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target substance, et ceters. In the interest of time,
have you respond in writing.

Mr. CETTESHAYE. We would be glad to do so.
Senator EAGLETOS. Thank you. gentlemen.
Mr. CRUIKSHANK. Thank you.
Senator EAGLETOS. Dr. Binstock.

STATEMENT OF BOBERT H. BINSTOCK, PH. D., VISIT

OF HEALTH SERVICES, HARVARD UNIVERSITY
LIC HEALTH, AND PROFESSOR OF LAW AND POLI
UNIVERSITY

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Dr. BIXSTOCK. I hope my statement will not be

you I would like to comment specifically about a num! were just discussing.

Senator EAGLETOS. Do it any way you want. M comment.

Dr. BENSTOCK. Why do we not wait until your qu I will work in some of the specifies then.

It is truly a privilege to be here to present my vi subcommittee has earned my respect. You are not in pushing along a conventional bill with a small n dow dressing. I am confident that your aim is to that will have a substantial impact in helping ol their families who are concerned for them.

I very much share the views that you are outlini My central message to you is that drastie new a Older Americans Act are essential.

The current legislation and the pattern in whicl plemented has many positive features, but the su proach has brought it to a point of diminishing r is now at a point where it is a cruel hoax. If you ing titles with more funds, and tack on one or t titles to the present roster, you will make happy tl dustries in the field of aging. But you will do lit alleviate substantially many problems of disadvant icans. In order to have an impact on the lives strong priorities will have to be set.

In short, a bold strategic departure is needed to Americans Act from an initial phase-12 years and bureaucratic development-to a second ph solving. The objectives of the Older Aparicans A lined, Senator, in your opening statement are 1 being fulfilled. As Mr. Cruikshank pointed out, w that chart the billions, tens of billions in socials In fact in some ways it is a good thing, because we we are adding up to a quarter of the Federal buc in all the social security payments and if we dealt we have not made any progress in the last 10 yer the number of older Americans below the near think the issue of priorities would emerge. We s billion in income transfers now.

Before making a set

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care services, transportation, nutrition, leisure programs, protection
against crime, legal services, regulatory ombudsmen, and a variety
of other health care and supportive services. This process of pro-
gramatic elaboration has provided important leadership in direct-
ing attention to the issues of aging. And there is little doubt that
American society has become more time of these
Unfortunately, these strengths of the Older Americans dost
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r participation as win3 revise the act to make e there, and as long as o we not use them for ney might choose legal ge and mileage through • medicare and medicaid wonderful home health ey have skilled nursing many things to be done its. It could be very well that this is perhaps befice are interpreting the nd billions of dollars to rsing; a class action suit City's Office on Aging, the title VII nutrition program is meeting about 1 percent of the national need. Are we looking toward an appropriation of over $20 billion to fund the nutrition programs throughout the country? And tens of billions for each of the other programmatic needs? Certainly not. Yet our failure to confront the illusion that the Older Americans Act presents solutions to any of the problems on its agenda lets us ignore the challenges of making priority choices, and the challenges of looking to local priorities and resources.

A third weakness is that the bureaucratic components of the network—the public and voluntary service agencies and the universities and colleges—have quite understandably become preoccupied with sustaining and expanding the different, thinly funded program elements with which they are directly involved. Each program element has a corresponding set of bureaucratic or educational mechanisms, and each of these sets has developed its own professional organization or association. As a consequence, one finds a great deal of attention given to the apportionment of Older Americans Act funds earmarked for each of the bureaucratic domains in the network, but little, if any, attention to how a given problem confronting older persons is to be solved.

In my own State of Massachusetts, for example, we have continuing conflict among statewide associations for area agencies, for nutrition projects, for home care corporations, for senior centers, and for municipal councils on aging. Last summer this conflict became so intense, and so unrelated to older persons and their problems, that the Governor's Citizens Advisory Committee felt impelled to convene a statewide meeting at which these five State associations were charged to straighten out their bureaucratic differences and come to some settlements about their division of the territory and its resources. In Massachusetts, as elsewhere, these settlements are not made with an eye to solving the problems of older persons so much as with an eye to entrenching firmly the role of the bureaucratic components.

There are additional problems that we might discuss, but perhaps those I have already addressed are sufficient to convey my basic point-namely, that the Older Americans Act and its programs are not well structured for solving or even for making a substantial impact upon the problems of aging in our society. The legislation and its programs have been effective for some essential first-phase purposes, particularly in spelling out an agenda of issues affecting older persons. And the act's programs have been well designed for helping each Congressman and Congresswoman know how many constituents in his or her district have been served a meal or provided with some other form of assistance. It is now time, however, to address the larger issue of how, if at all, the act might help solve or have a substantial impact upon one or more problems affecting older persons.

