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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

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(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, 1601 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 quote this report at length so that there will be no doubt in your mind as to the radical seriousness of the crisis of the central cities:

Since last summer's outbreaks segregation has increased and tensions are building anew. The insurance industry sees unusual risks here. The Home Mutual Insurance Co., of Binghamton, N.Y., wrote to its local agent that “quite frankly, we are concerned at the racial situation in Cleveland and feel that quite probably the next blowup will not be confined to any particular area," it was learned.

The company's agent, William E. Wilson, wrote to Mayor Ralph S. Locher that all insurance carriers were “extremely cautious about writing any type of insurance within city limits ***.” (St. Louis Post-Dispatch, Apr. 9, 1967, p. 4 K.)

Does the economic community wish to seal off its central cities and segregated ghettos to let them disintegrate in their own racial frustrated confusion? This is already happening in the Houghs and Harlems and Watts and core cities throughout the country. There is a central city crisis in the United States.

But, you might ask, what does this have to do with quality medical care! And the answer is that health services for the elderly is just one small facet of the total urban social situation. A city is a social system of interrelated dynamic components. Health care, employment, housing, transportation, tax structure, education—all are interrelated and interdependent. If ghettos spread, housing disintegrates, crime becomes rampant, insurance companies withdraw coverage, industries withdraw, hardcore unemployment and welfarism become a way of life, and city administrations economically castrate and impotent, there can be no question of quality health services or quality municipal services of any type.

MUNICIPAL BUDGETS DRAINED

But let me return to the paper of our highly competent director of health and hospitals, Dr. Domke. Commenting upon the practical consequences of the inadequate budgets available to directors of municipal health and hospital systems.

Since municipal health service budgets are so inadequate the directors must devote a dysfunctional amount of their time and energy to “grantsmanship” in order to render their local health service systems eligible for Federal grants. This means that the interests and commitments of the Federal Government in health services must become the interests and commitments of the local directors of health and hospitals. Dr. Domke points out that health service is a continuum starting with preventive medicine, continuing through hospital care of acute and chronic disease, and stretching through rehabilitative services. Traditionally the Federal Government has concentrated on assisting local governments with the most expensive portion of this continuum: the provision of the brick and mortar aspects of hospitals. Local hospital and health directors have consequently had to concentrate their limited resources in innovative efforts in hospital buildings. Their creative energies have not been channeled into the extremely important areas of preventative medicine, rehabilitation, home care services, etc. Dr. Domke's very substantial suggestion is that some way must be elaborated to release the local and Federal health interests to include the total spectrum of quality health services rather than the truncated segment hitherto embraced.

THE UNFINISHED AMERICAN REVOLUTION AND THE AMERICAN

PROPOSITION

In my formal presentation submitted before this informal and spontaneous discussion before this subcommittee I made the point that this subcommittee was engaged in finishing the unfinished American Revolution and in furthering the proof of the American proposition. The American Revolution is an unfinished revolution because it set out to provide, implement, and operationalize the revolutionary idea that all men are created equal, that they are endowed by their Creator with certain unalienable rights and that among them are the right to life, liberty, and the pursuit of happiness. Health and health care for all and not just for the wealthy, the upper class, and the power structure is an obvious corollary of the American Revolution.

This subcommittee strives to implement one facet of the American proposition. It was Abraham Lincoln who stated that our forefathers dedicated this country to the proposition that all men are created equal.

A proposition in philosophy is a statement that is to be proved; in mathematics a proposition is an operation to be worked; in sociology, a proposition is a hypothesis which is to be tested and you hope it will be found to be a positive proposition, an approved proposition.

One of the reasons why it is a gratifying honor to testify before this subcommittee is that you are continuing the work of the unfinished American Revolution and you are striving to prove the American proposition.

THE CENTRAL CITY OVERBURDEN We may summarize our materials on the impossibility under present circumstances for the central cities to provide adequate services for their disadvantaged citizens by the following statements:

A. The central cities have become the depot of the disadvantaged from farm and the South;

B. Middle-class population and industry have fled to the suburbs;

C. During the next 10 years the cities will have a revenue gap of $262 billion; and

D. At present one out of four of the children of the slum areas need substantial medical assistance and are not receiving it; one out of two of teenagers need substantial medical assistance and are not receiving it; three out of four of those over 65 need substantial medical assistance and are not receiving it. These data are educated guesses derived from various knowledgeable sources and are not hard data.

CONSENSUS OF TESTIMONY FROM St. Louis

There is a consensus of opinion from those that I have canvassed in St. Louis area thatA. The Federal health legislation of the past 3 years has been

3 a tremendous boon to the overall health needs of the central city; and

B. That there must be some modification of the coinsurance and deductible principles lest the disadvantaged for whom the legislation was primarily intended suffer rather than prosper from this enlightened legislation.

ROLE OF THE FEDERAL GOVERNMENT

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In our formal testimony we finally addressed ourselves to the role of the Federal Government in its dealings with the local governments.

The danger of Federal assistance is the danger of a Federal takeover and the consequent deadening of local initiative, interest, commitment, and control.

The first point that we made was in reference to the shibboleth “socialized medicine.” This opprobrious term was used by the adversaries of medicare and medicaid in their unsuccessful fight to obstruct the passage of health service legislation. By "socialized medicine", as in England, is meant the ownership of the installations and the hiring of the personnel. But medicare and medicaid own no hospitals and hire no personnel for the practice of medicine. Whatever they are they are not socialized medicine. They are forms of insurance and not forms of medical practice.

We then went on to ask more specifically what the relationship of local government and the Federal Government should be. Three years ago on the occasion of his famous Great Society speech at Ann Arbor, President Johnson used the term: “Creative federalism.” On seven occasions since then he has had recourse to this term. More recently the phrase "creative federalism” has been supplemented by the phrase "balanced federalism.” These are pregnant phrases and bear investigation.

"Federalism” means complementarity between a limited central power and other powers that are essentially independent of it. “Creative” federalism accents the theme that local initiative and creativity will be held at a premium. In the long American dialog over states rights and the question of individual liberty versus Government domination, it has been tacitly assumed that the total amount of power is constant and, therefore, any increase in Federal power diminishes the power of the States or participating agencies such as hospitals.

Creative federalism starts from the contrary belief that total power-private and public, individual and organizationalis escalating very rapidly. As the range of conscious choices widens, it is necessary to recognize vast increases of Federal Government power that do not encroach upon or diminish any other power. Simultaneously, the power of States and local governments will increase; and the power of individuals will increase.

The Federal administration is following the lead of modern business. The Great Society is being built not on the models of central determination of all solutions in Washington, but on the concept of maximum feasible participation of all elements of society and of many centers of decision. Today there is no premium placed upon obsequiousness and inertness at the local level.

On the contrary, only those programs and proposals are being funded on a local level that manifest creativity, originality, initiative, comprehensiveness, and a soundness never before demanded on a local level. The old argument of Government intervention being one

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