portation will be provided for the press to places that Senator Randolph and the technicians on our staff will visit this afternoon. Various institutions and facilities for the care of the aged in the area are on the schedule.

We are glad to have you witnesses here this morning. You have statements prepared, as I understand it. We will ask Mr. Tompkins to start first and make his statement.

STATEMENT OF PATRICK A. TOMPKINS, COMMISSIONER OF PUBLIC WELFARE

Mr. TOMPKINS. Mr. Chairman and members of the committee, I already have submitted, at the request of the staff, my testimony in advance and in the interest of time I would merely like to emphasize two or three points which I believe are paramount in consideration of the problems of elderly people.

Senator MCNAMARA. Mr. Tompkins, we appreciate your suggestion and your statement in its entirety will be made a part of the record at this point.

You may summarize it in your own manner.

(The prepared statement of Mr. Tompkins follows:)

PREPARED STATEMENT OF PATRICK A. TOMPKINS, COMMISSIONER OF PUBLIC WELFARE, COMMONWEALTH OF MASSACHUSETTS

Mr. Chairman and members of the committee, I am both grateful and honored by the invitation of your honorable chairman to comment to this committee on the problem affecting aged people and the generic problems of aging. I am now and have been for over 14 years commissioner of public welfare for the commonwealth of Massachusetts, and I am in my 27th year of public service as an administrator of public welfare services and assistance, including old-age assistance, as a city, county, and State administrator. Prior to that, I was employed by the Family Service Society of Boston and the boys' bureau of the Charity Organization in New York City. I have served on a number of national social work and public welfare committees, including the policy committee of the American Public Welfare Association, and as chairman of the National Council of State Public Welfare Administrators. I have had, and still retain, an intense and continuing interest in the broad, national perspective of the Nation toward the disadvantaged of our fellow Americans, including, despite the dramatic and spectacular attention frequently focused on killer diseases, juvenile delinquency, and the spectacular epidemics such as infantile paralysis, the greatest social service challenge of our time- the adequate protective medical services for aged people.

The committee summary of the expert views presented to it at the hearings conducted in Washington on July 17-18 suggests that already the committee has had presented to it all of the statistical national data on a variety of problems and their priority besetting the aged population of America. I shall not further dwell on statistical presentations other than as financially they may serve to crystallize the immediate impact upon an individual who is old as related to the imagination, initiative, and desire of voluntary and governmental agencies alike to give assurances to the aged people of Massachusetts that their problems and needs will be met and that the dignity of the human personality in such plans and services will be preserved.

I am utterly and sincerely convinced that the No. 1 problem of the elderly person in America and, certainly in Massachusetts, is the problem of fear of medical disablement. It holds a triple-pronged threat to the elderly person in the sense that; (a) it is an emotional fear thereby comprising a major attack upon the internal security of the aged person; (b) it is a physical fear in the sense that thousands upon thousands of such aged individuals in Massachusetts are concerned and worried about the adequacy of the facilities and professional staff available in the event that medical disablement should occur; and, (c) it is

a financial fear represented by the self-evident costliness of short- and longterm care in hospitals and nursing home facilities and the tremendous cost for prescription drugs even if care is provided at home.

May hasten to point out, however, that, in large measure in the Commonwealth of Massachusetts, these fears of elderly people as related to medical illness or accident, realistic as they may be, in fact, are substantially groundless in the face of our liberal and comprehensive medical service program under the aegis of the old-age assistance title of the Federal Security Act as administered in this Commonwealth. Chapter 118A of the public assistance laws of the Commonwealth of Massachusetts specifically lists medical care as an item of need and subsequent amendments to the original Old-Age Assistance Act provide that such medical services may be purchased directly from suppliers. The State Department of Public Welfare has implemented such legislation by establishing a full and comprehensive medical service program which guarantees to each person found to be eligible for old-age assistance (including the cost of medical care) all of the medical and allied medical services which could be purchased by the most wealthy. The portion of the old-age assistance dollar which is spent for medical care in Massachusetts has risen from 8 percent in 1948 to a percentage in excess of 40 percent for the reportable months of the calendar year 1959. Price agreements are developed with committees of the State professional medical and allied service organizations, and a per diem rate for both hospital and nursinghome care is established by the division or the director of hospital costs and finances in the Commonwealth.

