ITEM 7. LETTER AND ENCLOSURE FROM M. KEITH WEIKEL, COMMISSIONER, SOCIAL AND REHABILITATION SERVICE, HEW; TO SENATOR DICK CLARK, DATED JULY 27, 1976

DEAR SENATOR CLARK: I was pleased to learn in your June 23 letter about the forthcoming hearings scheduled for August by the Special Committee on Aging in Iowa, Nebraska, and South Dakota.

In your letter you requested specific information concerning the Medicaid programs in these States as they might affect the rural elderly population. Each of these questions is addressed in detail below.

What is the official definition of a rural area in your agency?

Although Social and Rehabilitation Service/Medical Services Administration has not officially adopted a definition of rural areas per se, we are essentially in agreement with that developed by the Office of Rural Health Initiatives (HEW/HSA). This office defines rural areas as those geographical areas which are not included within a standard metropolitan statistical area, i.e., under 50,000 persons or are not listed as an urbanized area or as unincorporated places in the current County and City Data Book, tables 4 and 5 (U.S. Department of Commerce).

Do you agree with the Administration on Aging (AoA) designation that an "older American" is of age 60 or older?

Congress has mandated that for a person to be eligible for Medicaid, he must be 65 or over and either be receiving “old-age cash assistance" or, in those States having medically needy programs such as Nebraska, fall within a financial range not to exceed 133 percent of the States welfare income limits. Age 60 or older as the basis for dispensing AoA grants in no way conflicts with these requirements. How many persons in each of these States are eligible for Medicaid? How many of these are elderly? How many in rural areas? Could the committee be provided with descriptions of each State's Medicaid plans?

Current Medicaid eligibility data is not routinely available from the States although figures collected for a recent special study by the HEW regional office indicate that in fiscal year 1976 the total number of eligible in Iowa and Nebraska were 138,776 and 56,437, respectively. Of these the number of aged eligibles in Iowa was 6,695 and in Nebraska, 12,293. The most reliable figures for South Dakota is an unduplicated recipient count for fiscal year 1975 which totaled 41,966 persons with 11,540 of these elderly.

No information is presently available on the number of Medicaid elderly living in rural areas of these States. Enclosed is a current summary of Medicaid services by State which describes in general the scope of benefits offered in each State. I hope this information is useful to you during the hearings and if we can be of additional support as they progress, please feel free to contact me.

Sincerely yours,

[Enclosure]

M. KEITH WEIKEL.

ITEM 8. LETTER FROM ROBERT FULTON, ADMINISTRATOR, SOCIAL AND REHABILITATION SERVICE, HEW; TO SENATOR DICK CLARK, DATED JULY 28, 1976

DEAR SENATOR CLARK: Thank you for your letter of June 22 on behalf of the Special Committee on Aging requesting information about Federal programs for older Americans in rural areas. Please accept my apology for the delay in responding.

You ask specific questions concerning programs in Iowa, Nebraska, and South Dakota. In response to your first question, this agency has no official definition of a "rural area." Since title XX is a Federal-State program that is State administered or supervised, States decide what services will be offered in the dif

ferent political subdivisions according to the specific needs in those areas. In other words, rural areas reflect rural interests, urban areas reflect urban interests.

Contrary to the Administration on Aging, this agency, under the titles of the Social Security Act, classifies an "older American" as one who is age 65 or older. States are not required to accumulate and report precise data on age breakdowns of social service recipients. However, for your upcoming committee hearings, I requested staff in the Social and Rehabilitation Service Denver and Kansas City Regional Offices, to compute rough estimates regarding the percentage of title XX funds that are used for social services for the aged. In Nebraska, approximately 16 percent of the title XX funds are used for services to the aged; in South Dakota, 11 percent and in Iowa, 15 to 20 percent.

All three States provide the following title XX services to Supplemental Security Income recipients: health related programs, home management services, meal programs, and transportation services. Nebraska also provides adult day care services.

Title XX programs are coordinated with programs under the Older Americans Act through joint working agreements between the State title XX agencies and the State commissions on aging. This allows the agencies to work closely together when determining the needs of the aged and the programs that will be provided. In South Dakota, the State Office on Aging is under the umbrella of the State title XX agency. Therefore, South Dakota sees no reason to sign a joint working agreement.

Revisions to section 228.61 of the title XX regulations allow the States to establish any method or methods, including income declaration without documentation, when determining title XX eligibility. Nebraska and South Dakota require income documentation while Iowa requires only declaration of income.

I trust this information is helpful to your committee. Please let me know if I may be of further assistance.

Sincerely,

ROBERT FULTON.

