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Let me comment for a moment on the specific medical and health needs of California's aged and the coverage of the programs now available to them.

Theoretically, the elderly are being served very well by the ViediCal program. They have a wide range of benefits available to them as supplements to medicare. However, since Medi-Cal is basically a financing program, it has developed within the existing system which appears to leave a great deal to be desired as far as the elderly are concerned.


Medicare, and to a lesser extent Medi-Cal, place primary emphasis upon fairly short term acute care although the greatest need of the elderly would appear to be for long-term chronic care. They also place a great deal of emphasis upon medical care as contrasted with health care which has a much broader meaning.

For example, medicare institutionalized the extended care facility as a halfway stop between acute hospital care and home. At the same time, title 19 allowed for skilled nursing home care which in California was seen as long-term care. Then HEW required all skilled nursing homes to meet ECF standards which place major emphasis upon medical and nursing services.

However, not all nursing homes in California can meet ECF standards and not all persons in California nursing homes need such a high level of care so that such a requirement is unrealistic and we think needs to be met by more flexible and understanding programs.

Congress evidently realized this and invented the intermediate care facility which will be much the same as California's nursing homes but will not be paid for under the medical care program. In addition to the almost complete lack of coordination which has occurred at the Federal level as to the decertification of nursing homes and the implementation of intermediate care facilities, this episode illustrates the arbitrariness of the distinctions that are made.

And I think that, more than anything else, what is needed is an effort to provide care for the elderly with little regard to whether it is called medical or not. The primary objective ought to be to assist elder Americans to remain as healthy and as independent as possible. This is in their best interests and it also makes sense from a fiscal standpoint. It is much less expensive to maintain an older person in his own home than to place them in an institution and it is far, far better for him-whether it be nursing home or State mental hospital.

However, in order to do that we must develop flexible strategies which are directed to that end. An older person may need someone to assist with his housekeeping or taking a bath, bringing him groceries, drugs, or hot meals.

Even though these may not be medical services, they certainly have a direct bearing upon a person's health and whether he is going to require institutional care. It may be in many cases preventive. It is far cheaper, we feel, than the steps that have to be taken if we institutionalize him.

We also need to reexamine the impact of our policies upon the families of the elderly. The way our modern society has developed has

made it increasingly difficult for children to care for their elderly parents. This fact has evidently been reflected in the relatives' responsibility section of title 19.



One effect of that provision is to make it financially easy for children to place their parents in nursing homes. We could once again require relative responsibility as a deterrent to that action, but this might create added hardships for families of the elderly.

Let me illustrate, if I can, what I mean in regard to another program which the legislature developed in California in the treatment of our mentally retarded children.

For many, many years California had a mentally retarded program. That program provided simply that if you had a mentally retarded child, you would place him in an institution.

Now, the progress in institutions even of the best kind is generally slow for those children. In addition to that, it is very, very expensive, with the result that almost every 2 years we had to increase the facilities and even then we had a long waiting list.

We developed a flexible program which allows a family to acquire State financial aid for children, if they desired to keep that child in the home. We developed a system of foster homes and also local, private facilities, so that we now have alternatives.

We found, after conducting a very intensive survey, that the parents of these children, many times, did not want to institutionalize them. The financial burden, in addition to the emotional and physical difficulties in keeping this child in the home were just too much for the parent, particularly with other children, to bear.

If they could get a little help so that they once in a while can have a day or two rest from that, they still prefer to keep the child in the family. We think this would be the case with the elderly.

A more flexible system was devised so that instead of simply encouraging them, as the program now does to some extent, to institutionalize these people, many young people would keep the elderly, even those with some problems in the home, if they had some help.

And I think that is the general thrust that the program ought to take. A program would have to be devised in this area that is flexible enough to allow this. I think the program that needs to be devised ought also to be flexible enough to allow those who wish to resort to this kind of flexible approach, and other innovative ways of treating the elderly, or helping the elderly, to proceed with it.

I believe all Federal programs should provide floors, as I am flatly convinced that they must, because of the niggardliness of some of our States, and at the same time they ought not to comprise ceilings bevond which those States who wish to proceed with better care and more imaginative programs cannot proceed.

Senator WILLIAMS. I wonder if an idea that we have been advancing, but has not been enacted, fits in at this point. We call it the community service corps volunteers of older people in retirement, and one of the ideas that we thought could be incorporated into the program would be for older people who are active, energetic, and understanding could help in this home service situation that you are indicating.

I haven't described it fully, but does that idea suggest merit to you?

Mr. UNRUH. Yes, it does, Senator: I am very strongly in favor of that program, particularly I think it is apropos to the elderly who sort of get pushed out of our society now to feel, among other things, they aren't wanted. That is unfortunately, I think, too much the case.

I think the program in addition has broad social significancesocially significant values—and if we are indeed to have the change in the kind of politics that too often has pervaded us in government and in our society in the past, that is, I think, more and more people have to be concerned with something other than simply No. 1, and this is a group of people who obviously could be.

They have the time, they have the experience, and I think it has great, great value.

Senator WILLIAMS. Thank you.

Mr. UNRUH. Senator, I just want to conclude by saying that I think our goal should be the maintenance of the health and independence of our older citizens.

To accomplish this goal, we have to realize that health is dependent upon all sorts of nonmedical factors, as well as medical factors, that thiese ought to have equal priority with medical care in any programs devised for the elderly.

Thank you very much. That concludes my testimony.

Senator WILLIAMS. I have interrupted you many times. It has been a magnificent statement, and we certainly appreciate it-I am not sure everybody will, but any statement of importance will have to find some disagreement—whether they live in Sacramento or New York City. I know one person who will not be in disagreement, and he is from the most beautiful State of West Virginia.

