The CHAIRMAN. In addition to the figures indicated in the above statement, I assume that there is a contingent insurance liability of approximately $1,240,000,000 over a period of 20 years, or about $60,000,000 a year on the average?

Col. FORBES. Yes, sir; about that.

The CHAIRMAN. So that, in addition to the amount of cash paid out, aggregating $1,517,468,885, the amount of liability assumed as a result of the insurance, aggregating $1,240,000,000, would make a total of $2,757,000,000. How much balance have you in the insurance fund?

Mr. ROUTSONG. The balance, as of February 1, is $87,000,000 in that appropriation.

The CHAIRMAN. From the amount above indicated there should be deducted the amount of premiums which come in from time to time? Col. FORBES. Yes, sir. We are reinvesting converted premiums in Liberty bonds.

The CHAIRMAN. How much do they average?

Col. FORBES. About $44,000,000 has been invested.

Mr. ROUTSONG. I think you are confusing two types of insurance in this discussion. The term insurance premiums are not reinvested. The CHAIRMAN. What I want to get at is the aggregate amount here.

Mr. MILLIKEN. You should take the total premiums received from the beginning up to date, and subtract them from the total liabilities for term insurance.

Mr. ROUTSONG. The total premiums amount to $374,150,000.
The CHAIRMAN. Approximately $370,000,000.

Mr. ROUTSONG. Yes, sir.

The CHAIRMAN. The $374,000,000, in round numbers, received in the form of premiums should be deducted from the $2,757,000,000 to show the net liability and expense. I am attempting here to show just what has been expended for this purpose. It is frequently charged that we are not doing anything.

Col. FORBES. Would you mind letting us prepare a statement covering the matter?

The CHAIRMAN. We will be delighted to have you do that and insert it in the record.

Col. FORBES. The active term insurance in force amounts to $2,502,656,000. 53.

The CHAIRMAN. What was the cost per thousand for that insurance?

Col. FORBES. Between $1.03 and $1.08 is the cost of writing $1,000 of our insurance for administration.

Mr. BREINING. The rates are figured on the American Experience Mortality Table.

The CHAIRMAN. What does it cost the man?

Col. BREINING. Anywhere from 67 cents up is the cost to the as

sured per thousand.

The CHAIRMAN. That depends upon the age, I suppose.

Col. FORBES. Yes, sir.

MEDICAL AND HOSPITAL SERVICES.

The CHAIRMAN. The next item is medical and hospital service. In this connection you are asking $20,000,000—is that right?

Mr. ROUTSONG. $20,278,930.

The CHAIRMAN. Tell us what makes it necessary to have this additional $20,000,000 for the hospitalization of the men.

Mr. ROUTSONG. The medical and hospital appropriation is an appropriation that is disbursed by the director by direct disbursement and by allotment to the various branches of the services which furnish hospital care. We have had to estimate the requirements of all branches of the service for the period of a year.

NUMBER IN HOSPITALS.

The CHAIRMAN. How many people have you in the hospitals now? Col. FORBES. About 30,650.

The CHAIRMAN. Can you tell us where they are?

Mr. ROUTSONG. Yes, sir; we have a statement showing just where all of them are located.

Col. FORBES. I suggest that you give it by disease groups, so that the committee may know the character of the hospitals.

Mr. ROUTSONG. These figures are as of February 2: There is a total of 12,344 tuberculosis patients, 8,802 neuropsychiatric patients, and 9,633 general and surgical patients, making a grand total of 30,779. The CHAIRMAN. Is the number increasing or decreasing? Mr. ROUTSONG. It is increasing.

The CHAIRMAN. How are the hospital facilities, compared with the demands?

Col. FORBES. The hospital facilities are inadequate.

The CHAIRMAN. How many of these patients are in the Public Health Service hospitals?

Mr. ROUTSONG. A total of 14,451.

The CHAIRMAN. How many in Navy hospitals?

Mr. ROUTSONG. One thousand eight hundred and four.

The CHAIRMAN. And in Army hospitals?

Mr. ROUTSONG. One thousand seven hundred and thirty-four.

The CHAIRMAN. How many in contract hospitals?

Mr. ROUTSONG. Nine thousand one hundred and twelve.

