May 30, 1973
Page 17286
MAINE TESTIMONY: HEALTH CARE BARRIERS TO OLDER AMERICANS
Mr. MUSKIE. Mr. President, in March, the Subcommittee on Health of the Elderly of the Special Committee on Aging began hearings on "Barriers to Health Care for Older Americans." As chairman of the subcommittee, I was very much impressed by the testimony given on national issues at our first set of hearings, March 6 and 7. We heard excellent arguments, in particular, against the administration proposals to increase the coinsurance and deductibles paid by medicare participants. All in all, the initial testimony provided an excellent foundation for additional hearings to be held in Washington, D.C., and in the field.
To continue the inquiry, the subcommittee heard from witnesses in Livermore Falls, Maine, on April 23. This field hearing was especially valuable, because it provided excellent, firsthand testimony on health care issues at the grassroots level.
First, the hearing gave us facts on the imaginative efforts being made to improve health care for the elderly in west-central Maine through Project Independence. Funded by the Administration on Aging, this project provides services to the elderly on an areawide basis. It offers transportation, outreach services, information and referral, health screening, and home care. In less than a year of operation, the project has provided 57,200 units of service for 8,000 different individuals, or 43 percent of the total population over age 65 in Androscoggin, Franklin, and Oxford Counties.
Mr. Richard Michaud, director of Community Services for the State of Maine, testified that Project Independence has a direct relationship to medical services:
Project Independence addresses itself to reducing the three most important barriers to health care.
They are: lack of information, lack of transportation, and lack of money.
The objective of Project Independence is to increase the accessibility of older persons in the area to health-related services: (1) through linking older persons to available health services, and (2) through establishment and expansion of low-cost alternatives to high cost and often unnecessary services such as hospital and nursing homes.
Project Independence did not spring up overnight. Mr. Daniel V. Lowe, vice president of the project's Executive Council, explained that the groundwork was laid before the White House Conference on Aging of 1971; regional task forces in Maine had been organized before that conference and each had identified major needs. The Task Force that led to Project Independence actually began its work in 1969, and it has done its work well. At the heart of its success is what Mr. Harold Collins, now serving as coordinator for Project Independence, describes as cooperation and coordination. He explained:
Each senior center throughout this area is linked through representatives of the TriCounty areawide Task Force ... In each county we have many senior centers scattered over the area. These do include large towns, small towns, and the cities ... To effectively reach all centers and areas, a county organization representing every center is needed.
Thus, we formed a Council, a county senior citizen advisory council.
Furthermore, Project Independence does not try to do the job alone. It works closely with the Androscoggin County Home Health Services, the Tri-County Health Planning Agency, health and welfare offices, the Rural Health Associates and other programs directed through Mr. Michaud's office.
We received additional testimony from project representatives including a bus driver, a homemaker, and a physician who has given his active encouragement to the project. I will not give excerpts from their testimony here, but I urge that those elsewhere in the Nation who wish to have a model for similar action in their regions request the transcript of our hearing. I believe that they will find it rich in information and ideas that can and should be applied elsewhere.
The hearing was also valuable because it provided excellent testimony on current health issues of considerable importance to the Committee on Aging, and to the Congress.
Dr Dean H. Fisher, Commissioner of Health and Welfare for, Maine, warned, for example, that the threatened dismantlement of the Hill-Burton program can cause wasteful disruption of plans long in the making. He used the situation in Houston, Maine, as an example–
Two, and perhaps three, small hospitals are willing to merge. Community plans are agreed upon and complete. However, they will need $6 million for a new physical plant. Without Hill-Burton funds, or interest subsidy, they now need to borrow about $5 million in the open market. This means some $200,000 per year of interest charges, and another $250,000 per year of debt retirement. The facility might expect to provide some 30,000 patient days of care per year. This means some $15 per patient day for 20 years for interest and debt retirement alone. In the long run Titles XVIII (Medicare) and XIX (Medicaid) will be paying for half of it.
