I just want to echo the words of Senator Muskie before he left, that though he had received just a part of this testimony he was tremendously moved as everyone here.

Mr. Miller.

Mr. MILLER. Mrs. Romero made reference to other people who had been blind since the age of 6 and their vigorous activity and active living. The American Foundation for the Blind has a task force that is concerned especially with the problems of the elderly blind. Of course, we have a different kind of problem for those whose blindness comes late in life, which is the more common occurrence and will undoubtedly receive much wider attention in the future. Because they have spent a lifetime as sighted persons and then in their advanced years are unable to see, they have a very special problem and a very difficult problem of which I am sure you people are very much aware.

Mr. ORIOL. I would like to thank you for coming and really extend my personal appreciation as well. Thank you, Mr. Cruikshank.

We will resume here at 3 o'clock when we will hear from Dr. Fisher.

Mr. CRUIKSHANK. Thank you very much.

(Whereupon, at 1:15 p.m., the subcommittee recessed for lunch, to reconvene at 3 p.m.)

AFTERNOON SESSION

(The subcommittee reconvened at 3:10 p.m., William E. Oriol, staff director, presiding.)

Mr. ORIOL. The hearing will come to order again.

Dean Fisher, Senator Muskie has sent word that they are still in session and he can't break away. He very much regrets that he can't be here, but he asks us to continue. And especially in view of his long working relationship with you, he is very regretful he can't be here, but he asks us to go along with the hearing.

STATEMENT OF DEAN H. FISHER, M.D., COMMISSIONER, MAINE STATE DEPARTMENT OF HEALTH AND WELFARE

Dr. FISHER. Mr. Chairman and members of the panel and of the subcommittee, first, I apologize for the lateness in getting a statement to you. This was supposed to catch up with me in Boston last night and, unfortunately, didn't do so. So I tried to recreate it this morning, and it is the best I can do under the circumstances.

I shall skip through this statement, and then I shall be more than happy to answer any questions that I may be able to answer. And should anyone choose to interrupt me as I proceed, I hope you will feel perfectly free to do so. And I am sure you will.

This is an extremely interesting subject to me, one in which I have had considerable concern and considerable involvement for a long period of time, and I know that Senator Muskie has had an equally long and sincere concern with many of these same kinds of problems. There will be probably some additional statements submitted by people from Maine in writing to your committee, or your subcommittee, later on for inclusion in the record of your hearing. The

people from whom these statements may come are also extremely interested in the problems we are talking about. They are deeply involved with them. And through such activities as the Older Americans Act, I think there may be real contributions to solving some of these problems.

To introduce myself officially, I am Dr. Dean Fisher, a licensed physician, a former State health officer, and for some 15 years now the Commissioner of the Maine State Department of Health and Welfare. We are a rural State, of 33,000 square miles, with a population of about 1 million. We have less than 30 communities with populations over 5,000. We have about the 35th or 36th lowest average income in the United States. It is this background against which I shall talk.

I also point out that we have areas in our State, counties, for example, whose incomes must be considerably less than the average for the State at large. So we do have real problems with which to deal.

We have few sources for statistical information, but if there are any kinds of specific information that you would like to have about my particular State, I shall be more than happy to try to develop something of this nature and give it to you if you would like me to do so.

But it would seem to me that we are talking about a problem that is very broad, rather generalized, and perhaps it is not quite appropriate to dwell too much on the peculiarities of the individual State.

The problems I shall speak of are not profound and not unique. They are not necessarily peculiar to the elderly in a welfare program, although those in welfare programs do present these problems in exaggerated or extreme degrees.

The subject of your hearing will tend to focus attention on medical care, its economics, adequacy, et cetera. I shall not talk to this aspect of the problem, for I am sure others will deal adequately with it. I prefer to talk about more general and perhaps more important problem areas where there are steps to be taken that can reduce the health or medical needs of the elderly and, more importantly, enrich their lives.

Again, I prefer not to talk too much about my specific problems, but about more general, and perhaps more important problems, where there are steps to be taken that I think can reduce the health and medical needs of the elderly and, more importantly, enrich their lives. These are common, ordinary kinds of problems, and I think they tend to be lost when we talk about some of the more esoteric kinds of problems associated with the medical care program and delivery of medical care, where we are looking for means of rebuilding a whole system. Aging, and the economics of aging, and its health aspects are not isolated phenomena unrelated to other community conditions. Therefore, I urge that we not be completely preoccupied with the problems of the aged as such. Perhaps the resolution of problems of the aged can lead to a better system in which we all may live. For example, medical care costs for a young family can be catastrophic in both immediate and long-range terms.

Obviously, the kind of system that can best deliver medical care for the elderly can probably also best deliver medical care to the young families to which I refer.

The quality and problems of aging are determined by all of the preceding experiences of the person and may be the sum of preceding deficits in health needs, earnings, housing, education, employment, place of residence, et cetera. On these, specific disabilities of age may then be superimposed.

I think this is extremely important to me as I look at our rural areas, and I see all too commonly and all too pathetically the elderly person who literally is showing all the deficiencies, all of the neglects, literally, to which he has been subjected through his entire life, and, finally, at the stage of being elderly, these are all brought together.

The qualities of aging are also shaped by the community in which the individual has lived-average incomes, ethnic background, community resources, et cetera.

RURAL DISADVANTAGES

Here, again, I point out the elderly living in the rural areas are very likely to be more disadvantageously located in terms of this previous experience with relationship to community resources, average incomes, and so forth. I think this has to be emphasized specifically. When we talk about the economics of aging, we are not talking about the wife of the local banker, and we might as well accept that fact. She probably has very few problems, she probably has very few health needs, and the main difference between her and the people we are talking about, I think, is essentially one of income, and perhaps not only income after achieving some magic number of years of age, but income during the preceding years of her life.

