OF
                                            R      .1 0   p 0            D 0 rC, @l
                                                         Tf---S
                                   -file


                                                      fk PEPOF?'F !)Ir.@Plr,,P'D FO'?

                                                                                     liEP@LTII
                                             'fli- pSSISTP..!-!T



























                                                                                                     APRIL 5, 1973







                                                                                           AC I-\'I IO If LEDG'[-i'.!ifL7 t@TS






                                                                                   o aci,iio,..,,Iedge -lie important contributio@,is
                                    The l,iloi-k, Group t.,,islies t

                                    of several persons.

                                    Elvin Ilil                  Office of the Adriinistrcitoi,, IISI,IHA, @.,,oi,,@ed clos.-l@,
                                    wi tli    the uroup throughout                               study and .,,,as of                invaluable  assis!@,,-rce.
                                        i,ti-,it  Elden,  Co:-,,.-,,,@uiilty  Health  Service,                                    provici                 -sta!i,li ng
                                    lla                                                                                                        ed out
                                    typing        and secretarial support. iic@ael Street, Office of tl-ie
                                    Regional   Ilealth  Director,  Region                               X,   gave  substcintial   assistance  on
                                                                                               -I'  -Lhe  study.     Gc
                                                                 -i-fi:@e  porr-ioll  o                                        -,oroe  Scl,-o@-rhors+
                                    the  ll,cgional  0
                                    national   Center  for  Toxicolocical   Resecii-cli,  FD,@,  prepared  higli'y
                                    professional   visual  aides  on  extreirely  Short  notice.     In  addi+Llioii,
                                    rK, a   II a.;!iri c, a                                           'fice  of  the  Ad,-iiinisti,,-)@ot,,  I'S'.'!13
                                        y                    tid Dorothy Trol.':,-i-, O.i                                                             L          I
                                    and     fifth  Vicker%,,  Center  for  Disease  Control,  HSI"Ii..fk,  carried  out

                                    numerous  essential   tasks  for  the  ',,,fort,  Group.








                                                         TA['ILE OF  CO,@ l@l'E ;T S






                       I       Study Perspective               .................................
                                                                                                       5
                       II.     Study Findit,igs          .......................................
                                                                                                     26
                       III.    Recom;iiendations       ....................         ............
                                                                                                     47
                       IV.     Next Steps              .........................................

                       A pendix A. Perso?)s,Ititerv,ic,@..,ed Dui@ing   study Of
                        p                                                                            52
                                      [lSt.',HA Proclraris and Oi-canizatioll     ...............

                                                                                                     56
                                                  1@,tiA Oi-(,,,inization      ....................
                       Appendix B.    Current HS,t

                                                 of
                       Appendix C.    Ai 'ys
                                                                                                     57
                                      Altern,itiv.es          ..................................







                                                          @CT.1 V@L
                                               STUDF    Str r_

                                                                           -d by
                      On February 21', 1973, aspecial %@iorl, group ,,as conven@
                      the Assistant Secretary for Health %,,,Iio delivered the

                      follc),,@iii,,g charg-.:

                       ... undertake a broid-revic-@-i of HS,@@'i,@A's programs and
                      organization, and their interrelationships i@iitli the

                      other health agencies.


                       ... submit to the Secretary, by April 15, 1973, an
                      organization plan %,ihicii iiill-

                           (1) reflect recent and projected changes in
                                  programs ctd[iiiilislc-red by

                           (2) be designed to help achieve the Depar'Lnient's
                              goals in-the field of health services Keith
                              maximum managem-Int-effectiveness and

                              efficiency."


                      1.   EXTE14SIVE It,%!T!-TRV-,-E';S CO','Di-'CTED.
                           Also explicit in the c!iarge i-ias the desire to achieve broad
                           input into the study through extensive interviewers.  During
                           the course of the st@dy, ri-,,.)re than 80 officials and
                           staff inside and outside [IS@'.'ilLIJA @,iere interviewed b,./ the
                           task force.  The list of intervieiiees is stio,.,in in

                           Appendix A.







                                                                                          -D  T[I'z BASIS
                                      p@, p P.@
                           2    TI iE     OPDTI@,T!7                       i[7AI-TH PROVID"-,
                                          0                      -,.!-')'S 1  S

                            -.---Ttie ap[)ropria'L-.c-   federal role    in health has been sur@.rnarized    in

                                recent s4L,.ateii,,eg@s by SecrL-@LFry Weiiil)-,,rger  and  Uno.-r Secretary

                                Ca'rl LICCI   Tiii s role is:


                                 1    F ii Et n c i ti,,i, o f H e a I t li S.-i-vices   to   reduce   financial

                                    barriers ,affecting access to health care.

                                    The   current    vehicles  for accoriplisiiii,,g this are

                                    Irlil-d-icare and 1',!,r-,dicaid. A, iriore comprehensive

                                    approach to na@Lional health insurance is

                                    I i I,,ely.


                                                             r)                   'es
                                 2    I   t h a. r -i I,, - cl 4

                                                                                 4 gll
                                    broad nzitic,.ial benefits but      whose  hi         investment

                                                     difficult for      the   private   sector   or
                                    costs.nial,,e it

                                      -ate and local govert,@,,.@-rts   to-m@lle an adeqL,,ete
                                    S'L.

                                    annual investment.


                                    Preventive              and C@,i--Isiipler P)-,-)'L-ecti-n
                                                                                           dctiv4ities

                                    that can be achieved bC!S'- till'OLIO'
                                                                           _,,I collective action,

                                    SLIcii as reguiai-lion of. t@ie  manufacture   and   sale    of

                                                                             -s; and  pie,.icr,4tlve
                                    foc,ds, drugs  and t,,iedicF.'l  product

                                    health and sa-l@e-ty activities, such as the coi-itrol of

                                    colli-im.Linicabl,, diseases.


                              -(4)  1-im-@i-ted-l'echn-ical  Assis+larice  and  SD@,cial  S'L-art-Up

                                                                                       cl,
                                    Fun.Iiii,q for                  of             @@             I'll
     I*

       k




                               the'system, to introduce new types of facilities or
                               P,,,anpo,.,;er, or to dc-i-,@oiis'L-Irate near 't-,,?pns ol delivery
                                                                j


                               systems.

                          (5)  ti,,2altli i.-il-@,n@jcl@,.,,,2r Education Proqr;',,,-,,-.s as part oi' a
                               general educational initiative that will place
                               principal reliance for accomplishing this role  on
                               the institutions of higher education with  Federal
                               support throuch general student assistance programs
                               administered by the Office  of  Education.  Limited
                               Federal assistance riiy be needed to overco-,,e
                               especially difficult supply and geographic  distri
                               bUtion problems, or to dentonsti-,@tr-, @Ltip validity of
                               now types oi' health professionals.

                           (6) DirecL- Provision of @ll--,alth Care Only as a Last Resor'L.
                               Tlie Federal gov-ern..-@,e.nt's responsibilities to provide
                               health and medical services directly +o certain poplila-
                               tion'groups, such as reservation Indiaiis and -;..erchan'L.
                               seamen, %.,,ill continue until these groups are provided

                                                    04-
                               for adequately under  Llier mechanisms.

                       3.  T[iE STUDY @iAD TO BE      @iLED BEYO@'D JUST Til,--- @1,E,,,LT[i SECTOI,.,,
                           OF D@
                           With the study requirements to reflect actua.1 and rrojec@.,-d
                                                                              r
                           pi-ogi,arii Chances and achieve the Departnient's goals in the
                           field of health services with maximum management effectiv@-




                            ness and efficiency, the scope    of the study could   not be
                            limited to program--,         the .1,1111, FP;k, and HS',"-.1k. l,'ia i or
                            decisions have been made by.the    Administration tfia@z have,
                            Widespread im@,act ,-ind iitiplicitions bo,,,ond the present
                            health services organizatio,,ial,structure.  Therefore the
                            issues identified and roccrr,,-ii-.nda+.ions developed cut across

                            agency lines.






                                                                           STUDY  Fi@',DIt.,"-)S
                               The-findings         in this  study fall  into  three general  categories:
                               those  impacting health services across  ageiiry lines;  t'liose

                                              -ith  the hS!,i;
                               (leal i  ng  @,i                lil@ organization  as  presently structured
                               and        those pertaining to regional  operations.

                                                                                          17
                                       H L17ALTII                                          D TO    l)@- -@E"ff7LO@'D @ilo
                                                                          T  X'F 0    A         L  !I:           -1@ i
                                       ADtllf,'ISTERED               CC;'
                                       Medicare     and I-led-icaid     togejl-, li e.i, represent  the  largest
                                       sinole     Federal     influence     oil     the natioi-@'s  health care
                                       delivery       system.       Together       they pay    for     almost     one
                                       third   of      the      inpatient      hospital bills  in the U.S.
                                       Expenditures     for     these      progra,-il,@ are estimated at
                                       $17.4    billion    in     1974,     or     almost       of the HEI,,L     heal '-Llh
                                       budget.   Because of their uncontrollable  nature,                           outlays
                                       for health financing and  their  share of Federal                          health

                                       outlays can be expected  to increase.

                                       An important factor in the rapid  r-i--zp-  in health ca@.-e
                                       expenditures        is    the    failure     to     achieve     changes     in -L-1-ie
                                       supply and organization of health services  that are
                                       consistent     iiitli     tile     increased      demand      gp-iie,-B-Led-by the
                                                       -y of fi,tiaticirg.         -P;ccLuse
                                       availabili4t,                                           of     tile     impact
                                       financing progr-.iis  have  had oil  inflation  in health car,,'
                                       costs,    new    methods    are    being    d@vised     to     at@Leript     to
                                       uti-lizb Federal  financing  pro!-,rati-is  to contain  these rising.
                                       costs.       In line @..,ith  these efforts,                                      4ion







                                                     op.-is and i.;icf@iciencies of
                           needs to be paid to probl
                           providers and to financing Decisions that affect
                           provider activities and  costs.  In  addition,  plans  and
                           programs that affect the financing of health services need
                           to be integrally related to activities aimed at the
                           development and modification of systei.-is of health  care

                           delivery resources.

                           Currently, the major Federal health   financing programs are
                                                                          he substantive
                           operated by agencies @,,,hose concei@iis are not t
                           issues of financing insurance programs' ir,,ipact upon health
                           care delivery, but rather managing large scale     payment
                           programs and  determining  eligibility  of  beneficiaries.
                           Although some HSt'HA programers are attC,-,Dting to capture third
                           party reimbursement for -services, and  have provided professional
                           advice regarding standards for participation in financing
                           programs, the health agencies of 11,El@.1 have not been in a
                           -Posltioli to significaii+.I,J, affluence Medicaid and Medicare.
                           14orcover, the Assistant Secretary foi,@Heal@Llh, even Keith
                           nominal "policy guidance" responsibility for health financing,
                           has not been able to affect the financing programs in an

                           appreciable .@iay.

                           The effect of a broad national lic-al@Lh iisLir,@nce -program
                           upon                        -,ire delli,@er@y systen'
                                 the nation's health c                      @,,,i I be

                                                     t.1,;, t
                                                          of 1.1.14
                           even  more profound than             'lil-@iid end




                           It is critically important that the present and future
                           health financing. programs be integrated       other

                                                'ties.
                           Federal health activi

                               following are exl,-,Iples of the integral relationships
                           The
                           beti,,,een future health activities and the financing
                           programs that can be achieved most successfully through
                           single leadership:
                               The benefit package for national health insurance
                               Sliould be designed i@iith a vice to@,iard medical
                               necessity and efficacy of services covered rather
                               than their similarity to other insurance plans.
                               The continuing Supply and distribution of health
                               care resources need to be integrated %,,rith the
                               demands for services Generated through financing.
                               The development and administration of national
                               health insurance si-iould embody the experience
                               gained from I!iedical-e, Medicaid       and ','IH
                                                                     Of CCt4VitieS
                               bionledical,researci-, in a viliole range
                               such as treatments for specific diseases, and

                               efficacy of giedical care.
                               The determination of @-ihcit constitutes the essential
                               mental health servic-es to be covered under national
                               health insurance should be i)as(,d On the expertise

                               of NII,'ili.




                              The effective development of preventive health
                              activities should consider viiietiic-,i, preieiii@,io,-i
                              iiould be accomplished more effectively through
                              coverage of preventive services Linder financing
                              or through collective action.
                              Coverage of preventive health services under
                              national health insurance should be based on
                              the experience of [ISI@,'il]A as to their efficacy.
                              Reimbursement of Fedc@ral service projects through
                              national health insurance can be accomplished i@,uch
                              niore easily and quickly under single leadership
                              that could mandate, for instance, reimbursement of
                              frpp-standing clinics under l@edi(,aid or i-eii,,,ibui-se-
                              ment of N@ISC personnel by I-ledicare.  There is
                              presently no single-focus to effect this integration.
                              Research priorities for both health services and
                              biomedical research should be developed with a
                              View towards the health py@obleillis encountered

                              through the financing system.
                              Economic considerations of providing' and influencing
                              distribution of ,health resources through reimbursement
                              policies faced to -be fully explored.

                           These examples illustrate niaior issues iii Federal health
                           programs that can only be fully explored and'resolved if
                           all health programs are considered integrally and if the




                           financing programs are fully utilized to determine the
                           ou+.cc@,,ies. Such issues can most successfully be resolved,
                                solidation of all      heal t[i I)i-ogrFi,-,is including financ-
                           by con                   r
                           ing programs, under single leadership and responsibility.

                           The present operations of health financing programs are-
                           not integrally r,--Iatcd to the other program activi'L.-i es
                           within SRS and SSA.  Both t@iSA and BHI receive adminis-
                           trative support and overall policy direction from their
                           parent organizations.  Eligibility determination for
                           Medicare is the only function that @-jould have to be
                           maintained %,iithin the current context of the inco,-,ie
                               L-cnan-.e Pr                                  cn a
                           r. @zz i r.41 cgi-ariis, but il- could @e ,crf crme@
                           service basis by SSA, @iith reimbursement fro.-,I the
                           operating health agencies as appropriate for the services

                           provided.

                           In the case.of f,',edicare, eligibility for all social
                           security benefits is determined uniformly by    SSA staff,
                           and records ol'-eligibility are maintained centrally in
                           SSA for each beneficiary.  Records on utilization of
                           I,iedicare are maintained by the carriers and iii@Ler,i,@edi ari es.
                           Records on beneficiaries' payr,.2nt of the required @,'iedica-,,e-
                           deductible.ai--- Vept centrally in SSA, but are not a part
                           of the larger record sys-Lo-pi on social security beneficiaries'





                           utilization of other social security benefits.  These
                           activities are routine and do not@iti@.,oact significantly
                           on the health delivery system and could, therefore, be
                           continued in the current fashion and paid for by DIII on

                           service basis.


                         -'Tiie. operation of the Medicare program and its p-,i,lin.-ent
                                                                            i
                           system are relatively self-contained %.iitliin B.111.  The
                           activities conducted in B@ll -- the certification of
                           providers for participation in Medicare, contracting @-iitli
                           the fiscal iiitc@rii,,ediaries and II)tate health agencies, an
                           determination of reimbursement policies in teri,,is of
                           reasonableness of cost and appropriateness of care
                           received -- are the ones that have a i-i.iijor influence on
                           the health care delivery system.  The removal of B@iI
                           from SSA would not seriously disrupt either thcse
                           activities or the other ongoing operations of SSA.


                           For I.'iedicaid, both eligibility detei-i-iiinations and the
                           payment of individual claims are  the responsibility of the
                           States.  The Federal functions with respect to loth
                           eligibility and reimbursement policy are limited to
                           developing regulations a-tid Cl Llidelines. Federal payments
                           to the SL-lates for Medicaid are made centrally it) ')RS,
                           but the operation is a relatively siml)le one of
                           determining th,@-allo%qable Federal share of the total States'




                            i@tt-,dicaid costs The par' of the payment operation   in S,O.S
                            that relates to 'il,'iedi cai (I coul d easi ly be i de,,-t'L-, I @i ed and
                            run by MSA.  Although  @.';cdicaid admittedly has less infllj,-.nce
                            on. the health care delivery sys@Le;ii than l,'iedica-e, it is the
                            development by "iSA of Federal guidelines to the States
                            for reimbursement poli cy that is critical to influencing
                            the system.  In addition, these guidelines need to be
                            consistent %.iith Medicare i-eimburseii,,,-tit policy in order IL-lo
                            achieve the maximum ir,,,,)act on the health care delivery sy8tei-,I.
                            lliSA could be reiioved from SRS without disrupting either the
                            I,Icdicaid program or the other-operatitig programs in SRS.


                                                                -/'.nNt t7
                            Ti'E OFF'10r'- O.- Ti2,f@- t".Sr,jTS-,rtA,,k!T
                       2.
                                                                    '@O E
                                    STP,':
                                              s        L r
                            -iksslj@@",E ITS                                  i-""  D

                            Although the Assistant   Secretary for  Health has been
                            .identified as the principal official   responsible for
                            the Departflient.'s health policies since April I-Q63, his
                            -office@has never been  staffed or  aligiied to
                                                                            carry out
                            this responsibility effectively.  ,irth-2rnioi-e, tic has
                            not been in a-position to direct    or to be li,-"id accountable
                            for the implementation of established policies.       The
                            Assistant So;,_-rotary, fo, instance, has budgetary respo,.is-i-
                            bility for only about 20,"i cf the       health LI-L.,,jget. Tlic!




                                 result has been lack of       an integrated health s'Lrateg@,,.
                                 The author i ties.a iid c apibi Iities di@' the Assis'L-arit  Seci-@i-@Lry.
                                 for Ilealth t:,-,u-.t be cn,,i@,!-.,ceci @o resolve these i-,i-oblems.

                                 There has been increFs-i@-.,,j  overlap     and dLIPI i Cat4iOil Oi'
                                 and activities bet,.,,,eeii  tire various health pro-,-t-ar@,,s of
                                 Department   especially   in'@Lhe   areas   ol' reseai,cj@i,
                                 and financing standards.        The    current" fragn,.eiitation'6-i-
                                 leadership and accouiitability'n,,eans duplication and
                                 of staff as %.fell as lack, Di' any effective focus for activities
                                 that bridge the financing and service programs, such as PSRO'S.
                                 This lacl,,.of focus has resulted in coiisiderE@i)le confusion of
                                 responsibility and activity not only @,iithin                but also
                                 throughout the private sector i.iliicil trust i,e.late to the fc-clei-al
                                 health financing programs.   The Assistant Seci-etary's
                                 responsibilities should be        defined so that he can be held
                                 accountable for the planning and          iriplcTentation   of   all    the

                                 Department's health programs.