Dr. Richard Chamberlin, member of the Executive Board of the Maine Medical Association, warned against inappropriate use of scarce health care facilities, and he called for effective review of utilization patterns.
A vigorous presentation was also made by representatives of the State Council of Older Persons.
Mr. Jack Libby, president, was concerned, in particular, about the costs of prescription drugs. He said:
This buying medicine or prescription drugs is the roadblock to happiness for too many people. Their income, although adequate to keep them afloat while they are well and able to live without drugs, seems to evaporate so quickly when they start doing business with a pharmacist.
Mr. President, the testimony by Mr. Libby and all the others was especially valuable to a Senator from Maine, but I believe that it has much to offer anyone else concerned about the many health care problems facing older Americans. I commend the transcript of the Livermore Falls hearing to their attention.
Mr. President, I also ask unanimous consent to have printed in the RECORD the opening remarks I made at that hearing.
There being no objection, the remarks were ordered to be printed in the RECORD, as follows:
BARRIERS TO HEALTH CARE FOR OLDER AMERICANS
Today the Senate Subcommittee on Health of the Elderly has come to Maine to continue its inquiry into "Barriers to Health Care for Older Americans."
Our proceedings will be published. They will become part of a record of hearings which will be extended into other States and which will continue in Washington, D.C.
At our first hearings last month in Washington, we heard from witnesses who told us quite bluntly that for many older Americans, barriers to health care are formidable and often insurmountable.
They told us that health care costs are too high for the budgets of many older persons.
They told us that health care is often unavailable or too far away for elderly residents of cities or remote rural areas alike.
And they told us that Medicare, essential and welcome as it may be, is far, far from adequate.
On the matter of health care cost, I have an announcement to make.
In preparation for this hearing, I wanted to know how much older Americans pay out of their own pockets for medical care, as compared to what they were paying before Medicare went into effect almost 7 years ago.
The answer to that question disturbs me very much.
New tabulations, to be officially announced next month, show that for fiscal year 1972 the average out-of-pocket expenditure by the elderly for health care was $276 per person.
That figure is $42 more than the average elderly person paid in 1966, before Medicare paid any of their health costs.
These figures confirm what many elderly know from personal experience – that health care costs generally are rising faster than they can keep up with.
It is no secret that out-of-hospital prescription drugs for persons of age 65 and up average about $86 a year, almost three times higher than for younger people.
It is no secret that nursing home costs continue to rise, and that in many cases Medicare and Medicaid are far from sufficient to meet those costs.
And it is certainly no secret – certainly not to older Americans – that Medicare pays only about 42 percent of all health care costs of persons of age 65 and over.
Yes, Medicare has its shortcomings; and in some cases they are tragic shortcomings. I believe that Medicare must be improved.
Unfortunately, most of the recent discussion about changing Medicare has centered around proposals which I believe would make Medicare less effective.
I'm referring to the Administration proposal to increase the charges that Medicare participants must pay.
As things stand now, an elderly person pays $72 when he enters a hospital under Part A of Medicare. He then pays nothing until the 61st day, and even then only $18 a day until the 90th day. The Administration wants the elderly to pay more. Under the plan advanced by the President in his budget message, a patient would pay the first day's hospital charge – whether it was $40, $90 or $150 – and then 10 percent of each following day's charges. For instance, a stay in the hospital of 21 days now costs the Medicare patient $72. Under the Administration proposal, the same stay might cost about $330 in a typical case, a 358 percent increase.
That's not all that the Administration wants to do to Medicare.
They also want to increase costs under Part B, which pays for physicians' services.
Today, a person pays the first $60 of his doctor's bill, and 20 percent of the rest of the bill. The Administration wants to raise the $60 to $85 and the 20 percent to 25 percent.
How does the Administration attempt to justify its proposal? It says that increased fees will reduce what they call "over-utilization."
