more instance of creeping socialism and womb-to-tomb welfarism is losing its relevance.

The new emphasis is upon "problem solving" and this is at a local level.

Let us take the case of medicare. When medicare was first debated in the thirties and forties, the accent was upon what the young owed to the unfortunate and what the Federal Government could do by giving a single monolithic plan excogitated in Washington.

Today this emphasis has changed. Medicare and medicaid are put forward as devices to deal with a problem with solutions derived from local cooperative initiative, funding, and administration. So likewise with the programs to improve education, rebuild the cities, clean up rivers, beautify highways, reduce air pollution, decrease unemployment, minimize discrimination, and fight the great war on poverty.

We welcome the fact that the new role for Washington is not that of "big brother," but "junior partner." The "monolithic" is out and "polycentric" is in. The old-fashioned business paradigm of the "captain of industry" and the industrial absolutist has yielded to the corporation "team approach."

There is a conscious, unceasing effort to insure that any given decision will be made at the most appropriate place-high or low, in Washington or out-and on the basis of the best information. Programs and projects are not being funded and social blueprints are not being approved unless there has been local initiative and, as much as possible, local consensus.

So I think we can summarize what I have tried to state in three points.

1. I am gratified to have been asked to testify before this subcommittee since I feel that the provision of health services especially for the aged and disadvantaged is of primary importance in the forwarding of the unfinished American revolution's guarantee of life, liberty, and the pursuit of happiness;

2. The central cities' overburden must be recognized and compensated;

3. The Federal Government's accent upon "creative" or "balanced" federalism is appreciated, and should be promoted.

Mr. ORIOL. Father Cervantes, I would like to thank you for a magnificent summary and a magnificent total presentation. As you know, these are survey hearings. We wanted to get basic themes that we will develop further and I think you have given us several themes that will certainly be discussed often here.

To come to one of your chief points, the central city overburden, I think, in effect you are saying that we have a tendency for people most in need of health services to congregate in the area least capable financially of giving that.

Reverend CERVANTES. Exactly.

Mr. ORIOL. You have very high concentration of elderly in St. Louis, I believe it is above the national average, or is this true for central city areas throughout the Nation? Would you have that information?

Reverend CERVANTES. I think that our 15 percent is slightly higher than is true of the other central cities. There is a constant pattern,

however, of a dense concentration of the disadvantaged-young and old-in the central city, and a concentration of the affluent and a smaller proportion of the elderly in the suburbs. The elderly in the suburbs are better able to afford quality health service irrespective of the suburban broader tax base.

Mr. ORIOL. The Comprehensive Health Act, which got off to a start last year, would work through States. Do you think that central cities will be benefited as much as they should be through this program?

Reverend CERVANTES. Anything that is run through the States, I feel, has the bias of the out-State or noncentral city people. Traditionally, as our 49 capitols not being in our central cities indicates, the power structure of our country has tended to pit the rural population against the urban populace. The Supreme Court's decision demanding reapportionment has instituted a new axis, a new alinement of power: the suburbanites and the rural population now tend to be alined against the central city and the increased demands of the growing proletariat of the central cities.

Mr. ORIOL. Do you happen to know whether, at the National Conference on Health Costs, which begins next week, great attention will be placed on the central city overburden?

Reverend CERVANTES. I do not know. I would hope so, but frankly I have not seen this developed any place.

Mr. ORIOL. That is why I asked. I think this is an area of inquiry that should be followed.

Reverend CERVANTES. Right.

Mr. ORIOL. I have other questions, but I will ask Mr. Miller if he has any.

Mr. MILLER. No.

Mr. ORIOL. Mr. Norman?

Mr. NORMAN. No questions.

Mr. ORIOL. Some other questions will be submitted in writing. I remember back at the conference at which this presentation was discussed, we got into a conversation of, as Dr. Domke called it, grantsmanship and the amount of time it takes from staff at a municipal level. We actually got to the point where he was wondering out loud whether instead of devoting his time to making the application, he should be out working with the limited resources he has to give more direct help to the people who needed help.

Could you develop that a little bit more?

EXPENSES OF "GRANTSMANSHIP"

Reverend CERVANTES. Paul Zimmerer, who is the head of the Committee for Economic and Cultural Development of Chicago, maintains that the city of Chicago cannot ask for anything less than a grant of between $100,000 and $200,000 because of the amount of time that is required to make the application.

The Real Estate Research, Inc., which has undertaken any number of research studies for the Economic Development Administration here in Washington, recently submitted a proposal for the city of St. Louis to develop a municipal business development agency.

The young man who prepared it, a man by the name of David Wuenscher, showed me the proposal. He had been working on it for

some months. He said, "How much do you think this has cost to prepare?" I said, "I would guess about $3,000." He replied, "No, it would be closer to $25,000." It takes a tremendous amount of time, energy, and money to apply for grants.