                            3.   Tllr CHARACT!!D   0!7           ST            DI",,-@,STIC          l'O
                                                                     POLE             I
                                 The  present cliaracter-of HS,'.'.@IA reflec-L-.s the devl-lopq,.eii'L-  of
                                 a   variety   of   categorical   grant   programs   during   the    1950's.
                                 It is composed of 16 categorical programs %Keith
                                 defined missions, each operating relatively





                                          I             tilout  a           definition of th       eir   i,c, I ci tc) n -
                                       and argely    %-Ii
                                       ship to an  overall  health       strategy.     These      prograr's      and
                                          -Liol-is   must be reoi,@,?,,iized and redirected to contribute
                                       fuiic
                                       more effectively to the        D-.,partni-2nt's       health       leadership
                                                                                       s must be established
                                       responsibilities.       tl ew - re I a t i o ii s I i i p
                                       to relate HSMHP, programs Tore           effectively l@lith the Current
                                       health financing programs and to a future program of

                                   .national  health insurance.
                              4.       TtlE Plc-SPLur-TIVE ROLES OF TPE [IFP.,LTII PGEi,'CIES,  ESPR@CIALLY
                                       IN                                                                             lo\ .
                                       Since tllt establishment of IISI,',,@IA and the realignment of
                                       the   other   health   agencies   in    1968,    the    major    tf-end    in
                                       health scrvices programs has been to,,,iard the delivery o
                                       health services in a comprehensive nianiier.                     Bio,-iiedica
                                       -or,disease-oriented    research     has     been     maintained     in     a
                                       categorical      setting.   The Cancer and Heart and Lung Disease
                                       Acts of 1971  and 1972,  ho,@iever,  call  for initiation of

                                             or--i ca I "control" programs  in
                                       categ                                           c o,-iiiiiu ii i @Ly settings to
                                       expedite the translation of the results of research into
                                       medical      practice.      The      reintroduction      of       categorical
                                       service    activities    in    a    research    setting     his     coniL,sed
                                       both the role of research programs %earth respect                    to
                                       delivery of health Services and the role of service
                                                        L           t,                         -ippr
                                       p@ogi,ai-@s %,,,ilh- respcc'    to coi-,,.prehensi,,,.o       oacho,       to

                                       service delivery.






                                                                                              ibly
                                    In  addition,  aOi)lied   res(-,,ai,ch tyiat   is    ostens

                                    relevant  to many
                                                         1-icalth activities lids              up in
                                    vii-tually,every  [i.,@altil  ageric,f of          'I'lle question
                                    arises, then, of @-,,,'-iet'tier   this research   is more effectively

                                                                                  -cl-is
                                    carried  out   in   an   indepetir!-nt reseal       -,ttitig, or
                                                 sho,,il(I be integrally related         'o 'he p,,-c;,ii-ans
                                    whether it                                           L

                                    it Supports.


                                        p
                                         O! E
                             5.     T 1-1, E                7AT I O'                      Ti r; [iE,@! Tl,' I-,'POI,"Q
                                                                   Z, j i-,.-  L)
                                    The health niaiipo,,.,,-@,r develol),,,i nt activities of the Dc-partri-ieiit
                                    were organized in a Bureau of the Public Health Service                    in
                                    January 1967.   The organization provided policy focus for
                                    maiipca@,for education; unified                     of a nui-pbcr of special
                                    educational support progrei,-@.s for health professionals and a
                                    focus  for developing innovative ri,,etlicds in health
                                    education.   The Bu)-eau      i,ias r@,,oved to -IL-h,, 11-11H in IO.'OS in
                                    recognition of the overall  ii@,lpact of research it-id educational
                                    support pi,oyr8nis on medical                   and                    of

                                    higher   education.

                                    Until recently, the           programs in the          have been concerned
                                    primarily %-iitli ti-,2      education of health                 and have
                                    therefore     focused     on     academic     institutions. Questions of
                                    utilization, dis@Lli-ibution, and p-ay;-i@,ent l'o-t- [iian,n'c,@.:oi, fare
                                    considered by. health services and f4,iia,,icing progro.;i,,S.

                                    t,lost of ti-ic health sor,.,ic,2
                                    established separate i@ii,-lripo,,.,,er cievelopiiient activities to





                                              'S           relate to their
                          address these   issue   as they
                                                -rvice. mission.
                          particular health se
                                              01- c@ducatiolli viill be provided
                          Federal support f
                                                         tudent assistance rather
                          primarily through general s
                          .than categorical Support for educational institutions.
                                                                    ut many of the
                          Thc budget request for 10,74 phases 0
                                                                                .,Iii 1 e
                           institutional support programs of the Bureau,
                                                         S to Stimulate development
                           increesin    special program
                                     9
                           of iievi and flexible methods to train and utilize

                           personnel.
                           These activities and     the manpower efforts that have
                            proliferated among II.S@,','IiA progra,,,Is need to be cor,-,@@irie
                            to eliminate the duplication and confusion @,,,Iiich currently
                            exist.   A focal point is needed that vie%.is the provision
                            of trained m-atipot,,ier for the delivery of health care services
                            as a form of resource develop,-,icn@Ll to be               @-iith a
                            view to',,,iards 4.ts- ultimate utilization and reiri-,bL.! I- Se P,-. en
                        6.   Pi S I? 'ILIA IS A CO! 1.0:.'!@-RATE OF SPECIT,,I-'-7c"D CATEC-. I C f@, L P R 0S
                             C,l  U T


                                         created in  1 9 C", 3 p r i,, iia r i I y @k-o bring together a I
                             I[St'.'iA vias
                             procit-ams concerned %,fit!-, tiie.pro,iis.ior, of     care.    It

                             cur    'tly
                                        economists of 16 separate ot@2ratiiin, --ograpis,
                                 ren                                             i





                            most of %.ihich have a separate and uniq,,io'legisla,tive

                            mandate  to address a nai-y-o,.,ily defined problem

                            the health care  deliver-,,,,,, system.


                                    [iSill@IA as a vihol.,2, there. is a 1.)i-oc-id range of

                            diverse  activities   that has evolved as each program
                            established separate co:i-,pDnetits desigiie@l to ,,eet -71 ts
                            unique objectives.  These range from direct     deli@,ery of
                            care to technical assistance and basic research.  t@'iany of

                            the functions established in the separate     progra,@s   are
                            similar.  Most programs:have developed a     technical assistance
                            and grants management capability, for instance, and hall' of
                            the programs have specialized training and research

                            activities.


                            There  have  been  attempts,  through  special  projects  and
                            committees in such areas as data mancigr-,Tetit, third party
                            financing, and services integration to involve api,,i-oi-,riate
                            programs and co5ibine resources in a [IS;"i.',,;A-%,iide e-i'l@or-@, to
                                           'diiiated approach to a particul
                                     a cooi-
                            achieve                                          ar health
                            services  delivery  issue.  These  efforts  appear  to   have
                            been limited in scope    and effectiveness to bleiid li'S,@-ii@IA

                            efforts under   a broad  health services s-Llrateny.


                            HSIIHA planning has traditionally been done on       pi-ogrc-,rii-
                            by-program basis rather 'than in  support  of  agency-,,.tide





                             goals. '[iS@','[iA-viidc, g als fici e been st
                                                  0       v          ated in general
                             terms of improving access,   ef'icib,-,cy, quality and
                                                            T
                             effectiveness of health.services.  This general approach
                             to goals is a best attei@,-t to su,,i,,,nat-ize potential

                                               4OUS programs,
                             lillpac I         I
                                  t o' the var                  bull- unfortunately these
                             generalized goals  have been beyond the aggregate ability

                             of       to achieve.

                             In fi'ovei-,,@bcr' 1971, IISI@','f!A programs i,iere grouped into four
                             clusters, each under a separate Depu4L-ly  Ad,-@iinisti-atoi-.
                             These clusters represented the major areas of activity
                             within IIS,f@',Hj@, namely Prevention and Coiisu;-,l--i- Services-,
                             llcaltl, Sorvi--cs De!4.,.'--ry; Dc,,elcpi,,,n-:,.t; ard I-ic.,ital
                             lieal th. (See Appendix B for   current         organiz@L-
                             tion chart.).   From interviews   i-iith the 16 Progra,-i Directors,
                             it appears that @,,,Iiere clusters served any purpose iL- ..,,as
                             to improve the interaction among progra,-,is, but only those
                             within the cluster.    Nevertheless, IL-lie interviewers a so
                             revealed that pi-ogr,-ris Britain th,-- cluster still d,,,plica@Lle
                             efforts and maintain separate staffs; that the r,,ost
                             effective program. interrelationships are still at the
                             operating level;        that there is little joint planning,
                             operation and evaluation.     Half of the Pi-ogra:,,,. D@ii-I,cl@.oi,s
                             felt the cluster had no effect     on their pronraT., and i@our
                             felt the cluster system had even hindered their efl'o,-ts.




                                                                                                   J- C)

                                                             y of pei-cc[) -ici
                               Intervie,is revealed  a  variet           t  is on.the   role'
                               of the cluster Deputy P%d.@,inistrat'o:.  Of the resr)oiises
                                                                    r
                               from the Prograi,,i Dii@ec-t,)rs,. three consi(,Ict-ed the cluster
                               deputy to be a line ni-ap,,-.'c:er, four a coordinator, i.;@,-Il,e eight-

                               tliouc@@lit h,
                                          served as both.    I'@,.ei-e %.,,as agrec-n,.cnt -i-,g the
                               Prooram Directors that        clusters %,,ei-e orig!r),@lly
                               estpblislied, 'Llh-, cluster deputy @.ias intended to coordinate
                               prograris'and act as  a  crisis solver; but, in  some  iiisL@atices,
                               depci,ding on the deputy's personality, his' role Gr'd,,tally
                                                                                      a

                               became that of a line supervisor.
      t
                               In sLIlilTary, the Clusters appear to  have  offered  a  convenient
                               way to conceptualize the broad array of            programs and to
                               have reduced the direct spaii of control o-F the    Adii-iiiiisti-a@Llot-;
                               but not to have [)con effective in coordiiiz,,'-ing proci-
                                                                                         an

                               resources to achieve broader health services goals.


                         7.    THE If@ITE,",FACE
                               PROr'l@@",!S 'ri'S
                                         tA

                                                                                              onlv
                               Di s cti s s i ons %qi tti Prog -,-am D i rectors revealed .@-,ha4L
                               few steps had been talen at  o,,)eratitig  levels  to  assure  'that
                               adequate relationships exist be@Ll,@,i--,en liS!.',IL'IA-financed service
                               activities and SSil and SRS financing proni-ei,"Is.  -In addition,
                               the relationship of the  health  s--.riice  and  health  'inanc-ing
                               programs- in the processes of policy d-lvoloi-,-,,,@,nt and program
                               planning is not-cotisistent oi- adequate.  As a result,
                               OPPOrtLilli ti es or an integrated policy   ,.,,ith respecL-1 to health

                               cl         a 2







                                                               nati orii Iheal til i nsu,@lailicl@
                                  n t a t i on. and operation of
                                                              ubste,,ntive input f- "Om
                       program deserve  a more thorough and  s
                                          ealtli of@icials.
                       q.-fic Dc-p-3i-tr.,,,(-@nt's h

                                                                               health
                       I,,Iith increasing dependence on finaticing.progranis foi
                                                   'ise from the lack of a coo)-cliiiated
                       services, many questions ar
                       health  services  policy:

                                                              fferetit benefit
                            Should grant programs provide a di
                            package from financing programs?
                            Are soi-..c' of these services medically desirable,
                            irid -,Yi-uijld 'L-"iiey bn covered under f4,nancing?

                            l@lliat necds to be done to bring the Iiidiin @iealth
                            system tip to standards of participation for financing.
                            '14hat is the maximum potential for reimbursement of
                            project grant activities through existing and future
                            -firtar'loing prbg'ra,-,ls?
                         Ansvi-.rS to Such questions are essential to developing a
                         unified health  strategy, and they are possible only
                         through a close integration' of all IIEI,-.1 service activities






                                                                  -0 C
                             TIIE I-','L--I-f@TIO!@!iS!IIP OF        )'F !'E 11   ACTIVITI'LS

                                                                             or,@,,iized, in
                             At the time t@ie- Public I:ell'fl Servic(2 @,jas re
                                                   had enveloped  sizable service delivei'Y
                             1967 and 1968,
                             program elc-i,,ien-L-s in addi Lic)n @Lo. its @)asic I-ese@it-cli activities.
                             It had bcco!,@c a disease-ot,iented, vertical oi-g,@,rization,
                                                            b"c-i-,,,s Through a vai-ic-i-y of
                             approaching         health pro i
                             activities.  The placement of         in [iS,',,'r',A i@-) 1,0'08 appears
                             to have iiiad6- sc,@nse as Oi"c@L-1 iiiza-Llioii-,l    and
                             because I,,Ili.'IH had many functions in           otliei- [IS[.'itiA
                             programs.  Its size, variec,,, of activities, and spangle focus,
                             ho@.,,,cver, riiake it unique. As    is divested o,'  its i-esporisi-
                             bilities to finance the operation of cogimuriity ili@-ntal health
                             centers and other mental                     and services, it
                             begins to asSL,,@-i-- the chcii-E,,@.r@tei-istics of the ol@-hei- research

                             institutes at

                        9.   T@IF          171-,,TTO.',@' 'r,i'JST 1,I),O',IIDE F@,,r) Tril.7 PI-IAS!' OtiT OF

                             The' 1974 budget calls                    ioh and redirection

                                                     -1 S
                             of several niaioi   pi-ogr   c-i ii dactivities in line i,,,itli
                             a redefinition of the   Fed o,,-a I' role in 1),2altli.A
                             reorganization tiici-L-1-lool,,,s Lc)@,.,ai-d the future roles in
                             health i',lLlst at the same t i @,! i -L' provide for the o,-dei-ly

                             transition of ongoing operations.


                             Wi'tliin [ISi,l@IA,. the Regioii,?.l 1,;,-,dical Ili,cgr,Eiiii, +,lie flill-Bui-ton

                             Co-is-'u-'L!Cti-n






                                                                SuP!),')'-t for co"-' @l' ty
                           be terminated by the end of FY 107@i:.
                           n,,ental li(-@al @Llh ceiite-i-s, alcohol abase projc-,ts and long r2 r,@l
                           training   viill be gradually phased out beginning in F'I' 1974.
                           St'. Elizabeth's Hospital viill  be transferred the
                           District of Columbia, and contracts @,iitli
                           and other Federal facilities %,fill  replace (!4ii,ect provision
                           of inpatient care in PHS hospitals.   Project grant support
                           for 14a-tcri-ial and Child Ilealtli Service @,iill.be ,-epl-ced. I-,,y
                                                                             I
                           formula grant funding.   Although no specific action i.,,as
                           requested in the budg(@lk-, several  o-ic
                           programs anticipate significant changes in response to
                           the     to,.,iard health services fiti,)nrino )tid the
                           discoiitiii!jatice of activities.best Supported at the S@Late

                           and local level.
                           In the Bureau of @lealt',i f,ianpo@.,,ei, Educatiott, the bud,,-e,t-, calls  i'O@,
                           termination of categorical  support in allied and public
                           health, and for schools of ,iursii-,C,, veteriri:--i-Y P.,,edicii,e,
                           podiatry, pharmacy and optometry.   Funding is increased
                           for special  projects and educlat4loi,,-al
                           in order to focus health           training SL!rdpor'k-, in
                           areas of spt-2cial  need.


                           10. TtiE c ti.11, p F!@!
                                    ,-.,T RCLE 0'7    R":GT-C.@II."311. CI'F-TCES
                            S!
                                                                           'sis O'l
                            A


                                            I-                     '7 r i
                            T,.L,,-i s i o,,,.





                             national categorical proc-iro,,-iis. Tli@ regional offices are
                                 ally concerned @-iith helping  develop integ",a,,,,ed
                             g(-ner
                             br-@alth service systems to meet State end local needs
                             and priorities   On  the other lia d, national programs are
                                                                n
                             generally concerned @,iitli specific objectives under more
                                   categorical missions specified in legislation and

                             appropriations.
                             The integration of these categorical programs in supporting
                             comprehensive health service developpieiiL-1 has been define
                             as a responsibility of tiie-regional offices.  Recent
                             decisions to accelerate the decentralization of programs
                             to the region,,.stress the need to I)iece decis-ion-P,@al-ling
                             authority closest to -L-lie point of pro@ii-am iii,,pler,,.,enta-
                             tioii in order -IL-lo improve the effectiveness of programs and the
                             coordinated use of all resources in meeting local health

                             care needs.

                             DecetitralizatiGri of HS,','@"IA grant programs to the 'i-egions
                             has proceeded to the point  @,,,here 25 grant programs have
                             been   decentralized,   representing 60i@3 of the total IIS,'.',@IA
                             grant  dollars.   Additional   grant programs have been
                             partially decentralized finite another 20 remain centralized.
                             14ost of this latter gl-OL;p have been determined appropriate
                             for centralized.operatioll.  Alcohol and drug abuse service
                             grant programs (-Ire  presently  ceiitr.a I i, --7od, although

                                                       ai-c not b;-,Ifig



                                                                                                 23


                            l@,lhilc@ consider,@i@le pi-ogress has been    in the  (Jecen-
                        --.--tt-alization of grant             the          have ex,F,,-essed.'
                            difficulties in achieving program integration.  During
                            interviews the Pegional            Directors sta-L-led the

                            following cop,,.i-,,,on problc-,riis:


                               There are serious differences bet@,;een regional ol@fices
     r                         and h--adCi Li i 1-ters staff i, C, i JL-h respect to the of
                               achieving objectives.     I',--adquartei-s procj@ans liFve v i e,,,,, c, d
                               some efforts at integration as obstacles to the achieve-
                               niciit of national progr@ir,.,:Ii,.a, ic objectives.

                               Inadeotiate integration of p,-ograT-,I--, @,t lleAdqtlai-i--i's lplv---
                               too much responsibility for coordination a+, the regional

                               level.


                               The fact that regional offices receive separate
                               allocations tied to individual,Eippi-opria@Liotis instead
                               of a consolidated opei--,u-ing budget is vic-,..,,ed as a
                               constraint to their ability to integrate activities.


                               There is inadecluiate stl'U C tLli-ed regional office input

                               into national poli-cy and budget development.


                               RelatiQns i@iitli Medicaid and t!,edicare staff are generally

                               episodic and unstrLICtU)-ed.




                                                          To@                  PS TO. REFLECT -FIIE
                                  -fliE ROLE Ot@ TIIE PEG,       0.17FICE   [,El
                                                                 IL L
                                                       LES PIT
                                  F- u I
                                                                                                    heal th
                                                the   prip,,.ar,l  role  of  the        regioiil'l  I
                                    presents

                                                                                            -,ri oL.,s
                                  staff is to    iRipleiT-.ent  ar."I  integrate           v,
                                                                      i 4               region.
                                                                        Llhin the JILF-"
                                  categorical    grant progi-z@.-,@;
                                  orgaiiization-,it the regional        level  is a reflection of
                                  lloztdqiiai-ters orc-lonizci-L-.ioi-i alo,-ig cluster and categorical
                                                                 t4oll @.litll
                                  program lines.   Coordina                    the health activities
                                  of other   agencies is liiiiii,@2d in the regions just as it is
                                  ill headquarters.      As the         health agencies respond to
                                  change s in the federal roles in health, the RO health
                                  staff i-iill be   expected to Etssu.-ne the follo,.,,,ing

                                  responsibilities

                                      Ai,iai-ding. funds to and r.,,@,,)nitoritig performance oi
                                                                                    in surveillance
                                      organizations established to i-,iiii,.4L, i
                                      of     professional      standards.
                                      Monitoring      performance      of agencies k,@iiich  have roles
                                        ii -heal th i:nSLI-,-ance f i ii@.iici ng syste,-,is.

