more than that, so they really would not benefit so much generally by this. Of course, the reason for the retirement test, as you point out, is partially a cost.

It also ties in with what do you mean, someone is retired, so it is the definition of retirement to qualify.

Senator DOMENICI. We understand that there was and perhaps still is a concern for the available work force in America, and what retirement should mean in terms of the work force.

Let me proceed to another subject on which we get many complaints, and I am sure you do also. I understand that these complaints are at least regional in nature and are with reference to the conversion to the Supplemental Security Income program, and subsequent problems. We had one gentleman testify today, and if the facts are correct, there was a 5-month lapse in terms of getting the conversion from Social Security to the income supplement program.

Do you find that the advent of the Supplementary Security Income program has increased your work significantly, and have you had any staff additions?

Mr. MORPHEW. Yes, sir. The workload has increased remarkably, and we have not had a remarkable increase in staff. We have had to start with programs, as you pointed out. One of the highest workloads has been the frustration of the conversion to the Federal system, where we have been unable to get something accomplished, as maybe for this gentleman here, and unfortunately, there are some instances where we are unable to give them emergency help.

In most instances, we are able to give them emergency help, but for some in a certain category, we are unable to do that.

Senator DOMENICI. One last question in this regard. Are you aware of any inhibitions in terms of going back in time, or can you tell us, if it takes us another 7 months to clear up these records? If you find the constituent was entitled to benefits back to January 1, are there any restrictions on that?

Mr. MORPHEW. No, sir. The payments go back to when they were due. The only way a person loses anything is if they are not actually signed up, and they did qualify.

You can only start paying under this program the month they signed up. I would just like to make one more suggestion. First of all, I think the Supplemental Security Income program does not pay enough or it does provide payments that are high enough. One would help, even if the payments were not raised. If they will be raised $9 for a couple in July and $6 for an individual, it would be helpful, but even if the payments themselves could not be raised, if there could be some proviso qualifying for Medicaid, that the person might not qualify for monthly cash payments, but they could qualify for Medicaid if their income was below $300 a month, or whatever figure might be a reasonable figure. There should be two types of qualification, one would be for health care, and the other would be for monthly payments.

Senator DOMENICI. Right. We will make your analysis part of the record, and we thank you very much for your testimony and your cooperation in the last few days.

Mr. MORPHEW. Thank you very much.

Mr. CHAPMAN. Mr. Chairman, may I speak from the floor? There has been a gross injustice here to the older people.

Senator DOMENICI. Mr. Chapman, you will get a chance after the formal witnesses speak. If you could hold up until then, we would appreciate it.

Mr. CHAPMAN. Fine.

[The prepared statement of Mr. Morphew follows:]

PREPARED STATEMENT OF DON MORPHEW

Medicare and Medicaid together paid two-thirds of the total health care bill for the elderly in fiscal year 1972-$13 billion of $19.8 billion.

Those older citizens who qualify for both Medicare and Medicaid get their entire medical costs paid-including eyeglasses, drugs, hearing aids, and custodial care-all but routine dental care.

Ironically, those older persons who have too much income to qualify for the Supplementary Security Income program (and therefore can't qualify for Medicaid) are hardest hit. These people pay their own Medicare premiums for part B$3 in 1966-$6.90 in July this year. They must pay their own part B deductible each year-currently $60.

They must pay their own first day of hospitalization-currently $84. These people must buy their own drugs, eyeglasses, dentures, hearing aids-everything Medicare doesn't provide.

All of these expenses are tied to costs. The yearly rate of inflation in March was 11 percent. The rate of inflation on essentials-food, clothes, shelter-appears to be even higher.

Fixed income-rising costs. The problem is not hard to see.

A single person who has $160 per month income doesn't qualify for SSI or Medicaid.

A couple that has $230 per month income doesn't qualify for Supplemental Security Income or Medicaid.

Outside larger towns few medical facilities exist. This means even those elderly persons who have the means must travel for adequate treatment if they live in rural locations.

Senator DOMENICI. Our next witness is Dr. Robert McCarthy, Ph. D., assistant professor, department of psychiatry, University of New Mexico, Albuquerque.

