But so long as no provision is made for financing such care beyond what individuals and families can squeeze from their incomes and assistance agencies can finance the standards are bound to be low. A few family agencies actually use their limited funds to supplement what families and assistance agencies can provide but this is almost prohibitively costly for agencies like ours whose principal job is casework service. Only the broad risk-sharing of the social insurance system can provide an adequate financial base for good hospital and nursing home care. As long as we have to rely on retirement income, family generosity, private philanthropy, and public assistance to pay for nursing home care, standards will be a problem.

This brings me to the third area and the principal burden of our testimony: the unfortunate impact on family relationships of the present gap between health needs of the aged and the provisions now available to meet them. We find it diffcult to understand the current sporadic revival of conservative thinking which holds that socially organized measures like social security tend to discourage or minimize family ties and solidarity. Our experience runs directly counter to this.

It is our observation that family ties are weakened when burdens placed on the family relationship exact too heavy a toll. Present-day older people are just as resentful of being dependent on the generosity of their children as their children are torn by the conflicting needs of young and old. But despite this well-known fact of modern life I am told that 32 States will not give assistance, including help with medical care, to older people whose children are considered economically able to help them. This would seem to put a clear limit on the ability of public assistance, even as liberalized last year by the KerrMills amendments, to meet this need in a way that fits American concepts of family relationship.

The whole approach of relatives' responsibility laws is bound to have an adverse effect on family relationships. The assistance agency operating under such laws must not only inquire into the resources, assets, and needs of the older person who seeks to help but must also do the same for the responsible relative, for example, a son or son-inlaw.

His income, too, must be scrutinized; his family situation weighed in the balance. Junior's aspiration for a college education is weighed against Grandma's hospital bill and the whole equated against the earnings of the family breadwinner. Even the most gifted public assistance worker would have trouble easing the tensions, anxieties, and resentments implicit in this whole process. In many cases the old person would rather forego needed medical care than subject this family to such an ordeal; in other cases the family will make any sacrifice rather than turn of public assistance.

Still another source of family tension in the public assistance approach to medical needs in old age is the requirement that the applicant cash in all or virtually all of his assets to pay his bills before he can qualify for assistance. This is particularly hard on old people for whom a savings account, an insurance policy, a house, small family treasures, or even petty cash under the mattress may well stand as a lifetime symbol of self-respect. Again families that love and respect their older members may well make financial sacrifices far beyond the

expectations of State assistance and support laws in order to spare them that humiliation.

But if the same family cannot manage to do this, it is often difficult for the older person involved, or possibly his friends or neighbors, to understand just where the blame lies. Many families that have made tremendous financial or other sacrifices for their aged relatives find themselves the subject of unjust and confused censure when a staggering hospital bill forces them to turn to the welfare.

Public assistance has its role in providing for unusual and extreme situations of need. But it is not geared to meet the widespread situation which now confronts families in financing health care for their aged relatives. The very dissatisfactions and tensions which now surround our public assistance programs, often unfairly blaming public welfare for the very situations it is trying to relieve, are a sign that some better way should be found to anticipate and prevent need before it occurs. One of our most successful methods of preventing need in old age has proved to be the system of social insurance through which people can pay in their working years to cover their needs in retirement.

It seems to us that this system which has served so admirably to provide cash income in retirement should now be extended to the field of health benefits. This would not only solve the economic problem involved in financing health services in the high risk-lower income years but would do so in a way that would strengthen family ties. The older person, knowing he has earned his own benefit, feels himself entitled to the respect of all members of his family. The fact that no possible illness of his threatens family solvency frees the family for its traditional role: source of the mutual respect, affection, and moral support it alone can give its members.

In order to support this general statement we have asked our member agencies to give us examples from their own case records of the actual problems of individual older people and their families in meeting health needs. Some of these, naturally disguised to protect the privacy of our clients, are appended herewith. Since any major social problem is simply the sum total of many individual problems, we feel that these actual stories concerning particular older persons and their health needs forms a natural conclusion to the plea we make in their behalf today.

(The material referred to follows:)

CASE ILLUSTRATIONS-SUPPLEMENTAL TO TESTIMONY ON HEALTH CARE FOR THE AGED

(Submitted on behalf of the Family Service Association of America, New York, N.Y., by Clark W. Blackburn, general director, August 1, 1961)

I

Boston, Mass.

