American Association of Homes for the Aging, March 1975
Reprinted from the Congressional Record, Proceedings and Debates
of the 94th Congress, First Session. Vol. 121, No. 57. Tuesday, April 15,
Old age is the last and most devastating segregation in our country. We are a society obsessed with youth and staying young, whose citizens and government have turned their backs on the lives and needs of the elderly.
The problems of older Americans have received much publicity in recent years. Those problems have been the focus of reform efforts by senior citizens' groups and others, including your members. Nonetheless, the problems of aging have yet to become a popular cause, like the consumer movement or the environmental movement, attracting widespread support among diverse groups of citizens and politicians.
Perhaps the reason is fear -- fear of the wasteland we have made of old age. The truth is that old age is an empty legacy for millions of Americans: it is losing your eyesight, being deprived of your mobility, and finally robbed of your human dignity.
In certain ancient tribal societies, where the chief pursuits were hunting and warfare, when a person became too old for these activities he was placed ceremonially on a raft and allowed to float down a river.
The tribal leaders assured everyone that the hapless elder was floating to a better place and a better life. No doubt many of the younger members of the tribe had secret misgivings, and some thought with apprehension about their inevitable turn on the raft.
In modern society we repeat in many symbolic ways the ritual on the river bank. We who participate in it also doubt its validity, fear its implications for ourselves, yet yield to what appears to be its necessity in the pursuit of our immediate preoccupations.
There must always be a justifying mythology when a dominant group systematically and for its self-interest disadvantages a less powerful minority. In this case, we have developed two stereotypes of the aged to justify our neglect -- serenity and senility.
On the one hand our images of old age are idealized images of the beloved and tranquil grandparents, the wise elders, the serene and gracious white-haired matriarch dispensing wisdom from the kitchen or the patriarch from the front porch rocker. On the other hand, the opposite image disparages the aged. Old age is viewed as irreversible decay, decreptitude and loss of mental powers.
A survey by the Louis Harris organization recently commissioned by the National Council on Aging found that younger people regarded the aged as an "inept, ineffectual, physically depleted group waiting for death." We see them as rigid, guerulous and resistant to change; narrow and superficial in intellectual activity; and almost universally senile.
This dual set of images and attitudes is mirrored in our public policies and programs. Our public statements speak reverentially of "senior citizens" and their needs while our public programs carry out the assumption that there is not much we can do. So, we talk of the need to meet the health and medical care needs of the aged and we design a program which leaves them to take pot luck in a medical care system designed for the young. We talk of the desirability of providing housing and living arrangements which will enable the aged to live comfortably and self-sufficiently, and we design housing programs for the elderly which will not work, so that we do not interfere with more lucrative uses of land and capital.
Let us take a more detailed look at what we have been doing and what we need to change.
THE ELDERLY AND POVERTY
The economic situation of the elderly is a desperate picture of struggle and suffering. Almost a quarter of the aged live below the official poverty line. The median income of an elderly couple is about $5,500 per year -- half that of their younger counterparts. Half of older couples cannot afford the Bureau of Labor Statistics' budget for a "modest but adequate" standard of living.
Older Americans, strapped down with fixed incomes, have been running a losing race with inflation. 80% of the income of older people goes to food, shelter, health care and transportation -- areas where price rises have in many instances exceeded the overall cost of living increase. Thus, social security and other retirement payment formulas that are adjusted annually for changes in the cost of living are only partially helpful. Their helpfulness is further diminished by the fact that they provide income increases after prices have gone up, and older people have little savings to carry them over the hump. And their helpfulness would be practically destroyed if the President's proposal to limit to 6% the adjustment for a 12.5% inflationary year were implemented.
To relieve the greatest degradations of poverty, the government must improve the Supplemental Security Income program to bring all other Americans above the poverty line. We must not plunge the elderly deeper into poverty by abandoning the automatic annual cost of living adjustment in the Social Security program. We must find and establish ways to implement a goal of adequacy for retirement income. That means drawing on a mix of Social Security, private pensions, and other sources of income, and not penalizing SSI and food stamp recipients for other earnings in ways that lock these people into permanent sub-poverty status.
NEGLECT OF THE AGING IN OUR HEALTH CARE SYSTEM
Turning to our health care system and how it accommodates the elderly. I am reminded of the story of the 94-year old gentleman who was experiencing pain in his left leg. When he went to see his physician and complained, the doctor said to him, "Well, what do you expect when you're 94 years old?" To that, the old man replied, "But doctor, my right leg is 94 years old too, and it doesn't hurt."
This story illustrates our tendency -- and this is true not only of doctors but of many of us -- to attribute to "old age" the variety of problems facing an older person without looking further.
American medicine is not attuned to the special needs of the elderly generally, and least of all to the problems of the so-called "old elderly" -- those 75 and over, with whom this organization is directly concerned.
