to such persons, which are best suited to adequately and efficiently administer to and care for such persons. 3. To prepare and submit estimates of the cost of any proposed con- struction of such institutions, of the cost of adequate equipment, and of the annual cost of maintenance. 4. To draw, or cause to be drawn, a bill for introduction in the Sixty- fourth General Assembly, to provide for the construction, equipment, and operation of such institution or institutions as the Committee determines to be necessary. All findings, determinations, and recommendations of the Commit- tee shall be reported to the Sixty-fourth General Assembly at the same time that the bill drawn by the Committee is introduced, and thereupon the Committee shall cease to exist.” oThe building of the Illinois Research Hospital was authorized in 1925 in an appropriation to the Department of Public Welfare. The Act of 1931 made the Department of Public Welfare and the University of Illinois jointly responsible for management and control, with the Department generally responsible for administration and the University for research, educational and professional activities. 21 It will be noted the General Assembly planned that the Committee re- strict itself to the indigent among the chronically ill and directed that it focus its study on the feasibility of establishing state institutions for such persons. Testimony presented at all of the hearings of the Committee has emphasized that sound planning for care of the chronically ill could not be arrived at by re- stricting inquiry to the indigent (see pages 8-9 of this report). The Committee has, therefore, extended its inquiry into chronic illness and physical impairment as it affects the entire population of the State of Illinois, without regard to their ability to pay for care. Two factors have caused the Committee not to limit its inquiry to the feasi- bility of establishing state institutions for the care of the chronically ill. The first and obvious factor has been the unavailability of building material under present war-time conditions. Second, and probably more important from the long-time view, is the costliness of such institutions and their general undesirability for the morale and rehabilitative potentialities of the majority of chronically ill persons. The Committee has found medical opinion and the opinion of experts in the field of public aid and public welfare unanimous in the view that institutionalization, especially state institutionalization, should be looked upon as the last resort in plan- ning for care of the chronically ill. The opinion of Dr. Herman L. Kretschmer, President of the American Medical Association, in this regard has been quoted on pages 3 and 4 of. the present report. In the same article Dr. Kretschmer had this further comment: “Whether or not the chronically ill should be hospitalized in institutions dedicated to that purpose or whether they should be housed in wings built as additions to our present hospitals for acute diseases is a subject still under debate. Some believe that they should be cared for in the separate wings of the so-called acute hospitals and others believe that special hospitals should be built for that particular purpose. “In planning for extension of institutions or hospitals for the future, we should bear in mind the fact that prevention may reduce the number of cases that will require institutional care and that such extensive expansion might not be necessary.”1 In testimony given in the Committee’s public hearing in Springfield on April 25, 1945, Mr. Rodney H. Brandon, former Director of the Department of Public Welfare, said: “Establishment of state institutions for the chronically ill will create a new group of state charges. It will also segregate the ill from their home communities where they have personal ties and thus contribute to the de- pressing nature of chronic illness.” Conversion of County Homes into Facilities for the Chronically 111: The Rennick-Laughlin Bills, 1945 During recent years, County Boards of Supervisors or Commissioners, in those counties which have maintained county homes and infirmaries, have become con- cerned with the problem. With the State’s Old Age Pension and Blind Assistance Acts depleting the number of able-bodied persons residing in these institutions, 1Jhe Journal of the American Medical Association, April 21, 1945, p. 1026. 22 interest has developed in modernizing the physical plants of these institutions so as to convert them into county-maintained nursing homes and infirmaries for the chronically ill. As instances of this movement, the Henry County Home at Kewanee and the Du Page County Convalescent Home in Wheaton may be cited. Other counties, faced with the depopulation of the county homes as a result of the Old Age Pension and Blind Assistance Acts, have discontinued to operate such homes and have either closed them down or rented them out for operation as private nursing homes. Sangamon and Grundy counties may be cited as examples of this type of action. As a result of a broadened policy announced by the Illinois Public Aid Com- mission in the Fall of 1944, which made available to Old Age Pension and Blind Assistance recipients aid in excess of $40 per month to purchase care in nursing homes, county governments having plants which were convertible to suitable nurs- ing homes or infirmaries have taken active interest in bringing about amendments to the Illinois law which would enable them to develop these county plants into desirable local facilities for care of the chronically ill. County officials, in coopera- tion