The CHAIRMAN. How many are in marine hospitals as distinguished from the Public Health Service hospitals?

Col. FORBES. A few get into the marine hospitals that are used by the United States Public Health Service for its beneficiaries. The CHAIRMAN. How many are in the hospitals of the soldiers' homes?

Mr. ROUTSONG. Two thousand eight hundred and fifty-one.

PER DIEM COST OF PATIENTS IN HOSPITALS.

The CHAIRMAN. What is the per diem cost of maintaining a patient in each one of these hospitals?

Mr. ROUTSONG. We have been unable to revise the estimate which we previously submitted to you, Mr. Chairman, as to the per diem cost, which was for Army hospitals $4.28, for Navy hospitals $4.24, and the Public Health Service $4.64. We are unable to give an estimate for the soldiers' homes, except in two of the hospitals which are occupied almost exclusively by our beneficiaries. I will have to check up the statement I am about to give. I think the average cost is about $3.75 per day in those two hospitals.

Mr. WOOD. Where are those two hospitals of the soldiers' homes. located?

Mr. ROUTSONG. At Marion and Johnson City.

The CHAIRMAN. That compares with $4.28 in the Army hospitals and $4.24 in the Navy hospitals.

Mr. ROUTSONG. Yes; $4.28 in Army hospitals and $4.24 in Navy hospitals. It might be interesting to say in this connection that while we had estimated on a basis of 1,247 as the average in the Army hospitals throughout the year this statement shows that we have actually 1,734 in Army hospitals at this date. Of course, at the beginning of the year, the number in hospitals was below the average of 1,247, and at the end of the year I believe we will be able to show that the per diem cost, on the basis of the actual number of patientdays' service rendered, will be less than the estimate of $4.28.

The CHAIRMAN. What method do you pursue in ascertaining the cost? Do you make contracts with these hospitals for the number of patients you allot to them?

Mr. ROUTSONG. You are speaking of the Army and Navy hospitals? The CHAIRMAN. I am speaking of all hospitals.

Col. FORBES. My instructions to the statistical department have been to go through the books of each one of these organizations for the purpose of finding out how they distribute the funds we allocate to them and to charge up to the various divisions of the particular service that which we believe should be charged up to the cost of operation. We have put in a considerable length of time on the Public Health Service in working up their disbursements, so that we could arrive at the cost of operation or the cost per diem. The Army is furnishing us a similar statement, as is the Navy. During the last several sessions of the Federal board on hospitalization we have been dealing more particularly with the cost of operation of hospitals, but due to the way they have expended funds allocated by the bureau it has been very difficult to arrive at the actual cost as yetthat is, the per diem for our patients. The figures we have here are the result of the investigations thue far made.

The CHAIRMAN. Why do you not bring them in and require them to make a contract with you for the amount they charge for the care of these patients and allot them the amount of money which will cover the expense of the number of patients you have in their care? Col. FORBES. In that connection we took up that question with the soldiers' homes. Gen. Wood was there, and I asked him, inasmuch as he had stated to your committee that the cost was approximately $2.75, as I recall it, whether he would be willing to accept allotments from us on the basis of $2.75 a day. At first he said yes; then, after a consultation with his financial people, he said that sum would increase, but he was not able at that time to state how much. So he did not agree to accept allotments from us on that basis.

The CHAIRMAN. They make the statement that the reason why the cost increases is that your board of so-called experts, who fix the character of the service, have so many fads connected with the service that the cost is very much greater than it would be if it were not for that.

Col. FORBES. In answer to that, Mr. Chairman, our board has never set up a standard for the soldiers' homes; the standard that was set up was by a board of consultants of their own.

The CHAIRMAN. Well, somebody.

Col. FORBES. Called by themselves and who are not members of any of the governmental agencies.

The CHAIRMAN. You do not follow their dictation?

Col. FORBES. Well, not entirely; no, sir. That was made up of some doctors that Gen. Wood brought in for consultation for the purpose of working on standardization of treatment. We believe that our requirements for the care of the younger men are much different than the requirements for the care of older persons, basing our argument on the fact that the soldiers' homes have been dealing with older men whose association with the institution is custodial, domiciliary, and not purely medical. The medical attention required for inmates of old soldiers' homes is much less than that required by the younger men, who are there purely for medical care and

treatment.

