groups, leaving the poor, the unemployed and other unprofitable high-risk groups and individuals to the Government program. The Nixon plan would require a complicated system of income-testing-a more polite name for "means" tests-to determine eligibility under AHIP. Additionally, insurance companies would have to keep records on the income changes of their subscribers in order to adjust the individual's deductible and coinsurance requirements. Income testing is, per se, repugnant to American workers. It dilutes the principle of health care as a right of all Americans into a thinly disguised welfare program. As the States have found out in administering their welfare programs, income testing escalates administration costs, further reducing benefits. The paperwork that would be required for insurance companies to bill and collect deductibles and coinsurance would threaten to swamp the health care system in a flood of red tape. As with welfare, when administrative costs exert pressure on limited budgets there is the temptation to reduce costs by cutting benefits. This happened under Medicaid, and must not happen under national health insurance. President Nixon claims consumers would have an important role in his program. The fact is that the only role for consumers is to pay high deductibles, coinsurance and premiums. A particularly distressing role for consumers in the administration proposal is the procedure whereby insurance companies could charge patients an unspecified amount of interest on their share of doctor and hospital bills. Credit cards and interest charges are no substitute for comprehensive benefits with no deductibles and no coinsurance. The Nixon program is for the doctors and the insurance companies, not the consumer. SUMMARY The Nixon administration national health insurance proposal falls far short of the minimum standards for national health insurance established by the AFL-CIO executive council on February 17, 1970: Universal coverage as a matter of right. Encouragement of prepaid group practice plans. Strong cost and quality controls. Reform of the health care system. The Nixon program would not provide universal coverage as a matter of right. It would not provide a single standard of comprehensive benefits. It would be financed through the private insurance industry and not like a social insurance system. It would not encourage prepaid group practice plans. It would not effectively control costs and quality. It would not reform the health care system. Only National Health Security-the Griffiths-Kennedy bill meets the goals of the AFL-CIO. ITEM 2. STATEMENT BY THE AFL-CIO EXECUTIVE COUNCIL ON NONINSTITUTIONAL SERVICES FOR THE ELDERLY BAL HARBOUR, FLA., February 19, 1974. Many older people are confined in expensive nursing homes and other institutions for relatively minor health conditions only because the range of community services that would enable them to remain at home are not available. This problem is not insurmountable. All that is needed is a greater national and community commitment to development of these services. Unfortunately, noninstitutional services for the elderly are given little or no priority in most communities. Even where such services are to some degree available, they are usually provided on a fragmented basis from a variety of agencies. These services should be brought together in a coordinated, general service program. They would cost the community far less than it now pays for nursing home care and would provide the elderly greater satisfaction by enabling many of them to remain in their own homes. Successful programs will require a wide spectrum of services ranging from home health services and visiting nurses to homemakers and housing for the elderly. Of course, elderly persons should not be denied care in a nursing home or other appropriate institution when such care is the best for their condition. The objective should be what is best for the health and well-being of elderly people. The core of any noninstitutional service system should be an effective home health services program-a complex of services which may be brought into the home to sustain individual health and independence. But there has been a glaring inconsistency between stated public policy and what has actually happened to home health services programs. In many areas, home health services are not available at all. Where such programs are operating, they are generally underfinanced, unable to adequately cover the target population, and deficient in essential elements which would make them an effective resource. Both Medicare and Medicaid authorize home health services but with such tight restrictions that they have created roadblocks to the development of such services. Less than 1 percent of Medicare expenditures now go to home health care and even that small portion appears to be decreasing. Some health service agencies have shut down and many others still operating appear to be in financial jeopardy. A good first step toward more effective health service programs for the elderly would be greater emphasis on such services in the Medicare and Medicaid Programs. But more than this is needed. What is needed is a program of noninstitutional services that is capable of being a major component in a comprehensive health care system such as the National Health Security Act would establish. The AFL-CIO urges the development and passage by Congress of a comprehensive system of services for the elderly, and that such a program of services be included in any national health program that may be adopted. Appendix 3 ITEM 1. NEWSPAPER ARTICLE SUBMITTED BY SENATOR WALTER MONDALE, ENTITLED “AGING SISTERS IMPRISONED BY POVERTY,” FROM THE WASHINGTON POST, MARCH 13, 1974 [From the Washington Post, Mar. 13, 1974] AGING SISTERS IMPRISONED BY POVERTY Imprisoned by poverty and hounded by inflation, two elderly sisters are closing out their lives in a Massachusetts Avenue apartment in a constant state of anxiety and depression. Mary Smith, aged 