with the Public Aid Commission and the General Assembly have brought about action in this regard through Senate Bills 210, 212, 213 and 534, sponsored by Senators Rennick and Laughlin. These Bills, which have now been passed by the Sixty-fourth General Assembly and signed by the Governor, represent one of the most important acts taken by the General Assembly of Illinois to provide decent facilities for care of the chronically ill in their home communities. This is accomplished by the following provisions of the Rennick-Laughlin Bills: 1. Old Age Pension recipients who need institutional care will be per- mitted to retain their status as Old Age Pension recipients if they re- side in a County Home, provided the facilities for such Home with respect to its construction, sanitation, and general hygiene are in con- formity with standards prescribed by the Illinois Public Aid Commis- sion for safeguarding the health, safety, and comfort of the inmates and patients of such Home. (S.B. 210). 2. Blind Assistance recipients who need institutional care will be per- mitted to retain their status as Blind Assistance recipients if they re- side in County Homes, provided such Homes meet standards prescribed by the Public Aid Commission. (S.B. 534). 3. The “Act to provide for the establishment and maintenance of county poor houses” has been renamed “An Act in relation to the establish- ment, maintenance, and operation of county homes for persons who are destitute, infirm, or chronically ill, or who are able to pay for their care and maintenance therein; and to authorize the care and mainte- nance of needy residents in county homes of other counties.” (S.B. 212). This Bill is an important milestone in modernizing public facilities for the indigent ill and those with borderline income. All references to the out-of-date “poor houses” are stricken from the Act. The nature of these homes, which has in fact changed over the years, is thus recog- nized and the “pauper stigma” removed. It is also significant that Sen- ate Bill 212 provides that any resident of the county who desires to 23 purchase care and maintenance in a county home with his own funds, may do so. 4. The Pauper Law is revised to delete all references to “poor houses.” Instead, there is substituted the term “county homes for the destitute, infirm, or chronically ill.” (S.B. 213). This Bill, together with S.B. 212, removes all language in existing Acts pertaining to County Homes which implied that residents of such Homes were necessarily “paupers.” Chicago’s Central Service for the Chronically 111 Interest in the problem as one demanding community-wide planning was mani- fest in the City of Chicago where the Central Service for the Chronically 111 was organized in January 1944, under the auspices of the Council of Social Agencies and later taken over by the Institute of Medicine. The purpose of this organization is to study the need for facilities for chronic care in the Chicago metropolitan area, to establish a central registry for such facilities, and to stimulate and help in their development. The Administrative Committee of the Central Service for the Chronically 111, under the able Chairmanship of Dr. William F. Petersen, has given leadership in exploring the problem and in organizing community facilities to meet the need. Ex- tensive surveys of the problem and of varying types of facilities have been made. The Central Service for the Chronically 111, through its Director, Miss Edna Nicholson, has made its findings and recommendations available to this Committee. Development of Facilities in Homes for the Aged Homes for the aged maintained by religious and charitable organizations have always been interested in the problem of the chronically ill since many of their residents are afflicted with chronic illness. Many of these homes have developed extensive facilities for caring for the chronically ill among their residents. Illinois Convalescent and Nursing Homes Association Privately operated nursing homes and convalescent homes have also been in- terested in the problem. The Illinois Convalescent and Nursing Homes Association, through its President, Mr. Russell McKay, has cooperated with the Committee in making its investigations. Regulation of Nursing Homes Wide public interest has been developed during recent years in improving the standards and facilities of nursing and convalescent homes operated for profit. Out of this interest, there has developed a recognition of the need for licensing and su- pervision by a state agency and for developing resources whereby indigent persons needing care in such privately operated institutions might have the costs of their care met through public funds in such amounts to enable the operators to maintain adequate standards of safety, sanitation, and service. This aspect of care for the chronically ill has resulted in the introduction of several bills in the present General Assembly which propose to license hospitals, nursing homes, and other institutions giving care to the sick, including those af- flicted with chronic illness. These bills are discussed in the last section of this report. 