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ciency, cardiac lesions, are examples of the serious uncared for health problems. Draft board rejections for reasons of health among poverty neighborhood draftees are the source of the 50 per cent estimate of uncared for serious uncared for health problems among disadvantaged youths. As for the health service needs of the older Americans I call attention to the observation that among the disadvantaged the co-insurance and deductible components of Medicare have frequently in face of resultant cost increases made the obtaining of health services more difficult.

D. THE ROLE OF FEDERAL GOVERNMENT Granted that the impecunious older Americans are tending to becoming centralized in the impecunious central cities which in turn are becoming regressively incapable of providing even basic services -medical or other--what should be the role of the federal government? Granted that broadly speaking the federal government has the bulk of this country's taxes and the central cities have the bulk of the country's problems, what direction are we to expect the relationship between the municipal and federal government will take? Let me make several preliminary remarks:

(1) The central cities are deeply gratified that Congress and the federal executive administration have decided through the revolutionary health service legislation of the last several years that the criterion of the reception of quality medical assistance shall be the need of the citizen rather than his economic capabilities.

(2) The federal government's aid to older citizens through Medicare is not "socialized medicine." This spectre when raised against Medicare and Medicaid is a fraud. In England there is socialized medicine because the government acquires the hospitals and hires the medical staff. But in the L'nited States, titles XVIII and XIX acquires no hospitals, hires no physicians to practice medicine, treats no patients, strives to conserve and support the existing voluntary agencies, and merely performs a function that was not being and seemingly could not be performed on a lower institutional level. Medicare is an insurance and not a medical treatment plan.

(3) The interposition of a fiscal intermediary for the Federal government in the Medicare act has worked well. The St. Louis Blue Cross, for instance, serves as the fiscal intermediary for the Federal Government in an 84-county service area paying $35 million to hospitals and related agencies in the 10-month period from July 1 through April 30 as well as $41.5 million to hospitals for member care. Mr. Elzey M. Roberts, Jr., chairman of the St. Louis Blue Cross pointed out to the board earlier this month that the major problems of transition to the medicare era have been overcome through the co-operation of the hospitals, the medical profession and the public. We in St. Louis are gratified that the Under Secretary of Health, Education and Welfare, Mr. Wilbur J. Cohen was able to state: "Thirty years ago people who wanted reform couldn't even have a dialogue with the medical profession. . . . Now there is a breath of fresh air, and even though there isn't

always total agreement all the time, we have a completely open dialogue." Granted that responsible individuals do not speak of the federal insurance plans in the area of health services as “socialized medicine" I do wish to draw attention to the suggestion that government support can be bought at too high a price. "Big brother's" price is too high if this "help" leads to the deadening of local initiative and the burying of local creativity in a grave lined with triplicate forms, computer tape and spindled data processing cards.

Three years ago at Ann Arbor President Johnson delivered his famous Great Society speech. On that occasion, and many times since, the President has used the phrase "creative federalism.” Federalism means a relationship, cooperative and competitive, 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 dialogue 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 organizational-is 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 model 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 more instance of creeping socialism and womb-to-tomb welfarism is losing its relevance.

The new emphasis is upon "problem solving" and this 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 old and what the fortunate 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 ensure 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 iniatitive and, as much as possible, local consensus.

THE GREAT SOCIETY AND LOCAL INITIATIVE

The new look in the Great Society is local participation. The Peace Corps will send no one into an area without being invited; the anti-poverty program demands "maximum feasible participation" of the beneficiaries of the program and refuses funding of programs not thought out on a local level ; Health, Education, and Welfare is providing little more than guidelines, blocks out options for local choice, and depends upon local administrators to come up with the specifics; the Labor Department and the White House Conference on Civil Rights are calling for the establishment of metropolitan job councils “to ensure that the business community, labor organizations and government agencies assume maximum responsibility for expanding job opportunities for Negro workers,” the Model Cities program of the Department of Housing and Urban Development is little more than an invitation to local leadership backed by broadly based local community support for a locally planned proposal to rebuild one's own city. The Johnson Administration has come out four-square for the ideology that in the private sector, not in the public sector, lies socio-economic salvation.

What this means for hospitals is that the deluge of assistance offered to them by the eight major health care acts passed by the federal government during the past two years will not swamp them in a molasses sea of federal directives. The dead hand of bureaucracy is not stifling their breath or chilling their blood or choking off their initiative. Socialism is not here to take over the hospital, treat its patients, hire its staff, provide it with a minute-by-minute daily order, and do all its thinking for it. Medicare and Medicaid are considered as a challenge, not a threat. I submit that never in the history of health care has so much creativity, initiative, drive, involvement, knowledge of the best in so many fields been required of administrators and staff in the hospitals of the United States.

