another minority is covered for medical contingencies by private insurance. At the other end of the income scale are the indigents whose needs are being met at the public expense (through old-age assistance, and-in some States-through the Kerr-Mills Act). In between these two groups are the majority of the older people, middle-income people who have saved throughout their lives for their old age and who have saved up enough to take care of all their ordinary, everyday expenses, but not enough to pay for the huge expenses associated with caring for the major illness. It might be said that these people should have had the foresight to purchase private medical insurance, but the fact is that they didn't, and it probably will always be true that a large proportion of the young people of the United States will not foresee themselves getting cancer or heart disease in their old age so they take out medical insurance to pay for it in the distant future. These middle class people do not need and do not want government "relief" and they do not want, nor should they be subject to, a means test. They can afford to pay for insurance, but since many of them won't think to take out voluntary insurance, universal insurance under the law is the only answer.

(2) While illness has always been associated with old age, in one sense there is a new problem here. Until around 1945, most people died of "acute" illnesses-such as pneumonia and influenza-and they were carried off quickly and cheaply. With the advances in medical science particularly the discovery of sulfa and penicillin-—the acute illnesses became readily curable, and most people survived them to eventually get one of the "chronic" illnesses, particularly cancer, heart disease, or arthritis. Now the last-named illnesses are much more expensive to treat and to care for, and few middle class people can afford to pay for several years in a hospital or nursing home, even if they have been saving diligently all of their working lives for their old age. Now it is true that only a minority of people need to pay for several years of treatment and care of cancer or heart diseaseperhaps 10 or 15 percent-but the problem is that no individual knows whether or not he is going to wind up in this minority. Thus older people today feel very insecure about the matter of medical care costs, unless they happen to be in that fortunate minority that are protected financially against any contingency. The logical solution, when any unpredictable minority of the population is going to face huge expenses that they individually cannot meet, is insurance. All individuals deposit small amounts regularly over a long period of time, and thereby build up a fund to take care of the extraordinary expenses of some of their number.

(3) This is very difficult to do by private insurance. If private medical insurance plans are going to cover the expensive illnesses of old age, they have to charge high enough fees to make it financially inadvisable for young people, who are seeking only current medical coverage for their young and growing families, to subscribe. Marion Folsom, former Secretary of Health, Education, and Welfare under President Eisenhower and now president of Eastman Kodak Co., has come out in favor of financing medical care costs for the aging by means of social security primarily for this reason. He wants to see the

private insurance companies do a more effective job of offering lowcost medical insurance for those under 65.

It is for all three of these reasons that I favor financing medical care costs by means of the social security program. As with any Government program, safeguards must be provided so that incidental abuses do not occur: There should be individual contributions to the expenditures for each illness so that the program is not overused; there needs to be some protection for those providing the services so they do not become victims of bureaucracy. In my judgment, the King-Anderson bill is a very cautious, conservative in the true sense of that term-measure that safeguards against these and other possible abuses. Finally, in terms of overall national wealth, providing for medical care costs for the aging through social security is the cheapest way in which this Nation can handle the problem: The social security system is already in operation and it is very efficient. The tax needs to be raised only slightly (one-fourth of 1 percent on both employer and employee), and an additional payment system be inaugurated. Even if private insurance could be extended to cover most people-which I said before they cannot-or if the Kerr-Mills plan were to be extended to cover all aged persons with expensive medical costs-which is also not feasible in view of the variations among the States-such efforts would be far more costly than the social security approach.

I respectfully recommend to your committee that it strongly support the King-Anderson bill as the most feasible and reasonable approach to meet the current most serious problem facing the older people of the United States. Thank you.

Senator LONG. The next statement will be by Prof. Wendell M. Swenson.

STATEMENT OF PROF. WENDELL M. SWENSON, DEPARTMENT OF CLINICAL SOCIOLOGY, UNIVERSITY OF MINNESOTA

Dr. SWENSON. Senator Long, because the hearing this afternoon is primarily related to problems of older people in nursing homes I have been asked to present a very brief statement in summary of some of the research that I have been working on, both at the University of Minnesota, and at the Mayo Clinic in the past 3 years.