The further facts are that from 30 to 40 percent of all new persons seeking old-age assistance make their initial application for such assistance from either a hospital or a nursing-home bed. This, in fact, means that the existing retirement plans of management and labor, including government retirements and old-age insurance, are already seemingly adequate to meet the basic maintenance needs of retired workers and their spouses, but are completely inadequate financially when medical disaster strikes.

On July 17, 1959, it was my honor and pleasure to testify before the Committee on Ways and Means of the House of Representatives in support of H.R. 4700, legislation introduced by the Honorable Aime J. Forand, Congressman from Rhode Island. This legislation, though it may and probably in some particulars is not perfect, is the only proposal to date which embraces the plan of preinsurance during working years for medical, surgical, and hospital benefits during elderly and unproductive years.

The report of the Department of Health, Education, and Welfare submitted to the Committee on Ways and Means in compliance with House Report 2288, 85th Congress, on the subject of "Hospitalization Insurance for Old-Age and Survivors Disability Insurance Beneficiaries," although not making precise and specific recommendations, can, in fact, be deduced to have stated forcefully and with clarity the case for adding hospital and surgical insurance to the present federally administered social insurance programs. H.R. 4700 represents a major start in that direction, and I strongly recommend it to your committee for support during the second half of the current session of Congress.

The additional expert testimony which you have received has, undoubtedly, reviewed statistics of available income to aged people and the very minimal annual amounts available to the great majority of the aging population of America. It has doubtless presented factual data on the cost of both commercial and nonprofit group insurance against the hazards of illness and accident as well as the minimal benefits and the cancellable character of most such policies for such aged people. You have, undoubtedly, further been presented with testimony that the addition of hospital and medical insurance to the workmen's current social insurance coverage would, in fact, assist commercial carriers and nonprofit carriers alike by eliminating the high cost and risk cases from their planning.

Today, there are approximately 16 to 18 States that include in their old-age assistance administration a relatively comprehensive medical service plan. In all of these States, the percentage of the old-age assistance dollar spent for medical services is rising year by year. I urge, for purposes of retention as well as employment and refinement of these medical care public welfare plans, that this committee consider lifting the present $65 per month ceiling on which the National Government shares the cost of old-age assistance. These States in their average monthly old-age assistance grant substantially exceed the $65 per month ceiling on which the Federal Government shares the cost of such assistance.

For example, the following are the average monthly old-age assistance grants for May 1959: California, $84.11; Colorado, $98.29; Connecticut, $112.52; Illinois, $69.65; Kansas, $77.33; Massachusetts, $99.33; Michigan, $71.25; Minnesota, $84.61; Nebraska, $68.41; New Hampshire, $71.04; New Jersey, $87.78; New York, $104.09; North Dakota, $83.38; Oklahoma, $76.42; Oregon, $79.29; Rhode Island, $74.20; Washington, $90.17; Wisconsin, $78.81; and Wyoming, $72.45.

It is a continuing national indignity to compel elderly persons to seek public assistance for medical costs who otherwise appear to maintain themselves through insurance or retirement funds. It is to be noted that for many such short-term hospitalization applications, the administrative costs in the public welfare deparment of determining eligibility will almost equal the cost of shortterm hospital care.

The preinsurance medical proposals of H.R. 4700 will, in fact, strengthen the dignity and the self-sufficiency of the elderly with respect to medical care costs, abrogate continuing fear, reduce, or at least stem, the tremendous avalanche of medical costs in public assistance, and afford public welfare departments opportunity to concentrate on services rather than on financial assistance alone.