24 FACTORS REQUIRING PARTICULAR STUDY IN CONNECTION WITH PLANNING FUTURE ACTION The urgency of the need for more and better facilities for the care of the chron- ically ill, and the prospect that this need will steadily increase in the future, are so great that action must be taken as rapidly as possible. It is important, however, that action be based upon sound planning. The organization of the necessary facilities will be a complicated administrative problem and the provision of adequate care for the large numbers of people needing it will entail significant expenditure of funds. Full consideration of the varied aspects of the problem and careful planning are therefore essential if an effective and economically sound program is to be established. Particular study must be given to (1) the type of facilities needed to achieve maximum rehabilitation of patients,- (2) proper location and coordination of facili- ties,- and (3) methods of financing care for indigent persons. Types of Facilities Needed to Achieve Maximum Rehabilitation of Patients In testimony before the Committee in the public hearing at Springfield, April 10, 1945, Miss Edna Nicholson, Director of the Central Service for the Chronically 111, Chicago, stated; “Two quite different but supplementary types of facilities are needed for adequate care of chronically sick people-. (a) facilities and services for diagnosis and treatment by competent physicians making use of good hospital facil- ities,- and (b) Homes for people who do not have homes of their own in which care can be provided, and who do not need diag- nosis or active treatment in a hospital but do need some personal care and nursing services during the months or years through which they must live with their disabilities. “Although homes should be distinguished from hospitals in planning for the care of the chronically ill the mistake should not be made of assum- ing that medical services are not important in the homes. Careful study by competent medical authorities should be a part of the admission pro- cedure in every home in order to assure that all possible efforts have been made to cure or relieve the conditions which are disabling the patient be- fore accepting his condition as permanent and hopeless. Provision must also be made for continuing supervision by competent physicians of care given patients in the home and for periodic re-examination of the patient as changes in his condition may occur. It has been pointed out by authori- ties on the subject that one of the most tragic aspects of the care which has been available in many county infirmaries in the past has been the lack of good medical service of this kind, and the extent to which, once admitted 25 to the infirmary, people have been left to live out their lives in invalidism— a burden to themselves and to society—when better medical services might have cured or greatly relieved their disabilities.” Proper Location and Coordination of Facilities In this same hearing, Miss Nicholson also summarized problems pertaining to the proper location and coordination of facilities for the chronically ill. Miss Nichol- son said: "Thought will be needed on such questions as: TAedical services: The best methods for assuring competent medical services for diagnosis, treatment, and continuing medical super- vision; the relationships which should exist between medical serv- ices in homes and hospitals; the relationships which should ob- tain between these medical services and those available to other patients in the community. Care for indigent persons: The relative advantages and disadvan- tages of establishing and maintaining special homes and hospitals • offering “free care” to the indigent, as distinguished from the ad- vantages and disadvantages of permitting indigent patients to receive their care in the same homes and hospitals as serve other persons in the community; etc. Advisability of specialization: The relative merits of establishing special hospitals for the chronically ill apart from hospitals al- ready in existence. (Many of the facilities and types of equipment needed in diagnosing and treating persons suffering from chronic illness are identical with those needed by patients suffering from any other illness, and there is increasing opinion among physi- cians and hospital administrators that establishing separate hos- pitals for diagnosis and treatment of chronically ill patients leads to unnecessary duplication of expense and administrative complica- tions.) Thought should be given also to the advisability of estab- lishing specialized hospitals for the various diagnostic groups, i.e. a cancer hospital; a cardiac hospital; an arthritis hospital; a hos- pital for kidney disorders; etc. Here, also, opinion is increasing among persons familiar with the problems that generalized insti- tutions, perhaps with specialized wards or units, are preferable to specialized institutions. "The practical questions outlined above, and many others, will need careful thought as a preliminary to definite action if an effective and eco- nomically sound program is to be established in Illinois.” Methods of Financing Care for Indigent Persons Miss Nicholson’s testimony just quoted included reference to the problem of financing care for the indigent among the chronically ill. In testimony before a subsequent public hearing on April 25, 1945, Raymond M. Hilliard, Public Aid Director, Illinois Public Aid Commission, discussed the possibility of extending the authority and financial responsibility of the State with respect to aiding townships and other local governmental units in meeting the costs of the indigent chronically ill. 26 One possibility mentioned by Mr. Hilliard was that of amending the powers given the Public Aid Commission so as to permit state funds to supplement local funds more readily when township or other relief authorities are unable to meet the problem fully. Mr. Hilliard described present limitations and difficulties as follows: “Townships and other local units administering general relief should provide one of the chief