...Doctor, before you start, you are going to speak, at least from the professional standpoint, on boarding homes. We do want to tell the people here that we had intended to call the news reporter from the Tribune who wrote a series of articles on boarding homes. Her observations are the basis of her story. She is not available. She just does not happen to be in New Mexico at this particular time, and she could not adjust her schedule to ours.

We have her articles as the basis of her findings, and certainly that does not mean they are scientific in light, but we have them. We are sorry she cannot be here to supplement what you have to say, or to be part of the panel.

If you will proceed, we would appreciate it.

STATEMENT OF ROBERT J. McCARTHY, PH. D., CLINICAL PSYCHOLOGIST, ASSISTANT PROFESSOR, DEPARTMENT OF PSYCHIATRY, UNIVERSITY OF NEW MEXICO, ALBUQUERQUE, N. MEX.; COORDINATOR, PROGRAMS ON AGING, BERNALILLO COUNTY MENTAL HEALTH/MENTAL RETARDATION CENTER; PRESIDENT, NEW MEXICO (STATE) PSYCHOLOGICAL ASSOCIATION

Dr. MCCARTHY. If you will allow me, I will read a statement. I would like to get it all in.

1 See appendix 2, item 2, p. 1126.

I have worked directly in the valley sections of Albuquerque for the past 5 years on the outpatient teams of the Bernalillo County Mental Health/Mental Retardation Center (MHC). My background in geriatrics incudes 1 year's psychology internship on a geriatric, psychiatric ward, and nursing home care unit of the Wadsworth (Kansas) Veterans' Administration Center.

During this time I have had opportunity to visit several boarding homes regarding mental health center clients and have chronically discussed living situations with our own staff as well as staffs of various public agencies. At present, we have approximately 110 boarding home residents who are patients of the mental health center. These patients include both the young and the elderly.

I would hypothesize that if formal psychiatric or psychological evaluations were done on all residents, this number would easily increase. In addition, with a handful of homes, nontraditional psychotherapeutic activities are carried out with residents not formally registered as patients of the mental health center, based on more of a consultation to the home model, that is, some operators are interested in help. In regard to the elderly, this has become a pilot project focus this year.

In general, I would agree with Ms. McCord's reporting on boarding homes this month in the Albuquerque Tribune which is understood to be included as part of the committee testimony. It would only be redundant to repeat similar testimony. Such reporting has been made in the past and unfortunately the only result has been that the good operator suffers. Thus, although responsibility for what you now find rests on many operators, it also rests on the community at large which has been told but has chosen not to respond.

COMMENTS ON NURSING HOME RECOMMENDATIONS

I would like to comment briefly on recommendations made in yesterday's Albuquerque Tribune regarding steps to end the problem. For example, requiring compliance with standards for homes with three or more SSI patients: (1) The word "patient" which appears several times implies the receiving of medical or allied health service care; you do not get medical care for $4 a day ($140 minus the theoretical $20 for personal use, divided by 30 days). If allied health care is expected then adequate financial assistance should be provided; hotels and motels which provide rooming and are not required to provide assistance with tasks of daily living do not have "patients"; (2) if an operator has less than three SSI residents, what is the leverage then; (3) who is going to take in the SSI recipient? The denial of Federal funds to facilities not meeting standards, for some facilities may mean nothing, as they may do quite well on the unfortunate situation where relatives are willing to pay the private rate to have mother or father or son or daughter in a less than adequate situation "out of their hair."

On the other hand, what is an adequate situation? The regulations somewhat clearly define physical plant requirements but what are the requirements for the psychological and medical environment, for example, sitting all day with nothing to do in some instances decreases

1 See appendix 1, p. 1113.

muscle tone, healthy blood circulation, et cetera, et cetera, and can simulate a sensory deprivation situation which lends itself to cognitive confusion, disorganization, and personality decompensation, all of which may set the stage for more intensive/extensive need for medical and psychiatric care which often for the elderly in formal institutions across the country is second rate to begin with.

As is less common with the young, the interrelation between physical and mental condition becomes somewhat more critical with the elderly.