I believe that one possible way to shift to a problem-solving orientation would be through a strategic departure-a legislative approach that eliminates the compartments separating the various tiÎled programs of the act-area planning and services, training, research gerontology centers, senior centers, and nutrition and consolidates the funds available. Each community would receive its total formula allotment of funds as at present. But, working through its area agency, each community would be required to make a priority decision for using those funds, in order to have a substantial impact upon the most extreme problem confronted by older persons in that community. The legislation would not provide restrictions as to categories of priority other than the extensive agenda of legitimate general concerns that has already been elaborated. Rather it would provide that most of the funds available, somewhere between 80 and 90 percent, be expended by each area for a priority program in accordance with its perception of the most pressing local concern related to the needs of older persons.

Senator EAGLETON. You would let this decisionmaking process be made on the community level?

Dr. BINSTOCK. Yes, indeed.

I have generally found that when people are in severe enough condition to need governmental help, and I am sure you have found this, too, they do not have much trouble sorting out their priorities, whether it is starvation, blizzards, or whatnot.

Senator EAGLETON. Let us use Boston.
Dr. BINSTOCK. All right.

Senator EAGLETON. You would send a bag of money to Boston, to the mayor and the city council of Boston. Who would receive the bag?

Dr. BINSTOCK. In this particular case, because Commissioner Fleming approved it this way, that would be to the area agency of that community, which is the mayor's Commission on Elderly Affairs.

Senator EAGLETON. That is a committee appointed by the mayor, I will take your word for it

Dr. BINSTOCK. Agency run by the mayor. He calls it the MOBMayor's Office of Older Bostonians.

Senator EAGLETON. Is it fairly representative—that is, are poor people on that, minorities and so forth?

Dr. BINSTOCK. The consumers are there for participation as window dressing, but what I am saying is, let us revise the act to make sure they make the decisions. OK? They are there, and as long as they are going through the motions, why do we not use them for genuine decisions? In some communities they might choose legal services, figuring that is the way to get leverage and mileage through class action suits.

Let me give you a concrete example. Under medicare and medicaid you cannot really get reimbursed for these wonderful home health services we are all talking about, unless they have skilled nursing components in them. Yet there are a great many things to be done that do not require skilled nursing components. It could be very well through legal challenge that we might find that this is perhaps because of the way people in Mr. Califano's office are interpreting the legislation, and we could open up billions and billions of dollars to home visits that would not involve skilled nursing; a class action suit would be good.

Senator EAGLETON. I hate to interrupt you, but let us assume by some formula-let us assume it is going to be $50 million that is going to Boston.

Dr. BINSTOCK. Right.

Senator EAGLETON. Do we give any guidelines as to how that should be spent? Do we have a nonbinding, but a statement of purpose saying to help America's senior citizens, to help their health, their nutrition, their transportation? Do we have at least certain objectives?

Dr. BINSTOCK. I would take the ones you have legitimated through various transformations of the Older Americans Act. Say it has to be one of those objectives, but spend it on the one you think is your problem.

Senator EAGLETON. On the statements of purpose I will put the statements of purpose in the record. I think this is not an exhaustive list but here are statements of purpose out of title III. We have model projects, and they have a bunch of statements of purpose. Title III: Transportation, in-home service-homemaker service legal services and counseling; residential repair; assist in meeting special housing needs of the elderly; provide continuing education for the elderly; provide free retirement education services; provide services to meet the needs of physically, mentally impaired elderly; meet the special needs of low-income, limited English-speaking elderly; and develop and establish day care centers for the elderly.

I am sure if I look around I can find several more statements of purpose. Let us suppose we put all of those together. Woodrow Wilson had 14 points. Let us assume we narrowed it down to 14, and say—all right, Boston, the mayor's Council on the Elderly, you have $10 million, $30 million, whatever you want within reason. Let us say a pretty nice piece of change. You have a go at it and given these statements of purpose, it is up to you. Is that about, in rough form, how you do it?

Dr. BINSTOCK. I would, and I will tell you why. Because if I picked it or you picked it, and we narrowed down that list, and I would have no trouble telling you what my No. 1 priority would be

Senator EAGLETON. What would it be?

Dr. BINSTOCK. My No. 1, if it were not legal services because of the multiplier effect of class action, would be very specific things to help supplement the family's desire to take care of its older relatives, such as day boarding services, housekeeping services, somebody to mind mom or dad while you are out earning a paycheck that keeps the roof over your head.

Senator EAGLETON. You would realize that reasonable people disagree. I like the nutrition program. You like that program.

Dr. BINSTOCK. Right. It may very well be that in a rural community what I am talking about would be impossible, and in an urban area they may find that the most important thing to do.

There is no way somebody sitting here in Washington should tell the 80,000 governments that we have in this country how to do it, and say we are going to administer from here a comprehensive coordinated system, coordinating 80,000 governments. That is absurd. All right, if we are putting out the money, and nobody wants to be

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