So, to come immediately to your point, would it be better for an administrator of health and hospitals rather than dedicating so much of his time in grantsmanship, to dedicate himself more completely to the administration of his health system with the resources he has at hand? I would say if you are taiking about small grants, yes; but if you are talking about large grants, no, because the centrai cities simply must obtain supplementary funds from the Federal Government.

Although we have not talked about it throughout our discussion, there is a question of restructuring the tax system in the United States and the restructuring of the jurisdictional boundaries so that each political jurisdiction has an adequate tax base that can support the services that need be given.

I think that each one of the administrators ought to enlist the services of a professional proposal writer. The obtaining of a professional writer of proposals will again present an all but insuperable financial problem for the central cities. A professional writer is about as difficult to obtain under civil service salary limitations as is a psychiatrist. We have empty child psychiatric facilities in St. Louis because it is impossible to obtain the full-time services of a psychiatrist under the civil service system which does not allow anyone even a psychiatrist-to earn more than the mayor's $25,000 salary and no psychiatrist will work full time for this "paltry" salary.

Mr. ORIOL. In Mr. Johnson's statement he recommended stimulating the establishment of the national accreditation for home health service agencies which involves review of patient records by a team of competent specialists, and so forth.

Unless you would like to comment on it here, we will submit a request for further information on that proposal. It sounds interesting and something that we should consider.

Reverend CERVANTES. You will notice likewise, Mr. Oriol, that every one of the individual comments from St. Louis has been most enthusiastic for the Federal assistance in the area of health. We all encourage a reappraisal of the coinsurance and deductible features. We encourage you to hold fast to the requirements demanding fuller participation of State governments in doing their part in supplying quality health service for the disadvantaged in their States which are centralizing in the core sections of our metropolitan areas.

Mr. ORIOL. Any more questions?

Thank you again.

We appreciate your coming here, and your complete statement and other information you have submitted will be placed in the record. (The statement and information follow-testimony resumes on p. 135.)

STATEMENT OF LUCIUS F. CERVANTES, S.J., PH. D., DIRECTOR, SOCIAL RESEARCH CENTER, ST. LOUIS UNIVERSITY; RESEARCH DIRECTOR, MAYOR'S OFFICE, CITY OF ST. LOUIS

Senator Smathers and members of the Subcommittee, I consider it a distinct privilege to have been invited to testify before the Senate Subcommittee on

Health of the Elderly. The work of your distinguished subcommittee is dedicated to the provision of quality health services to Older Americans, irrespective of race or economic condition. Cooperating with your subcommittee in the conservation of life and the pursuit of happiness for all Americans is cooperating with the fulfillment of the American proposition and the unfinished revolution which is the United States. Permit me a prefatory digression.

A. THE AMERICAN PROPOSITION AND THE UNFINISHED REVOLUTION

When it is stated, as immortally done by Abraham Lincoln, that the new nation which our Fathers brought forth on this continent was dedicated to a "proposition," the propriety of the term is pertinent. In philosophy a proposition is that statement of a truth to be demonstrated. In mathematics a proposition is the statement of an operation to be performed. The founders of our country dedicated the nation to a proposition in both of these senses. Our belief that all men are created equal, that they are endowed by their Creator with certain unalienable rights and that among these are the right to life, liberty and the pursuit of happiness must be demonstrated in our legislative enactments and operationally performed within the historical contingencies of our times. When Congress pursues the unfinished American revolution by affirming that all elderly Americans shall have a right to the health care that the medical genius of this country can provide and when this Subcommittee seeks out strategies whereby this right can be more equitably implemented irrespective of age or race or economic condition you are demonstrating the American proposition.

The meaning of recent federal legislation in the area of health services bears reemphasis. In a clear breakthrough against the opinion that quality health service is a private commodity to be provided according to income capabilities, Congress has asserted through Titles XVIII and XIX of the Social Security Act that quality health service is a right of every citizen of the United States, is a legitimate concern of public policy, and that enabling legislation will be invoked when this right to quality health service is jeopardized or rendered inoperative. When President Johnson announced the Medical Assistance Program he stated: "We are learning to think of good health not as a privilege for the few, but as a basic right for all." Such do I take to be the philosophical underpinnings and American tradition of this subcommittee's quest to assure quality health services to older Americans.

B. THE CENTRAL CITY OVERBURDEN

My first specific observation in reference to "Costs and Delivery of Health Services to Older Americans" is to point out what may be termed the "Central City Overburden."