sources of funds for paying costs for the indigent chronically ill. There are 1455 such local units. The State supplements local funds used for this purpose, provided the local unit has made a 3 mill » levy and otherwise qualified for state relief funds which are allocated by the Public Aid Commission. At the present time, however, less than 200 of these units have made the required levy and thus have access to state funds. “A special problem is presented for the chronically ill who live in the City of Chicago and the Incorporated Town of Cicero. If they are already on the relief rolls, care can be provided for them at the expense of the re- lief officials in any suitable institution, public or private. If they are not already on the general relief rolls, however, the present Pauper Law makes the County of Cook responsible for their care, rather than the Chicago Welfare Administration or the Supervisor of the Incorporated Town of Cicero. “The County of Cook restricts the care it offers to the services avail- able in the Cook County Hospital or in the Oak Forest Infirmary, which is the poor house maintained by the County of Cook. The County of Cook does not have access to state relief funds allocated by the Public Aid Com- mission for care of paupers and care of the medically indigent. As a re- sult of this situation, no public agency in the City of Chicago is at present meeting the costs of an indigent chronically ill person, not otherwise on re- lief, in a private nursing home or in hospitals other than the Cook County Hospital. Any such care given is left to private charitable agencies. “Amendment of this present provision of the Pauper Law to place responsibility on the relief officials of Chicago and Cicero, as it is in the other 1455 relief administering units, would raise some problems. For ex- ample, the practical effect would be to change the Cook County Hospital and Oak Forest Infirmary from county operated institutions to institutions operated by the City of Chicago, since the majority of the patients come from such city. This would destroy the advantage of having a county in- stitution maintained by county funds. It is suggested that the Committee, if its life is extended by the Sixty-fourth General Assembly, give special study to the problem arising in Chicago and Cicero because of the present provisions of the Pauper Law.” Summary of Fundamental Questions to Be Considered Dr. Kretschmer1 has ably summarized the fundamental questions which must be considered in developing a sound public policy. Dr. Kretschmer says: “Before any sound program can be instituted, careful and serious con- sideration must be given to the fundamental questions, as: 17be Journal of the American Medical Association, April 21, 1945, p. 1027. 27 “1. The relative distribution of responsibility which should be main- tained by voluntary, philanthropic and proprietary services for establishing and operating the necessary homes and hospitals. “2. The responsibility which should be assumed by the government for the indigent. “3. The desirable size and location of the facilities to be established. “4. The extent to which beds are needed in hospitals or treatment centers as distinguished from homes for patients who cannot hope to profit from treatment and need only continued personal care and nursing attention. “5. The most satisfactory method of financing care for patients un- able to pay the costs of care, in whole or in part. “6. The most effective means of maintaining adequate standards of care in institutions serving these patients, i.e., through licensing laws, periodic inspection by state or local authorities, and so on. “Whether there are to be special institutions for the chronically ill, i.e., chronic disease hospitals separate and apart from those serving acutely ill patients, or whether they are to be separate wings or additions to these hospitals. Much discussion must be given to this question.” Such problems as those outlined above make it imperative that the work of the present Committee be continued during the next biennium in order that well- considered recommendations may be made to the Sixty-fifth General Assembly. In the meantime, certain immediate steps can and should be taken by the Sixty-fourth General Assembly. These recommended steps are discussed in the next and concluding section of this report. 28 CURRENT LEGISLATION ON THE CHRONICALLY ILL Conversion of County Homes Into Facilities for the Chronically 111: Rennick-Laughlin Bills (S.B. 210, 212, 213, and 534) It has been mentioned previously that the Sixty-fourth General Assembly has already enacted into law the Rennick-Laughlin Bills which provide for additional facilities for the chronically ill by converting county homes into homes for the desti- tute, infirm and chronically ill and making such homes as meet proper standards accessible to Old Age Pension and Blind Assistance recipients without loss of their assistance grants. These Bills also make care in such homes accessible to borderline income persons who wish to purchase care therein. The Committee views this legislation as the most important action taken in recent years to develop facilities for the chronically ill. Aid to Persons Afflicted With Cancer or Tumor Three Bills have been introduced in the Sixty-fourth General Assembly pertain- ing to care for persons afflicted with cancer or tumor. These are Senate Bills 191 and 192 (Lohmann) and House Bill 55 (Hayne). House Bill 55 passed the House April 10, 1945, and the Senate May 23. The Bill reduces the number of legal voters in the county required to file a petition for the