I have yet to meet any person – young or old – who goes to a hospital or to a physician's waiting-room for fun.
I have yet to meet any persons – young or old – who shop around for the least expensive hospital; they go where the physician tells them to go, when he tells them to go.
This Subcommittee dealt with these Administration proposals in its first set of hearings in Washington. Our witnesses and our record built what I believe is a solid case against the proposals. I have spoken against the Administration plan on the Senate floor, and so have other Senators, Republican as well as Democratic. All in all, the Administration proposals, are unpopular, and I would be very much surprised if they got anywhere.
I would expect instead that Congress will gradually attempt to improve Medicare by adding to, not subtracting from, its coverage.
Surely one of the first of those improvements would be to include some out-ofhospital prescription drugs under Medicare. I expect to see some progress in this area during this Congress.
But Medicare is in some ways the victim of shortcomings in the health care system of this Nation. We must, therefore, turn our attention to the context in which Medicare must operate: the system itself. To citizens of Maine, the deficiencies of that system are obvious. I'd like to give you a few excerpts from their mail.
A Fryeburg woman, for example, said that Project Independence is critical to senior citizens in her county. She wrote: "There are a lot of our Senior Citizens who do not have cars and have to depend on the minibus to take them to the doctors (or to the store).
Illustrating further the problem of health care delivery in rural Maine, a physician in Union, wrote in a recent letter to me: "The people in the country do not understand Medicare ... Added to that, most hospitals present to them unitemized, confusing bills which the patients are not sure whether or not they should pay. And many elderly patients in the rural areas do not have telephones ... which confuses the matter even more."
Another evaluation of certain defects in the system was powerfully expressed right here in Maine as part of the Report of the Governor's Committee on Aging in August 1970. I'll read that paragraph to you now:
"The range of health services for older persons is inadequate since some elements are available only in certain parts of the State, while other elements are misused or overused. Today group care facilities cannot provide the level of service demanded of them, while general hospitals are overburdened, and home health care is drastically insufficient. The question of the quality of service and the high cost of drugs complicates problems throughout the entire range of health services. One of the most persistent, yet difficult to verify, complaints of the task forces was poor quality care, especially in group care facilities."
The "task forces" to which that excerpt referred, of course, were the groups of citizens who worked so long and so hard in 1970 and 1971 to prepare Maine for its role in the White House Conference on Aging almost 16 months ago.
In other States, the task forces met, made their recommendations, and then disappeared from the scene. But in Maine the task forces not only stayed alive; they are apparently flourishing. They are working to make their recommendations become realities.
And it is largely because of this strong, grassroots structure that we are here in Livermore Falls, today.
One of our primary purposes is to receive direct, firsthand testimony about the work done over the past year by Project Independence, which serves thousands of persons in Androscoggin, Oxford, and Franklin Counties.
The project draws its strength from what might be called organized neighborliness – people who care about people and who work for people.
I am especially interested in the Project because it clearly demonstrates that health services can't exist in a vacuum. They must be related to other programs, and they must draw strength from the, insistence of the citizenry that no person, no matter what the age, can be forgotten or even denied the help needed to live at home independently, unless institutional help is absolutely necessary.
And so Project Independence has developed its five components – Health, Nutrition, Transportation, Information and Referral, and Recreation – for a 3-county area in a coordinated effort to provide services that make sense.
I'm especially interested in the fact that the major source of Federal funding for Project Independence comes from the Older Americans Act. And I'm happy to report that both Houses of Congress acted last week to broaden and extend that Act. I hope to say more about this as the hearings proceed. I will say no more about Project Independence, however, because our first panel of witnesses are admirably able to tell that story.
Other witnesses will tell us of statewide issues and proposals for improvement. And we will conclude by hearing from leaders of SCOOP, the State Council of Older Persons, now – I understand – about 5,000 members strong.
It is good to be here today in Maine talking to neighbors about matters of concern to the Senate Committee on Aging and to all citizens of this Nation.