A great deal of attention has rightly been paid to such facts as the following: Hospital costs between 1960 and 1965 rose 6 per cent per year but last year they experienced a startling rise of 16.5 per cent;

Five years ago a day of hospital care cost $36.38, today it averages $57.93 and in five years from now the cost will be $96.38 a day; (U.S. News and World Report May 22, 1967 p. 77)

Physicians' fees increased only two or three percent a year from 1960 through 1965; they rose 7.8 percent in 1966;

More than a third of those age 65 and over earn less than $1000 per year and the median annual income of unattached individuals of this same senior citizen age is less than $1.250; (Leon H. Keyserling, "Progress or Poverty," Conference on Economic Progress quoted in John G. Field, "The Diversified Community," Community Development, Vol I, No. 4, p. 22)

Older Americans' slight incomes are not expanding commensurate with the economy;

An elderly person can be much worse off with Medicare as it now stands than he was before without it.

Where before Medicare he might have managed, for example, to stretch his $60 monthly Social Security and $37 state old-age assistance checks to cover rent, food, clothing, and incidentals he is no longer able to do it because he now has deducted $3 a month under Title XVIII plus $50 deductible and finds that he must pay $86 per year and then 20 per cent of the health service balance when previously he was paying half that for his total doctor's bill. As the supplementary testimony from Howard C. Ohlendorf, Chairman of the Planning Committee on Aging, Health and Welfare Council of Metropolitan St. Louis, states:

"With the advent of Medicare, older individuals qualifying under the program, who previously used the out-patient clinic services provided at (the St. Louis) City Hospitals, are now billed the full fee for a clinic visit, whereas prior to Medicare, they were billed approximately one-eighth of this amount. This is very frustrating to many of them who are living on reduced or fixed incomes and cannot afford to pay this fee." (It should be pointed out that the welfare payments in Missouri are quite inadequate and, as yet, we do not have Medicaid). All of these facts are pertinent and important. Very important. But what is scarcely recognized in the health service literature is that the impecunious older Americans are increasingly coming to be located in the central cities of our metropolitan areas. And it is these central cities which are increasingly incapable of providing the escalating demands of the poverty-stricken for the needs of health, housing, education, employment, security, transportation, and the dozen other basic services. The City of St. Louis is typical of the central cities of the United States in that 15 percent of its population is age 65 or over whereas in the affluent county there are but 6 percent age 65 or over. The central cities overburden consists in the fact that it is increasingly becoming the depressed corrals and tax-shy repositories of the aged, the unskilled, the disadvantaged children and the dispossessed minorities. During the past fifty years the suburbs have increasingly become the refuge of the affluent seeking to avoid the problem peoples of the central cities. The resulting central city overburden is now reaching crisis proportions.

May I draw the attention of this Subcommittee to the study of TEMPO, General Electric Company's Center for Advanced Studies, which found that the nation's cities face the staggering revenue gap of $262 Billion during the next ten years. The study likewise points out that without any federal tax increase the federal government during the next ten years will have a revenue increase of % of a trillion dollars. ("Revenue Sharing," Nation's Cities, April, 1967, p. 7ff.)

Our point of citing the "central city overburden" is to indicate that the disadvantaged elderly are selectively being concentrated in the central cities which are becoming progressively bankrupt so that the older Americans are afforded little or no hope, without federal assistance, for quality health services.

C. EXAMPLES

I had hoped to be able to present to this Subcommittee a profile of health needs within the City of St. Louis that could be directly attributable to lack of government funding. I had set for myself an impossible task for the data are simply not available. I have managed, however, to obtain the following suggestive examples which I feel are pertinent.

Comparative data from 19 of the largest cities in the United States shows that in 1964 the City of St. Louis ranked as follows (rank #1 means that the city is the worst of the 19 largest cities): infant mortality rate, first; accident rate, second; heart disease, second; maternal death rate, third; influenza and pneumonia, third; tuberculosis, fifth; and cancer, fifth. Saint Louis has ranked first in total death rate among the 19 largest American cities in four of the past five years.

There are 13,000 patients in the Missouri state mental hospitals. One Thousand of these patients need not be there, but because of inadequate personnel to prepare them to leave and inadequate family and social structures to receive the patients when they should be prepared to leave, this lost legion of 1,000 is doomed to die within the darkened confines of institutional incarceration. Older Americans are disproportionately represented. The Health and Welfare Council of Metropolitan St. Louis estimates in regard to mental health services that "less than half of the individuals who need the service receive it." (Seventy-Nine Services, February, 1963, p. 35)

The closest estimate I could obtain as to what percentage of the disadvantaged were not receiving seriously needed medical assistance is the following: disadvantaged children: 25 per cent; disadvantaged youths: 50 per cent; disadvantaged older Americans: 75 per cent. I do not present these estimates as scientific evidence; I present them as educated estimates. The genesis of the first estimate of the incidence of failure to obtain seriously needed medical service among children is from a Dr. Anne Bannon. Through a federal grant of $205,000, some 2,000 children enrolled in Head Start underwent a series of medical tests under the general direction of Dr. Bannon. The results indicated that one out of every four of the disadvantaged pre-school children were in need of substantial medical assistance. Systemic infections from infected teeth, iron defi