                                       Certifying     facilities      for participation as      providers

                                       in health fir,,-tiicing


                                       Providing technical  assistance to I)I'CPE'.I@e
                                       I-evel heal -L-li care deliv('@i,y projects for financing

                                       through reimbursements











                                                                                  -e
                             Pro                             tcF community or Sta'
                               viditig technical ass
                             level. authorities for the prevention of co@in@iiiica")Id

                             diseases.



                                               SS4
                             Coordinating and a  isting in collection of data on
                             health tare resources and health status.

                             Awarding funds for  State-@-jide and con,@riunity level
                             planning and coordination efforts.

                             Assisting in the implementation of programs to provide
                             care for bcne-riciii-ies through direct delivery

                             activities.

                             Assisting programs for safeguarding liealth'throuch
                             eiif ol,cericn4L,, of la,,.is governing tare manufacture and
                             sale of food, drugs, and other substances.





                                                                                                                                                    f- u








                                                                                                                                  3s
                                       Tile                     a-ency      str,,ictlil,'e       for                   service

                                                                                                                       nani zed
                                       act i,,, i t i e sof  IIE@,,' contains     @t'@ree      net,.i agencies  or,)

                                                                                     ;,-Iii-,g and
                                       z,@. r ',),u, id 'L li f Li c -Libiis  of                       I   ILI                  L
                                       sei-vi ces,    devel ol);l,,,@nt  o'            th  resources           and  prev,,@ti'ioii
                                       a 11, rj c O,-i o Iof  health                          litl)in       each       oi'.tliese
                                       functions,       the    fed,,i--rtl    role    @,-&i-ies    from     one     of     direct
                                       action  to  oi-,,@  of  serving  as  a  -@oc,us  foi-                                    ind

                                       advice.       Four  otli-@i-  orgai,.izat;,-,
                                                                                        , , n;-, I o p @Llions @-,?,Iiicli i.lc.,,-e

                                       considered  are  discussed  in fkppetidi>,  C..

                                       linpleiientitig  these  three  agencies  i-iotild  result  in  a  health
                                       s Lrucju-,,ir.,--  consisting  oil  l'ivc-  a-,,ncies,  c-acl-,

                                       specific  hca'.tli mission:

                                               Food    and  Drug                                    conSL@'@,,-,Ier protection
                                               Ila-Lioiial  Insti-L-lut(-@s  of  liecil'Lh--'  bio,-,-,--dical  research
                                               Center  foi-  Disease  Coti@Lli-ol  -  prev.-njG-ive  and  n!,;'ulic  health
                                             -tfeaith  Pesou,,-ces,  fkd:@linisti,atioti  -  Iica'th  care  resources

                                               Health  Services           Ac!i,.,,inistrZ,,4-4
                                                                                                uion    fiea'['L-l-,  set-vices


                                       The  purpose  of  tiii.s  s@,,,-Idy  has  been  to  create  a  structure  that
                                       facilitate -,  the  dcvelc)o;,-eiit  and  iriplc-!,@c-n T@- 2, -L-ion  of  coisisl@-ert
                                              health  policy.            The  functions  of  t,io  tl,,i@ee  ne@,,,  ag,-@.nc-ies
                                       provide  a  continuing  focu-.  on  t,ie  ele;,,,ei,,ts                                    have  to
          t
          I
          i                                                                                                I-
                                                                                                          "i
                                       .  be  considered  in  the                                 of o,.,e,".'l  hoalt!i  )-@ii-ly.
                                                                                                                                I
       0
                                                                                                                 I





          f'




                                      Since  the  est(-,I)Iisil,9'.cllt  O'        CDr" Ds    a     scl)ziratc-     a(j(,ncy      reqtiii,Cs

                                                                                                       s  o-"
                                      very  little                                         e I C,!
                                       2     o  c C) 1'. s o 1 io, e . i n t o      E), g c- ti c i c F, j o rIE I.   a    v i t i  s    1 1

                                            C)    t        -ovision  o-l'           I                             L
                                      ,Iipj         he    pi                            h    set-,.lic:os    and '-fie    d.-velop:-.l-@,.it


                                      I,!itliiii  a  nc-,@-i agency    foi-    hec@l!',,i    scr%,-ices,     all                 no,.-:
                                      financing   oi-   dii-ec@Lly   sL,,i)pc),,-tiiig    tii.2    cl(--.@livei-y    of             care
                                      %,,Iou 1 cl I)e  co,-soli(la'Lled.     T@;,,@@  n@,ed  to  I)','i!lg  the               fitiaiici,,i-
                                      prog,,o@i-iis  o-i'                i,,,iici              uiic!2r  health  pol@icy
                                      has  been  discussed  eai-liei-.in  tli.is  report.                       In          addition,
                                      the  current                  health  s(,i,%,ic'c  1)1-cnl,-El.!Ils  %@,,oule!  1),@,  cons6licl@"L-ed
                                      to  facilitate  a  coordinates  approach  in  redirecting tliesc
                                      activities  to@.!ai-d  sup-ort  t@,.,rou,@.ih             i-Ili@  finciiicit--,g  si@tc,,,.l
                                      ti-iati  direct  Fed,@,i-al  assistance.               Tl-iesc,  currciit                 se,,-%,icc@
                                      programs  are  SL@ppoi-'Llcd  through  a  vc-ii-'$,,,ty  of r!r-,c[iatliSl-.IS,
                                      foi-riiula  and  p'-,,-oiQct  gi-oiijL-.s.,  coriti-ac's,         ciiid  d i i- c.,t federal  assistance

                                      for    beneficiary,        care.


                                           is
                                                r c-,,-, o i  e cl th@a@L  t ii    -.icfective     ot)2i-a t i on     c o n s o          0 1 1
                                      and 'redi                    -ir  these  activi-LLics              1  pl arm    o,.,tersive
                                                   rcction  o
                                      adininistrativ--  burdens  o-ii              'a  net  cigo-ii.-y  tliit  is     cil.so. che,,.-gc-ci  @,ii th
                                      operating  iiici  it-itegratiii,,            -'I-ie  iierilti)  s-2i-vic-  fin:%i-tc:rig
                                                                                   L
                                      14evcrtli--Iess,  i@L-  is  stroii-ly                                 that  ti,CSO  I'LIIICJLiO!!',  bl
                                                                                  -j                              L

         L
                                      in  a  single  agency  to                           a  sti-ofi,@,,  lolity                 l'or
                                      services,  to ii,,cet.trie  i-icccl  for             i,-Iol-c Cfi,cctivc.,





                                        -vice and fiiia,.i-@iiig pi-ogr,-ti-,,is, (Ind -L-o (,Iinlirat(-' costly
                              (iii,ect sei
                                                                    -ItiOll Of                L         L,;-q
                                             Coll'JiCtilly C:L!PliC,            e-rfot-I s
                                 at  ,           I
                                     L

                              The                  of a.C'L',iv4,-'--@'es si.ipl)oi-ting  the  clevelo5,@-.,.@@rit
                              o-F              i-escL.!-,ccs is 'L-t..2 sccoi-id P.@ajoi- pi-o@,!isioii.
                                 propose          Hi@\A- i;i-ill  're@,,, ire i!!@,@ediate z,.iid c-x'L(@ns -i ve
                              redirection and into(-,-o,'-ion of oiicoii-,g pror@i-,@,@is.    A grc,,-,Itei-
                                             :.-etence n,,L@st be develor)cd
                                                                               to  pi-ovid- the
                              degree of c@
                              stii-veilli,t,,-.e and rese@i-cli activities ii-,-cessai-@f for
                              0-ir a coordinated rLsOL@l-CC-S Stl'a'L-,C','@Jy. In addition, this agency
                                   reqtiii-c              ii-itc.,grajL-,ic,@i of ongoit,g resoii,ce
                              dc,velopiiil-ii'L-, F@-i-ogran,,s ,.!-itriin a coordinated resOL11-ces sti-a'L-e.9i/
                              'flie long tci-,Yi llocus of this ageiic,@, i,,-,-,ist be   provision o-j-
                              i ii l'o ri-,q:i t i on ,,iialysis and advice o@,-i the overall  suppl, c!,-i-.1ati,,d
                              and effective utilization of health c&,.i-e i-csc,,,ii-ces.

                              Resource development has been articulated as a Federal
                              responsibility in,the pE,,s@L, and hills been the general
                              -goal-of I)LIl..@'I'OUS, scattered efforts.      Conc-o'lidation of
                              these activities %.iill facilitate more effec-Li@.,e Utili7,1-
                              tioii of Iii;,iited Federal  l'uiiding @kl;]I-CL,'-h          JL-la i,g e ti i-i 9
                              of activities.      Problciiis should Lie idet,,-Li l'i cc', in a
                              broader co-,,.-Lcx-L. of ti-ic overall vi',l,-,, of         resources
                              in the 'U.S.  -Ttie iilz)Ect of this               viill@ iio'L- depend  as
                              iii0cli On tli,2 o,n,,,ratioii of direct pi-ogi-cip,-,Is, as on their
                              indirect role i@n     ini"Itic@ncing   the   policies'ard    programs    of






                                                                                                                                              TIIE                 FO!
                                                                        S                           @'I S -F n T'I' 1, o;


                                                                                                                                                                       oil
                                                                                 s -i   I-, of                           Serv-icc,s  'cl@-11

                                                                                                                                                                  I C c-, s
                                                    be to ,)rovic@n aiici               f i -,,a I I c c-, II c  de I  i  very      c f 1',

                                                                                                c@i i d ,    (,rciiits

                                                          vc, i-y,     a, i I -d u i  i I!:,a e -1 y
                                                                                             r, i ri s   e,.,- i i-i gtile             '-[I   cEti,e
                                                    f L@          is       C    LI Ci C'    Z:. (,I
                                                                                                                                                                -i toi-i iig
                                                    prog -z@ris          ec, i ca. i-e    and    t.'i-dicaid);     d     ve'oi)ing     and               P..,@ o n
                                                                           i 'u i I  s t a i I d ---@ r d so     1)   i, t i c i         o  n  o  f  p   o                 i I

                                                                                              tile                                       of     cai-c,                         ri
                                                    f i iiaii,-i i,,g;   revi                                                                             i,ec-ei vc-
                                                    teri-ns of cost,  qLiality,                                                               prelial--ii,,,.  existiiiri
                                                    he a l  'L-,Ii  service                          I' 0 I-  S LI 1) p 0 I' t    11 C; L@     -'L-'Il i I'Cl     -i@"LY
                                                    financi!ir,i f)y                                                                           cclt)-@,I)ility alid
                                                    enSLII' I iig               i,-,cet ciccef)@L,@i't)l(-,                               for
                                                    and   providing    h.-@ii't-,h    sei,v-icc@s    to                 specific  -1@edei-c@l
                                                                            t-latitig   coii\,ei-sio-,i   of            tile,                                L
                                                    t@ihile facili4                                                            @e  actvities  "C'  SL)i)rort

                                                    t-hrouch financing


                                                    The Heiltli Scrvicc.,-3                                         i Oil    k,:OUId             i!lClLde    1 1
                                                    health        c    i- e I' I'       c i i-I q  e c t             s          the  B'@l"t-eEiLl Of      III 0  'I 'L-,  'II

                                                                                                                                   4
                                                                                                the  SC)CiZIl   SC-CLI             I Ly
                                                           l'i,-,dical,  Sci-viccs                                                            froii            @@,-,cial   2,114c@l
                                                    [ZehabilitLition 'zc,,%,ice                                    'L-lh(-, Pro-I' n-- s s    c)    il

                                                                                                                                                Af-i'a-i i-s

                                                    fro!n tile         01@l'ice c),@ 'L-ho Pssist@,ii'Ll                                         for    Ic,   11  'LI

                                                                                                                                    r
                                                    aiicl   '.Iic,,Iical   Care    Standards    1-tcLivi'L-.ies    )'o;ii                        il C'  C C,;   L! 1   '-L Y 11





                         --Sey,vic(-,.    In additioi-i,                             311

                              ,icti\,ili@s:   f,-riily                Ilrojec-L   n,@
                                                            (-:cii'ei-s,  and            liealt,,i projects;
                              Centers

                                                                iric!   Child


                                                         4   f
                                                                 S     Cil 4 11 I 1,@ -1 I11               ai@d
                                                                         I    I I - CI S  j- V i C e
                              ii. ii d ci
                              Federal  Ileali--Ii Pi-oir@-ji,,.ls Service (FIIPS).

                              llithin this egc-.,icy,  the financing activities eight be integi-a-Lp-d
                                                       3 r;izijoi,                                  tl,-2 B!'I
                              and                .-I to                       L,

                                                                     ilar,Ci ng C C.
                                                                                              @.!OUI -1   be pol 4 Cy
                              substructure.      These three fi                                     u

                                                                         -Lion, (.i ri dr) i, oii    I
                              dc-vr:,@lol-,lll,-2tit, progrciin                                 li'@o 11 to 1, r,
                              The service did  l'Ol-l-,-,Llla gi-ciiit activities    r..i i (j [,,'L-. co,,,.@),,,ise a
                              self-contained con-i-ooti,-iit of liSA that has                  it functions
                              comparable to the l'iiiaricit,.g SLII)'.trLIC'I,-Llt-e.        (!rated sc,,rvice@s
                                                                                                    t4ol@S,   oll..2
                              co,T,poiien
                                        t could contain a uiiit for polic,, cind i-eit,,Ia
                              for technical assistelicc and                                           ai-@d a 'L-hii-d
                              for program Monitoring            (Ti-aining of gi-zi,.itee s'Llai@l's  is co,-isi@-ei-.--d--
                              a forni of technical  assistance.)            The Correct care ectivil@,I'CS
                                                                                                  aC,-4 V4 +-'(-..S
                              nliglil- colilpris-2 the f@ll'th                of lici,@,,. These
                                   L.                                                                t, II @ I
                              are relatively Self-coiit-Diiied @,,Ig,,iiiisti-(itivelv b.@cEiuse of          river r
                              distinct operating requii-c,,,,,,2iits, and could retain rich of               t!-, e i r
                              present organizational Stl'Llc@Llui,e.




                                                                                L      'for 1),,@ograiii ei,,'cction
                                         Ttic, Z,d;l-iiiiistl'otiVe Stl'Uc.,tii-c-
                                         SUI)POI-T ill l@,,Sii% @,,,Ould Lci, cl(-@i,iv.ed f,,,o!',,i- Sc-,Al,         and    @i S  1,
                                                                                                                               -ti i n'
                                                                                                                  "I t s
                                         addi4L-lioti  to  tilo  integral  "[I  and  I-ISi'i  COP',i@0,                    cei
                                         a(li-iiiiistrat-ivc@  Support  @tl@-ICt        ons      -LICII as Pet-SCI:--i@el       and  f-n--,iicial
                                                   ei-it,  are  no,..i                 out                     ill  S@'S   and  @S[@,,  ar!d  a
                                         ij 11 a g c ir,,
                                         proportion    of    ti-,c)se    s'L-a.-l'-I's    should bo           identified Eiiii  trz,,iis-,rE!-@-i-cd
                                         to    [ISA.  Tliei,e  care,  as                  soiiic policy  suppoi,JL-.  activities  in
                                         SSA  that  i@'ela'L-e  to  f,'ic-clicEire.         Thc@ relevant      portions       of       'L-Ihese
                                         activities  --  i.e.  SU[)-Lilli'LIS  of  ti-,c@  Office  of  tlic--  Actuary,  0-iri@ice
                                         of    Researcii    and    Statistics,     01'1'ice     of     Progi-zii,,i     EvcilLiatiOl,     E@iid
                                         Planning,     and     tfl,,'     Bureau     of     Hearings      and                    should be
                                         identified        and  transferred  to  O@NSII  Bid  HSA.


                                         The    liec
                                                   -il th  S-i-vicc-s  Acliiii-iisti,a'Lioi, i-!ill  serve  as  a  policy
                                         I'C?SOLII'Ce   ior  issues  concerning  tli--,  cic-,livery  of'  'Health  so,,-vices.
                                         Information  on  utili7-,tic)'ti  of  all  feclcrally-fiiiaiced
                                         servi'ces              be  col'lcctc(t  throlicl'ii  I-ISA,  alth.,)Li@,:Ii  all  others
                                         dcita.-ga'Llhei-iti@i  activities  k','ill  be  COt",-]LlCtCd  in  ti@"A.                 T h c s,,-
                                         operational                 v.,i'll  iiicl L,-de                       of sel-ViC6S till-OLIC,"'l
                                         reiil,,bui-sei-1--@iit,  gi-an-L-1,  and  Jirect  service  I)rfio)-i,l!s  and                        i,,n-ed
                                                                                                                    .1   ...
                                         to  I).2  clos,,@l@,  relates'  to.L-,,3seliiie  an(]  oth(--,i-  cl,7tta  develoi)cd  in  HPP,.
                                         All  research                  be   co:-l,,!Licted   -'In          including  I-ese@ii-cli  L- i@d
                                         c,xperi             k;i   'h -Liie  '-i ii,@ki-ici n@ s   'L                  L- I -1@
                                                                                                             [IS[@  s' @k@


                                                           4 til
                                                                             -in.--ii-ig   sys'ei-i   t'(,,it licivc,  I)c)'-icy         i      io  s,
                                                   .ns i,, I       i@ c  f i ii L              L
                                         probl   c,.                                                                                       c       11
                                         and  they %.!i I 1               c 1 o s c, I   i  th  I!        s c a r c !I c@    survci I I
                                         staff  to       dck!clop    expei-i;ii,-:!iits     tl,.at     Trip     resolve     -Lliese     poli@,,



                                                                                                                     32


                                                                   I"r", T 1
                        2.
                                                                                       S I
                                                                        S.

                                                 of the                                           c,)n
                                I II -@iiiic L  I
                                                                    sui-vei'll@,111-e of tl-le status
                                o-@ l@.riilth cE,i-e in the          tiii-otig!) Stz,@te anc; local
                                       plz@t,@ri-iiig ci c @L- i v -'I i eas i..;el Ias collection a@-icl analysis
                                01 dDta on i-eso,,irce SLIIJ,!-.Iy all(i           Vital  StL-tiStiCS,

                                z;.nd disease
                                            --i)icideiice; c'---velopitig i.,i,,d testing (in
                                ,cr,c),.-diiicitioi,. ,.iith Fe,lici@@tl health sct,vice activities) iim,i
                                -,I),,)roaci-i,2s 1-1r) the provision, ei!is'L-.ril,)tit-iO'.I, &Ild LI'L-IiliZatiC)II
                                     -iltli                        faCili.L-iC
                                C lie(                                         S          -al th care
                                o                                                  and he
                                systell,.s; pi--o-,,4,ding         special  support foi- de,,elop-


                                tiii-ou@i'ti       sci-vicc@ -l'itiancirig or c,,c-iieral CdL.Cat@.on


                                This .igency brings                  the entire set of IIS'.',Ii'A

                                organizations iio@.,,
                                                          Cc-,.'itcf- for         Sei-vicos
                                -.Cluster
                                P\c-seat-cli     D@-@velop:.@,n- I,. jL-.  Ilea]-tli C;,,-[-e Facilities
                                SC-.)-vice, Co;,,@.-              Itli Pl,il-@iiiiij Sei-@Y,ice, [,,co on,;il
                                                i) I i,.sive l.leo,
                                I.'ieclical  Pro@.-,-E::i,,s Sci-vice, ii-id I?jec-31tLi l@@iaititeiignce
                                Oi-gaiiizatiot-i c,--,,vice -- @,iiLl the
                                Sol-,v,ices ai-@ci'          Ce,.iLt@i- for           S'Lla'L-listics  1'ro?-Ii
                                the [IS!.'it.-]A Ot"-f-ice of the                     Tlic- BL!r-(!ciu of





                                                                                                                                           -he    i!,itional 1, Iltll
                                                                                                                                           L
                                                             Sc,,i-vi-IC!  Ccii-ps,                Ut!IL'I-                     sei-,,,-ice        i, search
                                                             training acti,,,itic2-  tii;llt are                                     loca'-          iii   various   fiS"@-IA
                                                                                                                                             Le


                                                                                            c:, t) i- o i.ij i
                                                                               -c a                                                                         T
                                                             pi-ogri;ii,,s ai
                                                             P, C!;o  -Cos                                                                                                  Z'IICI
                                                                                                                            O'    oiir                         i- e@             n
                                                             ziciditic,@",I,  a                                d-,i,,-I,2iision access to be cl.@,,,clcpcd
                                                             to provide ci l@@,'L-,icn-al  polir-.,v focus fit),, )-aspect to
                                                             resources                                  da'L-.a.
                                                             niajoi                        @-i i I I be @Lhn 'i-i-st step  iii  ci-ea'Liii,r,l  E,  strong,

                                                             Collt4

                                                             activities.