The CHAIRMAN. Do you make an allotment in blank of a given amount, without respect to the number of patients that are in these hospitals?

Col. FORBES. When I first came into the job I did; I made them an allotment of $2,500,000, which in part was to be used for construction and alterations in soldiers' homes; since then I have made no further allotments to them, and we have told them that we wanted an itemized statement from them as to their disbursements.

The CHAIRMAN. Do you not make all of these people who have the care of your patients render a monthly statement showing the number of patients they have and the cost per patient?

Mr. ROUTSONG .Every Public Health Service hospital renders such a statement and the Army and Navy hospitals render quarterly statements on the number of patient-days service rendered, and they are all carefully checked against our hospital records before any further allotments are made.

The CHAIRMAN. Does the same thing apply to the soldiers' homes? Col. FORBES. It applies to them, but they have not rendered us a statement as yet.

The CHAIRMAN. Why do you not insist on having such a statement?

Col. FORBES. We will, because we have not allocated them any more money than the $2,500,000 that was first allocated to them.

The CHAIRMAN. Is there no way by which you can ascertain in advance just what it is going to cost you per patient when you send patients into one of these hospitals, so that you can make an allotment on the basis of the number of patients they have?

Col. FORBES. No; you can not do it, and for this reason: We have a very rapid turnover in all of these hospitals; our population is changing every day; and under certain rules and regulations we have recently promulgated, when we discharge a man from a hospital, after he has reached the maximum hospital improvement, we are reducing our population as rapidly as we can, but, of course, new people are coming in all the time. A hospital to-day may be employing a personnel of 700 men and only have 250 patients.

The CHAIRMAN. Of what class of patients would that be true? Col. FORBES. General medical and surgical cases, and of the quiescent cases of tuberculosis.

The CHAIRMAN. Do you require more personnel to take care of that class of cases than you do other cases?

Col. FORBES. Not necessarily; but, as I say, a hospital may be depopulated to a goodly extent to-day and filled up next week, so that we must continue the employees there in the hospital.

DEMAND FOR FURTHER HOSPITAL SPACE.

The CHAIRMAN. Are the facilities for hospitalization keeping pace with the needs of the service?

Col. FORBES. No, sir; they are not.

The CHAIRMAN. What is the state of the case to-day in respect to facilities?

Col. FORBES. We are without adequate facilities for our insane and for tuberculosis patients.

INSANE AND NERVE PATIENTS.

The CHAIRMAN. How much more space do you require for them? Col. FORBES. As to the insane, we have just had a conference with the leading neuropsychiatrists of the country, and they concluded their work with us the other day, seven of the biggest men in the United States. In our expectancy of the peak for mental and nervous cases we had 9,350 at the peak of our nervous load. At the conclusion of this conference they reported that we would have to provide for 12,200.

The CHAIRMAN. Do you see any evidence of truth in that conclusion?

Col. FORBES. Yes; we do, in a way. I am speaking now as a layman, Mr. Chairman, and not as a medical man.

The CHAIRMAN. But you could tell by the number of applicants? Col. FORBES. If I were to judge from the number of communications we receive on this very subject. I would agree with them. They have made a study of the ex-soldier population in the various States of the country; they have taken the normal expectancy for insane per thousand as found among our ex-service men, and they have by that method arrived at the percentage of expectancy of insane among the ex-service men in the various centers of the country. The CHAIRMAN. How soon do they expect that peak to be reached? Col. FORBES. Our expectancy was in 1925, and, of course, if insanity does develop as rapidly as they claim it will our expectancy will not be reached until 1927.

GENERAL HOSPITAL CASES.

The CHAIRMAN. How about the general hospital cases? Is there any decrease or increase in the number of applicants?

Col. FORBES. The curve to-day shows that the mental cases are the highest.

The CHAIRMAN. There is a growing number?

Col. FORBES. Yes, sir; and also as to tuberculosis. The general medical and surgical cases ran along at a fairly even line until this industrial depression showed up, when we had an increase in the number of that particular class of cases.

The CHAIRMAN. You mean mental cases?