Senator RANDOLPH. I can agree that that is the most beautiful State. I don't know if I can agree on the rest.

Senator WILLIAMS. Let me draw back, if I can. "The most beautiful State of West Virginia.” That doesn't mean that I rule out my State.

Senator RANDOLPH. Well, autumn touches West Virginia with beauty just now, you understand.

Mr. Speaker, on page 2, would you refer to your informative statement-very informative statement.

You say that Congress has been irresponsible. Now, I think for the record, you want to be definitive in reference to such a statement. I imagine that I know what your reply will be, but I think it should be on the record.


Mr. UNRUH. Yes. I refer to the capping action which Congress took after throwing out this program, and then finding that one State was somewhat more enterprising than perhaps they should have been in utilizing the open endedness of the program. That really pulled the rug out from under us on our Cal-Med program, which I think, if we had been allowed to develop it, would have provided a better cap to the costs of this program than is provided by the rather arbitrary action of simply saying, “This is the flat dollar amount that we will support."

I think a program which is devised to meet a particular social need ought not to be largely altered, as I think this was—the possibility of the program being developed was—by the capping of a fat dollar amount which had to significantly cut into the purposes of the program.

Senator RANDOLPH. Are you specifically referring to the 1966 social security cutback?

Mr. UNRUH. I think in 1967. The Mills amendment, as I recall.
Senator RANDOLPH. The medicaid cutbacks?
Mr. UNRUH. It was the Long amendment, I believe.

Senator RANDOLPH. Well, of course the Long amendment has not become law,

Mr. UNRUH. I am not talking about the
Senator RANDOLPH. Mr. Oriol, let's have an explanation.

Mr. ORIOL. Well, there were two Long amendments, so-called because they were introduced by Senator Russell Long. That of 1968, which did not become law, and that of 1967, which did. You were referring to the 1967 ?

Mr. UNRUH. Yes. The 1967; that's right.
Senator RANDOLPH. And what was that amendment ?

Mr. UNRUH. That was the amendment which said that the income of a person receiving this could not exceed 113 times the AFDC limits.

Senator RANDOLPH. You recognize that the Congress was faced, Mr. Speaker, with, let's say, a cost squeeze. And not on one program, but across the board, and I am not attempting to argue the point, but would you agree with me that once this situation in the Congress

Mr. ÜNRUH. Well, I am not in a position to argue with you, Senator. You know the facts better than I do, but I am inclined to believe in a system of alternatives that this ought to have had considerably more value than other things that Congress did spend money on. I am not prepared to argue that. It may serve little purpose. In fact it has been done.

I think the net result of that was to drastically cut back the quality of medical care in the State of New York, and to hobble innovation in the State of California which might have provided a considerably better health care program, and even at somewhat less cost, had we been allowed to develop a program as we thought we were being invited to do by the Congress, the year before.

Senator RANDOLPH. I think that is a valid statement; that there was encouragement given. I just wanted it to be on the record, because West Virginia is one of those States—38 in number—that have had the necessary implementing legislation on medicaid, as California, of course.

Mr. Speaker, would you turn to page 4.

You have underscored a statement here—a situation in California. You used language, let's say, which is very understandable I would say it is strong language--you speak about the undermining of the medical care program to the people of California.

Now, where does California stand in this list of States---percentagewise? Of Of course,

New York-very liberal. Arkansas-very conservative.

Mr. UNRUH. Well, I don't have that in front of me at this point, but as I remember, the cap on our program, as far as income is concerned, was far, far below that of New York, and considerably below that of several other States. How many, I do not know.

Senator RANDOLPH. Mr. Speaker-
Mr. Unruh. Our cap on income is $3,800—in the State of California.
New York was $6,000. I think there are two or three other States
with a

Senator WILLIAMS. Notwithstanding the size of the family?
Mr. UNRUH. A family of four—which is the usual family.

Let me say that is one of the tragedies of not being able to develop the Cal-Med program, because we felt that quite clearly, $3,800 is not a very wildly irresponsible figure insofar as the cap is concerned. It is clear that any little extra jiggle in the health pattern of a family is going to upset that.

Those people with more income ought not to be thrown into the poverty level by an unforeseen health consequence. That is the kind of a program we were trying to develop here so that we could help those people above that level with unforeseen costs.

Senator RANDOLPH. This would not be in the category of the aged alone, but would go across the board, even including the middleaged; is that correct?

Mr. UNRUH. That is correct. That program would have covered, in effect, virtually everyone in the State.

PHYSICIANS' INCOME FROM MEDI-CAL Senator RANDOLPH. Mr. Speaker, a final observation, and perhaps a couple of other observations.

Would you turn, please, to page 8. The percentage, Mr. Speaker, of these, let's say, unethical physicians—members of the medical profession—that you had spotlighted here by your use of the figure 1,000.

How many persons are involved in administering that program in the State of California ?

Mr. UNRUH. I don't believe I could—are you talking about the doctors that are

Senator RANDOLPH. The Medi-Cal patients.
Senator WILLIAMS. Patients, or doctors?
Senator RANDOLPH. No, the doctors that administer the program.
Mr. UNRUH. Somewhere between 2,200 and 2,400 doctors.

Senator RANDOLPH. You mean that when you say 1,000, you are speaking of, let's say, 80 or 60 percent—50 percent?

Mr. UNRUH. Forty percent-roughly 40 percent of the doctors would be making that figure.

That is a gross figure, Senator, I would hasten to add.

Senator WILLIAMS. That does not include the expense of medicines and nurses?

Mr. UNRUH. No.
Mr. MANLEY. May I add something here?
Mr. UNRUH. Yes, Mr. Manley would like to

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