So I think this cannot be emphasized too much, whether we are talking about medical care, health needs, or whatever. Basically, we are talking about a group of people with low incomes.

Now, there are no specific inherent economics of aging per se. We are talking about a set of economic circumstances that we have chosen to create in the society where status and economics are largely related to the ability to produce goods and services.

The problems we see are the results of conscious and deliberate decisions on our part in our economic and social system, and I think this needs to be emphasized.

I point out to you such simple things as retirement practices at some given age. This may have had some validity years ago, but I am not sure it still has the same degree of validity.

It seems to me we have much, much more flexibility in the use of people, and I think we should accept these kinds of flexibilities and take some very serious looks at the results of so-called retirement practices.

There are no specific, inherent economics of aging per se. We are talking about a set of economic conditions we have chosen to create through "program" decisions in a society where status and economics are largely related to the ability to produce goods or services.

The aged thus do have problems of both status and economics. The economics are the economics of poverty, by and large.

PROGRAMS THAT DON'T "MESH"

Even in such programs as title XVIII we have chosen to complicate already complicated lives by coinsurances, deductibles, assignments, and other "fine print" that the elderly have difficulty in understanding. And I guess on that basis I must call myself "elderly," because I, too, have some difficulties in understanding them. These technicalities, incidentally, make title XIX unnecessarily costly and awkward to administer.

In OAA, I go through all the processes of "buying in," and I have developed computer lists of people, and I finally windup and pay the monthly premiums for them, and this monthly premium is about twothirds Federal dollars. I can't see much sense in going through all this kind of falderal for little or nothing.

The social security system itself creates economic and social problems by inadequate basic retirement benefits. A great many people have as their only financial resource the retirement benefits of the social security program.

I have an OAA caseload of about 11,000. The "average" recipient is a 74-year-old widow with minimum OASI benefits. The caseload is some 10 to 12 percent of those in Maine over age 65. We are not highly industrialized. OASI benefits are low. Some 55 percent of my ОAA caseload also receives OASI benefits.

It seems to me a little bit ridiculous that this should be this case. For 55 percent of the people, I must now be involved in all the processes of determining eligibility, I must have all the staff services and all these kinds of things to make a simple decision, and that is that an individual has an inadequate financial maintenance base.

By virtue of my operation, I am putting a certain amount of State money into the basic maintenance of these people. But here, again, I am putting roughly two-thirds Federal money in.

It seems to me not illogical to supplement, if necessary, the OASI program with some general tax revenue, and let just one agency send a check to my old-age assistance recipient instead of my sending one and social security sending one, with all the complications again of tying in under part (B) and all those kinds of things.

I think we should ask a serious question as to whether there is any reason at all, any justification for the operation of an old-age assistance program that in effect provides a financial supplement to the basic maintenance income.

Instead of my making out some 15,000 or 18,000 checks per month and all the rest of it, if Congress has problems finding money, I think I would probably be ahead of the game if I would write a check once a quarter and send it to you and tell you to put it in your "pot" and you send the checks to my old-age assistance recipients, only give them a little more money than you are giving them now.

I think that would save all of us a lot of trouble. What this might do, however, might be to free my resources for a much more useful endeavor, because if I were not concerned with the problems of administration, determination of eligibility, and so forth, I might then well be able to design a service program for all elderly people, with an attempt to assist with the many peculiar problems that they have.

I might well be able to provide this kind of service to elderly people purely in terms of their needs rather than in terms of any financial standard for eligibility. And I think if I were to do this, then I would be doing the kind of service that might be most appropriate for me, rather than to be involved in a financial assistance program, which is essentially supplemental to the national program designed to achieve a goal of some reasonable income floor.

Mr. ORIOL. When the old-age assistance payment is combined with the average social security benefit, what would you say is the rough average in Maine?

Dr. FISHER. Somewhere around $70 a month. I am talking about cash grants now.

Mr. ORIOL. So it is less than a thousand dollars a year.

Dr. FISHER. Considerably less.

It would seem to me that the kind of income program I am talking about could be expected to reduce health needs by providing for better food, shelter, and mobility. I think there is inequity between people in different States, and perhaps more serious problems than that, because of the general malodor in which many people hold welfare programs per se.

Next, I think we have to remember and recognize that inflation leaves the elderly person with fewer expenditure options for anything other than the barest of necessities, and such things as glasses, dental care, medications, even food, may be deferred purchases in favor of shelter and fuel.

I remind you that in the middle of the winter one can go without eating for a couple of days, but not without shelter and fuel.

These same inflationary trends force people to come to the public assistance programs. Inflation prices people out of the market for medical care, for nursing-home care, and in some instances where they are very much on the borderline, they are priced out of the market for the simple necessities of life, food and shelter.

ISOLATION AS WELL AS ECONOMICS

I think related to these economic problems are other things. The elderly have problems in isolation and loss of meaningful human contact. Isolation may be physical, social, or emotional, but, in any event, it leads to poor diets, poor medical care, accidents, and I am convinced it leads to mental deterioration.

Isolation may come from the need to accept the poorest of housing, particularly in rural or semirural areas. It may come from alienation from family by rejection, or the sense of rejection as the limited finances of the elderly force family sacrifices. Or the elderly may feel the family is being forced to make some sacrifices, and the elderly person doesn't choose to be in that situation.

General deprivation may force the elderly into situational depressions creating added health needs, or even suicide.

Economics may force resort to medical quackery or self-treatment, because they may feel this is a cheap way to solve the medical problem. And in the long run it probably means an added burden on the health-care program, rather than the opposite.