Through all the years of the Older Americans Act and its subsequent amendments we have had the strong, steady support of this Special Committee on Aging of the U.S. Senate which has, in many ways, shown the way to legislation for new and farsighted programs and services for the elderly. I am particularly pleased and proud that our own Senator Dick Clark is now a member of this distinguished body and, I believe, this hearing is an auspicious beginning to his service on the committee.

I testified before the committee in Des Moines, Iowa, in 1969, at which time I introduced former Senator Jack Miller and the committee to the "senescity index"-a concept I believe to be particularly useful in looking at some of our age-related problems. The senescity index is a figure which represents the relative weight of the population of any given geographical area which is 65 years of age and older, modified by other age-related, and dependency-related factors as shown

below. The index is obtained by multiplying the several variables together. Below I have compared my 1970 census-based data with that presented in 1969 which was based on 1960 census information:

Thus, it would appear that the relative weight due to senescity for the State of Iowa as a whole has increased during the 10-year period. The proportion of aged, ratio of aged to those under age 5, and the number of aged per family all contributed to this increase. The lower median age had a contrary effect, but the net result was an increase.

One of the ways in which such an index is useful is to apply it to various political divisions in order to identify those subject to relatively high and relatively low senescity factors. Using the index in this manner, I first calculated the senescity index for each of Iowa's 99 counties.* I then identified the twenty counties at each end of the continuum. These are shown in table 1 and are located on the map of Iowa in figure 2. As may be seen in the table, all of the high senescity counties are far above the State index ranging from 758.28 to 2116.65. The low-senescity counties have index values which surround the State.

TABLE 1.-The 20 highest and lowest counties by senescity index

*I am grateful to Mr. Gary Miller of the Commission on the Aging staff for his help in these computations.

As was true in my previous report, the map shows that all but five of the high-senescity counties are in the southern two tiers of counties and comprise all of planning and service area 14 and most of area 15. This is essentially a rural, sparsely populated portion of Iowa. On the other hand, the low-senescity counties include all of the major urban areas of Iowa: Iowa City (Johnson County), Ames (Story County), Davenport (Scott County), Cedar Rapids (Linn County), Waterloo (Black Hawk County), Dubuque (Dubuque County), Des Moines (Polk County), Council Bluffs (Pottawattamie County), Clinton (Clinton County), Muscatine (Muscatine County), Newton (Jasper County), Marshalltown (Marshall County), and Sioux City (Woodbury County).

Some demographic characteristics of these two groups of counties are presented in table 2. These data show that in the high-senescity counties 18.3 percent of the population is 65 years of age and older, while in the low-senescity counties the comparable percentage is only 10.1.

Over half of the population of Iowa lives in the 20 low-senescity counties, and only 7.6 percent live in the high-index counties. The population projection for Iowa between 1970 and 1980 is a modest 2.4 percent gain. The low-senescity counties will gain some 7 percent, while the high-senescity counties are projected to show a median loss of 12 percent. Thus, the counties now laboring under the burden of an ever-increasing proportion of older people will continue along this route, but with less and less of a population base to support the economy. The urban areas, on the other hand, will gain in population, have increasing numbers but about the same percentage of older people.

TABLE 2.-SOME DEMOGRAPHIC CHARACTERISTICS OF HIGH AND LOW-SENESCITY COUNTIES IN IOWA

SOME INCOME AND POVERTY IMPLICATIONS

Senescity also has significant implications in the areas of family income and various indices of poverty. The median income for all Iowa families in 1970 was $8,069. In the high-senescity counties the median was $7,154, 11 percent below the State level; while in the low-senescity counties the median income of $9,665 was about 20 percent above the State median. (These and other data are presented in table 3.)

Using OEO poverty guidelines, it was found that 14.5 percent of families in the high-senescity counties were living below the poverty levels compared to 8.9 percent in the State as a whole. In the low-senescity counties only 7.6 percent of families are living below poverty levels.