The most recent fiscal formula for old-age assistance developed by Congress provides that four-fifths of the first $30 and from 50 percent to 65 percent of the next $35 will be matched by the National Government on the average monthly payment in each State to old-age assistance recipients.

Because of the Federal Government's recognition by both executive and legislative departments of the preeminent position that medical costs and medical services play in the life of each individual and, particularly the retired elderly person and his spouse, if any, it is a moral responsibility, within proper controls exercised administratively and with the approval of the Secretary of the Department of Health, Education, and Welfare, for the National Government to share at least 50 percent in the cost of all assistance rendered to needy elderly people in excess of $30 per month.

May I further add, without posing as either an expert at Government financing, or as an economist, but since most medical persons and authorities have continuously and constantly emphasized for years that there is no stigma nor distinction, except in functional disorder, between mental and medical diseases, that the present statute in the public assistance titles of the law, which prevents the Federal sharing of the cost of care of elderly and disabled persons who are patients in both public and voluntary mental hospitals, be deleted. It is self-evident that the ability of the individual State and its political subdivisions to finance the cost of care, both medical and mental, for elderly individuals is diminishing, and may well reach the saturation point if humane professional facilities and services are to be available.

The recognition by both the executive and legislative branches of the No. 1 position of the medical problem of the aged is established by the increased annual appropriations for the National Health Institute for Research for the multiplekiller disease areas presently unconquered by medical science. All this is good but does not for the immediate moment either pay for or guarantee the availability of such facilities and services rendered at this time. I should like to further recommend more liberal construction and categorically appropriated grants for building and staffing modern, long-term disease hospitals and publicly administered nursing homes. It is evident on reports from State after State that, much as we dislike building structures under public auspices, the currently available physical facilities of proprietary, voluntary, and governmental programs are altogether woefully inadequate to provide a continuing medical and nursing service required by sick elderly people.

The No. 2 problem with respect to aged people is the adequacy of housing. Excluding the custodial medical care cases receiving old-age assistance in Massachusetts of whom there are approximately 16,000, almost 40 percent of the recipients live alone and of these 7,600 live in furnished rooms. It is unnecessary to belabor the quality of average furnished room occupied by an elderly person living on assistance grants. Other expert testimony will, undoubtedly, point up this area of need more thoroughly and graphically than any testimony of mine. There are, without a doubt, many other personal and serious problems that beset the aging population of both this State and our Nation. I am not at all convinced that a great number of these are the special responsibility of the society within which we live, particularly the problem of recreation, preventive medicine, loneliness, or creative and constructive leisure-time activities. With the increasing number of the aged population and the percentage increase

of the aged population to the total population that this group represents in the Nation, individual case and social work services are in a very real sense metaphysically impossible to provide. Moreover, habits, traditions, and personality characteristics of aged people are not likely to be changed in any substantial measure so long as they feel a personal and financial self-sufficiency despite heroic and skilled attempts at the provision of such social services.

The resources of voluntary and governmental agencies alike-local, State, and National-will, within the framework of our foreseeable future, be concentrated on the two most challenging problems of magnitude; namely, medical care and housing. With respect to the former, H.R. 4700, nationally known as the Forand bill, represents a giant stride in preinsurance for major surgical and hospital services. A revision of the present national financial formula for old-age assistance grants-in-aid with realistic recognition of the spiraling cost of all medical care, and particularly hospitalization, with deletion of the current exclusions from sharing in the cost of mental care, would improve both the quality and quantity of services for sick, elderly people.

At least in Massachusetts, the acceleration of public building for elderly persons is beginning to dent the gap in adequate and protective housing for the elderly, retired person. Local councils for the aging, under the leadership of the Massachusetts State Council for the Aging, with local housing authorities under the leadership of the State Housing Authority, coupled with general health and welfare planning, as well as neighborhood location, are making hundreds upon hundreds of new efficiency apartments available annually and scattered through rural, urban, and metropolitan cities and towns. The Federal subsidy for such public housing for the elderly should be encouraged and continued in constancy with the capacity of political subdivisions to build for the growing need for housing for elderly persons.