THE P. FAMILY

Mrs. P., aged 70, is the widow of a teacher who died suddenly 5 years ago, without having made adequate pension arrangements for her and their daughter. Mrs. P. has as regular income only a veteran's widow's pension and old age and survivor's insurance totaling $114 a month. The daughter, 40 years of age, lives at home, receives disability assistance on the basis of an emotional condition for which she is treated at an outpatient psychiatric clinic. They live in an

old house owned by the P.'s, at a monthly figure well below what it would cost to rent, and in the community where they have been known and respected for years.

Their income is just above that allowed for eligibility for old age assistance, but there is no provision for the cost of medical care for Mrs. P., which is mounting. She has a stomach condition which cannot be corrected unless extensive surgery is done. She needs treatment for rheumatoid arthritis. Money, which formerly was carefully apportioned for upkeep on the home, is now going rapidly in payments to her doctor and for medications.

II

Camden, N.J.

MRS. F.

Mrs. F. was a woman in her early seventies who made her home with one daughter who was severely mentally retarded and a son who could accept limited responsibility because of a severe mental condition.

She suffered a stroke and a private physician was summoned who tried to arrange for hospitalization. There was no bed anticipated in the hospital for a while. He suggested that Mrs. F. be cared for at home. Mrs. F. was living on old age and survivor's insurance which she received for herself and for the two dependent children mentioned above.

For several days a married daughter who had two small children of her own would come each day after an hour and a half trek from Philadelphia to look after her mother and would return late at night to care for her own family. She left her mother with a great deal of trepidation because of the concern she had over the handicap of her brother and sister should an emergency arise.

The family was referred to the family service agency, who provided a homemaker on a 12-hour-a-day basis to help relieve the situation until bed space was made available at the county hospital.

It was a physician's opinion that Mrs. F. could have been provided for at a nursing home of good standards and thus it would have avoided costly hospitalization had she the means to afford a private nursing home. Had there been adequate nursing home arrangements the strain on the married daughter and her family would have been greatly reduced as well as the risk of leaving Mrs. F. alone with two adults who were physically and mentally unable to cope with the situation.

III

Chicago, Ill.
MRS. E.

Mr. E. in his late thirties sought the agency's help in planning for the continuing medical care of his mother, age 68. A widow for 10 years, she had shared an apartment with a friend and had an active life. She was able to manage carefully on her $70 old-age and survivor's insurance payment and modest savings, supplemented by some baby sitting. Her son and daughter were both married and rearing young families on modest incomes.

Mrs. E. suffered a heart attack and after a period of hospitalization needed nursing home care, since she could not return to her friend's apartment, and her children's homes had neither the privacy nor the quiet which were essential for a convalescing invalid. Both son and daughter were unhappy and conflicted about their inability to have their mother with them, and even more unhappy as they examined available medical resources. The family finally settled on a nursing home of modest standards which charged $250 per month. Additional costs would include clothing, personal incidentals, regular medical care, and medication. Mrs. E., in addition to her $70 monthly income, had savings previously reduced by hospitalization and medical services to $1,000. This would be completely absorbed by ongoing medical needs in several months. Both of the E. children came to the decision to contribute $50 each a month although these contributions jeopardized their small savings and the future security of their own families.

IV

St. Louis, Mo.

THE D. FAMILY

Mrs. D., a 74-year-old single woman, has supported mother now 94 for the past 28 years by working as a saleslady. She has been able to draw old-age and survivors insurance benefits the last 2 years in addition to salary and had saved close to $1,000. Mother has no income, was recently hospitalized 3 weeks for surgery. Hospital bill, $730; surgeon, $250; and family doctor, $100. Since discharge, drugs are averaging about $10 a week. Visiting Nurse Association is giving free visits three times a week. Miss D. is no longer able to leave the home to work. This one illness has wiped out savings, so that in the future they will have to give up the physician they have depended on, and try to get by on clinic care.

V

Los Angeles, Calif.

MR. M.

Mr. M., an 88-year-old widower, who had been receiving the maximum of old-age assistance under the California law, and medical service and medicine through a private physician, also provided through public funds.