We welcome and need the “creative federalism” or “balanced federalism" approach. The federal government is thereby living up to its role of providing for the common welfare and recognizes its role of expediter, enabler and catalytic agent rather than as a monopolistic repository of all wisdom, creativity, resources and administrative fiats.

To summarize my testimony:

(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.

STATEMENT OF ELMER M. JOHNSON, ASSOCIATE DIRECTOR OF THE METROPOLITAN ST. LOUIS HOSPITAL PLANNING COMMISSION, INC.

I wish to provide information about the status of home health services in the St. Louis Metropolitan area, and to cite obstacies to the further development of this service.

The present total annual expenditure for organized home health services for the sick in the metropolitan area is $1,100,000. We have about 2,300,000 persons in the area, so this represents a rate of less than 50 cents per capita.

Eight home health service agencies serve the area, employing 57 registered professional nurses and 102 home health aides. The number of nurses employed today is about 20 greater than one year ago before the beginning of medicare. There were no home health aides a year ago, although a few homemakers performed similar functions. Training programs financed by the Office of Economic Opportunity trained 88 of the presently employed home health aides. Another 20 were trained but there were no immediate job openings in this specific type of service at the time of completion of their training.

The great majority of home health service here is provided by non-hospital, community based voluntary agencies. Only one nurse from a tax-supported agency provides home health services for the sick in the metropolitan area.

Charges for visits by registered professional nurses range from $4.50 to $10.65. The lower rate is charged by a small-town visiting nurse association—the higher by a city hospital-based program. The average charge is about $9 per one hour risit-up 25 percent over a year ago. Home health aides customarily work in each home about 4 hours per visit. Charges for aides services range from $1.60 per bour to $2.50 per hour.

The ratio of aides to professional personnel is 5 to 1 in one agency, while another has no aides. The biggest agency has about 2 aides for each 3 professionals. Generally, the visiting nurse associations have lower ratios of aides to professionals than other types of home health agencies.

The total active caseload of all home health agencies in the area at any one time is approximately 1,000. This compares to average daily occupancy of 8.800 in short-term general hospitals and 8,600 in log-term care facilities, excluding mental and T.B.

At the present level of care home health services cost about $3 per active case per day in the metropolitan area.

The rate of use of this service here is only about 23 the rate in communities where home care is highly developed. I believe the reasons for under-use of home care locally are:

Inadequate interpretation of home health service to doctors and the public.
Lack of relationships between home health agencies and many hospitals.

No home health service benefit payments for public assistance recipients under age 65 in Missouri.

Limited number of hospitals (6 of 42) qualifying to admit Blue Cross patients to home care.

Some parts of the metropolitan area with only nominal home health ser ce coverage. In addition to problems of insufficient use of the service, existing home health service programs need to be examined to determine if there is:

Too little medical surveillance of patient care.
Inappropriate "mix” of professional, technical, and aide services.

Inefficiencies caused by duplication and overlap of service areas of home health agencies in metropolitan area. Increased use and more appropriate use of home health services could be encouraged at the federal level by:

Requiring that each medicare certified hospital and extended care facility has a transfer agreement with a home health service agency, or itself provide home health services. 83-481 067-pt. 1-9

Adding home health services to the present list of five services that are mandatory under Title XIX of the Social Security Act.

Developing educational materials and resources for local use in interpreting home health services to doctors and to the public.

Stimulating the establishment of national accreditation for home health service agencies which involves review of patient records by a team of competent specialists in mediicne, nursing, physical therapy, etc.

STATEMENT OF BERNARD FRIEDMAN, MEDICAL DIRECTOR AND

SUPERINTENDENT, ROBERT KOCH HOSPITAL, KOCH, MISSOURI On June 3, 1967, I attended a meeting, with others, at the request of Mr. William E. Oriol, Staff Director of the United States Senate Special Committee on the Aging. At the time we discussed the question of federal programs and health services to elderly Americans. Subsequently, we were asked to write a statement on the particular facet of health services in which each of us was most interested. This present statement repeats in general the oral statement that I made at that meeting.