                                                                                                oi'             /t,@i  @-'!-;Cy  Si-iOLild  clearly                                       e
                                                             coiitii-ititi,n of                         res,:)u.-i-cc,                           ng:        fi-oiii
                                                             of  V,"IlEtt  i.s  happening  ii)                            "-12altil systc@'i cind its coi'@",Poilellts;
                                                             to rc@s,,,arcii at,.d evcalllucal-@on                      of     speci i@i C                              etid             iSSL18S
                                                                                                       L                       to d
                                                             related to the li@,al                    '-.ii                               L, -@2 o i.,.; -2 i-i t  a i-.. d  o        t i  o  ii
                                                                                                               .Y

                                                                                               d@;i,otisti-atio!@s ard                              t,
                                                             of                                                                                              i-esoLii-c,-

                                                             dCVCI Oi,);,,loll,L a. c         -,I v i t I 0- s
                                                             The surveil l@;f,,c@                                        is etivisioi,,ec! to                   i n c I L,'@l        h  e
                                                                                          I 4Li        o I,        L@  C        i- e       r, s v c           I t h  P 1 @. r,@    i  n   g
                                                             Set,vice,   t.)-ie                               Ceiii-ei-       for                       SI,-atistics,

                                                                                      r
                                                             the                                          @,,-Iiice  utii t i ii                        e@i).d   CLI'   C'tlt    I-!IS!-i;'    A





                                acti %!i -Li C-IS rc@l -.ttc (I to  th(-,  dc:l@-iriition  of  f@,,-@,ilth  scai-(.-it,,

                                ai,ea,3. T'tie
                                          Cen-'L-ei- @i -o r- Pealti-i. St,-i'vices Reseorcli  and  1).-vclc),')ii-,ent
                                and   tire    i-c@seai-cii        o-,'  take            otlic,,,,       progi-iii;,.@-,.
                                Ti-ic               ai-io'               .--o!-Iir)ozi-@@nt  -ii!c:lude,,  file  CIC-1.@,o,-ISJL- a JL- 1, C) 11
                                and                                    'L            the   @l'ationc:,     I t !I
                                Service Coi-ps,             l,ilaintcr@atice       Organization        SC-i-vice,'        and
                                Emerg@-.,ic:y i%',--dical  Devices;  @ii,,d  the  opcr,-,-'L-1 -ioiial           o-F
                                            Pegiati,,,!  i,@lf-,dical  I)i-c;gi@cipis  Scrvice,  and    [@ln-altli

                                Care  FElcili-ties  S-,rvic,,,.

                                It  is              to  ei-,iphasizc-  'the  need  foi-.collsolicl@'t-lif-ig
                                       rl  i-,-LSeiircii   JL-li-ain-ii,,ri  Eci-livitic@s. l@!iiere  s,.;cli
                                IIC,Olli-
                                ongoi i-,,g @..,c)rr,  goes  be@,ond       ng  the  n2.-.@cis  of  sp,.%ci fc
                                9 r a n t  o i-  c o ii JL- r,@ C t  o,.,@ i--! -a -LL e d  p i-- oEtri st 11 Y S 1. 0 LI I d 'L)
                                included     in     li'PA. Pi-og,-ani direction  and                 s    o i-
                                for  this  n-,-%.,, agency  sl,.o,.ild  obtained                          BIL '(,',@IE

                                and

                         '3.    T I I E  C i@, FO..@  Di                                  FOCIJS  F C.'
                                                        S      Co,,,,r7-,r i. I-'T!-L P) E  T!'@
                                                                          .... ........
                                P.-
                                OU'f   tl!l'!'iiii@, I ;S.
                                                             1.1 be  to  Pi-ovide    ii;,>, -t i
                                Tiie           Diissi---                                    nal   lc,--ic'-@rship
                                  11  the I);,-. 0 v e I                  of    coil,,,i,@Liiiic(ible    anc,'    \,cctor-
                                fo                -itic)il a.",(i COI]TL,
                                bo,-iie  diseases  ii-ici                         co;i@'-I@Lic)tis- I;aj c)i-
                                functi(,,iis         I-, c I L:t p I- L, Vi'      1   colil-i-ol I I lig
                                                                           g  anc       L

                                                                             i iig St@t 'C,@ -ai-id
                                COli!ll!lll')'icable discl--,@s by @L                           CC)il!"",tl ii i t3i








                                                                                  c
                                            -oviding  .11-iical
                                                                  I  L
                            action,               L

                                                             o
                                                                      C  C.  @j
                            effect4@,.Ie t 0 c II!, i

                                                                                      0
                            heal tii                                              -s       s @ie
                                                                       ns;          s t c, r i ri?,
                            safe etirj [ICalt@l-rL[l         co::(!   0      d  4 11
                                               I



                                                                                               t
                            progi-'ai,is  relatiiiri  to  cl-i-,,I-L-lh c) -@, (i I c@ a,@l -!) a -, cP) S,@,
                            and         i-Eit  coii-L,.-,ol ;  directii-ig  @oi-,eigii (-ad
                                                                                              L
                            quaraiitii-:c  activities;  (iiid  i[-@@i)-i-oviiig          of- cl i Ili Ca

                            I aborztjL-o,-ics.


                                                       -in  'I-,e
                            This          i,,,oulci  coittL,L     I                  Pr
                                                                              I I       cvc-ii'-@oii
                            ConSLIP,@er S,-@-vic-s  ClLlStOr -- CCIltel- -fOt,  [),,,as- Coi-@,--,.-c@l  (C")(-)
                            Bui-e(iu  o Co:,-Ii,,iuii iEnv i        1. I !I n ;.I (j 2 iC E!  c.1
                            IN'ati ona.1  I,,,,sti tu-L'e  f 01- OCCLI!I-,-;.'L- Sci f,, a tid I-le@-.1 0,S.".

                            The  ag@,t-icy %.,,olilci     tiic,
                            Disease      Control,      since       tile                s i s

                                                               4-
                                                                   ,C
                            Continue to be on the cLii,i-ent,            Livi-L-@ics.  T lie I c- d -
                            based pa-iii'L-. and i-o,,.eiit control                &.ssoci

                            which rci.,,ain in the FY 1974

                                                                                         z@ s(I  -Cn-
                            -into ti,o CDC structure,                               ,c
                            staildii,,,.,                 'ilTIOSill,. llo-.,:2ver, s i; I -@l r c@, I i 'I @Ls
                            indepc-ri@l,.@iit orgc-iiii-iii'L-ic),,ial S"%-,Z'@'l-LiS ill  cl@  I t-S

                            trans-ror   to   the
                            Presi(li,,@i-,,t' s                                      ri.     c;; I ill

                                                                  I T l@'   Z,, C4       ',ni, 'Ca
                                                                                    S
                            llevlei! sio@ild  bc.   dL ol   all
                            trans-i7ei-  to  DEA, to (!eLeri,,iinc,.                            ,-.c) i)e






                                 transferred and to es,-Z,,blisil

                                                    arcl


                                 rL)@,ii-i ng                   Spec-iii                       e
                                            to b2 ii-,adr- if l@,'IOS',!             0-r-c-ice s@,a.,.i  co@:@'

                                 to be Io,-; '-.--d in ti- :c
                                 CF)c i IIA I --, II ',- a f o r o v c., I - ap r oI- d i i- e c t i 0!11 ri t-I ',.II p@ I a II;--.
                                                                              -ations coli'd also be
                                 su.p,,)ort.  I'lic i-c@mainiiig BCI-IL  o p,-, I
                                                                    SpeC-i@
                                                                                      i S  t  t 4
                                                  Li;ider -c
                                 if it              desir-(,i!)Ie to                   their            location
                                 at Park]eL@,,fn.   It is e>,,,)octn-d tlict the
                                 available          this z,(,,-.iicy in                 be stjt@l'icicn'L to
                                 ra a g   t     1-1 C'@! 0 I- g a 11 7 a'- i o n


                                                              P@' F
                                                                i -f-,S I-!It
                                 OT[IER                                   -L. f'70!;TD-
                                                                                           S@ r'Cl@,L r-.T


                                 Preventik,.-
                                 In addition fo health sci-vices                   Health i-e---,r,,L@i-ces, tii,-,
                                 thi rd broad compl             -v@.1-Y cci,,,,@poncrit of all        I

                                                                oil
                                 strategy      is       fun-'        o f p     c i I4 r,,      c: -o!-, i-  r,l
                                                                           0-1 -1@-14S t@,pL, 4
                                 heal tii pr-obl           t@.cti vi 'L-i esI

                                                                  4Vitie
                                 consuii,ip-r pi-O'Lect-ioli cc'Lli       'S  o-i@      Foc;c't air,, Dl-u@l
                                 Adminisi.t-a't-,ioi, the  cr.;ll-,-,-iuiiicablo  dise,:isl- r))  o I-, L0 II  cl

                                                I-ivities o-@ CD,, 'Firici          ("CctlDI",
                                 control      .c'                                                      and
                                              1-1 t Z., IS a 4'0       @lelltil
                                        -oil
                                                                                 C, i,,i ti C_, Cf !,Ilol@l, all I
                                 onvi I


                                 DCEI.'i.





                                        Coiisid-i,Ett-ioii   @.ias   (@iveii  to  grol,!I)iiic  all  [))"vc"'Itive

                                              i  i, c'
                                                                 s  u i,

                                                                      E, s c ri   s i o n cl      o  t h e  D,@

                                                                                                                           Peol'g'
                                                            -S                                s  D@-p                             I-l'i z

                                        tio,-i            I'Iiis                   Igelicy
                                        third-  asl)r-,ct  of  all                              --@i-,itegy            '.-'ould  coi,,si cl  r
                                        b i-o a dCl L!           of          -Lo                                            frciii  L,,D-'L-11
                                        a   pc-i-soti,-Zl   licaltli   a.-Id   a    public health  aspect.             Such  an  agency
                                                                   S C,     C              I_ -t-sc,                   'I-,e
                                        VIIDL[ld solve as a                 C,
                                        o f  v a rc,,,,i s j) c- v e ii 'Lli,@c- lil,,il-L@li  sc,,i-vi,@es  that      1,1@o")Osc"l  f"))-
                                        coverag.2               I-ieal'L.i-i -ic-iti-anc-irig                   It I-,"O'Llid  also  %.@,cigli
                                        the I-olzitivc-,                 0-ic  coiiducti:io  pi-evert-i%,e                      activi4Lies

                                                                    h
                                                                       ,,J-Lil    01-     ColleC,-4
                                        thro,,tg    ci        I                                 Li,,le  ec-i-lioi-.  @,,,,proLi c I I  I- i-,

                                                      -,o @-il  I-lezil@L-11  Services
                                        than  a  1)c@l  ,   -c

                                           Ideas  gc?ll,. clil-Ilklly  felt  that  consoliclia-bii-,g
                                        it                                                                              --ive
                                        activities    Li)-idor     s-itiglc,     le,-)d-c) -s.iip            cl@rify  tli,,
                                                          of -preventive  ac-Livitie,.;                ho,-,flvei,  i'L-1 @-.,@)s  also
                                                                                                                             y   .,,4
                                        recogni zed' tl----,,t  the                  of  all  ci,, 'orcei@
                                        agl--ncy              i-ias              ,,iitli  Sig;lilriCallt  SLIC",@C-@ss      oil  c O!-,., D at i v e
                                        and technical assi'--,-'L-l a r,, c e ci p p i- o,,@ c 1 i c-  o Li 1 d ri o 'L-1 s,L-11-otig'(-.i-.,@ll
                                                          -1y's  abili'L-.%,,  to                      Tlit,,,s,  a   i:;,qve   to
                                        eitlic@r     @,geri                      L
                                                                                             in  this                     The
                                        [:D,@        CD,,'  is  not                                                                              a -

                                                    -OU',)S        c
                                        tioii  gi                    IC-,-ii-ly   Iii-c-veri@-iv.-, activi'U-ies  'L-"riat  ai-e
                                        in IISI.'ii'll'k LiijfJ,,2r CDC.1cL-,,,Ic,.i-sliip,  ii,,cl                         sei)ai,@iti(,!l  ol'

                                        Ff)A.








                                                                                                                         calls                       c i,                                        c i,
                                                                   f" - c; I
                                                     1) i-e v  ti t i v     a, c'-'                                 s 'Li I            fi their @Ll)-l-tiOnS frcrf,-i                        tfiose
                                                                        e         Livit-ies,  to
                                                          C)                                        c e s                         f)  i- c s o!.i    c;@ s         p 1, C-

                                                                                                                                                                        eT@for-ts
                                                                                I L I
                                                                                      c i--i          a. ri @i                  tile                      o-f    or    @,,o@d
                                                                                                                                                      L

                                                     to    iiii'ec-tious     or     uiic.afe                               or  coti,-@i'Lliciis  that F,,,ay  have  a




                                                                                    care                          nor  slio@ild  -@li,--y  ov(?I-Ial,)

                                                                             (I     4
                                                     to  ii,;,-rove                               of                        (es                         to  I)i                                        ces

                                                                                         D       -I I' tl,.-I c I'l t s                                                         L
                                                     by State  11,3al                      a  P,                         1.1-itl.,,ouL  c,  clc-,.c                  -,:,,i-ca'ioii  o'

                                                                                                                                OLit  for                                  I-',-ay
                                                     tii  Is  II,   t   .                 I      L  i   e@                                                      L I

                                                                                                                                        cei-e  service-,.








                                                                                                                                             'Le


                                                                                                                    I S         L I 'C'--, S   0    0 1
                                                     PI acei                                                                                                                       in

                                                     the
                                                                                       'L-.!-,,-se                  b,, c i     -'L-,  actio,-is  co,,-,sis'Lc            -i t  ,,-i jLli

                                                                                                                                                                               -vice
                                                     tli e  ii o@-i  F             @l I     o I e  i n  I,,2 zi I jLli  i..-iiicli                                        s:,- i
                                                     (lel-ivev-y                                         t i-  -i i,i i         I- r) (I 1- O!@l     -,L i    ' 'C   (I I   I I'.' g
                                                     c-iiii@ll-iasis  oil                             as  t!ie                                       Li    I I- C@  I- 0  C'   0 II-
                                                     and  tl', 0          L! 1-1 C -'L-, "I 0 1I  i  ii  't-      'Lion                                          4111   jL-I-i,@
                                                     recoi;:iii,--iided    -irive--areii%--y    l,pi)rc)@icii                                                rcsoi,,)-ce@,  services,












                                                         S
                                        Tli@re z@i"c


                                                         Of

                                                                                                                   pl-0 4 C.Ct
                                        Statistic,al                     to         ard  ser%!icc, del-i,,e)-@,

                                        and                        to ,-!.SA.    I!-,is          aci-,ieve a  c    o ,I I-

                                        collr>olic'a-'-ioi-i of -@Llie           services and

                                        -ind                 tlic,  i-,Lccssary conversion  to o-L@ii,,,- financing

                                        mecliai@ii si;-is along                     activities    in    than    ricl-!

                                        It %,,,ould               !-,,ol ic@;
                                        for -@Licii  1),,,OgrE:;-iis. In odd4i'L-, -'Ioii,  tl,,e    expertise @,-,C)Llld

                                        facili'L.            itIC:]L!SiOl. 0-1: Co,,,e-,,acle for

                                        Iie-cilth services  in  'Llic                   p,(-ogi-ai:is.  Urid-et- -LI,, i s

                                                                                                                       4  4  4


                                        would Lie moved  to the


                                        'rile       2,1@oliol   aiic?l   di-L@,g   ob,,ise    sc@i,vice    ic-Livities,

                                        require  lcg@lslEi-,L-.icii  @Llb  be sc@P,7-,rateci  -i'7rori        Si tice

                                        feasibili'Qi of

                                        consicic-i-c@4L-ion., 4,-.Il,-- sc-pe,-t-atio!i o-F alcol,,oi     d-,,-,,;g   s .2

                                        services fi-oi-,,i               not                       -Tjiis  decision

                                                                                                 Se,-ViCe aCtiV4  i@S
                                                         -e'-ciitic)i-i of cit  le;,st science
                                        implies  the i

                                        Witllifi         i-iill                           a  research  pi-ograr,,I.


                                        At tfie                            is  iilei,-it to  placi@',-,!  -Ill^irial-y


                                                                     L- 0 11@     Lt                        L
                                        eltll)IIE@SiS I)Y 01-C
                                                                                                         -.t I-L, -e

                                        role 0.1'          .is  a  I-csc,,I-Cii-ol,ieiitccl  or@i  II i i-.@i @Lli Oil

                                                                       ic,ivii-,i--,  1-n





                                        vic)ttld result      in    ci               o -,r disruption  ,.titliin

                                                                                           SSi@
                                                                                                , 1,   I        Of  C  :,.i.
                                                                       @'li tj  t   I

                                                                      Sion ol      s c@
                                        tlic,,  future    co;il      'I               )-vice    a rid             e r              ,s


                                        Gi veii  these      cc)i,,sicleratioiis,      i-L      is
                                        be  retained  is  a  free-stot@,,,rJing  Insti'L-.L!tC  and  be  p"l@(-ed

                                                                                                                           ,,,eii ii,,ore
                                                                 a CO
                                        wi ti       IIH.     P        Tile-,nt of  '!!!@ll  in  11,1111  I    @',cs  i t
                                        inlt,)Ol,taiit  to  give  attention  to              resolutioti.0-ic  tile  issues
                                        coricci-iiii-ig i-el,-A@-ioiisliips                  the                 se-l,vicc,  cl-2livel,@,
                                                                                              par-iculzirl
                                        aspects  of NIII  progra,,iis                       L                 those  i i-i    '-fie  l@atioi,.@,l
                                        Cancer             Itistit@l@Lc End  'LI-,-,   i@',@ttioral           a@--iul  LL,'YI!L! institute
                                        and       -L-lic       proposed Health  Services

                                        ResOL,
                                                i'CCS



                                                                                                               o  rc ..,s
                                        He?.Itli  Sci-vicn  @-eli,iery                          of          Pi   q  i@@

                                                       -f     s      Li   en    b@-sic    bi ci@.c-di cal     i-esear,c'              n s   i-@ -
                                        Thc,,            acc          t,.,: -2
                                        tioti,      and      direct      dc@livei-,f are   co,,,.i,,)Ie,<.    I ii  t I,, specific  ai-c@a
                                        of  de:                                                                  'I'V I CC            r,,@o s
                                                      ,,l,onstrati,@,@i and  direct  @-live,,y  ok            S C.       --S   ,L           L
                                        obvio!is  area  of            concern  is                                           o@@ con',-rot
                                                        in  ti,.,-!   ','a'Llio.-icil C'--iicer IIIS@L-li-!'.Ll'tp- and  tl,,,@    'L, i c.,,i,.-, I

                                        He(ir4' and LL!I-i@l, 'institute.