82, and her younger and sicker sister Elsie Sager, 79, survive, and not much more. Rising prices have stolen even the smallest of life's material pleasures from them. The sisters' lives provide a frightening case study of life in inflationary times for many of this city's 103,000 people over 60 years of age. Too old to work, with no close relatives, the sisters depend on a Social Security income of $296.30 and a pinchpenny budget that allows them $2 a day for food. Penury has forced an almost total divorce from the outside world upon the sisters. Only the buzz of traffic and their own suppressed longings remind them, they say, of a normal life. They have one another and all the comfort an antiquated and flickering television can bring. In the course of a long interview, the suspicion of tears misted Mrs. Smith's spectacles just once as she was saying, "Sometimes I see women in this building all dressed up for a swell lunch at Woody's or Garfinckels and I almost burst out crying." They lack sheets for their beds, shoes for their feet. Rising prices lay constant siege to their diminished diet, making one sacrifice after another-fresh fruit, then milk, then meat... Stoic by nature, Mrs. Smith says their situation is "laughable." But she does not laugh. In fact the once jolly person whose pleasant face bears imprinted smile lines rarely laughs these days. For the two sisters, the closing out of their lives is proving a bleak ordeal replete with depression, indignity and suffering by deprivation. Inflation continually threatens their precarious existence on an already inadequate fixed income. And inflation, in a remorseless progression, has canceled the few pleasures from their lives. Mrs. Smith, for instance, "an avid reader" used to devour the morning paper cover to cover. She had to cancel it a while back. The women worked a combined total of 39 years to earn their right to the monthly social security checks-Mrs. Sager as a beautician in Richmond, Mrs. Smith as timekeeper in a now defunct Washington laundry. They are single. Mrs. Smith was divorced in 1925 and her sister has been a widow for 44 years. "Every night." says Mrs. Smith, "I thank God for what we have, but it's mighty little." Her dress was a gift from the manager of the building. The print flowers have been laundered to a pallor, so that the dress matches her indoor complexion-notepaper-white. Her shoes are a work of artistry-15 years old, the many slits and holes carefully welded shut with glue. "In the past year or so." she says in her usual firm and unself-pitying manner, "it looks like I'm really getting crushed. I shouldn't and I'm trying to get out of it." But her sister Elsie is depressed most of the time-"what we've been through is enough to tear the heart out of anyone," Mrs. Smith explains. Asked to comment on how the sisters' situation could be equated with that of thousands of other elderly people in the city, social workers with various voluntary agencies and a spokesman for the District government's services to the aged office agreed it was typical. "These people are almost among the affluent aging," said George Robey, acting chief of the social services division. In 1973 food prices soared by 25 per cent, placing a specially heavy burden on the fixed income poor like the two sisters. In January this year, grocery prices in the Washington area went up another 3 per cent. "Inflation has had a tremendous impact on the elderly here," said Geraldine Brittain, a social worker with the private Family and Child Service who has helped the sisters. "There are relatively few social workers and it's a big population of elderly. We just touch the tip of the poverty iceberg. I think there's lots of real suffering." Defenders of the Social Security system are quick to point out the payments are intended to supplement, savings, pension or other retirement income. The two sisters were left with no savings when they retired due to ill-health in their early 60s-Mrs. Sager because from the small profits of her beauty shop she had to look after her mother and two nephews and Mrs. Smith because her $60-a-week salary permitted no savings. Although the sisters are receiving their full entitlement, they are skeptical and disappointed: "All those years," says Mrs. Sager, "they kept telling me my social security was building up, building up, and then when I got where I couldn't work but half a day that's what they based it on." The grim reality of the sisters' cheerless life is worsened by the contrast with their falsely optimistic anticipation of how "the golden years" would be. The absence of forethought to retirement is cited by experts as one of the contributory causes to distress in the aged. Arguing for more community concern in treatment of the vulnerable and powerless aged, they like to gently threaten that as a multitude advancing to through life. We should pay heed when distress falls on those in front. Mrs. Sager, a stocky invalid figure in a white nightrobe had seen her retirement as a chance to go to the zoo, the Smithsonian, the Washington scenes she never got around to seeing while working. Now even those limited ambitions are beyond reach: "I was going to have myself a ball," she says in a voice huskily wistful with the memory. "I thought when I got to be in my old age," remembers Mrs. Smith, "I'd have enough to eat, a place to sleep, plenty of time to read and nothing to worry about. And having a lunch out or something like that once in a while." Her life now is, she says, "certainly nothing like that. We can't afford to buy a bus fare and if we got downtown we could not afford lunch. You couldn't do it for less than $1.50 or $2-we can manage for a day on that-it's out of the question for us." In a splitting of financial responsibilities common among elderly roommates, Mrs. Sager uses her check to pay the $140-a-month rent on their two-room apartment and Mrs. Smith cashes hers to buy food and other essentials. Anxiety over making ends meet is a constant for them, incalculable