purpose of submitting to referendum in the county the question of providing for treatment of persons afflicted with cancer or tumor, in accordance with the Act of May 12, 1943 which enables the counties to provide for cancer and tumor relief. Senate Bills 191 and 192 propose the establishment of an Illinois State Cancer Hospital to be included among the State charitable institutions and supervised, managed and controlled by the Department of Public Welfare. Care for the Tubercular Three Bills have been introduced pertaining to care for the tubercular. These are Senate Bills 47 and 48 (Libonati) and House Bill 325 (Gibbs, Van der Vries, Powell, Stransky, Jenkins, Davis, Prusinski, Fred J. Smith, Sullivan and Ray). Senate Bills 47 and 48 propose to create a State Tuberculosis Hospital Fund from a portion of the moneys received under the Illinois Horse Racing Act. House Bill 325 proposes that the State of Illinois pay $1.50 per day for each tubercular patient receiving care at public expense from a sanitarium board or hospital approved by the Department of Public Health. On April 5, 1945 the Senate concurred in House Joint Resolution 29 offered March 28 by Messrs. Nelson, Hannigan and James J. Ryan. This Resolution pro- vides for the appointment of a legislative committee to study the feasibility and necessity of constructing a public tuberculosis hospital in the southeast and south portion of Chicago. This committee will consist of three members of the House and three members of the Senate. It is to report its findings to the present Sixty-fourth General Assembly. 29 Concerned as it has been with exploring the problem of chronic disease in its entirety, the Committee is not prepared at this time to offer recommendations con- cerning care of the tubercular but it does wish to call attention to the statement of Governor Dwight H. Green in his Second Inaugural Address, January 8, 1945. Governor Green said: “Illinois is the only state, except Nevada, which does not either main- tain state tuberculosis sanitoriums, or subsidize local sanitoriums. With more than thirty-two hundred deaths and approximately ten thousand new cases of tuberculosis reported annually in Illinois, and the likelihood of higher prevalence after the war, the need of additional sanitorium facilities and a more aggressive and extensive control program is serious. “The Department of Public Health has proposed, and I commend it to your earnest consideration, that four tuberculosis sanatoriums, of two hun- dred beds each, be constructed in downstate Illinois, and one or more, with an aggregate of two thousand beds, in Cook County. The estimated cost of construction, exclusive of sites, $7,570,500. The proposal has been of- ficially endorsed by public health and tuberculosis organizations, and the American Legion. “The plans for these sanitoriums must be considered in connection with a unified and statewide post-war program, but I submit that effective state action to curb tuberculosis is one of the pressing needs of Illinois.” In accordance with Governor Green’s recommendation, Senate Bill 417 (Peters and Ryan) includes in its proposed appropriation for a statewide system of public works projects, an item of $3,850,000.00 for the construction of tuberculosis sani- tariums, with fixed equipment installed, one of which is to be located in Cook County, and four in other sections of the State. The appropriation is proposed for the Department of Public Works and Buildings. Extension of Facilities for Physically Handicapped Children (H.B. 412: Van der Vries, Edwards, and Prusinski) This Bill proposes important extensions of state aid and service to physically handicapped children. It includes a proposed hospital school which any educable handicapped person under the age of 21 would be permitted to attend. This Bill has been endorsed by many persons interested in child welfare as well as those interested in improving facilities for the chronically ill and physically im- paired. It may provide, among other services, some opportunity for the rehabilitation of spastic children for whom facilities are practically non-existent. The Committee recommends this Bill for consideration by the Sixty-fourth General Assembly. Regulation of Hospitals and Related Institutions Three bills have been introduced in the Sixty-fourth General Assembly which propose the licensing and regulation of hospitals and related institutions. These bills are House Bill 103 (Welters and Granata), House Bill 252 (Gibbs, Van der Vries, Wellinghoff and Stransky), and Senate Bill 373 (Downing). House Bill 103 proposes to license and regulate private hospitals, nursing homes and sanitariums. Responsibility for setting standards and issuing licenses is placed in the Department of Public Health. The proposed annual license fee is $5.00. Hos- 30 pitals maintained and operated by the State or by any political subdivision or munic- ipality in the State do not come within the proposed regulatory provisions. Excep- tions are likewise made fey* hospitals and municipalities which have by ordinance provided for the regulation of hospitals in accordance with at least the minimum requirements of the proposed Act. The bill does not specify the minimum number of persons required to classify an institution or home under the proposed Act. House Bill 252 proposes that the Department of Public Health license and reg- ulate nursing homes which care for three or more persons. Hospitals are not brought within the provisions of the proposed act. Homes or institutions operated by the Federal or State Governments or by subdivisions thereof are