I have long believed that America possesses no greater responsibility than the assurance of quality health care to all citizens regardless of age or income. No group in our society is more dependent on our commitment to this responsibility than the elderly, as the following statistics will bear out: Over 80% of all older Americans have at least one chronic health condition. The most frequently reported chronic conditions include arthritis (44%), hypertension (39%), heart conditions (27%), visual impairments (12%), and diabetes (8%). The elderly use health care services at a significantly higher rate than the rest of the population. Persons over 65 use hospitals 2.8 times the rate of those under 65, and their hospital stays are nearly twice as long. People over the age of 65 visit their doctor an average of 4.5 times a year, whereas persons under 65 average 2.4 visits.

An important step toward fulfillment of that responsibility was the enactment of the Medicare and Medicaid legislation in 1965. With the creation of these programs, Congress established a sacred covenant with the American people-access to quality care shall not be limited by wealth or age.

Although there is little doubt that Americas elderly have benefited from the vitally important Medicare program, there are problems. Expenditures by the elderly for health care have increased from 16% of their individual income in 1970 to nearly 20% in 1984. With this increase, average health care costs for elderly Americans have now returned to the same relative level as in 1965, when Medicare was enacted.

In addition, many essential health services are not covered by Medicare and are either only partially covered or not covered by Medicaid, as well. These services include the cost of drugs, eye examinations and eyeglasses, essential home health services and nursing care, foot care, routine physical examinations, and dental care.

And while the cost of services not covered by Medicare and Medicaid has increased and existing benefits are being reduced, we also know access to health care is being denied to many who need it. Government estimates show that 1 of every 10 Americans is without health insurance. The poor are two to three times more likely to be uninsured as the rest of the population.

Clearly we face a difficult challenge. We must maintain and improve the quality and range of health care services available to our Nations elderly while at the same time working to reduce spiraling health care costs. It is a challenge that can and must be met through our joint efforts. The elderly must be assured of our continuing commitment to providing them the quality health care they rightfully deserve.

We in the Congress are always looking for ways of cutting health care costs without jeopardizing quality of care. In scrutinizing our societies health care program for older Americans, many experts point out that it has from its inception been biased toward acute, institutional care.

The United Sates is spending well over $25 billion each year for nursing home care, roughly eight times the amount we spend for home care and support services. This institutional care is costly in both financial and human terms. An important goal of a good health program, one that seeks to provide a high quality of services at the most reasonable cost, is to maintain senior citizens in their communities and in their homes as long as is appropriately possible. Long-term care institutions should be the option of last resort.

A very high percentage of our oldest citizens are women who live alone. Approximately half of the non-institutionalized women in the United Sates live alone. Approximately 25% of women over 65 are currently in nursing homes, and this number is likely to double by the year 2000.

Many of these older individuals have to be institutionalized when they develop functional limitations that may threaten their health and safety if they do not have immediate contact with neighbors and health and emergency services.

Personal Emergency Response Services
We can improve our health care system by reducing unnecessary institutionalization and improving the elderly access to emergency assistance. An idea that has been proven to do this as well as to reduce ever-increasing health care costs is the personal emergency response system. To this end, I introduced legislation in 1985 that would be the first step toward making such a system available through the Medicare program.

The emergency response system allows the very frail and often the most vulnerable in our society to remain in their homes and communities by putting them in 24-hr contact with medical professionals and emergency services.

What are emergency response services?

An emergency response system has three basic components: first, electronic communication equipment in the home which automatically signals for help over existing telephone lines (the elderly person wears a monitor for this equipment) second, a 24-hour response center to receive the incoming alarms and send help when required and third, local emergency response organizations such as visiting nurses, police and emergency services, or individuals chosen by the user who agree to respond to specific calls for help.

The emergency response system, in the most basic terms, works as follows. A person in need of help at home presses the personal monitor he or she is wearing, activating the emergency base system at a hospital, health center, or comparable facility. The system base station then calls the person to determine the nature of the problem. If no response is received, a neighbor with a key to the dwelling is called, as well as the appropriate emergency response services. The emergency response will occur within minutes.

Each day the participating elderly person checks in with the base station. If the participant doesn't check in within a definite time, usually 12 or 24 hours, the system is automatically activated in order to make sure the person is still able to respond. Thus, he or she is always within contact of the base station in his or her home, even if unable to physically reach a telephone.

A study by the National Center for Health Services Research found that those elderly persons using personal emergency response systems: (1) required one day in a nursing home for every 13 needed by those not employing the system (2) experienced a much lower rate of emergencies-roughly one-half that of those not using the system and (3) felt much more comfortable living alone and more confident about continuing to live independently.

For the one-third of the population classified as severely functionally impaired and not socially isolated, each dollar spent for the use of an emergency response system produced a net savings of $7.19 in total long-term care costs, because of reduced use of institutionalization and community care.

Several studies have been reported. One study evaluated the emergency response system in California. It was primarily interested in behavioral responses. The leading reasons for using the emergency response system were falls and chest pains. Families felt less burdened, and recipients who were not socially isolated had improved feelings of security and control of their environment and reduced helplessness. No experimental trial of efficiency was done.

Sate and federal funding for emergency response systems has been obtained in nine states through section 2176 Medicaid waivers. The average cost is $25-$30 a month. In four states, local funding has been used. The Older Americans Act Title 11 program has also spent about $1 million on this service.

Most of the state and community reports are very favorable. Regrettably, there has been no good scientific evaluation of emergency response systems since the original NCHSR study. Other types of emergency response systems are being marketed. There is a perceived need for an emergency response system, especially for the frail elderly living alone. The systems will continue to expand and will have to be paid for-whether by Medicare, Medicaid, state agencies, Older Americans Act funds, voluntary organizations, or individuals and their families.

There is a critical need for scientific evaluation of these systems. There is a very real probability that the system will be of substantial health and social benefit to frail elderly and possibly reduce institutionalization. A very limited evaluation is being proposed as part of the social health maintenance organization (SHMO) demonstration, but this will not evaluate such a system's efficiency in the community. The bill establishing this service I introduced in 1985, H.R. 1223, died in committee. I will introduce a similar bill in the 1987 session of Congress, which will provide for a good scientific evaluation of both the costs and health benefits of emergency response systems. The results of the study will provide a sound basis for the selection of individuals who will benefit from the use of such systems, the cost per patient, and the rationale for future implementation of the program. It currently enjoys the support of members of Congress.

It has been estimated that 40% of all nursing home admissions could be avoided if proper services were available in the home and community. For the psychological and financial gains this could bring if it were accomplished, I believe we need to put a high priority on the testing of emergency response systems.

We must look beyond the acute, institutional bias of our current programs to the availability of preventive services and community and home-based care. We must not only maintain our commitment to the poor and elderly by defending Medicare and Medicaid-we must find ways to make these essential programs better.

America is one of the richest nations on earth. It is only fitting that we devise a way to completely and equitably provide health care for our citizens.