                                        It  I,,,as   )lot  possible  ill  t!14.,j   C--,Lf@,@dy          give full

                                                                      r
                                        to clo-')7ii-iing             I)t).,-iatc, -I-C.!, 0. @Li -,,rise) ia ITT!
                                        patterns bet@,:,-@@ii health               set-vice (le'livil---t-@., and L)ic,',i rll,,i :Ical





                                  arch.  Control programs    and other li
                                                                          @al @Llh service
                               rese
                               acti vi ti es of   vii tli thci r categori cal focus       zi@L, e;;-, p t
                               to bridge from research   to services through tile es'Labl i sii,-i@n-n@.
                               of disease-oriei-ited            syste,-is ol- health        I t ,.,,as
                               tile general -assL,,@,,i,,)tion o' this study these services   ri,,, s +
                               in the long run, be tied to health                            @.!hi I e
                               no recon-@-ilendatibn is being iflade for oi-ganiza@Llioii,:,l -changes -L-o
                               address the relationship of-service delivery and research
                                         the area requires further study and resolution.
                               prog
                               -Legislative, pi-ograi.-,,-natic, and pi-ac@.a@Llic concerns should be
                               in corpo,-,--ted into an analysis of alternative steps the
                               Assistant Secretary for llc@ilth could tall,,., to clarify these
                               relationships.   Ti-@ese coiisiclc-,ratioi,,s  have
                               on the H---A service delivery program policy and ir,,,pleir,.eiitatict-1,
                                                                                            0 11 S i
                                                                                       rc-s
                               decentralization actions, regional office progi             p
                               and the  futj're role of  research programs.


                               Lpl i ed H,2p-lth Peseprch

                                                                                           11 i s
                               During  the study, it @.ias evident that applied i-eseei-c,
                               being  carried out in virtual  .ly every @i'E',,! health agency.
                               Applied research       both biomedical and health -services
                               research      is needed to develop rieails of -'ii-.-,.pi-c,@4ing the
                               health @et-vice delivery s@,steni and preventive health se,-vices
                               and to provide a Sound scientific basis for regulatory action
                                         Th                   initially the responsibility     o f '! T.,@ ,
     0                         by FDA.      is research @-ias       c                              i

       L










                                                                                                                          -esc
                                          but has    gro,,.,,n ul) else,,,,,iierc@ la)-gely.     because     the     "Ili i      r c h
                                          has  be                 lisive  to olier pt-ogr@,rl needs.
                                                  en unrespo


                                          Environl,.iental  health                      is  probably  the        r,,Io s t

                                          diffuse area of applied                         research.        ',!i thin
                                          enviroti;iiental  health  research  is  carried  out  -ir,
                                          by the f,ationa'i  Cancer          Institute,  the National  IIISti'L- L,t C
                                          for Eiiv'roniiiental  Ileal'Llli      Sciences,  the radiational  Institute
                                          of Child 'iiealth  ei-id Human Developr7,ent;  in                FDA i L'  the tlcitioiial
                                          Center for Toxicological  Research;  and  in 1-isil-lil,j.A @%/ BCE,"I,  t!IOS'i'!5
                                          and CDC.   The primary            need  for this  research  is  as  a  scientific
                                          basis  for FDA's  regulatory decisions, yet Piost of the research
                                                   Lli@tti  that aL i,@CTR is  not influenced  appreciably by FD,"@'s

                                          needs.


                                          In addition,  the applied              research        problem         includes touch

                                          research that falls  into              the   "gap"   be'L,%-,,een   t\'IH   and

                                          This    research    @-iould    be    useful     both     to     the     financing   ,nd

                                          delivery of health  se,-vices  and  to  th-- de,/eloprilen@L- o I'

                                          -health resources,  but @ilif considers  i-L.-too  service-ot@
                                          technology-orieiited and liS,'@',Hf@ considers  it  too  bio-,,Iedical-

                                          oriented.         This  research could  be i,-,,,de i-iiore           res .ponsive  to
                                          the program,      needs      either      by      placing      it       organizationally   i It,- 11 i 1-:
                                          the -pi,ogripi    that I-IOLild use       'the  research  results,  or  by establish
                                          a iiiecliiiiis:,l for the  progi-a,-,,, that needs  ttie results  of the re@.ep.1-

                                          to  -i nf I LI,-IlCe the  priorities  for and  the Plays  the research  is



                                                                                            li3

                         It was i-ccognizc@d@'liat neither of the,t,,,,,o possible sol titi
                                           L                                        oils
                         to the appl i ed research pf-obl eiii ,,,ias liapreni tig in HS,,'.'I[!P@. , It
                       @i-ias also recognized that the solution to the environ,-,,,olita.1
                         heal4L-I;i research pi-oblei,,i probably did not lie in  since
                         the. problem concerned primarily FDA and Illq. To cittei,i,,,)t to
                         address that problem through an applied health research
                         organization in HS,?.IFIA i-iould tend to complicate rather than
                         siiii,-,)Iify it. l@,lhile the problem req@iii-es early attention,
                         it was considered more appropriate for StLidy and resolution
                         outside the context of this StL;dy.

                                                   searcn  p                        IIH, the
                         In general, the applied re         roblem arises because t,
                         agency those primary mission is research, has o-ici@-en been
                         unresponsive to other programs needs for this research.
                         The solution lies either in devising %-Jays to make this
                         research responsive while leaving it in its present
                         research setting or to place the research activities
                         in the respective prog)--,Pl settin(is @,-,ihere it can be
                         responsive.  The former alternative appeared   more
                         attractive because the direction @,i,,cl se-L t'i tig of research
                         priorities, including )polied research, is considered an
                         appropriate aiid a necessary acjt-livi@1-y for ,'Resistant., S c- -L-ai@y

                         for Health.





                                           -ALT[I           S't!Cl@l-D BE TI!,- I-Cp HE!@t-T.",
                       5.  TIIE REGIO                                                   CF17T'C, T,' I
                                 ff
                                 -ly
                            .-Cf  II i.
                              The major future  resl)o:isibli'tics o l@ the regional o'i'ficc-_, (PO)
                              health staff @,iill be to help z).(I!- ' ister and P,.onitoi- national
                                                                iii n
                              health insurance activities, provide surveillance of the health
                              delivery system, and assist in resource de%,elopr,;nlnt and public
                              health activities at  the  State and local level.  Tl'ie overall
                              mission includes the  following major functions.

                              Standards Com           This %qill be a niajoi- activity in tfie
                              administration of f,'Icdicare and I,'iedicaid and in future national
                              health insurance and revenue sliai-4,ng pi-ograi,.,,s. Standard
                              setting and compliance activities relating to health pi-     ovidei-
                              participation  influences  the  mci nner in %,i!iicii those se-,,,vices
                              are organized and delivered.  'Fliis function ii,.ust be conducted
                              in cl,o se cooperation Keith the designated State and local

                              agencies.
                              Surveillance.   Regional Offices @-iill play an ir,-iportaiiL-1 role in.
                              the health intelligence   net,..!oi-',,,. Infoi-i,-atio-.i on health care
                              needs, co,,i,@itions, and program effectiveness must be gathered
                              and analyzed on a State and regional basis to monitor ni,ogi-ai-,s
                              and problc,-ts; to predict 4L-.i-ends; to assess resource utilization
                              and to provide the b,,sis for developing strategies for change i
                              health  fii-i@i,,icing aii,,l i-esoi,-rce      programs.

                              Resource Develon@eiit.    As an oujL-gro,,@itli of surveillance and.

                               s s






                                                                                               end r)t@ovilcle
                                                    support to   States'(ind co
                             a.i-)d d e,,io n s tr z). t i o ii
                                                                                        dge Died "C-11  devel@')P-
                                                               altii services          0
                                     for
                                                                                 It  of research.
                                     in science and                   as a. i,esu

                                                                            d Li     7 C capacities
                             Technical clssistall'@e activ".-'Os      s@loul
                                                                             five central
                             availa@le witi-lill the RO's-,       ti-iili the
                                                                                                 sr    alized
                             and elsc@,,;',-ici-e in the Depztrt@,-;-2nt, as %,,,ell as in othe   .,,eci
                              resources throughout the nation.   Technical assistan-@e'l,esoui,ces
                                                                           I-opi-i ate.. SuPPOI-t O@ this
                              Trust be c-111-1@.liced aiif  exp@in--d as IPP
                                                               U-
                              tYI)e vii I -1 need to be   pIi,ovided to co:,,,,@liunity groups and agencies,
                              as 'vicll as ".iealth institutions and c,-icficizil agencies.
                              Preventive    iind PLi!)lic ll,,@,:ilth Activities.  The Depai-ti,,ient's-
                                                                                         ciall    c o', c c- c- -d
                              health activities have t)-adi'Lionc-Ally been         espe       i
                              vtith helping the d-@vclor,@,,,,cnt  of State anJ     local public liaal'Lh
                                                                            ie through the PO's, al@L-hou-h
                               services.  This focus should        colitiii,,
                                      Lil(@ b' develo@)ed in a cciitex,  of concern for a to'--l
                               it stio       0                            t
                               health strateay.   Effective assistance in this at-ea will i-,2qu-ire
                                                  ition of pi-ev-ii'-iv,, health activities 'L,iat sh,,-,,il-d
                               a. clezir,--.i- Ct--fi ii             L
                               be  focused On Pi-oblenis of disease Coi@Li,ol through epide,,Iiology

                               and i ril,i,.IL4, 11 i z,@i Jk,, i o n
                           Given the s-@uat@d nlissio!,-] of- the regional health staff and the related

                                                           L
                           f LI n C t i o n s I'C C O@,,!.l i@,,J ai o n s on t r,,,, [I 0s a r e
                                    Tile Regional 1.1e.al',-,Il Llii-ec'Lloi, (U!D).'.@liould be 'the principal
                                    health) official in the PO.        This role should include a







                                                                                  ii ng
                                          n,, -il)assing program leadership, Plan'
                            broad Mandate c
                            irpplepi,,iita'-iori an'! direction Of-'     O'@in rc I'l 0 "Is
                                                               V
                            It also should i IlCl Lide areld'L-lionship i-ii tli the Pegi,Dtial
                            Director as principal health advisor,  iiialirg unnecessary the
                            position of Associate Regional Director for Heal',-h.   The 'i?.!iD
                            should be responsible for all health progi-an,.s -iii his region.
                            The RHD's should report  to the Assistant Secretary for
                            Health thl'O LI g 11 the Deputy Pss'is'Latit Soci-e'Lai@y for Prograni

                            Operations.
                            The capacity of RO staff to provide technical assistance
                            should bc increased as appropriate.

                            Grant decentralization slioLil.d be cor,.t,)Ieted pi,oi-i-.,'ptly.
                            The RIID should develop'meclianisi,-,s for the full integration
                            of the efforts of the regional health staff such as
                            consolidated vior,, plans; consolidated operating budget
                            for salaries and expenses; and flexitility in Litilizcitioii

                            of personnel.






                                              IV.  tiE):T S'FEPS

                              factors need to be consicloi-cl,l c@'trefLIll" i n the

                     dc\,elolj;,-,,ent of in           strategy.


                                   is -Irescritly a1-.igh degree of ii-.or,,,entLir,,

                              associated     the      leadership in

                              i-,,Iiicli could bC,' SLli)i)O@"L-i\,e of i-eoi,gani-,a'L-,i on.


                              Nevi zigency lieicls %@.,i I 1be designated in the near
                              fLItU'f-0 .Reorganization activities should begin
                              as soon as possible to avoid territorial
                              disputes that riay develo-p- i,ii t[i del a,led action .

                              The o@erall impact of  the lie,,-/ health leadership
                              to cf-['c@ct the proposed organizational changes

                              will diminish      prolonged delay.


                              Tile CLtrrent uncertainty and restlessness thaL-.
                              permeates HS,?.@',Illi,@ cloi-,,,,inds in',@i-@ediate action and 77

                               -i-otig leadership.
                              st


                              The abolishment of       and creation of tl-.,o
                              nei@i'age'ncies (Stealth Services Administration and
                              1-1caltli Resources Adiiiiiistratioii) co,,,-Id L,., done

                              in@Lc2)@@nally uricle-i- the direction of an acting
                              Acii,,iinistra'L-ot- of               @,I)p@arance of
                              this il@proacil, lio,,,,,--ver,. Could viell be construed





                                p                              ion of carrying
                                 i-ocrastiiiation, @@ii tli no    intent

                                                             Cl 4-0
                              Oli Ltile               Tile nee    avoid    I)i-oloiiged
                              organizational chaos i,:ould arg,,je strongly for -,n
                              iniiiediate br@!a'r,, of HS"li@r,% into @RA and II.SA, %.,,ijL-ii  each
                              agency  reporting   directly   to   Oi@S@l.

                              iiice all  o-'  tile  reccniiiiiended  actions  can  be  c.,ffected
                              'S
                              within the authority of the Secretat@y, conCLiri@etice
                              in  the   overall   concept   at that level will  be SLifficient
                              to begin iripleii,.etitatioti under the leadership and

                              d  -,tion o           L-lant Secr
                              ire       f the Assis'        etai-y for Healti-i.

                          .   'file development and approval of a co,,Iple-Le ot,.gpnizatiolic-zl
                              pl an containing detailed mission and function s'L-late;,,6-nts
                              for all units is a tii,.il--consuming process.  Effective
                              reorganization will be seriously jeopardized if this
                              process Must be completed before implei-nen@Latioii begins.

                           .  lininediate ii,,,,,r)lenientation will require iiianageTi,,--nt
                              flcxibilit,,, for mat,,ing operating decisions ;,iitiiin
                              the overall           of the reco:@.1,@'i,,cnd,--d plan.


                              DLtails of tile organizational strL,CtL,'i@e can be
                              developed is ii-iiplementotion proceeds.

                      Considei--iiig these factors, it is recorpmeiided that iniplc,;iiiitatio,.i
                      proceed under the- leadership of a rianag.@;i,.cii'L tearn asseri@;',)Ied by



                                                                                                                       'Ci


                           tiie P@ssistarit   rr--cretary   for Ilealtii.     -I'fic, 'L-ee@i,  sl,.,)ijld iriCILi"e:

                                                                                               -ion
                                                                  --etai,y foi- /\dFiinis' -a'
                                       Del)ut@, P,,sistant @'o,                           L   L      and
                                       I,', a n i 9 e; i,, @--, n t
                                       Depiil,-,%,, Pissistaiit            foi- I.',ediccil  and

                                       Deputy Assistant Secretary for Prograp.-i O',)oi-a'L.         oils

                                       Adriiiiiistrcitor of 11,Si@

                                       Adi-niiiisi'li-ator of li@'@A

                                       Directoi- of IIIH

                                       Director    of CDC
                                       A nucleus of three or foui- managers that can direct
                                       dav-t@D-di,f activities                       areas   of    the

                                       reorg.iiii zciti on

                                                      ipal  issues regarding the rrial,,eu,@) of the
                             There are t@@io priiic

                                                                                            a4-i
                             ri-iaiiagei,lent teani. The first, involves the integr  LI on of DHI
                             and IISA and tlieii- ulti.-,izite transfei- to @ISA.        The responsibility
                             for this Piergor could be cissigiicd to the P-,dmitiis-111-citor of
                             HSA  along  i-iltli  ttie realigni-@,,,,-tit of the service pi-or-.@i-am-s froni
                             [iStill IA. Because     of the r@,a,iiitLIde of both tasl,,s,  the Assistant
                             Seci-et,iry could elect to retain in his office the P),",I/!,',SA
                             re-.i)oiisibilit,,, until  stomach 'L-.iTic- as the                     details
                             are finalized, thereby CIISLII-itig.aii o,i,derly intc!g,.@,,,U-ion of these

                             programs    into    IISA.
                             The second issue involves the agency               1-ic,@lles' direct l')ai-tici,,),-@ticil

                                                                                                  I I-CqLi I ,t2 LI




                      close %.iorting relationsliii) ti,,,c-it might o@llo,,,,,.Iise occur ii
                                                                          ci-ive  por@'
                                                       to            i,esp" L.
                      each agency is  left on its oil
                      of tile i,eco,,,,i;iieiidatioiis. it is quite i i;,
                      that the entire tea-rii be held accountable for the total

                      reorganization.

                                                      ta@,en to            tile
                      The follo,-Iirig steps should be

                      reorganization:
    t                      Step I - Obtain Secrej-,iry and Undc@i- Secre tai-y concurrence
                                                      pt.   Vlitli this concurrence,
                                      in overall coii-le
                                            te                 aLi their JL-y and
                                      delega
                                      responsibility to th e Assistant  Secretary    for

                                      lic-a'l tli..

                            Step 2    Brief  appropriate  Congressional  and   ExeCLiti%,e
                                      Of f i ces. It is essential that these briefings
                                      be completed  before details of the  i-coi-ga ii i za ti oil
                                      becorie general lno,,-,,leJge.

                               p      Appoi          ;iageTnent t-@ir
                            Ste  3         ,it the n@a              and develop an
                                      implementation  strategy  end plan.

                                                                        4
                            Step 4    Transfer Nll,,'.1i to  and ii,,itiaL-e further Study Of
                                      its internal oi-ganiZ,34-
                                                                    and

                                      intei--.relationsliirs.

                             Step@5   Esta.blish CDC as  an ageiic@,.;,,,nd transfer 'bCcl"l

                                      and ill"I'OSH.



                                                                                                                                51


                                                 - Establish t,,,,o tie,,,i   agencies                   '!S!@) and
                                      Stop 6

                                                    abolish 'iSi"ii'-!A.


                                      Step 7 - Transfer                  fi-ci,@i     to

                                      Step 8 - Establish Regional  Office liaison st@,-f-ic under
                                                           eputy Assistant Seci-e@z,@-y for Program
                                                    tile D

                                                    Operations and begin to  iniplei,l,etit oL-her
                                                    recoi,.i,,,,endcitioiis relating 'Lo the Regi(",]@il

                                                    Offices.


                                      Step 9        On a prede@L-c i-:,,i i ii c d' date to be established by
                                                    the Secretary,  preferably not later than
                                                    July 1-5  1973,  t,-ansfc-i- BIll  (SS,'%)  and ','.S"  (SILIS)

                                                    to the direction  'Di@ the Assistant              S,-c)@e'Lai@v

                                                                                                     4
                                                    for I-lealth.      '@-litliiii 90 deals of th@s action,  the

                                                    OASI-I and '-L-he                   ol'       and @ilSA fill

                                                    determine and  i,-,,,I)leTei,t the t,,,ecessai-@,
                                                    actions to integrate           @Ippi-,,priaLe     u,,i  i b r, s a n cl

                                                    establish their stafi@s           in IISA.


