OFFICE OF THE MAYOR, Hon. GEORGE A. SMATHERS, Chairman, Subcommittee on Health of the Elderly, Washington, D.C. DEAR SENATOR SMATHERS: I welcome the opportunity to be of some assistance in obtaining professional testimony for your Subcommittee on Health of the Elderly, Senate Special Committee on Aging. I recognize your eminent endeavor as one of the critical thrusts of the War on Poverty and as one of the firm bases of the Great Society. The Health Legislation of 1965 established through our democratic processes that the opportunity for quality health services for every citizen of the United States, irrespective of age or race or economic condition, as a matter of right has become a matter of conscious social policy. As the Mayor of one of our nation's central cities, I was acutely aware that older Americans were not obtaining the type of health service that our country's genius and prosperity should be able to afford. I am likewise very much aware that despite the great advances made in the provision of quality health services through Title XVIII and XIX of the Social Security Act, that our goals in this area are by no means attained. There are persistent problems in obtaining adequate health services for the disadvantaged who are increasingly concentrated in the center cities of our metropolitan areas. I am happy to have been able to cooperate with the Special Committee on Aging's staff director, Mr. William E. Oriol, in obtaining local resource persons who would be knowledgeable in the field of your investigation. Our common goal of assuring an equal opportunity for all citizens to obtain a high quality of comprehensive health care has been a bridge of mutual interest and cooperation. Sincerely yours, A. J. CERVANTES, Mayor. Mr. ORIOL. I also would like to note that Father Cervantes has within just two and a half or fewer weeks given us a comprehensive and very helpful collection of statements from knowledgeable people in St. Louis and that, too, is here today. Are you going to give excerpts from all of the statements? STATEMENT OF REV. LUCIUS F. CERVANTES, S.J., PH. D., PROFESSOR OF SOCIOLOGY, ST. LOUIS (MO.) UNIVERSITY, AND ASSISTANT TO THE MAYOR OF ST. LOUIS Reverend CERVANTES. I could, Mr. Oriol. I do have another statement here, too, and it is from Dr. William Danforth, chancellor for medical affairs at Washington University in St. Louis. Let me say that I will be very brief. I know that your time is limited. Mr. ORIOL. Father, we have an hour and a half and we have one more witness, so perhaps we could parcel out 45 minutes to each witness and not cut it too short. You have a wealth of material to work with. Reverend CERVANTES. I would summarize immediately a key point. It is the question of the central city overburden. More specifically in all of the literature that I have read on health problems, practically nothing was stated about the selective concentration of the disadvantaged, including the elderly, in the central city and the selected deconcentration of the affluent into the suburbs. Mr. ORIOL. Father, may I interrupt at that point to tell you, you were not here when Dr. James made this statement and I think it bears on what you are saying here. New York City, with a fairly stable total population size, is aging by 20,000 persons a year. By 1970, we expect to have 1 million persons over the age of 65, making New York's aged the sixth largest city in the United States, just the aged population. I thought you would be interested in that point. Reverend CERVANTES. This is just half of my point, though. It seems to me you have stated, Mr. Oriol, quite correctly and quite pertinently that we do have a growing escalating population of the aged. However, this is just half of my point. My total point is that not only are the aged concentrating in the central cities but the central cities are incapable of supporting them. Central cities are not capable of supplying even the basic services for their citizens. In the city of St. Louis, and I think it is rather representative of the country, there are already 15 percent of the population over 65; whereas, in St. Louis County, there are only 6 percent over 65. The affluent county has less than half the percentage of elderly than do the bankrupt central cities which are no longer capable of supporting the growing masses of disadvantaged which are being concentrated there. May I draw the attention of this subcommittee to the study of TEMPO, General Electric Co.'s center for advanced studies, which found that the Nation's cities face the staggering revenue gap of $262 billion during the next 10 years. The study likewise points out that without any Federal tax increase the Federal Government during the next 10 years will have a revenue increase of one-third of a trillion dollars. Within the next 10 years not only will 10 of the larger central cities be predominantly Negro-and this dramatizes our problem by putting into it the element of race-with the surrounding suburbs a white noose of the affluent, but likewise the central cities are going to have a revenue gap of $262 billion. So when Senator Smathers comments to the group here, "I am going over and confer about the space program which has a yearly budget of approximately $6 billion"; or when Mayor Cavanagh at the U.S. Conference of Mayors mentioned that "in the 3-year period ending next June, we will have spent 13 times more on the space program than for all of the programs managed by HUD"; or you read that without scarcely debate or dissent