to the outsider: "All the time you're figuring out 'can I buy this, or buy that' and you're scared to death something will happen and you won't have the money." says Mrs. Smith. The telephone, for instance, is an oft-discussed but finally indispensable necessity that costs a precious $10.50 a month. The sisters seldom leave the dingywalled apartment-"if they whitewash it the rent goes up"-except for their once-monthly shopping trip. The telephone is a link to the outside world, with richer friends who call from Florida, New York or California-and for two old women with fragile health, a protection. Several weeks ago Mary picked up the red handset and called a doctor when her sister had a 3 a.m. heart attack. The episode put Mrs. Sager into George Washington Hospital for two weeks under the Medicaid program and emptied the sisters' slender cash reserve. Mrs. Sager was too sick to ride buses. Hiring a friendly car-owner to transport her cost $5 each way and then Mrs. Smith had to come up with $3 a day to visit her. They dug into their loose change and used the last nickel before the hospitalization was over. Lunch would be a can of beans Mrs. Smith said. How long since they last ate any meat? Mrs. Sager: "Four weeks." Mrs. Smith: "No. it was about six weeks ago we had some hamburger. So far as buying lamb chops or a roast of beef, we never do it." Their diet now consists of eggs, oatmeal, hominy grits, fruit juices, crackers and vegetables. They see no way of economizing further. Outright hunger is not a problem said Mrs. Smith: "If I get hungry I go and eat a couple of crackers." Until a third sister died four years ago, Mrs. Smith and Mrs. Sager lived in relative prosperity and ate heartily because rent and overheads were shared three ways. "We used to eat a full-course meal then but we've been cutting down, cutting down, so now we're small eaters." Asked if she was constantly aware of rising prices Mrs. Smith gave an outraged "Oh!" and snapped her head away. The prices have hounded them relentlessly, she said. When fresh milk went out of their price range they replaced it with condensed milk. A can of condensed milk that used to cost 18 cents, now costs 35, she said. "It seems to be getting worse all the time. Every time you buy something, it's so much more than it was before." The two sisters are white. The significance of that is that in a city with an over-all population 71 percent black, whites are in a disproportionate majority among the elderly. Of 72,000 people over 65 in the District, 57 percent are white. The imbalance is attributed to the reluctance that settled whites of advanced age felt about joining the general white migration from the city in the 1950s and 1960s. Another critical factor is the shorter life expectancy of blacks usually believed to result from poorer health care in youth. Nationally, life expectancy for a white female is 74 against 68 for a black female. In males the difference is even more striking with whites averaging 67.9 years and blacks 60. The 103,000 people over 60 are distributed fairly evenly over the District's nine service areas with one striking exception. In the area west of Rock Creek Park, 26,411 are concentrated and 99 percent of them are white, according to David Brooks of the District's office for the aged. Exact income figures are unavailable, but Brooks and other experts see thousands of aged whites caught between low limited incomes and rising prices with an abundance of hardship and psychological suffering. The sisters are luckier than most because their apartment, though taking half their income, is a bargain by current standards. "One of the most dramatic problems," according to Mrs. Brittain, the social work "is the inability to pay rent. Old apartment buildings are being turned into condominiums, the residential hotels are being torn down right and left and the problem of finding these people somewhere to live is very, very serious." Brooks goes further. The waiting time for a subsidized apartment in National Capital Housing Authority projects is 2- to 4-years, with no emergency capability at all: "There is no housing available for the elderly," Brooks said flatly. As viewed by the sisters, their situation could scarcely be worse. Social Security is due to go up by 11 percent between now and July, but they expect a rent rise to more than take care of that. Whatever the increase is, they will have to pay it. The costs of moving, deposits, a month in advance are way beyond them, they say. The experts do not agree on whether whites or blacks suffer most. Being black and old "is a double jeopardy," Mrs. Brittain belives. It makes for many more problems. They were usually in lower paid jobs so they rarely have as much income as whites and their health needs are more severe. The effects of discriminatory education and health care are really exaggerated as they grow older. On the basis that elderly blacks generally are paying lower rents and therefore have more money than aged whites, George Robey contends they may be better off. Besides, "people on the lower end of the scale manage better than those who are used to something better." "The ones who seem to suffer the most are those numerous people—mostly women, who worked in government or business for years and years and retired with what seemed a good income. The little place on Massachusetts or Connecticut Avenue which might have cost them $60 in 1948 is $160 or $170 now. Everything else has gone up and they're still trying to hold on." Holding on is what Mrs. Smith or Mrs. Sager have become very proficient at. With a ticking clock, paper flowers, fading photographs and a daguerro print of their father-a handsome man with stiff white collar and walrus moustachethe sisters pass their time in genteel poverty. Just before Christmas the nephew Mrs. Sager brought up as her son died at 45. The funeral was in Richmond. They could not afford bus fare. "Being, too proud to borrow from somebody," Mrs. Sager related, "we didn't go" |