My own special interest in the problems of the elderly came about through my work at Robert Koch Hospital. Our hospital was originally the municipal tuberculosis hospital of the City of St. Louis. As empty beds were made available, as a result of the impact of the modern treatment of tuberculosis, these beds were used to develop our Intermediate Care Divisions. Our Intermediate Care patients are patients that come to us usually from a general hospital, municipal or private, who no longer need the intensive care of a general hospital, but who requires services greater than that obtained in a nursing home or in their home.

Experiences with these divisions have been most revealing. For one thing, these divisions have become essentially divisions for the rehabilitation of the elderly. For another, it has become evident that very often the main obstacle preventing the patient from returning home is not the medical problem for which the patient entered the hospital. Very frequently the patient overcomes his stroke sufficiently so that he may again be up and about, his hip fracture heals well enough so that he becomes essentially self-care. 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 level 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 kind 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 can not be discharged because the home circumstances are unfavorable.

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 indispensable. At our Intermediate Care Divisions all efforts are made to prevent permanent institutionalization. The following is a table recording the disposition of our discharged patients in the last 3 fiscal years.

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These results are, in my opinion, not particularly extraordinary. A few years ago, however, a significant number of the people we now send home would have been sent to nursing homes. 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.

STATEMENT OF MORRIS ALEX, M.D., MEDICAL DIRECTOR, HOME

CARE PROGRAM, ST. LOUIS, MISSOURI At our meeting in Mayor Alfonso J. Cervantes' Office on June 3, 1967, with Mr. William E. Oriol, Staff Director of the United States Senate Special Committee on the Aging, it was suggested that I write up and submit to your subcommittee on Health of the Elderly the following portion of our discussion. I am happy to do so.

As a result of advances in the health sciences, there has been a profound change in the type of care required for many people. In the past acute diseases were predominant but now exacerbations of chronic diseases are more prevalent. With increasing numbers of older people in our population there has been a shift toward larger numbers of chronic diseases and as a result of this, need for longterm care and rehabilitative care. During the last 10-15 years, many voluntary and state organizations have arisen to help meet certain needs from either a social or medical point of view. Now it has become necessary to coordinate existing resources in order to make maximum use of the available resources and to develop new methods of coordinated care.

It is estimated that at any one time about one per cent of a communities population are not found in the world of the well. They have been withdrawn into the hospital world as patients. Of this number, some are there because they need treatment or diagnosis, and some are there simply because they cannot be contained within the world of the well but yet, do not require acute hospitalization. The latter group are the ones we are discussing at this time for if the occupant of the bed is not in a condition to use or respond to the expensive services of the acute hospital then doctors and laymen alike say that the bed is used for social rather than medical purposes. For most efficient use, in-patient medical care is to procure patients sent to them from the world of the well and to return them to the world of the well as quickly as possible. Home Care has a far wider use, it is responsible for managing the sick and all illnesses whether curable or not that do not require the acute hospital. In this management there is more than just therapy because this home care includes aid in living with the disabilities of the illness whether transient or permanent, limitations of disturbances in all the social systems which an illness disturbs notably the household in which it is contained and establishing a partnership with those charged with the care of the sick individual in the community.

The problem of chronic illness in the Greater St. Louis area has been primarily a problem of the core city of St. Louis because of the unusually large number of persons 65 and over residing within the City of St. Louis. In the City of St. Louis in 1960, 12.3 per cent of the total population was 65 and over. By 1970 it is estimated that it will reach 15.3 per cent. By the same token in 1970 it is estimated that in St. Louis County the percentage will be 6.4 per cent. To make this problem more apparent, almost 55 per cent of metropolitan aged population resides in the City of St. Louis; whereas about 20 per cent lives in St. Louis County. A public assistance picture adds another dimension to the extent of the problem of chronic illness. In the year 1963, of the 102,409 old age assistance cases in the State of Missouri, 13.1 per cent were located in the City of St. Louis as compared to 2.7 per cent in St. Louis County. Of the total of the permanent and total disability group 29.1 per cent were in the City of St. Louis and 4.3 per cent in St. Louis County.

It is estimated that there are some 24,000 cases of heart disease in the City of St. Louis, 22,000 cases of hypertension, 7,725 cases of diabetes, 12,225 cases of visual difficulties, 29,250 cases of hearing defects and almost 10,000 cases of paralysis of one or more limbs due to either cerebral vascular disease or to other neurological deficits.

The City of St. Louis has been and is now doing something about the problem of chronic illness and coordinating care. However, because of the extent of the problem and the late start, the solutions are not easy. In 1955, the City submitted

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