The OEO has derived an index of the severity of poverty by combining the ranks of each of Iowa's 99 counties on 20 categories related to poverty. This overall index of poverty is shown for the State as a whole and for the two types of counties in table 3. Poverty in the high-senescity counties is 25 percent above the median index for the State as a whole; while the index for the low-senescity counties is over 20 percent below the State median.

The foregoing is based on 1970 census data. What the situation is in 1975 with increased levels of unemployment and highly inflated costs cannot be precisely stated. It is certain, however, that the aged, so many of whom must, perforce, live on fixed and inadequate incomes, are feeling the effects of these conditions especially keenly. As table 3 shows, in the high-senescity counties, over one-third of those over age 65 are living below the poverty level compared to the State total of 28.3 percent. Even in the low-senescity counties, 27.9 percent of the elderly are living in poverty.

TABLE 3.-COMPARISONS OF INCOME AND POVERTY CHARACTERISTICS OF HIGH- AND LOW-SENESCITY COUNTIES

The data in table 4 are fairly accurate and up-to-date estimates of the numbers of various categories of health manpower personnel now active in Iowa.

The high-senescity counties are somewhat below their fair share of physicians in relation to total population (6.2 percent to 7.6 percent), and this deficit is even more striking when taken in relation to the proportion of elderly in the population(6.2 percent to 11.2 percent) living in these counties. On the other hand, 59.8 percent of the physicians are located in the low-senescity counties where they serve only 52.1 percent of the general population, and 42.3 percent of the aged population.

A similar state of affairs exists in the instances of dentists, registered nurses, dental hygienists, and physical therapists. Licensed practical nurses are located in the two types of counties in about the right proportion in relation to the general population, and optometrists are present in a slightly reversed ratio to the general population. However, even the latter two are in short supply in the high-senescity counties.

An added feature of interest is the fact that the ratio of general practitioners to specialist physicians in high- and low-senescity counties are respectively about 2 to 1 and 1 to 2.

Thus, the elderly, who as a group are more subject to long-term, debilitating, chronic illnesses and injuries, not only find health care personnel in short supply, but they are especially so in the various specialty areas. All too frequently health care must be sought outside their home environs.

TABLE 4.-COMPARISON OF HEALTH CARE PERSONNEL IN HIGH AND LOW-SENESCITY COUNTIES

In the area of health care resources available to the aging and aged, table 5 gives the pertinent data for three categories of long-term care beds in Iowa. Two striking facts emerge from this analysis. First, Iowa is sadly deficient in skilled nursing home and extended care beds and this is especially true of high-senescity counties. In these 20 counties there are a total of only 20 beds in the face of an estimated need for 337 beds. In 18 of the 20 counties there are no skilled or extended care beds at all. By this fact the elderly are being effectively cheated out of their medicare nursing home benefits which can only be obtained in skilled nursing homes.

Second, Iowa appears also to be deficient in custodial care beds (custodial, boarding, and adult foster homes). Again, the elderly in high-senescity counties feel this deficit more than their counterparts in the low-senescity counties, where, despite a need for additional beds, the percentage of existing beds far outstrips both the general population as well as those 65 and older.

Paradoxically, Iowa appears to be oversupplied with intermediate and basic nursing home beds. This is particularly true in the high-senescity counties. In the low-senescity counties, no doubt due to the large numbers of elderly, there is a need for additional beds of these types.

TABLE 5.-COMPARISON OF LONG-TERM CARE BEDS IN HIGH- AND LOW-SENESCITY COUNTIES

This, then, is the situation in which the aging and aged of Iowa find themselves. If one looks back over the data which has been presented on the high-senescity counties, which are essentially rural areas, a gloomy picture emerges. In summary, these areas already have an overlarge proportion of the aged, they are losing population as younger people leave to move to urban areas, per capita and per family income is low, and essential services as illustrated by health care personnel and long-term care beds are lacking.