                               If   implementation is Li-iidertaleii                            along th-@, @enei,al
                               steps outlined above,  the reo.-gani.-ation could reasonably be

                                                           r 1,  1973.
                               completed by OctoLe


                               Time is     of   the   essence   and   the    deg@,-ee    of                    in large

                               measure     depend upon the speed                    %,Hire!-, iii-@pleir:eiita'(-Iion call

                               pi-occ!?,l  in @n                              T      i f,              7

                               front the Secretary is  imperative.




                                                                                                   52
                                                            D D U R    S l'U D Y
                                             "S  I 'L- , I , @ @ ,
                                        PERSOii   I T r"" f T
                                                     01
                                                               'I Z'@ T,
                                           P R 0 G,"\ PiS@-,"iD O' TT k)i

                                       and I,Ic@rital

                        Acting Adiflinistrator:

                           David J.   Sencer'
                        Deputy, Associate and    Assista
                                                                      r,,,in-sl,,,ator and
                            Frederic!,, L. Sto,,e, iiiterir.,,@ 11,@,T)utY Au i L
                                                         to,, for Developi@---nt
                                 'I,,Ig
                                Act . peputy f,,@r-inistra@
                                 'Ice A.         Associatc Adplillis@Li,,a t c) r
                              Bever
                              Progre,.rii Planning and Eval@i-,Itic)n
                            John li. Kelso., Associate. Adi-ni ni stratoi- foi- l,i a n a gt
                                   1,1. lohnson, Associate Ad,,miiistrato)' for Re-io:,Ial 01--i@.1ces
                              David   v
                                                                                    1L;n@ ca'
                            Gerald [q. I',ui-JL-lz, Associate Ad5',inis@Li'atol' for Cci@l', 'Ons
                              and Publ-ic Affairs
                            Joan F. Bu!-,Iinel@, Assistant Aci,,,,iinistr@,tor for Legic-'iatill.,)
                            Robert J. I-aur, DelDLity Administrator 'or Prevention and
                               Coiisuriier Services
                            Emery A. Johnson, Ac@Litig Det)-u@tly                foi-
                               Services Delivery
                            Berti-,iin S. Bro,,.,,n, Deputy Ad.,iiiriisti-atoi- -for t@lp-ntal
                         Program Directors arid Staff:
                             David J. S--ncer, Center foi- Disease Coi-,'L-li,ol

                                                              L,U L
                             Marcus '@l. Key, National Inst-i'- -e foi- Ocoui)atioral Safety ari@,
                             Robert E. Novick, Bureau of Com.-nunity
                             f,larjorie A. Cos,,-a, National Cei,ter foi- r'c-tn,@ily PI-,Iln4ing Servt.--es
                               Albert B. LauderbaLigh
                             Arthur J. Lesser, @-laternal and Chil--',-         Servic2
                                G.i-ace t,l. Angle and Ralp.h   Pii-dee
                             Paul, B. Bataldeii, COi-@,@,-iLiniti Pealth Sci-,,ricc
                                         ).                                 -



                                                              I


       I





                                                                                                     53


                         Ei-,qery A.
                                                               Servi-ce
                          Ro!-@,-i-t E. Stroicher, Fectc--al Health Frograms Service
                              il.oland D. ip-ici@ae
                          [I. [-'.,-,Donald                         Sc-rvice Co,,-Ps
                                          'I tj i) a  'I                   Y
                              llot@lard G. 11,         cxander
                          Robert van          tlatio,,,al Irl en t e rfor Health Services
                              Research aid D,,velop@,,eiit
                                  Ii. Grz,,ning, Health  Care Facilities Service
                              Ruth E. Duniia!-,i
                          Robert P. Jc,,rir,s,                 Health Planning Service
                              John Capotii@Li, Jr.
                          Harold I'argulies, Regional 't,ledica.1 Programs Service
                          Gordon K. t,'i--cLeod, Ylealt'ri l,,ciintcnEincc@ Organization Service
                           Bertram S. B-i-o,,.,,n, National Institute c)f !,iental Health
                              James D. Isbister and jan,les D.
                           Morris E. Cliafetz, National Itistill-ul--,-, on Alcohol Abuse and t"A'Icoliolis
                              Kenneth L. Eaton and ic),'-jn f@.
                           I-lilliam E. Bunney, Division of Narcotic Addiction and Drug Abuse
                              Karst Bes'L-,c,:@,-@an
                           Theodore D. ',-!c.,olsey, '@,lational Center or Health Statistics
                              Ed,.@.,at-d B. Per-,-in

                        Regional Hea't,, Directors:
                              Gertrude T. ilLinter, Region I
                              C. Robert Dean (Acti.ng), R;-n,,,,-ion 11
                              George C. G@.i-diiier, Region III
                              Eddie J. Sessions (,@ctii-io)  Region IV
                              E.  Frank  Ellis,  Region  V
                              ltolmaii E.           RLgion VII
                                                L

                              Abel G. Ossoi-io, Region VIII

                                  cl p

                              David l@l. Johnson, Regi(.-,,,iv
                                                          A











                                     Staff
                                                                        Office of the Associate
                                      Vevei-ka and Alv",@      Harvel,                           L
                               Ad,-,iinistratoi, for Region. Offices

                                                                                   -Inistratoi,
                                   E. Goldstone, Office    -,f the Associate Ad,,ii
                                                                  L
                               lot, P,-ogi-ain PI,-,.nning @,,alua'ioii


                    0  e I-    c -i e sP, E
                                                                                            og4
                          t,ioi-l,is r,,. crinr,,'E2r, Director, tlational'Center for Toxicol   cal
                               f",-@-s,--arch, Fooci and Drug
                           Joseph P. Hile, Director, Executive Director of Regional
                               Operations, FDA
                               Ronald T. O@@es
                           John F. Sheri-iiati, Acting Director, National Institutes of Health
                               P,obert Berlii-,er, Thonias J. Kennedy, Leonard D. Fenninger.
                               e.,,,d Leon Ecl,,,,-,!ai,tz

                                                -t, Direct
                           Kenneth  Il   Endico4L          or, Bureau of Health l,icitipo,,,ier
                               Education, i',IIH
                               Daniel F. '.','I)iteside and Charles H. Doe'Lltner
                           Calvin B. Bald,..iin, Jr., Executive Officer, tlation,;il Cancer
                               Insti@Lute@ @,IIH
                               Jo,'-iii C. Ballar, III and John 14. Yai-I)i-o
                           Tlieodore Cooper, Director,- Stational lleai-4L-. and Lung Instit-, Li 'Le [,I H

                                                                  I TnSti@U@e of
                          --David P. Rall, Director,                               Eiivironme
                                                           4        L     k,L                 ntal
                               Stealth Services, illH
                                                                                        -e of Envii-c,@-.-,2r
                            Williai-i '.-I. Pa,,r).-., Deouty Dir---.ctor,      Iiis'Litu4L
                               Heal -L-h ServicC-S, 1'IIH, and Scientific Coordinator of Frederick,
                               Cancer Research Center
                                                 Commissi-,,,'.ei-, "'iedical Services .1ldmiiistra-tion,
                               Social and Re@iabilita@Lioii Services
                           -Tho,-ilas M. Tierney, Director, Bureau of     I!caltli In@-Lit-ance, Social
                               Security P.,,@..-.iinistratio,i
                               Ir@.,.,in I-Ioli,-.tein -lnd .','.oi,i@is B. Levy


                     Office of t,r -2   s i   li

                                                                  L  t,
                               Richard L. Seggr-,l Deputy issis--ati@ Secretary for Progra,-@i Opei-atio





                                                                                             5 5

                                           S',-Iociil-A,@7sistalit for Drug [\buse Prevention.
                                           Acting D-OPuty Assistant Secretary  for
                         Rupert F.
                          Adniinistration  and il@l-aiiageirlient


                  office of the Secre-F-,rv,
                         Bernard F. Felly, Office   of the Under Secretary
                         Eugene Rubel, Executive   Secretariat (,Health)
                         Peter B. Ylu-4Lt, Office of the General Counsel
                         Keith          Office of the Assistant Secretary for Planning
                            and   Evaluation
                         Peter Fox, Office of the Assistant Secretary for Planning
                            and   Evaluation
                         Thomas S. t,'icFee, Office of the Assistant Secretary for
                            ttd@clirtisti-atioli ari(i ',ia,,iagc-i-,leiit
                         Joh@,i Pinney, Office of the Assistant Seci@etary.fo,,- Pd@-iiinistratior,
                            and f,ianagenient









                                                                                                                   DrPARTiVENT OF HEALTH, EDUCATION, AND VJELFARE                                                                                                                       APPROVED: HS
                                                                                                         HEALTH  SERVICES  AND  MENTAL  HEALTli  AI)V@INISTRATION


                                                                                                                                                                                                                                                                                        DATE:    APR

                                                                                                                                       O@,  ICE      O'i7 THE AD@,,', It\!!STRATCR

                                                                                                                                                                                    DFPUTY
                                                                                                                              ADTV,INISTRATOR                              AD.,@l NIST@,ATOR
                                                                                                                                     j.                                 F@rc,lcri@k I-, St,,: 0,  i,iteriiii





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                                                                        of,  :Ioi@ I U t'i' !'IT
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                                                                                                                                                                                                                            t'\SST.  ADPi-@iN!ST,@A-                                       ASSOC.
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                                                                                                                                                                                                                            IFGISLATIO,4                                                    RE") 1 ri@@A L OFF.
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                                                                                                                                                                                                                                                                                             1)3,id W. I(,Il!llun
                                                                                                                           C;cruld N. lt,rtz
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                                                                                                   I S                        1.@l @Ty                                             !.IT Y           1 i'@ I S                                             I s -                  REGIONAL  HEALTH  DI@,.-;'.TO'@S
                                                                           A,           n
                                                                                                                                                                                                                                                    L71 H                    I t@O.S ION. Nl:%Ss.                 Ger-,rtik!@ 1: z
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                                                                                    i: V I C E S                                                                                                                                                                                                                                          interim
                                                                                                                                                                                                                                                                               illl:!,Al)ll 1.1'! !IA, PA.
             IDIRECTO@                                                                                                     l'iitvry A,              Acttyi,                                                                  l@ertrat@i S. Ilrown                            IV @'I I..,@N 1',\, (;A.
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                                                                      '@,@.TL  ir'ST.                                                                                                                                      T L. I i'@@ S T.
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                                                                                                                           S'                                        S 1
                                                                                   S    F E -                                                                             V.                                          A@IUSE

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                                                                                                                           C   U,%' I T Y                             S  I  VE  @!FPLL
                                                                                                                           i@ L7i H S RV.
                                                                      iTY



                                                                                                                                                                                   DIRECTOR
                                                                      D I R I C   0     R                                  D I P. E C T 0 R


                                                                                                                                                                                      (3QOO)



                                                                                                                                                                                (,@,,'A   L
                                                                                                                                                                                :'@AL F-20-
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                                                                                                                                                                                  DlrECTOI@
                                                                                                                           D I R E C T 0 R

                                                                                                                           1-iiiery A.





                                                                                                                                                                        I 1 F. A I
                                      !i,lie@l li% p2rt of                 L, 9  1-6!  6.
                                                                                                                                                                        Ti-@."A@ICE 01@'G.
                                                                                                                           !!@"ALT@i     P[ZO-
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                                       ,@fa              I;!.,! i%        t,ul I,I"t  @ctit is
                                                                                                                           DI ?. ECTO R                                 c I R E  C  T  0  R
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                                                                                                            .5 7

                                                                                                Appencii-Y C


                                        Ai'iALYSIS  OF OPGAi@IIIZA'FIC.!I'PiL AL j'i'. i'@,-,AT IV ES


                     Once the broad     federal  roles  in   fic,-Ith   Caere do'incd,  a  c,,Tr,-on
                     I)roblem thr@vuaho,,it the ri,.;-,jor issues as descried i,,,as ti,,C-it  (the
                     current oi@caniza@Lional  st-t-uc@Llui-e  ,,,,as  inconsistent  %,iith  these
                     roles and 'Lliei-efore inhibited                    them    .   Four oi-o,,ani-
                     z,,.tional options ,,iere  ci--@ielooed  @@,,hich  had  as  their  core  the
                                                                                              4-
                   ..,.,need for an organizational                  based  on   an   artic   lived
                     @ederal health mission.         The partiCLI lar 'options i,,,ere developed
                     to isolate iSSL12S and contrast                        -@-,,&ys ol@ addr-@ssina them
                     organizationally.       Th,@-,,, @,,,ere not         as "eitlier-o)-l' proposals
                     since tilei-c- are innumerable variations and cc:.Tib-ina-Lions possible.

                     A i-evie,.,i oil the current activities of the varioLs heal@Llh corp.Qoneii@Ls
                     of [iEt4 suggested @Lhat  there  %,iere  three  iraior  I-,Ieali.-h  program
                     functions -- health services, prevention of health probl,2,.is, and
                     development   o'   health   resources.   The    oi-gani.-,-ational    options
                                      I       L
                     were  atteii-,p'L-s  to  "package"  various  groupings  of  these  oi@ogra,@ii
                     functions iti@-o -,7enci--       1--h              s   c@                      L
                                                                c n t               !,-, add, -@o@ , 'h@-
                     options                a prar-@i,a4L-ic  concern  for  the  imnact  oil  any
                     organizational   ch7-nce    in    oncoina    o@@-rations    terms of the need
                     to minimize the negative        asnects oil disrUDt4,cn     and to          ze
                     the   use   of   exisL@ing    administrative    capabilities.

                     1.   DESCRIPTIOi@l OF

                                                          ,-inq  a  ne%,i  agency,  a   descriptive
                          For each alternative cre,4,
                          organizational ti@@'le, abl.-revia'Led Fission                       and
                                                                     Thes,@  fo,,ii-  al'err@a'ives
                          major functions
                          ai-e-sho,,i,ii in chart -lorm, on the @oll@-iirig p,.ge.













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                                                                                                                                                                                                        OPTIC,,6.'
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                                                                                                                                                   5


                                                                                Option


                                                                   Center  fc..r  Dise@ise         Control

                              Mission:        Prov'l,.'--                  leadership  for  the  prevention  and  coii.'@rol
                                                                               Li                                     --ions.
                              of cor,,-@,,uriicabil-  disease  a,-id  o@i,-@r  public  -ieaith  fuiict.

                              li@a, i cL                                                                                       @@u
                                                            Ce,.,elop means  to  pre%,,,.@nt  and  control  co,,.r.  r -1 c                     e
                              d i s C., a s @-' ss t I i a L, e  S 4L. C-1 Le  F-, i,, d  c c, iu  n  i  @L-v   action   tiiroLi,@-i@i   surveil   iai-,ce
                                                                                                                               t4otl  o@
                              and      educa-Ll'on;      pro,,,ic!e      technical      assistance      and      de;roiistra      1      1
                              effective  tech@,iiq@ic-s  for  control  of co;,,,,.,,,,unicable  diseL)ses;  enforce
                                                                                                                       -,,la  grant
                              forei@.@n  quaran+Uii@@-  reat.ila'Lioi-,s;
                                                                        alcol,,c)lisi7,,                an
                              programs  Tor  d                                                              d T.-,en'-,al fieL,,  I ii
                              servic-,2s,  and                      and               heal:'Lh;     @-ni!     develcr,      standards      to
                              assure  safe  and  @icai-Llhl@ul  i-ioi-Itii-ig  enviroi,,;-,@l-nt.

                                    e ii'L-  or@,aniZ  L
                              Curr                     a@ioiial  elem-nnts  include  the  Center  for  Diseaso
                                                                                           OCCUN
                                                                                                  . at4
                              Control,  the l,la-uionai  Ins@Gitut--  -,For.                           Tonal     Sai@ei',y      and
                              Heall-Iii,  and  all  formula  grant  programs.

                                                                                                4
                                                              Health  Rcsources  Ind,-,.Inisi'li@ation

                              Mission:        Prepare  exis-L-'i,ng  fed,--i-ally-assis-@-n-d  h e a I -L-Iii  services
                              manpo,.-,,,-r      proarans       for       financing       through       national       health       insurance
                              or other  appropriate  sources.
                              Major  Functions,:            Provide                         and  technical  issis'L-lance  to
                              existing  'i-iea-itli'service  prograri-I  for rfie,,tiig  financing  progr:-,ri
                                          I
                              standares- for                              .t,  continue  to  provide  or  arrange  ,Cor
                              health  services  to  sDn-cific  l@ederal  beneficiaries  ,..,iii'le  facili'Lla@Ling
                              conversion of -L-hc-sn- activities -f"-o support, through  fitiancira
                              programs; provide s+"L!den.+. and ins'--i-L,,jzi.enol assistance for the
                              education of                                       sp@r4a
                                                                                           ! pi-c,'-Ic-ms @-,Iiicfi are not
                                                                   L                               L)
                              effectively covered un,lier ceiiet-al educational SLIPPOI-'L.  @MeCh3niSiIS.
                              a.nd Support demonstrations desigti-2d to i,,i,r,)i,o,,,e the future pro-
                              duction and utilization of he,-!'Ln services ri-,anpo,,.ier.

                              HRfk includes all                      demonstration,  service,   and   training   pi-o4-ct
                                                                                                                                          J-
                              grant programs e,@'clusive of those in CDr-; direct care  i)rogra!-,Is;  ;-i-2
                              Bureau 01@                                  @ducotic'n       e;,,c-]L@si've of i-es,2circ.@ and !@.n-,c,,,,er
                                                                                                                        ;,,-ont activities.
                              intelligence activities; and the i@ursiiig                                    Iiiiprove,,,

                                                                   Health I 11 S Lirance Adi-,'Lirtistr@tioi-,'


                                                                                                                                        Y T  Y
                              Mission:        AdminiS@Lel'       Dresent Title XVIII                                   and Title
                                 c    c a i d   progr,-it-,,.s,   i nt-I udi ng devel oprent,            iri@l e@ilen'Ll@iti on    and
                                                  of
                              enfoi,cc,-,P-nt          standards.' policies              -1-r-d i
                              in f i
                              ii;ip'i                       1   I" I O.'l 31  ri c- i t @l  i 11 S LI
                                                  on   LI
                              for monitoring, evaluating, and testing                             ne@,@ approaches relating
                              to health insurance proot-ans.