This research has particularly to do with experiences of older individuals in the very latest years of their lives, particularly with attitudes toward death and their experiences and thoughts about it. Certainly the gerontic population with all its complexity and variability does have one common experience to be anticipated, death. We know the temporal aspect of life is one of the most empirically tested facts known to man. Because of this and with the cooperation of the senior citizen clubs in the Twin Cities, many of whom are represented here this afternoon, I was able to interview through questionnaire techniques about 250 individuals, primarily in the Twin Cities and all of them in the State of Minnesota regarding their general interests and attitudes, hobbies, and particularly their attitudes toward death. A checklist was developed and used in an attempt to elicit specifically whether the individuals had positive, healthy attitudes toward death,

whether they evaded the issue of death completely or whether they had specific fears toward the death experience.

The 210 subjects in this research were grouped generally into three different categories, those looking forward to death, those evading the issue of death, and those fearing it. A tabulation of the results revealed the following general breakdown of the individuals with regard particularly to their death attitudes. First of all, almost half of the group, about 45 percent, had a very healthy, positive, forward-looking attitude toward death. Almost half or 44 percent were evasive about their attitudes, indicating they preferred not to think about it, and third, and quite significant, only a very small and relatively insignificant number of individuals admitted to any particular fear of the death experience. By far the most significant relationship in the statistical aspect of this study was that religious beliefs and activities were strongly related to their death attitude, that is, people engaged in frequent religious activities or demonstrating a very fundamentalisttype religion had a positive death attitude, whereas those with little religious activity or interest either evaded reference to death or feared it. Perhaps the most significant result regarding the aspect of old age discussed here today occurred with regard to the subjects' living conditions and death attitudes. Individuals living in homes for the aged commonly looked forward very positively to the death experience, whereas individuals living with their spouse or living with other relatives tended to evade the issue of death. There was some evidence to suggest that a fear of death was found mostly among those individuals living alone outside of a rest home.

It is apparent that healthy attitudes will be seen more often in a community home for the aged situation. Group living fosters healthy attitudes toward the final years of life, and I think we should do all that is possible to encourage the development of facilities from whatever needs available to allow people to spend the later years of their life in group living arrangements. The individuals who lived alone seemed at almost every point to demonstrate the lowest level of mental health and adjustment.

Actually, no relationship between these attitudes could be determined whether they were men or women, their age, occupational status or their source of income had little or no relationship to these interests. In relation to the problem of nursing homes there seemed to be some results of this study that are particularly applicable. Individuals in these homes for the aged look forward positively to death much more than do certain noninstitutionalized gerontic people, whereas those who lived alone tended to fear the prospect of death. It is apparent, therefore, that living in solitary existence in old age is associated with a more negative or fearful concept of the later years of life, and I think one can infer from these results that older individuals living under relatively normal circumstances, that is, with husband or wife or other relatives, do not concern themselves with this problem, but those living alone, particularly, obtain a negative attitude toward death. Thank you.

Senator LONG. Thank you very much. At this point we will insert the statement of Dr. Swenson.

(The prepared statement of Dr. Swenson follows:)

PREPARED STATEMENT OF WENDELL M. SWENSON, PH. D., SECTION OF PSYCHIATRY, MAYO CLINIC, ROCHESTER, MINN.

DEATH ATTITUDES AMONG THE AGED

The gerontic population with all its complexity and variability does have one common experience to be anticipated-death. The temporal aspect of life is perhaps one of the most empirically tested scientific facts known to man. Half a century ago when death came earlier in the human race the death process was experienced mostly in a sudden or trumatic manner. Now in the middle of the 20th century death commonly comes to individuals who have long since been retired from active social participation and are physically or psychologically incapacitated. This recent development in history poses a number of rather stimulating questions-Do millions of gerontic individuals all have the same ideas concerning death? What are some of the characteristics of this "death contemplation" and does it exist in all individuals? Perhaps still more important as people grow less and less productive in our society, do they have less and less a desire to live?

In an attempt to answer these and many other related questions the writer recently set out to measure the attitudes about death of a large number of older people.

Method

The present investigation described here involves an attempt to obtain an objective measure of the death attitudes of a reasonably good cross-section of aged individuals. The procedure is described below.

1. A death attitude checklist was presented to more than 200 individuals in the State of Minnesota, all over the age of 60 years. The individuals were obtained from three separate sources: (a) homes for the aged, (b) so-called golden age clubs, and (c) a number of industries and companies employing individuals over 60 years.

2. On the basis of their responses to the checklist the subjects were divided into three rather well-defined groups-those looking forward to death positively, those avoiding any thought of death, and those fearing the death experience.

