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You see, prepayment is extremely important for many things I have tried to say because it permits people to come for care before they have serious symptoms. It is a treatment program for the total individual at all times and encourages his coming for the so-called preventive type services.

Mr. MILLER. Would it not then perhaps be more proper to voice the recommendations as a recommendation for subsidized loans or grants to group practice prepayment plans ?

Dr. JAMES. It would be a higher priority. Perhaps group practice without prepayment might be an interesting evolutionary step along

Mr. ORIOL. We now have about seven cities or eight cities that again have group practice, isn't that then about the total ?

Dr. JAMES. Very few. Dr. ROEMER. I recall a situation in a county of West Virginia some 20 years ago where a group of physicians attempted to organize a private group practice. This

was not with prepayment, simply a group practice.

The difficulties were tremendous. There was objection by the other physicians in the community. There were difficulties in acquiring a building. There were difficulties in recruiting physicians, and so on. The mere tasks of organizing this group practice, which, after some years, did take shape, could have been aided by the services of a person who could work on these problems. Physicians are busy. They don't have the time and they don't know many of the details of business management. It is this kind of service that I think can be of assistance.

Mr. MILLER. What was the focal point of the organization of this particular group?

Dr. ROEMER. A surgeon and a pediatrician and a few others who. wanted to get together to organize a clinic. I recall a similar development in my hometown in New Jersey.


There are simply technical problems along the way. If we regard the rendering of medical care as something with great public interest, something that affects the welfare of people, I think it quite reasonable to invest public money in improving quality through group practice, just as we invest in improving medical education or improving the quality of hospitals.

Mr. Miller. The inability to get a building and similar technical difficulties, however, does not relate to their inability to have obtained money, if the other problems are resolved. This, I think, is essential to the question I am directing:

Dr. ROEMER. You may be right. It is not just a question of money; it is a question of technical expertise. I would not want to imply, however, that the nonprepaid group practice is as important as the prepaid type.

It seems to me that prepaid group practice has numerous additional advantages, and that certainly requires organizational assistance.

Mr. Oriol. With two such knowledgeable witnesses it is tempting to keep up the questioning. I am looking at the clock. We now have an hour and a half before we must cut short this hearing.

I would like to note for the record that several written questions will be submitted to the two witnesses. For example, Dr. James, you mentioned the growing numbers of older people in the central city area.

Father Cervantes has in his testimony a reference to the central city burden. The question that we will put to both of you is, how can we get the kind of special attention that such areas require ?

Another question, perhaps I can get a word of comment from Dr. Roemer now, you refer to a vast jungle of medical care plans and agencies. Now this was when you were talking about the kind of organization you see for the future.

I take it that you don't mean that we scrap existing private agencies. I am impressed with the Project Well-Being in Detroit and how a private agency with Federal help and assistance from all over the community organized an effort.12

Dr. ROEMER. Yes, I think it is a task of articulation among the agencies. We have roughly 100,000 voluntary health agencies in the United States, according to Dr. Hamlin's study a few years ago from the Harvard School of Public Health. There is great duplication among them; there is extravagant use of administrative funds, and so on.

In the health insurance field there are well over 1,000 separate organizations. If the energies and dedication of these people could be mobilized and coordinated, I think we would get a much better product for our dollar.

Mr. ORIOL. Another question which will be asked is whether medicare and medicaid are encouraging or perhaps putting obstacles in the path of the reorganization you would like to see.

Dr. ROEMER. It seems to me that the design of the medicare legislation is rather effective at this stage in building its program into the existing structure; that is, the existing insurance programs, especially Blue Cross and Blue Shield, have been incorporated into the operation of the system so that their skills have not been lost, but have been mobilized.

The provision of financial support for hospitals and extended care facilities and home health agencies has certainly been a boost to their availability and the improvement of their quality,

Dr. James. I believe very strongly that where Government funds are used to support medical care, the Government has a responsibility to insure that these funds will be used to improve the quality of that

Mr. ORIOL. Again, I would like to thank you.

Dr. Roemer I would like to mention that Senator Williams of New Jersey hoped to be here to say “hello” to an old constituent. He is on his way and will be here shortly.

Thank you again for your testimony.

I would like now to call Father Lucius F. Cervantes, S.J., Ph. D., professor of sociology, St. Louis (Mo.) University, and assistant to the mayor of St. Louis.

I would like to note for the record that we have a letter here from the mayor of St. Louis and it will be put into the record at this point.

(The letter follows:)


See pp. 135–138 for additional discussion.

83-481 067-pt. 1-8


June 13, 1967.
Chairman, Subcommittee on Health of the Elderly,
U.S. Senate,
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 pro sion 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?



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.


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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.


We next come to a related topic developed by Dr. Bernard Friedman,

a 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 emphy. sema, 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.

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