                                                                                                                                       @GO


                            I'li--.,! fT -r@@ions:    A@iniinister Titl-         XVIII     and     XIX      pro-raii,,c"
                                       @-,-"ir'-a-i-ds and certify                           for                     in
                            fiti,-In-iiig  procii-a-,,s;  t:,,onitor                    -lnd  ad-c@Li,,@cy  of  standards;
                            v z-, I u   c)-,@-L-rall            of      stan-@ -ds  and  financing  for  Doli,cy
                                 i   c                     aDDropri,.'L-,@.-,,-.-@s  of  cc-ire  received  in
                            of c  o  s  q,@,alitv  and                            develop  and  I",,s@Ll  ii  '     EnDro@chn-s
                                            th                                                                       4
                            to i il,,) r o,., c-2 1 i e a I L"ii -1    nsut-anc,@.          i ricl udi ng  @ I        i n,,
                            d -, 1 i v e ry  s y sr-I s , a n  dI,,ea I th             collect data  on          hem-'Itii
                            Status          1-tc-alti               resources;  analyze  data                    Policy
                                                    i  services
                            i,-Iiplica.-L@-joi-Is  and  dissc-,-,,iiiate  irl'ol-.-;,.a@Lion  to  appropriate     a c@t'i on
                            agencies.
                                                                                                               aCt4Vi
                                               -the  health  fitiancitin  arid  related  support                         ties
                                                                                4,D,
                                                                             -i       and      t
                            in    the    S,,.c-ia']     Security                                   Soc-'icl  a,-,@  lehab-'Ii-
                            tation  '-z--rvice;              activities  in  medical  care  s@LI-Clrir,'ia,,-,-4s,  research
                            and  development,  comprehensive  liecilth  planning,  and  health
                                                                          I I                                  ,"E;  and  the
                            statistics;  research  and r,,,anpo!,:et@  intelligence  from
                               fessibiial  Standards  Revievi Organization  from O,"ASH.
                            Pro                  L






                                                             Center  for  Disease          Control
                            Mission:    Provide  national  leadership  for  the  prevention  and  control
                            of o@.,,,,,runicable  diseases.
                                or  FLn  Li?ns:    DeielOD means  to  prevent  and  control  co,-,@,unicable
                            diseases;  stimulate  S ,-, a 'L, e  a n d  c o m     n i 'Lly action  through  su-cveillance
                            and  educa4L-.ioti-,  provide  @L,,-,r-linical  assistance  and  de,-;.oristi-.,,tion            oT
                                                hniQ!je@-  for cont!,o'!                                dis--ases:  @nToi,ce
                            effective  tec
                            foreign  quarantine          regulations;  and  develop  standards  to  C-Is@-ure  a
                            safe and healthful           ,.,-orking environment.
                            The CDC  includes  the present Center f'or Disease Control  and the
                            1-4ational  Ins'(-Iitu@Le      for Oc-cupa@Llional  Safety and  Health.
                                                     @lation,@l  Inst4,1--,-@-@  of                 ",-2alth
                            14i ssi on:     Provide national  leadership  in the  field  of r..iental
                                                                          T-fO  L
                            health,      including      iii'etisi,,e      e   r@s  director       a+,-  such  -Irobl,-:-,-,s  as
                            alcoholism and drug abuse.

                            Maior       FLinc tioris:   Conduct     and     SLIr'pOi-t     rese
                                                                                              arch,  training,         and
                                             -cogi-aNis      i            -is    of     general -2n@al  he
                            cow.,Punity p                  n   t@ic    are,                                   31  tii 'drug
                                                     0  4
                                                                n't, c 1           s  T-2r    c

                                            L          I
                            dis
                            other rental  health           plot) I          serve as  principal  focus  izot-
                            behavioral'         science          activities and  'or cultural  and  social
                            problems  relaL-ed  to P,,eii'L-al  health.





                     The       includes  the  cui,r,2nt       activities  excep   t  for  St.
                     E I ia L,, s 11 -o s p  i  'L,

                                           Bene
                     14ission:    Provide  or arrange  foi,  health  care  for  Fpderal  beneficiary
                         "ations.
                     popul

                                              e
                     14ajor  Fuiicticns:  '.I .3 K-ii,rar,,nerents  Itoi,  oi,  Drovide  health  services
                                                                facilitate  -he  convei-sio,,i  of
                         Pc,@FFied  TC-C!                                    L
                   -beneficiary  c@-re  prcor-@,,-,is  to  -,,lnancit,g  thi@ough  national  health
                     insurance    or     o-@L@i-,i-     ri-Lchanisr!,s.
                     BCA  includes  tire  Indian  Health  Service,  Federal  Health  Prograins
                     Service,  and  SI-..  IL:-Iizabc-ths  @!ospi'Lal
                                     [real th Standards  and  Resoui@ces  Ad-7,.iiiiistretio,,i

                                                            End  41',lDlc-  enta-io,,i  oil  health
                     14ission:  Facili-L, a 'L- ed e v e-2 n t
                                         s throuch setting and                   oi@  standards
                     insurance       pi-ogl-z,,,.l      LI
                                          4                             r,v-illance  of  health
                     for       par-@icil,la-t-lion in il'.SL,,rancc-  programs;  su-
                     status       and       system resources;  and  preparii-ig  e\,is@Llitio  l@ceierally-
                     assisted  health  services  and  manDO.-!--I-  prooi-a,-,,s  for  financing
                            'i  na
                     throijgt   ,ti ori;41 health  iiizurance  o@-  oi-her  appropriate  so,,jrcl-s.
                     Ilialor  Functions:    Develop  standards  and  certify  providers  foi-
                     participation  in   Financing  progra!7.is;  it-,oni@Lor  compliance  and
                     adequacy       of       standards;       revic,,ii     of  care  received
                        tei,pis  of  cost,  quality  and  el@1'ec4@-iveiiess
                     in                                                  ;  evaluate  over-all
                     irilpact of  standards  and  fiii--iicirg  l'oi-  pr,,iicy                    develop
                     and  test  ne,@i  approaches  to  iii@ldi-ove  the     insur@,ice  Dro-rai-.is,
                     including  l'i ii 7-;ncirig,  delivery  SYS@Lc-ir@s,  and  health       collect
                                                nd  I-,calk'h  services  resources;  atlaIV7e  da-a
                     data  on  health  status  a                                                 L
                     for     policy     imolica'Llions     and     disse7.inE:,@e      11ITor.,.-,c,.@Lion      L-o      appi-oori,-.te
                                              'de  i                                      i'@e  to
                     action  agenc4ies;  --,i--.vi              and  technical  ess-ista!,
                     existirg  heal@L.,@i  service  proQ,,,a,@:,is  ioi, r,,,Leting  4in-ai,,,,-inq  pror-r@l.-I
                     standards  for  rei.-..b@irsel-.,-,-nn'L;  provide  st@dent  and  institutional
                     assistance  for  @uiie  educaz4iCtl  OT          -cc)      special  pi-o-blei-.s
                                                                                    -iu-ional
                     which are not effectively covc)@@-d u,,.,er general edjc@
                     support                  an.d support de;-,-,onstra-L-,ic,,is desi"ncd  to  improve
                     the  future  production  and  utilization  of  health  services  -,,.@,npo,,,,er.


                     The PSPA includes the Bureau of        @!eal4.--,h ,!..nnp-.l,.ier Education;
                     demonstration, service anci training projec@L and for,-,,uia
                     programs exclusive of those in              and. CDC;         riedical care
                                                                                    Statistics
                     standards                     @i-2al@Lli planning and health       L.   i
                     activities; li,,d the Professional Sta!,,cl--,,-ds Revic-%.i Orcaiiizal@-ion -,nd
                     fl?ljrsin-









                                                             Option 3


                                                                                              -i,@ti on
                                                                               rice pcl-,Iinist
                                                   Disease   c@,

                                                                                                caL-@aci tY
                                              tf,.e health           and health delivl,
                                                                             et urgent co--mui-.icable
                                        and provide assi@,             to me
                        disease and nanpo'vlcll- shortage pro@-lei-is.
                                                                  --hc-rina, monitoring or epi-
                        1-11-ior       ns:    Conduct data cEi,
                                       surveillance of ho.al-'L,.h status and of health delivery
                                                                to appropriate      action aqa '
                        resources; co-,,riutiicate findings                                     -ncies;
                                 c;a'L-la or poi-icv                                              e
                        diseases through s-@:I;;,.Lila4,-ing
                        or selective federal                        providn health pei,scrr,,21  to
                                        I                                   -                         L
                        critical shortage areas; and develop standards to,assui-e safe and
                        healthful @,.,orking eiivironF,-ien'Ll.
                        CDSA includes the             components of Center foi- Disease Control
                                                             l 4- il
                        (exclusive of S,-,,O'.i@-.g and Hea  L ), National Center for I-.'ealtli
                        Statistics, ila4L-.io-ial  Institute  for Occupational Safety and
                        11'eal@Li'l, di-id        'rileali--h Service Coi-ps; atid the
                        intelligence activities  ro,-,i
                                                 Substance P.,buse Ad,-,iiiiistration
                        Mission:   Provide assistance for the prevention and control of
                        ubsta@ce abuse.
                        Maior FLJ,n@tions:   Develop the means to prevent, control and
                        treat at)usc- oi- substances SLICII ZiS alcohol, di-L,,-,s, and tobacco;
                        provide training surpoi-t 'or lic@alth @-.,orl,,Icrs in SL]bs-L@aiic-,- --)@"Use;
                        assi clt States and co-,,@@i,.L:ni '-Li es i q de--, I i rg -L-h @t.hp-se ,)-cobl =-F.S
                        throue,li publ 1 c, ea@,,lcc-t@Li On,  '-Llec@,iii c-, I assi stance and cii-an@L.
                        assistance to provide foi, treatment, rehabilitation and other
                        coinidunity action programs.
                        The SPA includes the national 'Institute foi- Alcohol PbLIse, the                  Di@ug.
                        Abuse Pi-ogra,,.q, and S,-,lol,-,irig and Hc.@@ilt@n activities.
                                         Health Stati@,11,,rds 7i-d 'Resourc@s rl%clininistraticn
                        Mission                                    ,rid in,,,)le--,-.entation o-7 health
                                     Facilitate develop@,iieiit
                        insurance pi-ccrar,,,s                        and                 of SI-
                        for participation in insurance rpi-og,,-aris; aici preserving -existing
                                            --ed 1;7--a
                                            i.                              --    - -@-,r pi-og,
                        federall,y-'assis            .11@-h services and i,,anDo,.,          "aii',S tor
                        financii,,g through national health insurance.            -or otner al)or,opriate
                        sources.












                                                                                                            e
                                11     r  F Lj,-i   i o I,. s    Develop  stanil,i-ds  and  c                    t, l@Y  rrovidl,s     s   i,cr
                                                      ii in                                                    -or cc,-,-, p  a
                                                                                                                                    received
                                adequacy  of  standards-,  revirl,@-i  aDt-)I-Cloria@Llenr-@s@,  of  care
                                in  terms  o-f  cost,  qualit-ly,  and  ei@i@-nctiveiess;  c,,ialuate  overall
                                                                    ar,i 4-4
                                impact      of       standards                 liatic4,lr,     joy-   i,)Olic,"    -i 1-,l,) I i c ci t -:i ci s
                                develop  aiid                  iie-,,@i   at,)@,-)roacfies   to iii-:,i)i-ove      ti,,c@      @iealth       insurance
     k;                         programs,       including        financing,        delivery        sys-L-,c2@,-,s,        and        tiealt'll
                                provide                           and
                                                                            eclinical                 assistance       existinn  health
                                service     pro@@r@,r,-,s     for      r,-.-netinQ      fiiia.,,,ic@iig                stand-.i-@is       -[For
                                                                                                               -icr-ial             assistance
                                reiribursei:nrit;         provide         sudent          and          institL]'                    L
                                                                                                               L
                                for  the  education  of ril,",nnol.,.ler  to                          special        problems         that         are
                                hot    effectively  covered                 under  general,  educational  support  rtieciianisr-,,s;
                                support       cle-,,,c@istr2,tions       desicned       (@,,)        -ir-,i@rove       future  ,,-odiction
                                and        utilization         of@                     services                    and  con'Li  r,!Ii   L,   to
                                provide       or       arraiine       for              services  -Lo  specific                               beneficiaries
                                wiiile.facili'L-.ating      conversion      of      these      activities      to      support
                                through financing  programs.
                                The @ISP,4 includes  the                Bureau  of                      t,lanp@,,,,er Education  excluding
                                                                                                               Lio@i,  serve
                                ir.,,,npo!.,.ter intelligence  all  HS,                                   I'a                     ce,     and
                                training pi-o4ec@L. and  i'Or;,l,,,ila  aran+-s  exclusive of those  related  to
                                   cohol,  druo          abuse,  an                                 h
                                al                                        d  CDC:      (I-;Ire,-L.  -ene@ici,-,-v care pi,ec-r-ams
                                iiicltidina St.                                                                                 ill !r,@dical
                                care     standards,      co,-,.oi-e                                 plarinirr-!,       and      research      and
                                devel opii,,eiit;      and  Prol@essional              St@-n,@,arG's  Revie"i          Organization           and
                                l@@lursing lioTie      Affairs       activities.-I-rarii        OT@SH.



                                                                                                    4


                                                                                                                                                       1
                                                                  Health Protection                 f\ e. i n 41 s     t i o ii

                                Mission:   Provide               national          leadc,;rs!iip      for p@,otec+.ion  'rom                public
                                health hazards.

                                                      on. s      D@-veloo  l'-@lie                to  preve@,it,  control,  and  treat
                                diseases   and    other    health    p,-obie:,,,.s    that    pose    P-    threat    i-,o    public
                                health   through   in@e--@L-.i,   on   or   safety    h-,,-7          ar-'@,  zijch  as  co!-@--,., il"cable
                                                                                                          U-      -                  I;;"l  I
                                                                                               s-o',in,).  and  --,iisai@e ,.--i-king
                                diseases,         -llcor,@olis,:,.,  dr,,ic, abuse,
                                e n v i r o n   ii t      s @L, i' i,:. i I   ----te and  cc@:-!,@,-,;un-i         e, t i o n  +" o d --- a
                                                                                       l@Ve4 'I  I  ar,,r.e
                                with    these    Pi-obl-2i;-;s                       SLI      I                        c a     a i- i-, - s s  a n d
                                                    t,                        ti
                                edur-ation;         and direct  lateral  action  +.a                      provid,--  technical  assistance
                                                S4
                                and     de.-,@on     t-Ira-Le     effective     techniques.

                                HPA iticlullc,,s  the Ceiit@er for 'Disease Cont,@ol ,  e.Ico,',,ol                                       drug
                                abuse activities,  and  the national  iris'Litu'ue'l'or Occupational
                                Safety      and      Stealth.






                                                                                                         -ces   Ad,,qii iii str@iti on
                                                                             Health  Pesotii


                                       s s   o II:      P,["-;)are
                                                                        -C                                ougli  n@i'L-i.,)n,,l  health'.  insurance
                                                                                     a n c i ri g
                                         other ii.,,,,;)Y,opriate  so,@j-,,ces.
                                     or
                                     I.i,a@ior FLiricti,,)!@s:                                               and  @Llcc-.,',t,.ical  assistance                 to
                                                                               0                          r ri,,eeti i
                                     r_, xi s @, i II(@        11  se r,i, I
                                                                                                                +0                    oil                   for
                                     standards        l@oi                                   Coll               @     PI"                   i -I c  f;ilci
                                     heal  th  sei-v  i  ces   L-o                 l@i c    fec!r-@i-@t-I  i-)enc@f-iciei,ir-@s  ,-I'
                                                              r                               -i t4 C                                           f-")-',
                                                              .1 O_c    t,[,. r_ ,
                                                                              , r                                                                  I..alicl lig
                                                                                ,2  aCliV             S    @o                   L
                                     ing        convei-sio          I     ;__,          L         i  _    -                               -
                                     pilogila,,,is,;  !)rlvidr--        s4-:            and                                 as,:,isl-ance           c. r      e
                                                        I     v           L, ..@,                   -1 L. I k.                         L
                                     education        a-l@                      to i,-,eet                      DI-051@.;-s  @.lhici-i  ai-e  not
                                         ectively covered  Liricier geiioi-E,,l  -d'Llcational                                  suDnoi,t P,,-,z-ciianis,-,,,s;
                                     eff                                                                  I                         . t,
                                     and    support    cic,,-,,onsti-@j-ion-s    desici@,tcd    to                                the  fLI'Li.ii-e
                                     production  and  u4                                                  II  services          i-,cinpo,,.,,or.
                                     The HRA includes HS!',!!',,"@  dr-ir,-,ons'Llra  IL-  i  on                serv i ce ,  and  tra i air r,-  pro -c@ct
                                     and  forif,,Lilci  grant  pro.-jr-.-,;.-,s  excILISiVe  of  alcoi,,c)i ,  drLIO,  aL-,use  and
                                                              care  pror,,;i-C-ir.,,s  iICILICI
                                     CDC;           direc                                                    St.   lliy@beths               -sP-i JL-.E. I ;  the
                                                                                                                                      rese-          ii  c,
                                     Bureau          of                                 Educ@,-Lic@-i  exclusive,,  ol                         :ii-c!   and
                                     manpoviet,                                   and  the  l,Lir--,ing  'none               iiipi@ovei,reii'L-,  activities.
                                                                            I-lealth             StanrJLi@@-Is
                                     [4ission:          Provide  oi-ol'essional   ii,-,alth  gui@,--iiice  for  a-l@;,,iiiis'Li-ation
                                                                                                                    t  T;-'-I.@  YIN'
                                     Ff fi-rarici@ig  prog,-a.-,,s;  edniiniste-i@  t.@,.-esen                               L, . -  ,  ,  (. .-,I i -" I  i
                                     Prograpi;     facilitate      doieloDT,-ent      @,i-;ci                                              of
                                                                                                                           11,@al+ll  S@a4
                                     insurance          I)rOC,'I-aF',IS  tfll-OL@qh  survcill,-,t,,ce  of  ,--                             L   L-L@'S  end  sys'tl,-@@,;l
                                     resources;  and  -set  and  r,,@bnitor  standards  for  pai@ticipa4L-lion  in
                                     insurance          programs.
                                     flalor  F6nctions:     Develoo  standards  and  cei-til@y  pro,iidoi-s  for
                                     participation  in  fil,,@,li@Icing  pi-ogi-;@i:,,s;  adriiiiiistei-  Ti@LIc-  ",T-X  r'rcr-.rp,i;
                                                        -ID                        adCOLIaCy                                               -       4L"Ile ove
                                                                                                                                           ,. 4-e
                                     monitoi   CC,,, liance  and                                     of  standards  CV@-lL!                                       r-a I I
                                                              'andar-s
                                                              L         u   - d  financing  'or  ooiic,,i,  ii,,-,plicatioi,,s;  revie!.i
                                     impact          of s
                                                                             a  e  received  in  terms  of  cost,                                             and
                                     appropria'L-,.@-n,,2ss            ot c  i,
                                     effectiveness;  develc,,-,                    and  test                 a,,):)i-oacl,.es  to                         the
                                                              -,;!nce  pi-o,-
                                                                               I L                              T I n    c i .-, ii
                                     health             ii)sLii                  @;:is  ,  I iicl  ,(,ii  rf@l                       del    I
                                     and      hea.],L-1-i      iilanpo,.,iei,;      collect      data       on  health  status             of  disease  and
                                     health        services        resoui-c-2s;            aiiaIN2'c  d-a-@ci  for  policy
                                     and  dis-.u,,,iiiate  infoi-iiia@Llion.'Lo  cti)pt,opi-iate  action  agencies.
                                     IISA  iticILicics  the  ,Predict  Services
                                     support  ac'L-.i,vi-L-.ies-iii  'L-,I',,e  Sociil   @,iici  Re@abilit@t@Lion  Sc-i-vice-.  HS,@.i,i,4
                                     medical   COI-C@  s--and,:irds,                                                            Dlannirc,,
                                                                 L
                                     statistics,  End  research  and                           devl-lo@,i,,,ent;                            :--,nd
                                     intelligence  activities  -irroni                                       and  the  PS'@O  active               LIOS  TI-CM
                                     OASli.