3. These derived groups were analyzed to determine the relationship, if any, between attitude toward death and certain measurable physical and social characteristics. One general assumption was made the closer the proximity of death through age, illness, loss of relatives, and so forth, the more acceptant or positive would be the individual's death attitude, that is, the more he would welcome or look forward to death.

Results

Tabulation of the results revealed the following general breakdown of the subjects with regard to their death attitudes.

1. Almost half the group (45 percent) admitted to a positive or forward-looking attitude toward death.

2. Also almost half the group (44 percent) were distinctly evasive in their attitudes, indicating they preferred not to think about death.

3. Only a small and relatively insignificant number (10 percent) admitted to having any fear of the death experience.

Specific predictions were made with regard to the relationship between attitudes toward death and age, physical condition, home living conditions, and religiosity. Using accepted statistical techniques, the significance of these relationships was determined. A brief résumé of the results follow.

By far the most significant relationship from a statistical point of view was found in the individual's religious beliefs and activities and their death attitude. People engaged in frequent religious activity or demonstrating a fundamentalist type of religion evidenced a very positive or forward-looking death attitude, whereas those with little religious activity or interest either evaded reference to death or feared it.

The second most significant relationship and perhaps the one of most importance regarding the aspect of gerontology discussed here today, occurred with regard to the subject's living conditions and death attitudes. Individuals living in homes for the aged commonly look positively toward the death experience.

Individuals living with spouse or living alone tended to evade the issue of death. There was some evidence to suggest that a fear of death was found most commonly in those individuals who lived alone outside a rest home. It is apparent from this result that "positive death attitudes" if they are to be fostered, will be seen more often in a "community home for the aged" living situation than they will in any solitary living.

The relationship between death attitude and level of education and condition of health was of much less intensity and showed only suggestive significance. The more educated subjects tended to face the problem of death-either looking forward to it or fearing it and the less educated individual tended to avoid consideration of it. There was a tendency for those individuals admitting to good health to be actively evasive in their consideration of death.

No relationship could be demonstrated between death attitudes and sex, age, occupational status, or source of income.

Discussion and implications

In relationship to the problem of nursing homes, there seemed to be some results of this study that are applicable. Individuals living in homes for the aged look forward positively to death much more than do certain noninstitutionalized gerontic people, whereas those living alone tend to fear the prospect of death. It is apparent, therefore, that living a solitary existence in old age is associated with a more negative or fearful concept of death. Fear of death then seems to be related to solitude. One can infer from these results that older individuals living under relatively normal circumstances, that is, with husband, wife or other relative do not concern themselves with the death process and, therefore, neither look forward to it nor fear it. Avoidance of death contemplations seems to be typically associated with the more normal type of social environment. It would seein, therefore, that the one recommendation regarding living conditions that can be made from this data is that older people should be counseled away from a solitary kind of existence because this apparently fosters a stronger fear of death than any other mode of living. If the individual cannot live with his spouse or relative in his own home, it is apparent that the next best environment is that of a rest home or nursing home.

Admittedly, the above study as described is a partitive aspect of human personality and attitudes. However, it does seem to contribute even though in piecemeal fashion to our knowledge of the general attitudinal development of the older individual. We must continually remind ourselves that death is truly a universal experience contemplated by all men. With the tremendous increase of individuals in the gerontic age group, this consideration of death takes on now much more important meaning than it did even a couple of decades ago. The problem is a vast and multivariate one which should demand further careful consideration of many different disciplines other than the science of psychology. Leonardo da Vinci is claimed to have stated: "While I thought that I was learning how to live, I have been learning how to die."

Senator LONG. I find that all of you are Ph. D.'s. I am sorry I neglected to mention that.

Dr. Taves, I will be grateful if you will summarize your statement, please.

STATEMENT OF DR. MARVIN J. TAVES, DEPARTMENT OF RURAL SOCIOLOGY, UNIVERSITY OF MINNESOTA, AND PRESIDENT, MIDWEST COUNCIL FOR SOCIAL RESEARCH IN AGING

Dr. TAVES. Thank you, Senator Long and members of the committee.

In my expanded statement I prefaced my remarks by pointing to the paucity of empirical information on satisfactions and dissatisfactions among residents in nursing homes and then summarized information of nursing homes, and finally closed by noting some of the types of information needed and the feasibility of obtaining such types of information.