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

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 United 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 visit-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 hour 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 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 service 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.

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