August 5, 1970
Page 27421
LIKELY IMPACT OF PROPOSED MEDICAID CUTBACKS ON MENTALLY ILL OLDER AMERICANS
Mr. MUSKIE. Mr. President, as chairman of the Subcommittee on Health of the Elderly of the Senate Special Committee on Aging, I wish to express deep concern about section 225(a) of the
social security amendments of 1970, as passed by the House of Representatives on May 21.
The title of section 225(a) is: "Establishment of Incentives for States To Emphasize Outpatient Care Under Medicaid Programs."
If this section lived up to its name, it would be worthy of support rather than rejection. Outpatient care, after all, is usually far less expensive than institutionalization and it is more beneficial to the patient when applied appropriately.
But, in the name of economy, section 225(a) could cause serious problems for those older Americans in need of care because of chronic illness. It would put heavy economic pressure upon State government, which would – in all likelihood – be forced to lower the quality of care available to the elderly. And it would deal a crippling blow to the usefulness of medicaid for those most in need of its protection.
My colleagues from the Special Committee on Aging – Senators WILLIAMS of New Jersey, MOSS, HARTKE, and PROUTY are addressing their remarks to the potential impact of 225(a) on nursing homes, general hospitals, home health programs, and the health care for the elderly in rural areas.
My remarks will deal primarily with a proposed cutback in care for those older Americans in mental institutions. The Federal matching would be reduced by one-third after a patient has received 90 days' care; Federal funds would be completely eliminated after a patient had received 275 days of care.
This would mean an estimated loss of $500,000 for my own State of Maine. Significantly, mental health services will suffer the greatest blow – somewhere in the neighborhood of $250,000 to $300,000.
Section 225(a) simply does not take into account the special problems and needs of the elderly patient population in mental institutions.
The National Institute of Mental Health reports that in 1968 there were 775,000 persons aged 65 and over residing in institutions, or 4 percent of the total elderly population. Of these, 135,000 were in psychiatric institutions; the majority in State and county mental hospitals – 15.5 percent – and 1.6 percent in VA hospitals, and under 1 percent in private mental hospitals.
In a paper delivered before the 1970 summer institute for advanced study in gerontology at the University of Southern California this July, Dr. Richard Redick, of the biomentry branch, National Institute of Mental Health, said:
If one talks about the institutionalized aged population with mental disorders, rather than the aged population in mental institutions, then a minimum estimate of the total mentally ill aged in institutions would be 365,000 or almost half the total institutionalized population.
The National Institute of Mental Health has reported the results of studies showing that anywhere from 15 to 25 percent of elderly individuals living in their own residences also suffer from some degree of mental impairment. A minimum of 8 percent of this group are known to be severely impaired.
Mr. President, if States face a decrease in Federal matching for care of such patients in mental hospitals of 33⅓ percent after a 90-day stay, the result may very well mean a reinstatement of the backward "snakepit" treatment of the 19th century. Or State hospitals may discharge elderly patients to "alternate care" facilities on a wholesale level. And what are these "alternatives"?
Foremost among likely placement categories for elderly discharged mental patients are nursing homes. But another provision of section 225(a) limits Federal matching funds for skilled nursing care for medicaid patients to 90 days.
Medicaid patients are already being turned away by some nursing homes which cannot afford to give quality skilled nursing care at the present level of Federal support.
What is the other "alternative?" The community?
Where 62 of the l05 operating community mental health centers face a denial of Federal funds?
Where the lack of trained geriatric personnel in outpatient hospital clinics makes a mockery of such care to the older population?
Where boarding homes run by well-intentioned but untrained sponsors house sick, lonely old people?
Where mentally impaired older persons wander the streets, confused and frightened, open to mugging and attack?
A boarding home, no matter how clean, spacious and well-run, does not provide the kind of treatment which allows for continued growth and rehabilitation. Home health aides are not trained to notice, or to treat, symptoms of disturbed behavior. Such symptoms – obvious to a geriatric psychiatrist, trained nurse or a geriatric social worker – are attributed to "senility" or just old age. Thus, the patient lapses back into his old behavior and left more or less alone, his condition may worsen to the point where he returns again to the State hospital. He becomes, in effect, a body in the State hospital system – 90 days here, 90 days there – never receiving the kind of treatment and care his condition requires. Ultimately, his treatment will cost the State and Federal governments thousands of dollars.
A well thought-out, coordinated system of mental health – providing intensive treatment in the State hospital, continued care in a nursing home, home for the aged, or in the community through accessible and well-staffed mental health centers – would be a far more realistic, humane, and less costly solution to his problems than the proposed section 225 (a) cutbacks.
Mental illness experienced by older people is usually not of short duration. Mental disorders among the elderly are also often closely linked with physical illness. Moreover, limited and inadequate income makes it impossible for most older Americans to avail themselves of expensive private psychiatric services in the community. Additional difficulties such as inadequate transportation, fear and embarrassment at being treated for mental illness, and an increasingly isolated life-style, create further obstacles to community mental health care for this population group. This can be verified by the fact that even though 15 to 25 percent of older persons living in their own homes are known to be suffering from some degree of mental disorder, only 2 percent of the older population utilizes outpatient mental health facilities.
Perhaps the heading of section 225 "establishment of incentives for States to emphasize outpatient care under medicaid" – has meaning for younger persons who have the mobility and good physical health to make use of existing outpatient facilities. But, considering the facts and figures about mental illness and the elderly, it would appear that this section is misleading and I believe, punitive, for the older members of our population.
President Nixon has urged us to eliminate "outmoded and nonessential Federal programs" in order to "save" $2.5 billion during the next fiscal year by eliminating or changing programs which he called "obsolete, low priority, or in need of basic reform."
The "alternatives" which exist today to psychiatric hospitalization are clearly inadequate – and if the stipulations in the social security amendments are allowed to stand, I shudder to think of future "alternatives."
During the past 10 years, State hospitals have been actively rehabilitating patients and many have been discharged to the community. However, hospitals have experienced great difficulties in finding adequate placement for this older patient group – many of whom have completely lost family ties and friendships. The community they return to after 10 to 20 years in a State hospital is a very different place from the one they left years before. This patient needs some form of continuing care, even after he leaves the hospital.
While I agree that the medicaid program is in need of basic, constructive reform, I see section 225 (a) as a move toward retrenchment rather than reform. I do not believe we can draw an arbitrary line between long term care and intensive treatment for the elderly. Mental illness among older persons often requires long term medical and psychiatric care. And, I can hardly agree that the provision of quality mental heath care to elderly Americans is a "nonessential program." I would also question whether such care constitutes a low-priority program.
Mr. President, we must be especially careful, lest we "throw the baby out with the bath" in reforming medicaid. For if we cut back funds to States for desperately needed services without considering the effect on every segment of the population, that is exactly what we will be doing.