a $70 billion defense budget is readily passed but only with the greatest of difficulty is $12 million provided in the model cities program for planning grants for the rejuvenation of the central cities, we can readily see that there is an intolerable priority lag in this country's recognition of the crisis of our central cities. So what I am saying is this: that, even though $2 billion a month is being spent on Vietnam and many people say that, "Well, after the war is over we will try to get a great deal of that money into the central cities," still $2 billion a month would not take care of the grave needs of the central cities of our metropolitan areas. URBAN INCIDENCE OF ELDERLY To try to state this more succinctly and more to the point of health care for the elderly, in the city there is more than twice the incidence of elderly than in the county. Furthermore, those elderly who are in the suburbs or in the county are better able to take care of themselves financially, to obtain the health care needs that they have than the growing number of elderly within the central city. Since one out of three of those over 65 years of age in the United States have an income of $1,000 or less, and since the impoverished elderly are by central tendency gravitating toward the central cities we come to our key question: "Has medicare under its present limitations been advantageous or disadvantageous for the elderly poor within the central city?" I would like to include in this testimony statements from various knowledgeable individuals in St. Louis bearing upon this question. At this time I would also like to make several comments upon these statements. On page 1 we have the testimony of Elmer M. Johnson, the associate director of the Metropolitan St. Louis Hospital Planning Commission. He is speaking of home health service agencies. His statement gives rise to the following thought. It costs about $50 per day for hospital care, $20 per day for nursing home care, and $3 per day for home health care. U.S. citizens would not be getting their money's worth of health care for the elderly if they are paying $50 per day for hospital care or $20 per day for nursing home care for a person who could readily be taken care of for $3 per day with home health service care. But the disadvantaged and the city governments have to take advantage of what is available to them. At present the home health care services are not available to them through medicare. Consequently they take the higher cost health services. Mr. Johnson's specific suggestion is to add home health services to the present list of five health services that are available under the medicare legislation. INTERMEDIATE CARE NEEDED We next come to a related topic developed by Dr. Bernard Friedman, a medical director and superintendent of one of our St. Louis hospitals. He is speaking of intermediate care. Many patients, he observes, do not need the intensive care of a general hospital but require general care greater than is available in a nursing home or in their home. For these patients Dr. Friedman suggests intermediate care. I would like to read part of his material that refers to the fact that the type of care needed by many elderly patients is not strictly medical care but social care. He states: The problems that occur over and over again are social conditions that prevent the transfer of the patient back to the home or apartment from which he came. A third floor apartment of a patient who is short of breath because of emphysema, a toilet in the basement of a patient who has already fallen once and broken her hip going down stairs, a patient whose neighbor has in the past done her shopping and looked in daily but is now moving to another location-these are the kinds of problems that may actually make the difference between sending a patient home or to a nursing home. There is no question in my mind but that there are thousands of patients in nursing homes who have been transferred there not because they need to be in a nursing home, but because of the social problems involved in the patient living on the outside. Two patients can reach the same levels of self-care with the same diagnosis. One can be discharged to a family eager and waiting to have him back, another cannot be discharged because the home circumstances are unfavorable. You will notice this theme of "social" rather than strictly "medical" care is a frequent theme in the testimony from St. Louis. For instance it is elsewhere remarked that there are 13,000 individuals who are in mental health institutions in Missouri. A great percentage of these could be returned to their homes if the social conditions and care were adequate. The extension of home health services, home care, and such services as meals on wheels would help tremendously in keeping the elderly, chronically ill patients in their home. In working with these elderly people we find that an adequate social service staff both in the hospital and for out-of-hospital care is indispensible. At our intermediate care division all efforts are made to prevent permanent institutionalization. He concludes: On the other hand, a significant number of patients that we still send to domiciliary care institutions or nursing homes could be discharged home if some of the social problems of home care could be solved. I know that this committee and subcommittee are working on this problem, but nevertheless it gives support to your overall emphasis of the social needs of the elderly as far as health