American medicine is young people's medicine. It is oriented to diagnosing and curing acute illness. Few medical schools in this country offer even rudimentary training in geriatrics and only one has a chair of geriatric medicine.
Our health manpower legislation typically offers nothing in the way of training for health professionals in geriatrics, despite the fact that in 1973 the per capita health care costs for older Americans came to $1,062, or more than three times the amount spent for those under 65.
The national Professional Standards Review Council -- the new mechanism we have set up to rule on whether services paid for by Medicare and Medicaid are "medically necessary" and, therefore, reimbursable -- has no one on it with a background in or special knowledge of geriatrics, despite the fact that the elderly are among the neediest and greatest users of these health care programs. (It is worth noting that the Council has two obstetricians.)
Given the inattention within our health and medical establishment to the problems of aging, It is little wonder that, Medicare, a health program billed in 1965 as The Answer to the health problems of the aging was discovered recently to cover only 40 percent of the total health costs of older people.
Given our failure to examine carefully what the special needs of the elderly are, and how they can best be met, it is little wonder that we have discovered only belatedly that in many respects Medicare is remarkably unsuited to the elderly.
The widespread expressions of discontent that we hear with respect to the care of the institutionalized elderly, should tell us that it is time we asked ourselves whether the health needs of the elderly differ in such substantial ways from those of the younger population as to warrant our developing an entirely different kind of system for them.
The average hospital patient suffers from only one disease or medical problem. On the other hand the average resident of a long term care institution suffers from four chronic illnesses, and is considerably less vigorous and more frail than the hospital patient. The average hospital patient spends about seven days in the hospital -- while the resident of a long term care institution spends an average of 2.5 years in the institution.
The health care needs of the elderly are less intensive but more chronic and more continuous than those of the general population. At the same time their social needs are more intensive and acute. More often than not, the elderly are undergoing severe and acute social and emotional traumas, traumas associated with the loss of their spouse and friends, and of their physical vigor. With these losses goes the loss of their self-confidence, of their sense of importance to those around them. Since these emotional and social problems often bear upon the aged person's eating and physical habits, they may seriously affect his health and, in turn, his need for professional medical attention.
I know that the members of the American Association of Homes for the Aging have been saying for many years that Federal health programs for the aging ignore what are called the "social components of care" -- not recognizing that the aged person is a "patient" only a part of the day, and the rest of the time he is a "person" facing a raft of social and emotional problems which bear upon his health condition.
We should not delay any longer facing up to these realities and thinking through their implications, because, despite President Ford's opposition to enacting National Health Insurance in 1975, the Nation is moving inexorably toward a national health program.
If there were mistakes made with Medicare programs over how best to meet the health care needs of the elderly, then we had better think carefully about whether the direction in which we are now headed is the right one as we embark upon a program double or triple current costs.
The national health insurance proposals we have before us continue to ignore the need for a specially designed program for health and medical care of the aged. The one exception is a bill introduced by my colleague, Rep. Barber Conable, which is the first serious effort to design a health delivery system specifically for services to the aged. The bill deserves serious consideration. If National Health Insurance is not to be just a giant re-run of Medicare with all its attendant disappointments and frustrations, it must include such provisions carefully designed to meet the special needs of the aged.
One more question requires our attention: whether it is appropriate to run nursing homes on a for-profit basis. The answer, I believe, is no. The operator of a proprietary nursing home has a constant incentive to effect "efficiencies", in order to protect his profit margin, which in the end mean reductions in services to the institution's residents. It is intolerable for the government to continue to subsidize that kind of trading in the economics of misery. And as the recent investigations in New York show, the corrupting web of money flowing into the political process to keep the operators of proprietary homes plugged into State and Federal Treasuries leaves no room for half-way solutions, like tinkering with reimbursement formulas or beefing up enforcement practices. The transition from our current industry, in which 85% of nursing homes are proprietary, to a nonprofit system will require time and careful planning, but it is a goal which we must set and begin moving to implement.
NEGLECT OF THE AGED IN HOUSING PROGRAMS
For more than twenty years planners, builders, bankers and businessmen have been undertaking urban renewal and redevelopment projects in our cities. Old and deteriorated urban areas have been acquired with governmental powers of eminent domain to make way for commercial buildings, luxury apartment houses and so forth.
But who had been living in these areas? Many elderly were there along with other low-income and disadvantaged residents. They were there because they had come a generation before, when they built or bought homes in what were then modest, working class residential neighborhoods. The elderly, along with others, were offered relocation payments and an opportunity to register with the relocation agency for referral to other living units in other parts of the city.
Then the redevelopment bulldozer moved in and swept the neighborhoods away. My point is not to criticize Federal housing-projects or their sponsors. But to emphasize that the programs we supported were not directed to people and to enhancing the city as a place for people to live. Least of all were they directed to the potential of the city as a living environment for the elderly.