excepted. Limitations are set forth concerning the regulatory power of the State Department of Public Health over homes conducted for those who rely upon treatment by prayer or spiritual means. Cities, villages, or incorporated towns which provide for licensing and regulation of nursing homes in accordance with standards which substantially comply with the minimum requirements of the proposed act are excepted from coverage. The proposed original license fee is $25.00 with an annual renewal fee of $5.00. Senate Bill 373 provides for the licensing and regulation of all types of hos- pitals and sanitaria, nursing homes, boarding homes, and other institutions pro- viding hospitalization or care for persons requiring care by reason of illness, injury, physical and mental infirmity, or other disability. The power to license and regulate is placed in the Department of Public Health. The only hospital facilities excepted are those maintained by a penitentiary, jail or reformatory in which persons con- victed of crime are incarcerated. It provides that the Director of the Department of Public Health shall appoint an advisory committee to represent each class of hospital or institution to be licensed. License fees are graduated according to the number of beds in the home or institution. Proposed fees range from $10.00 to $25.00. The Committee has given careful consideration to all three of the above bills pertaining to the licensing and regulation of hospitals and related facilities. It recommends that Sen- ate Bill 373 take precedence over House Bills 103 and 252. Senate Bill 373 is complete in its coverage and will thus as- sure protection to all Illinois persons. It also has the advan- tage of codifying previous licensing acts pertaining to spe- cial types of hospitals or institutions and centralizing authority in one state department. Legislative Commissions to Continue Study of Medical Care Problems Two bills have been introduced in the Sixty-fourth General Assembly pro- posing the establishment of legislative commissions to inquire into the medical needs of residents of the State of Illinois and facilities for their care. These Bills are Sen- ate Bill 336 (Crisenberry, Thomas and Fribley) and Senate Bill 436 (Bidwill and Downing). Senate Bill 336 proposes a Commission to investigate medical and hospital needs of residents of Illinois. The Commission is to consist of three members of the House, three members of the Senate, and three members appointed by the Governor, In making his appointments, the Governor is required to give consideration to the recommendations of labor groups or organizations. This Commission is to report to the Sixty-fifth General Assembly its recommendations concerning the establishment of a State system of hospitalization and medical care. 31 It is recommended that this Commission, if Senate Bill 336 becomes law, cooperate in its inquiries with the Com- mission proposed by Senate Bill U36. Senate Bill 436 proposes a Commission to investigate the need of developing facilities for the care and treatment of persons who are chronically ill. It provides that the proposed Commission consist of three members of the Senate, three mem- bers of the House, and the heads of three State agencies,- namely, the Director of the Department of Public Welfare, the Director of the Department of Public Health, and the Public Aid Director of the Illinois Public Aid Commission. Through this means, members of the General Assembly and members of the administration most directly concerned with and technically informed about problems of the chronically ill, will be able to work together in pursuing further the investigations of the present Committee to Investigate Chronic Diseases Among Indigents. Senate Bill 436 carefully outlines the field of inquiry of the proposed Com- mission. This is stated in the following language: “The Commission shall make a thorough investigation and study of the hospitalization and other care and treatment facilities available in this State for persons who are chronically ill, the adequacy of such facilities, the need of developing additional facilities for such purpose, the desira- bility of enacting enabling or corrective legislation to increase or improve such facilities, and all matters germane thereto. The investigation and study shall embrace both governmental and private facilities and needs and shall relate to all chronically ill persons. The Commission may study and consider the matter of making State contributions for hospitalization and medical needs of chronically ill persons who are destitute and unable to meet such costs.” This Bill relates directly to the work of the present Committee to Investigate Chronic Diseases Among Indigents. As previously indicated throughout this report, the present Committee has only begun to study the complex problem of the chron- ically ill. It is obvious that further study will be necessary to provide the basis for a sound public policy which will coordinate State and local planning for the care of such persons. The inquiries and findings of the present Committee have established that the question of chronic invalidism is one of the most urgent problems in the welfare and health field confronting the State of Illinois. It, therefore, urgently rec- ommends to the Sixty-fourth General Assembly that it act favorably on Senate Bill U36. This Bill will assure to the State of Illinois a careful survey of the entire problem, upon basis of which adequate plans can be made to meet the need in a manner consistent with the State’s reputation for pioneer action in the field of public welfare. 32