ITEM 9. LETTER FROM LOUIS M. HELLMAN, ADMINISTRATOR, HEALTH SERVICES ADMINISTRATION, HEW; TO SENATOR DICK CLARK, DATED AUGUST 11, 1976

DEAR SENATOR CLARK: This is in further response to your letter of June 22 requesting information about the Health Services Administration's (HSA) role in serving the elderly in rural areas.

Within HSA there are several programs which serve rural areas, including the health maintenance organization (HMO), the emergency medical services (EMS), the community health centers (CHC), the migrant health, the national health service corps (NHSC), the health underserved rural areas, and the home health programs. Health service delivery programs for rural areas are coordinated through the Public Health Service's (PHS) rural health initiative (RHI) under the guidance of a PHS-wide rural health coordinating committee. The RHI is an administrative effort combining existing health resources of the Department to improve the delivery of health care to health underserved rural areas. We shall respond to the specific questions you asked in the order presented to us in your June 22 letter.

(1) HSA has explored and is using several definitions of "rural." The RHI initially defined rural as nonstandard metropolitan statistical area (non-SMSA) counties. Data subsequently received from the Department of Agriculture indicates that approximately 38 percent of the rural population live in SMSA counties. Accordingly, we reviewed the definition we used for rural, i.e., nonSMSA, and found that it would be more appropriate to define rural as non-SMSA or those areas not listed as urbanized areas or unincorporated places (places having 25,000 or more inhabitants) in the County and City Data Book 1972. tables 4 and 5, U.S. Department of Commerce, Bureau of the Census, Social and Economic Statistics Administration, Washington, D.C. 1973.

HMO regulations published in the Federal Register, October 18, 1974, defines a rural area as any area not listed as a place having a population of 2,500 or more in Document #PC (1) -A, "Number of Inhabitants," table VI, "Population of Places," and not listed as an urbanized area in table XI, "Population of Urbanized Areas" of the same document (1970 Census, Bureau of the Census, U.S. Department of Commerce).

The EMS program defines rural areas as those areas other than urbanized areas as defined by the Bureau of the Census.

Enclosed for your information is a copy of a paper* prepared by HSA in September 1974 which examined several other definitions of rural ir use.

(2) The Older Americans' Act title VII (nutrition program) requires that beneficiaries be "60 and over." Title III of the same act, however, requires that for the purposes of planning, each State should determine the age of an older person in accordance with a thorough needs assessment. Our position is that each State should determine the age in accordance with need. Farm area residents have higher incidences of chronic disability conditions, therefore, if by lowering the age (e.g., 55) individuals would have better access to health care through transportation systems, sponsored by the Administration on Aging (AOA), we would support that action. By intervening at the beginning stages of a chronic disability there is both a cost savings and slower development of disease progression. Nebraska has determined that an older person is "55" because of certain disabling conditions and is eligible to participate in a transportation system to health facilities authorized by the State AoA agencies.

(3) The NHSC assigns health professionals to critical health manpower shortage areas (CHMSA's) rather than to medically underserved areas (MUA's). Designations of CHMSA's for the States of Iowa, Nebraska, and South Dakota are enclosed. Also enclosed are lists of areas designated as MUA's. These designations are used by the CHC and HMO programs.

The PHS NHSC scholarship program was established in 1974 and the first recipients eligible for placement were assigned this year. Twenty-two scholarship recipients have been available for placement nationally through the NHSC. The remainder of the scholarship recipients who have completed their training have been assigned through the Bureau of Health Manpower and the Indian Health Service. One scholarship recipient has been placed in Faulk County, S.Dak., through the NHSC. It is estimated that 149 scholarship recipients will be available in 1977 for placement in NHSC designated CHMSA's, and this number will continue to grow as more of the recipients complete their education. The NHSC's placement of health professionals is not limited to recipients of scholarships. In addition to the physician placed through scholarship obligations in South Dakota, three M.D.s and one nurse practitioner (N.P.) were recruited and assigned to South Dakota. Also, five M.D.s and one physician extender (P.E.) were recruited and assigned to shortage areas in Iowa. The NHSC has only the one nurse practitioner serving within the three States at the present time. She is assigned to Onida (Sully County), South Dakota, and is working with a NHSC physician. Many nurse practitioners are employed by communities, however, we do not have any statistics available on such paraprofessionals. The NHSC assignees are as follows:

Iowa: 1 M.D. in Eldora County, 1 M.D. in Lyon County, 1 P.E. in Lyon County, and 3 M.D.s in Tama County.

South Dakota 2 M.D.s in Faulk County (includes the scholarship assignee), 1 M.D. in Sully County, 1 N.P. in Sully County, and 1 M.D. in Roberts County. (4) Iowa received $45,000 for a planning grant in fiscal year 1975 under section 1202 of P.L. 93-154 (the Emergency Medical Services Systems Act of 1973). This planning project covered a population of 339,000 (253,000 rural and 86,000 urban) in the northwestern part of the State. The 1976 appropriations for P.L. 93-154 stated that if a State and/or locale had not received monies in fiscal year 1975 under either section 1203 or section 1204 those locales were ineligible for fiscal year 1976 implementation monies. The lack of funding under these sections in 1975 precluded the operational funding of this region in fiscal year 1976. It is estimated that 42,000 or 12.4 percent of the population in this region are age 65 and over.