Mr. TOMPKINS. Mr. Chairman, members of the committee, I pointed out in my written material that I deliberately avoided presentation of statistical data which you undoubtedly have had presented in great detail at your hearings in Washington and which will be presented by other witnesses that will be heard during this hearing in Boston and the further regional hearings that will be held.

I emphasize in my written material the No. 1 and No. 2 problems of the aging as I have observed them over a period of 27 years of public service and public welfare administration as a city, county, and State administrator.

COST OF MEDICAL CARE

The first, without any doubt in my opinion, is the problem of medical care and the cost of such medical care.

I feel very strongly that the single outstanding concern of the aging person is the fear of the cost of medical care on the one hand and that represents a sort of triple-headed threat.

It is a threat to intrinsic security in the sense that aged people are fearsome of the lack of being able to pay for such medical services either in their own home for a doctor or prescription drugs or medical facilities in a hospital when and if they become debilitated through the diseases of advanced age.

It represents a further fear in terms of being a burden upon their dear ones, their children or nieces or nephews or sisters or brothers. And it consitutes a very real emotional problem which hastens the mental emotional degeneration that occurs, as Commissioner Mahoney has pointed out, with such high incidence amongst elderly people.

Thirdly, of course, it represents a fear of the unavailability of existing facilities because of the lack of funds.

Now, I recommend two major amendments to the Federal Security Act as presently written in furthering the availability of at least care.

One is, as has already been recommended by Commissioner Mahoney, in terms of block grants for construction of physical facilities.

It would add to that the possibility of adequately staffing physical plants when and if they are so constructed.

I do not pretend to be an economist, but I think it is almost selfevident that the States have a diminishing ability to finance the cost of care, both medical and mental, of the aged individual, and that they are rapidly reaching the saturation point if we are going to adhere to the high qualitative standards of both professional staff and decent and dignified facilities for their care in the future.

OLD AGE ASSISTANCE

The second recommendation that I make with respect to the Federal Security Act is the deletion of the present exclusions, making both disability assistance and old-age assistance available to mentally ill

persons.

For years we have had a good deal of public education on points that Senator Randolph has already made, the alleged stigma of mental illness as contrasted to the acceptance generally in society of the possible physical disablement of anyone at any age.

Now, the medical professions through medical journals, countless multiple presentations from the public platform, have advised the American people that there is no such distinction, that a person is ill and that it is merely an accident of fate that he may be mentally ill or he may be physically disabled.

So the original reasons for excluding the mentally ill aged from the benefits financially and the protection emotionally of the old-age assistance title and the disability assistance title of the Federal Security Act I believe now are obsolete.

If the amendments were made it would provide, I think, opportunities, both financially and staffwise, as well as in functional programing, to make available to the great numbers of mentally ill aged persons the kinds of qualitative high professional service in the mental health and medical care fields that are not presently available.

I also recommend that the present unfavorable financial formula with respect to old-age assistance and disability and blind assistance be reconsidered by your committee and by related committees of the Congress in the sense that the 15 or 16 States which, like Massachusetts, have a comprehensive and adequate medical care program for its aged needy, are discriminated against in the existing financial formula which is providing four-fifths of the first $30 expenditure and from 50 to 65 percent of the second $35 expenditure for the needy aged and the needy disabled of their respective States.

Now, the 16 or 17 States, 15 to 16 or 17 States, that do provide public assistance grants by virtue of purchase of services under medical care plans adequate and comprehensive medical care, will exceed the existing $65 per month ceiling by anywhere from $5 to $35, or in the case of one State, something like $50 per month.

Now, I recommend that the present $65 ceiling be lifted completely and for those States which choose to administer an adequate and comprehensive medical service program, that the participation financially of the Federal Government be at least 50 percent of all expenditures in excess of $30.