We have had some programs authorizing support for housing for the elderly. Section 202, the old program of ten years ago, was instrumental in creating many good apartment developments for the elderly. This program and others like it have done some good, but they have amounted to little more than tokenism. Housing and a convenient, supportive living environment for the elderly have never been an integral part of our housing and urban development strategy, and efforts by nonprofit sponsors to obtain sites and become a part of an urban development plan have rarely been successful.
Now we have the Housing and Community Development Act of 1974. This Act relates all the housing programs to a community development plan, spelling out the content of the plan and how it should be developed. As in times past, there is nothing in the Community Development title of this Act which recognizes the stake of the elderly in urban living.
After a community development plan is filed, sponsors of housing for the elderly may submit proposals to use the sites planned for redevelopment. If a sponsor of housing for the elderly is a successful competitor for a place in the redevelopment scheme and if he can obtain permanent financing, he can get temporary financing under the revised section 202 program. Now I don't need to tell this group that that is not a dramatic breakthrough.
My criticism of existing housing programs is much the same as my criticism of our health programs. The elderly take pot luck in a system designed for other purposes.
Instead, we should mandate that community development plans recognize that urban neighborhoods have special utility for accommodating the elderly. The elderly and their advocates must get actively involved in the planning process. We should subsidize the use of land and capital in the execution of community development plans, so that the social desirability of rehabilitation and construction of housing for the elderly, in neighborhoods providing convenient shopping, services, and recreational and cultural opportunities can compete with the economic advantages of commercial and luxury uses.
NEGLECT OF THE AGING IN OUR TRANSPORTATION SYSTEM
Although it might be argued that we ignore people in general in our transportation system, it certainly is true that we have totally and cruelly ignored the needs of the elderly when it comes to transportation.
Our entire transportation system -- if we can call it a "system" -- accommodates and provides for the needs of automobiles -- highways and parking lots -- but not for the needs of people -- convenience, thrift and shorter distances to walk. It offers little, very little, to the aged person who simply needs transportation assistance in getting from his home to the grocery store to downtown to visit friends.
Many elderly, particularly the old elderly, cannot drive or cannot afford automobiles on their severely limited incomes, nor do they need the great personal mobility a car provides. They must rely upon some form of public transportation.
But public transportation is still a joke in this country. While the proliferation of highways and parking lots continues to displace many elderly from their homes and destroy neighborhoods of long standing, we stand by and do nothing. Even despite the energy crisis, we have yet to begin to think seriously about the need to move away from our near-total reliance upon the private car and to begin to develop a convenient, comfortable and efficient mass transportation system.
We must begin to build the subways the railroads and the public transportation networks that are necessary to accommodate our general needs as well as those of the elderly. This is essential if we are going to reduce the serious isolation problem of older Americans, and to give them a measure of independence; rather than having to rely always upon someone else -- to ask a special favor of others -- to get where they want to go.
For whatever reasons -- our own fear of aging, or just a lack of understanding -- we have failed to embrace and include the elderly in our daily living. We ignore them. We shunt them aside. We makes jokes about them on television.
We need to reach out and bring them back into the system, into society's mainstream.
We need to nourish the belief that an individual in American society can have a social role which is not necessarily linked to economic status.
We need to develop the concept of a non-economic work force. In every community there is useful work needing to be done which is not compensated through the operations of the economic system. Work with voluntary organizations such a day care centers, the inspiration and guidance of children and youth, the monitoring of actions of public agencies and business, the support and development of the arts and the cultural life of the community, are all examples of important work which someone must do.
We must focus our inventiveness on the problem of designing a system which will give older citizens access to such community roles, encourage them to take them on, and reward their efforts with well-deserved recognition of their value to society.
We must also expand educational opportunities, to enable people who have left the work force to pursue new intellectual interests and to develop the talents which many have in these areas.
We must also recognize the great contribution older people can make to all of us as the living embodiment of our past. If we can share the experiences they have lived through, and the perspective which these experiences have given them on contemporary times, it will enrich our lives and our appreciation for our heritage and enhance the wisdom with which we confront the future.
There is no better time, and no more appropriate context, for the development of this idea, than in the forthcoming Bicentennial activities.
We should include the elderly in a major way in the Bicentennial in every community throughout the Nation.
And most important of all, we should include those in institutions, in homes for the aging and other institutional settings, in the national celebration.
If we are to stop treating old people like another class of disposable objects, which go the way of all things in our throwaway society, then our public policies and social attitudes must change. They must reflect the knowledge that aging is a normal part of the life cycle not necessarily to be dreaded; that those who have reached advanced age need and merit special attention from the society, and that given this attention, the contribution of the aged to society can enhance the quality and civility of life for us all. Those changes will come when we realize that older Americans are not just 10% of our population, but that old age is a fate which awaits us all.
by Morris K. Udall