Again regarding adequacy, what are the criteria for adequate operators-what are their backgrounds, education, experience, that is the basis for what is expected from an operator? "Let the buyer beware" cannot be the watchword as the "buyer" in many instances is often cognitively limited to make a realistic judgment.

Two areas that have not been mentioned to my knowledge, are the unlicensed boarding home and the low rent hotel. The unlicensed home can board two or less individuals. One caseworker estimated that there are about 700 such homes-this could mean a potential bed capacity of 1,400 individuals.

In addition, what is the quality of life for those elderly whose relatives attempt to maintain them in their home especially in the weeks or months just prior to the last resort of boarding or institutional placement. Often the problem here is behavior management, which could be assisted through mental health consultation and education to the family prior to the crisis stage. Outreach manpower and trained staff could alleviate the need for many placements or assist with replacement in the family home.

Economic considerations: In 1963, the Comprehensive Community Mental Health Centers Act was passed and funded. Among goals were future, local, and self supporting existence, new methods of service delivery, decrease of large institutionalized populations, et cetera.

Part of the developed and workable innovative delivery system relies heavily on so-called paraprofessional mental health workers (partly developed with Department of Labor funded new careers programs, incidentally now dated for financial deletion). Medicare, another part of the Federal system, however, does not recognize what goes on in other parts of the Federal system. Medicare will not cover outpatient services of a Ph. D. psychologist, let alone a mental health worker under his or a psychiatrist's supervision.

PRIVATE PSYCHIATRIC CARE "NONEXISTENT"

Private psychiatric coverage of nursing homes, let alone boarding homes, is virtually nonexistent. Further, gerontological research is preponderantly carried on by psychologists, but the Government does not recognize this expertise potential in the instance of medicare. To further complicate the issue, of eight bills under consideration for national health insurance, only the Scott-Percy bill recognizes psychologists as primary health care providers. If public health facilities staff of mental and physical health paraprofessionals, nurses, social workers, psychologists, psychiatrists, and physicians, are to generate income, provide and expand service and the like, something has to give from time to time.

Another aspect of the money game, is a review of the domestic Federal assistance programs. The Comprehensive Older Americans Act is the only specific program for the elderly. Other groups, for example, children, appear to be covered by several possibilities. New Mexico, as I understand, is slated for $691,000 under title III; if that were distributed to the 60 and over population in Bernalillo County alone it would amount to only $23 per person. And those moneys are not earmarked for health but the gamut of problems facing the elderly. We will be asked during the coming year-what's been done-the judgment will probably be not much-the decision will be it should be done away with-are we being set up to fail?

What can be done? Several recommendations have been gathered and reported by Ms. McCord1 and I assume the committee has made contact with the various proposees for further details. Indeed, immediate action is necessary. My own thinking on the matter has the drawback of not providing an immediate solution, but does suggest the cooperative effort of the public and private sector to develop the boarding home concept of a small semi-independent care facility. Assuming that boarding homes will continue to be around, what can be done to assist the operator to make a living while at the same time assist the resident, both intermittently handicapped young and elderly, to partake of a high quality of living possible in this country?

EXPLORE BOARDING HOME OPERATION

A living laboratory is proposed to objectively explore boarding home operation. What are the day-to-day problems of the operation'financial management, dietary management and purchasing, psychological and medical assistance required by residents, unidentified sources of stress on both the operator and residents, ancillary support available, used, problems encountered with, and so forth.

From data obtained, one would be in a more objective position to say whether operators are ripping people off or perhaps in situations where such and such is the case, a amount of supplementary public dollars would be economically and pragmatically spent. The method for a living laboratory could be trained staff working in a sample number of homes for a year or operating a facsimile home for approximately 2 years. In addition to the above, an end product would be the development of a boarding home operators training package for training and continuous followup consultation on a statewide basis. A more detailed proposal will be submitted.2

Briefly, I also wish to encourage the concept of skills of daily living centers. Occupational, physical, corrective, speech, psychological therapies are provided on a daylong basis for 1 to 3 months for an illness to restore and prevent major deterioration of the elder person. This is critical where the elder person is living with a working couple who can continue to maintain the relative in the home at night, during and after the period of therapies.

Finally, geriatrics is perhaps the least preferred area of work among