Nebraska has received 2 years' funding for grants under section 1203 of P.L. 93-154, fiscal year 1975, $1,236,836 and fiscal year 1976, $1,547,391. These grants cover EMS regions comprising 80 percent of the State's population and 60 percent of its land area. Of the land area covered, 80 percent of the area is rural to wilderness. The rural population in this federally funded EMS region totals 443,030 of which 65,952 (14.9 percent) are over 65. Current data being obtained from EMS facilities in Nebraska reflects only time-patient loading characteristics. Age is not now being collected for usage, but a standard ambulance form will be introduced this year which will report age of utilizing patients.

*Retained in committee files.

South Dakota received $90,000 for planning grants in fiscal year 1974 under section 1202 of P.L. 93–154. Two additional grants under section 1203 have been awarded, fiscal year 1975, $556,484 and fiscal year 1976, $714,519. These two operational grants cover 100 percent of the State and its population. Ninety-two percent of the State is estimated to be rural, 21.1 percent of the population are over 65, 55 percent of the population is classified as rural and 18 percent of the population actually live on farms. It is estimated that 42,000 rural elderly have access to the Federal service programs.

(5) At the present time the names and locations of operational or developmental HMO's in the three States mentioned are:

Iowa: None.

Nebraska Community Health Care Association, Lincoln; Missouri Valley Group Health, Inc., Omaha.

South Dakota: Health Care, Inc., Mitchell; Rosebud Sioux Tribe, Rosebud ; Western South Dakota, Rapid City.

(6) HSA has not conducted a total health needs assessment for the elderly, however, our home health program has made an assessment as to those counties within your investigation area that do not have home health services. It is the intention of the Under Secretary to hold regional public meetings on the status of home health care in five cities (New York, Atlanta, Chicago, Dallas, and Los Angeles) as to the needs of the chronically disabled and the elderly.

We have also enclosed for your information a list of health service delivery projects presently being supported by programs administered by the Bureau of Community Health Services, HSA.

Copies of this correspondence are being forwarded to Holman R. Wherritt, M.D., Regional Health Administrator in our Kansas City Regional Office, and to Hilary H. Connor, M.D., Regional Health Administrator in our Denver Regional Office, so they will be aware of your interest. If they can be of further assistance to you in your field hearings, their addresses are: Holman R. Wherritt, M.D., Regional Health Administrator, Department of Health, Education, and Welfare Region VII, 601 East 12th Street, Kansas City, Mo. 64106, 816-374-3291; Hilary H. Connor, M.D., Regional Health Administrator, Department of Health, Education, and Welfare, Region VIII, 19th and Stout Streets, Denver, Colo. 80202, 303-837-4461.

If we can be of further assistance, please let us know.
Sincerely yours,

LOUIS M. HELLMAN.

ITEM 10. LETTER AND ENCLOSURES FROM JAMES B. CARDWELL, COMMISSIONER OF SOCIAL SECURITY; TO SENATOR DICK CLARK, DATED AUGUST 27, 1976

DEAR SENATOR CLARK: With further reference to your inquiry of June 23, I am enclosing some material relevant to the questions which you posed in your letter. (1) While the Social Security Administration does not officially define an area as urban or rural, we can indicate the rural status of counties by using census data (see table C). Residents of less populated areas are served by contact stations on specified days of the month. Toll-free lines are also available and district offices have a liberal policy on accepting collect telephone calls.

(2) Information for items 2(a), 2(b), and 2(c) are shown in the enclosed tables C, D, and E, respectively. While we do not know the number of beneficiaries residing in rural areas, we show in table C a breakdown of the number of beneficiaries by the rural status of the counties in which they reside. (For detailed county data on beneficiaries, see enclosed tables A and B for Iowa, Nebraska, and South Dakota.)

(3) Information for items 3(a), 3(b), 3(c), and 3(d) is shown in the enclosed table F, which summarizes information shown in the enclosed table 4, the research and statistics note No. 8, and the advance release of supplemental security income (SSI) data-March 1976. We do not have information with respect to item 3(e). We are referring your letter to the Social and Rehabilitation Service of the Department of Health, Education, and Welfare for any information which they may have with regards to this item.

(4) Information with respect to the medicare program is as follows:

(a) Tables 4.a.1-4.a4 show enrollment and utilization data for both the hospital insurance (part A) and the supplementary medical insurance (part