Following recent hospitalization, however, Mr. M.'s physician advised that he could not return to his apartment and take care of himself. He now needs to be in a nursing home. Mr. M. had diabetes and a heart condition. The maximum which the county will provide for a rest home is $150 per month. It is not possible to find the kind of home that would give Mr. M. the care he needs at less than $200 per month. He had put aside $300 toward his burial and recently used part of this to supplement his old-age assistance in a nursing home. Mr. M.'s children are unable to meet any of his financial needs.

VI

New York City, N.Y.

MRS. O.

Mrs. O., aged 72, lived alone at a residential hotel, and suffers from arteriosclerosis, and has had several strokes. Until 5 years ago she had lived with her only daughter and her family, but with the advent of a third grandchild in the home and the first of her strokes, she elected to move to a small residential hotel. Her son-in-law, Mr. C., who had a moderate income, also supported his motherin-law at cost to his family's living standard and jeopardizing the college reserve he was attempting to build up for his 15-year-old daughter, who was a promising student, by supplementing the small old-age and survivors insurance income she received. The relationship between the C.'s and Mrs. O. was not an easy one. Mrs. O. was ill, querulous, self-absorbed, critical of her daughter and her sonin-law, and resentful that their contribution could not be greater. This situation had stirred up considerable family unhappiness and tension, with which the family sought help.

One step in helping this family was to consider a plan for Mrs. O.'s admission to a nursing home, where she would receive needed care and to see whether there could be other sources of income which would provide for the financing of this care and the medical care without keeping the C.'s in the precarious financial situation that their continued payments had created for them.

VII

Philadelphia, Pa.

THE B. FAMILY

Mr. B., 71; Mrs. B., 69

The two daughters of Mr. and Mrs. B. reached through to agency to ask help in planning for their aged and ill parents who want to continue to live in their own home. Mrs. B. has generalized arteriosclerosis, degenerative joint disease, etc., and Mr. B. in the past had two major operations-one for removal of a vocal chord (which has affected his speech) and other for cutting away part of stomach. Both require regular medical care, extensive and expensive medications. The B.'s receive $144 monthly old-age and survivors insurance and are quickly using up their savings (in the form of U.S. Government bonds) by cashing the bonds to meet their current living expenses at regular intervals.

The older daughter cannot contribute financially because of her husband's limited income. The second daughter had agreed to a weekly contribution, only to have her husband take her to task because in the past she gave of her time to parents each day; now she not only gives her time but must give a regular financial contribution. The older sister, feeling her own guilt in being unable to contribute, carries addition guilt for causing (in her opinion) a marital problem between her younger sister and the latter's husband. The B.'s only have $1,000 in savings and because their medical expenses amount to $15 to $20 weekly, they live in constant fear of how they will meet these essential medical expenses when their savings are gone.

VIII

Pittsburgh, Pa.

THE F. FAMILY

This case involves three generations.

Mrs. F., age 83, widow, was hospitalized 3 years ago with a broken hip. She recuperated to some extent from this but during the past year has required considerable care and within the last 6 months requires almost 24-hour care due to loss of bowel and bladder control.

Mrs. F. lives with a daughter and son-in-law. The daughter was in an automobile accident shortly after the mother suffered the broken hip, creating further family complications. She suffered a back injury that continues periodically to immobilize her. The son-in-law, age 65, was already facing the decision of retirement in the fall of 1961 when he, too, suffered a back injury on the job and was hospitalized, later confined to his home and inactivity. They were reduced to living on workman's compensation in the amount of $42.50 weekly. Mrs. F. receives old-age and survivors insurance of $36.80 per month. The problems created for this family due to physical disabilities, and reduced financial income, has created additional problems emotionally for the daughter and son-in-law that have further impaired their own physical health. As a result of their physical health breaking down and financial strain, their daughter and son-inlaw have been concerned about the total family problem. The granddaughter has offered help by giving time to her mother in the care of the grandmother, but she has her own small children and the family income is not sufficient to ease the financial burden.

The increased need for medical care and medication is more than Mrs. F. receives in old-age and survivors insurance. There is a need for the family to have assistance from a practical nurse but this is an impossible situation in view of the family income. The son-in-law recuperated to a point of returning to work for a few months but will be retired in September 1961. The daughter and sonin-law have had some hospitalization but due to the excessive needs have utilized the coverage, therefore have outstanding bills for hospitalization and medical care and medication. They see no way in which they will be able to pay these bills when the family income is reduced to old-age and survivors insurance.