care is concerned. The next paper is from Dr. Morris Alex. Dr. Morris Alex stresses my previous thesis of the central city overburden in contradistinction to the suburban underburden in relation to the provision of quality health service for the elderly when he states-"in the city of St. Louis in 1960, 12.3 percent of the total population was 65 and over. By 1970 it is estimated that it will reach 15.3 percent. By the same token, it is estimated that in St. Louis County the percentage will be 6.4 percent." He goes on to develop the fact that in the State of Missouri more than 100,000 are on old-age assistance, that 13 percent of these elderly are located in the city whereas only 2.7 were in the county. This observation reverts to our same thesis of the completely different type of tax base and of services available in the city and in the county. The next paper is from St. Louis' director of health and hospitals, Dr. Herbert R. Domke. One of his insightful observations is a corollary to our basis thesis that the central cities are bankrupt. I might point out in passing that, in 1900, 51 percent of the total Government taxes in the United States were collected by and accrued to the municipalities. Today the municipalities' share of all taxes is not 51 percent but less than 15 percent. OBSTACLES TO NEW PROGRAMS Dr. Domke points out that because of their straightened financial condition the central cities are no longer capable of independently initiating new programs. They don't have the money. They must follow the Federal leads in order to get more adequate financing through the Federal Government. They must forego their own initiative, and their own creative programs to abandon themselves to Federal grantsmanship. Let me just give you an idea of what our health and hospital system is in St. Louis. The following dramatized but adequately accurate account is taken from one of our local papers from this present week: PATIENTS WAIT FOR HOURS FOR HOSPITAL TREATMENT (By Jim Floyd, Globe-Democrat Staff Writer, June 20, 1967) While two doctors struggled heroically with a massive case load at the City Hospital emergency room Monday night, more than 100 sick and injured St. Louisans waited long hours for treatment. The case load at the emergency room for Monday up to 10 p.m. was 312. For all day Sunday it had been 273. On previous days the total case load had been 252 and 254. While the doctors handled emergency and police cases the rest of the people waited . . . and waited. "It's the heat that brings many out," a hospital clerk much too cynical for her years said. But the emergency room is a producer of cynicism. "They take the drunks and hoodlums first," a woman supporting a badly swollen ankle complained, "they don't want to hold up the police." She said she had been waiting for 6 hours. "I need the hospital," one elderly woman said. "It's terrible. It's dirty. The service is miserable. But it's all I have." One woman brought her sick cousin into the hospital at 6:30 p.m. She was still waiting at 10 p.m. "I complained so much they finally took his temperature," she said. “I don't know when they'll get around to doing anything else for him." Another woman, Mrs. Evelyn Glenn, 1604 South 14th St., hadn't been waiting "too long." She brought her daughter Alice into the hospital at 8:30 p.m. At 10 p.m., they were still waiting. Alice had stuck something in her foot and it had become infected. A member of the Chouteau-Ruskin Gateway Center Committee for Better Municipal Services, Mrs. Glenn pointed around her to the people strapped to stretchers, propped up on benches and sleeping in the waiting room. "Something's got to be done," she said. "We've been talking to Mayor Cervantes trying to get better hospitals and better emergency care. If more people could see this maybe they'd start listening to us." It so happens that the city of St. Louis is already spending $25 million-one-fourth of its limited budget-on its health services. It so happens that the administration and staff of this hospital system are unusually competent and dedicated. But it is also true that St. Louis as other cities should be spending far more to provide quality health services to their disadvantaged and medically indigent citizens. Municipal health services have deteriorated and this inadequacy of service is characteristic of the total spectrum of city services for the simple reason that the cities are all but bankrupt. We must bear in mind that the cities during the coming decade will have a revenue gap of $262 billion. The quality of city life in the United States will continue to deteriorate until Congress faces up to the fact that our central cities are just as fine targets for $6 billion per year programs as is the moon and that the slums of our major cities are in many cases in a worse condition than were the cities of Europe when we established the Marshall plan for their recovery. Speaking of ravaged cities in need of a Marshall plan for the cities of the United States let me give you the example of Cleveland. Not so long ago the New York Times News Service (April 8, 1967) carried the story of the "last firms leaving ghetto in Cleveland." My point is not that firms are leaving the ghettos in our central cities. They have to. They can't get insurance. But my point is that in Cleveland-a harbinger of what is yet to come to other central cities-the insurance companies are hesitating to supply insurance and consequently economic viability to any firm within the central city. Let me |