                                                                  TLTFi)'IirtTl@!ES.
                                 @@TIO@, I OF
                      2-.   EVAI..U"'
                            'f lie a ItE.,rri atives k,iere e%i@ ItiD-Leci acl@'i r'st six cri tci-i,@ @@!iiich
                            addressed ttic study finrlilIgS, as             as   tile   P-,aCtiCal
                            coiisidcl,atioils of                   a  nc-@-i                   alirini,,,,ent.
                            rfie ran,<ing of tile a                            -i        -c
                                                                     k,/it@iiii eccii ci-i4l@i-ia is sho,,-iri
                            in the               ci-j--r-L, ei-ici is discussed in d--tFil


                                                    f ODtiOlIS in              Orc,,eiiizational Cri'L-1c@i-i@,
                                 ,r fectiveness c

                                     Critei-ia                ODtion I         0 D@t i n@?   option. 3
                                                                                                             0   t
                            Facilitates c!le,.,elor)i-,,,ent       MOST          LEAST           LESS            l@'i 0 (I,
                            of integrated I,.L-alth
                            policy for a na@Lioiial
                            liealtli mission
                            Facilitates in+ler-                    MOST          LEAST           LESS
                            progi-ai,.i cooi-clinc,,t-ion
                            %-iitliin a single agency
                            nii @si oil
                            Provides flexibility                  MO-ST          LEAST           LESS            Il'OR
                            for future change
                            Facilitates regional                  IIOST          LEAST           LESS            l,'iORE
                            operations
                            Facilitates ir,,r)lc,-lenta-          l'ORE          MOST            LESS            LEA!
                            tion by buile.,iiig on
                            existing acl!,,iiiiist-i-a-L-ive
                            sti-engtlis
                            I-lini,,riizes disruption             LEAST          MOST            f@'iORE         LES'
                            of ongoing act i @i i    e s





                                  p.1 F)C
                                                    01,
                                                                                          i   s      E@   o r
                                                                         s ci-i4-ei-ioii ,@eii(-,cts '11-r,,e
                                 a na@Lioti,@] iioalf.      s
                                 adCqLl@,Cy C)f      Sui!l OT L.@ie agenc,,,, i,,,,issioti-) to cc,.,,,,ipri se a
                                 total           fission as ,-icll as the dcgi,e,2 to                oi-c-i-l'!Ii-
                                 zational                Of act;@VitiCS Supports cleveloppieilt of
                                 national I-iealtfi policy.



                                                                                                                                                                                  Go


                                                  a.   Option           1       ii-,ost effective

                                                           This all-ei-ri@,cive-b-i-itigs  @oc@ctli,2r
                                                           under single Health                                                  I I   ac-Llivi'L. I' 12 S      @r-e i a -@ed
                                                           to the fi,,iL,Lncing of @ie@,I'L-h care,                           t i-1, ei-,@,)st
                                                           I,,ea 1 t h                     '.@IOLIld !)c, coi@solicl,,--,'cc-."l in  a  siiiql.2
                                                                                                                                            C t i          4   S 0
                                                           (IIIA)  al ciiri            th ti-,C             i Cy  SLipt!.,C)-,    i                        e
                                                           SLII'\IeilIZ;.:)ce  and  heal              IL-@i  sf-@,r,vices                 cn.        in
                                                           aci,llitiori,  the  @L,,-.,o  other  ,@qenci(,s                              and    CE),@-)
                                                           most  clearl,,  represeii'L-,  -L-I,,e  o@.liei-                   ;I) i   c i   a
                                                                                .1
                                                                                                                                            t 4
                                                           roles  of  preventive  @ili-id  p@,i.[)Iic                                   ac           ties
                                                           and          resources          support.           The           consolidation           of
                                                           activities            supporting            health            care             resources
                                                                                                                                                     -@ective
                                                           facilitate            -@l,eii-  redirection  to,,-ird  a                     ri-or-           eTi
                                                           relationship  to  the  -I:ii-iaticing  system.

                                                           -Opt.ion 4 -.more effective
                                                           This  alternative  retaiii@                                adv@,.iita(-,e  oil  providing
                                                           an  agency  focus  for  'ri  &,,tii  Scale  Tliic@nc,lrci  @--tivi+.ies
                                                           (iiSA)  and  resources
                                                                                                          .14 tl-
                                                                                                          ,  I  11                 - rce
                                                           tio,..ievei-, 'is  diminished                            tii,2  a,,)s@           of  t;,e  lercest
                                                                                                                                                               ion,
                                                           the      @',PA      folr--Os      is       closer       Lo       i)roblei:i-solving       @Llhati
                                                           preventio,,i,        and         does         not         represent         Ei,,i         articulated
                                                           national   health  mission.

                                                  C.       Option  3             less  effective
                                                           'the  abscnce  of 'citlic-i@  I,!SA  or  B@ll  fLIl-@L, h                       I- u I-. d.         I-, e s
                                                           the  capacity  -L-.o  address
                                                           health  care  fiii-aticirg  cictii@4t4i   S.                            'fee          existit,.,o
                                                           health  E;get@cy  activi"'c-i'c,.  restated   '-Lo  stai,dard  sc-@L-tina
                                                                                                               'dated  in  @'S"3,   out  '-@,;air
                                                           and  i-ponitcj-,-ii-ig  are  co!ls   1-1
                                                                                                          o'
                                                           effectivc-i,,ess      %-joald      L,,@      ('ii!-,.iinisiieul       @)2c-@.,Lise       0,     ne
                                                                                                      1 4 1-y
                                                           additional   i-espot)sibi   if,                       to
                                                                                            -ect  cni-c
                                                           resources  a!id  clit                                 oi                    T'.-    -o    1     c@l
                                                           Support focus is                   diriiiiisii,-@d  i.:i'L-h                s e r,)    a LI Store  o-P
                                                                                                                                   ii      @l   L          i,,Y, c es
                                                           surveillance  activities  in  CD@t@
                                                           resecircii  in  'riS'@A.               Tli-2   iia)-rc),,,i   l'oc,,!s   o-ic    SiAl@,.  d-ciis  not
                                                           reflect  a  broad  federal                             s i o ii       s  @o  @L   b   -2  c,    i,
                                                           agencies.
                                                   d.      Option  2         -           least           effective
                                                           This       alternative       do--s       iir)t        p@,,o%,ido        for        --ons ol-i da'L-li ng
                                                           the' opL@ratiiig  heal tli  cz,,@-,a                                                            and
                                                           (lifil'illiSlICS      the      focus      01'      IISR,"@.      O','.      l'O,iCy      Support-
                                                                                                                       n F.,, 4


                                                           Of                       -.,.-e                 (across
                                                                                                        Tile  I,)ttei-                  a @7 e I
                                                           IISRA,       BCA,   -iii(i  Nltl@ii.                                                    i@,
                                                                                  L                                                                  es    do    n o







                                                              -s  i-ii,?  orll. 11  7       -'on    C 4,1
                                                                                                                                                on
                                                   c t s  t                              a     c'iea,,,                       each  @,g(2@icy
                                               t  u ri i f i c. s                                               Fi-,d      ci  1,  itate   s
                                                                                               L
                                           coordi naL-i 01-1       in    aciiiclvll,",    --),ierill    lt.,2alth     polilc,,

                                           a.      Option  I        most          el'fc--ui-@ve
                                                   Under       this                        each  Ei@,eii-y @..!oLild       1-1 -2
                                                   i- e s p c) i i,@- ic, o r  i  s i i i      a t,. d  cl i r. c t 1-i c     i
                                                   r.,i ssi on.    F,,i i-@ -@ t i o n s       i i 4L-1   t,,) -iiievitic-..     -LIiose
                                                   niissio:is  are  contaitilr,,jl                    each  aaeiicy.
                                                   Consiclei-z,ble        cooi-d-ii-ic-,I--icti         L-c-  needed   Let   !,,,,,-en
                                                            'I- 0 0 L- S L                       L             ces     co"2-        u
                                                        d               D Po I- t   G              I  s                   i   L I,,
                                                   in  the   11,Ri@          the                 care                       @,-,-D.@icy
                                                   (HIA).      This                                                    II     I  ,.i-    red
                                                   because       of duplicative           activities,  bi@L            4L-  0  ip -1 C.-,  t
                                                   overall  fed,2i-al  policy             i ri [,-io V,l rig  T 1-0,ril cl I 11   cto
                                                   financing  support.

                                           b.      Option     4      -      more      effective
                                                                                     L                  (J'  the          .,,!i'Lages     oi"
                                                                                                          i   L
                                                   the  EiL,:-)ve  cp4,-ion,  b-j'@-      1        1, r; 'E 0 n S
                                                   are  no-L-1  cii@Llii-c-ly  coi-is-is'L-,--,nt  --  i.e.      alcc)liol       and
                                                   drug  a!)Llse  trl-at,@@@-nt  pro@Dl@ 2, r,. S            ro'      as      c-iosely
                                                                                                     C      4 1 i e S  &, S
                                                   related  to  o-L-li-iei-  1),,-cvt,-;,.'.-ive       -I   I                 ,iey  are
                                                   to  the  service  activities  in                            The              coordination
                                                   of all.rcsoui-ces  a,tiv-ties  in
                                                                                 I       I      I       t          L    L-1
                                                   conversion  to  support-,  -Lhf-OLtgf)  'L-,Iie  l'ina-,-icii@g  s,,s--ei,,i
                                                                                                                                .y    L
                                                   Wi   I   I   thus   be   more   co,-i,,)iex.

                                           c.      Option     3      -      less      effective
                                                   As           oDL-lion  4            e,  the  COC@@-C,14           c -i o'  oii,,,-:)i  rig
                                                                                                            Iqa               I
                                                   service  resources  @,cjL-.ivi,Lies  is
                                                   b        hbLiSilIC,        -Ii  @L-1@.,,@o  scDara'L-1,2  @-:,-,ni-@cies.  ill
                                                   y
                                                   t%,io
                                                   diverge:iL-1     f Li n @Li o@;s.    C  D   S   oj I       e   re   s      I b 1 e I' o r
                                                   broad                 cire                                          ccii'L-1-i-o-I  of
                                                                                                  t It-, k_
                                                                                                                              ),.2  I-eSpor,541
                                                   co.r,.iiiu ii c ci c,  d 4, s e zi s r-, s  n cl
                                                   for  supr,,,)t-'Lirig  police/
                                                   filial-icii,.g  @,i)d  the  @,ci:@i-inistra-Lic)ti       oT'    tio-Eit'Ll'i     services
                                                   resources  pi-ogrct



                                                                                                                                                  0
        0                                                                                                          -




                                                                                                                                        Gu


                                              Option  2 -  least       e-icf ec'(-Ii ve
                                              RCSOLirces  acti,.,,i4,ies            d L,-)e distributed  across
                                                                                                                                 ng
                                                -cc,     zigeiicir                                   g     4- y       -       -
                                              thi                s             BC[@ and                          coi,,,)l i ca L
                                                                                       I
                                              ttiei r coo@,d   i      o,, and  coiis-stctit                        to    sut
                                                                                                     c)   the -)gen--' es
                                              I IS    z,, I,, j1 1    coi,'L-@iiii  .cve),al   (i@iDl I c,-
                                              f LI 1-1 C 'L- i 0,11 S  I-e e,,, a ii t-L-. o  I' e d (@- i- a I  Ia 1li i,.,, i s s i o n s

                                                               t
                                                                                                                      f  o)-
                                                                    s  c r i        n  r c    c,  S   t i -. 2  a I) -i I 'I, C0    T
                                                   -i -i za t, i o
                                       the    oi,gat           iia  Si-l@LIC'LLire  to accoi-,-,,lodate  c; atigzs
                                       which r,;lay he reasonably predicted at this  point  ill                       ti,.""e

                                       a.     Option    I      niost effective
                                              This  alternative  pro,-oses  the  greatest                                ent
                                              noi-i oi:  the  health  pi-o@,i-a,,,,s  into  agencies  that serve
                                                               L-li s      Cliaii,-,cs  coal              C)
                                              futurc,     fL@nc'                             cl  be  acc
                                              easily Britain  the agencies  becaL@se  their iiiissiotis  are
                                              broad yet distinct.
                                       b.     Option 4 -  mo)-e effective
                                              This  alternative  contains n,.@,nv of the advan'll-eces  of
                                              option   I   above,   but    is    @@ieci,.ened    by    the    addition    of
                                              the tiiie-liriitcd  direct i:ecin-ral                              in
                                              alcoholism   and    d,.-ug    ab,,,s@-    to    the    CDC,    and    creation
                                              of   a   near:   health   protect4loti   agency    @@,,hose    focus    %,iill
                                              have to L',-:.  changed  as  alcohol  and drug abuse
                                              activities  are  piicis,@-d  out.

                                       c.     -Option 3        less  effective
                                              This  alternative @-iould  create a  n e,,,i            agercli    for
                                                                                                              Y
                                              SUI)s@Llz,,Tice abuse to II-,Usc- tII2 tin,.e-li;@iijL-ed
                                              activities  in alcoholism and  drug  abuse.                      AS
                                              these      activities      are       P,@lased-out,        c,:itii-e
                                              agency            %-,'OLIICi      L-.2 ai-,ol-isiied,  since  its
                                              focus 41S  'LIOO               to.
                                                                                     sets          prece-".Ieti.t for
                                              establisli!@ion-L end  clissolutio-i of entire agencies
                                              in response to
                                              special  action  in  sl,-Icific  problei-.] areas.






                                         d      O,)tic)ti  2     le@st  (?ffective

                                                                                                         t'r,. E, BI,@ @-,i I li,ec,, ti i i,e
                                                Tt.,,o agencies,
                                                future                         si!-i--c- they have a specific,                 c    e ci o I- CZ,, I
                                                                                                                       I            L
                                                focus and coli 4t-,  @i  -@f  II  'L-li@-..,.e-lir,,iited  activities

                                                                                                                                         4-
                                                                                                                                    r,@  Li  o
                                         B asc-c;  oi I  Lj@-ici  Pf"@- i I: II1',@ I' 'j, T -1 lti I,",C:ls 0-i- S S-6!i I'-,!
                                         regional  o-irfic2                             it  is  assL!!'.-,-2(,i  that                    oi@i'I'C(@-S
                                         activi!L-1-i,2s           L@@,                    and    focL,s-,',     oil:          c,.ei-4L-, f i c 2, -
                                         ti on e@i@ci i-,,@oni  -Lor-i  iig  of  heLl      care  f  i   II i,.c i i-.,j s taiici --" i-,, t-;
                                         2)  data                      and     surveil     iai,,ce;     3)      developing      i,c-s,),,irces
                                         for  improved  heal              care     delivery;     and      4)      sti-erg(",heiiiiici      the
                                         S t a t c s     b 1, i c  I,, c-I    c a D c-@, c i 'Llies. This         Criterion         adc!,esse-I
                                         the            L
                                                alilOL11,1@-  0-r                o , I   ia.-L. ,,iill  bc,,                oi'    i-c-giotic@,l
                                         s t -ic f  i II  -1 r@,l, 1)    I-,  g  'Lii,2  p@)'@icv   and                              direction
                                         of  the  national  lie(:il-@L-li  agencies.

                                         a.     Option  1  -  niost  ef-Fec'Li ve
                                                Each     regional     activity     is      clearly      al'ic.ined      to      one      central
                                                agency      function,      requiring      'I--he      least      coordination       at       the

                                         b.     Option  4  -  niot-c-  effective
                                                Regional  officers  i-@-,ust  cooi-dii,iite  T)olicies  fi-o@-,i  2  aoc,,icies
                                                                                          ic@ivi@ies                  and  @,',",A)  and
                                                in  resources.dc-ve!oT               II               L
                                                in  health  care  Tiiiaiiciiig            activities  (SSfk  and

                                         c.     Option '3  -  less  effective
                                                Regional  resource  activities  @,iill                            to  cooi-ci-ftia'L-,   e
                                                policies  fro-.i              age!ici-@s  (S,,'l,A  and  'iS"r@i).         Rr-z   ona    i
                                                          -ds  a
                                                                             i      r               ,iiiate  policies           -i, @:),r ii 3
                                                staticlei         cti,,i      es       s ',  c o o r
                                                agencies  (HSr'\,A,.  S,@,S  7--nJ  SSA)
                                         d      Option  2  -  le@,st  c',-fccti,,,c
                                                Regional  resource  activities  ni-ist  coordinate  Dolicies
                                                floor  three                                  Br@,A,  and               and  i-eciioial
                                                s L'andai-ds                                coordinate  policies                         3
                                                agencies  (HSI't'@,  SSPA  and  SRS).

                                                                             ti-,e    o)    ,,,iiza.1-@ion
                                                                                                  ca 'C I.1@s   11 c@ I i,@i z i,l s ?

                                         a.     Option  2          niost  effective

                                                                                               I    Cril
                                                  Li L)    11     'I                                        I       C  i)
                                                                                                       can    b,2  readily             Created
                                                building  on  the  adi,,linistt-,itLiv              c c@l.i)acity of 11,@)












                                                                             -c
                                              b.     option                       e  @'f  ecL  Ive
                                                     One            agF-,nc,,              @-,,ould  be  created           .,I i   U-,]  tE"Ily
                                                     existing                                    sul,,l,)ort  cc@pac-i-@@/.           CDC  i s
                                                     relatively          sell@-sLiff-ic-ien4,-                       @-ioi-!Id   pic'-    1 p
                                                                     c, t i     c a r, L,, c i                    t r a ti s -['c r o f     I
                                                     and               In                      Icciislati.-ii                    be  recLii@i-ed
                                                     to s,,,)@irate alcohol  and  d:,-ug aLLise activities  l'i-oi@ii


                                                     Option      3        less           effective
                                                     One agency  (S[kA)  would  be created @-litlIOL@t any exi'sting
                                                                                                                                     (CD")
                                                                                                                  and                             IO
                                                                                               Ili S@               S4-
                                                     reclui   i-e                                    I     LI
                                                     resl)onsi bi I i 4L-1,  @or  all  sui-%,eilla..,ice  (-,c-i,,,ities  in
                                                                             ,   I                                          L
                                                     supl)c)-i--t@  of  health  policy  plpnril'ng.                    Legislation ,.,,c)Lild
                                                     be    required    to    seLE,,i,ate     alcohol     ind     drug     abuse
                                                     activities  llro.,i            I I' i'f I'

                                              d.     Option      4      -       least       effective
                                                     Two  ncii  agencies  k,,,oulci            be  created  @'lith,)Llt  existing
                                                     adi,,iini3trative  SLI!'-;         01-t
                                                                ']'his  option  ,iould  a]-so  require  legislation
                                                     HSA.                                                                               L
                                                     to  separate  the  drug  and  alcohol  abuse  programs
                                                     froii
                                              Hol.-i e f  (,c @Ll i v -,2 1c a n th @- o r c: -a n  i    t i o ii  IL-le  ir.-ir)le!.le,,Ited
                                              d i s rLi @'Lrl C@O  11  r
                                                                                   C -r- @,'@L I  e@  -

                                              a.     Option         2     most              effective

                                                     Unde,,-        this  al tertiajL--'I,,,e,  all      (@>,,ist4irig    progi-,iris
                                                     inai   iitai   tied  essentially  in'L-.zic'L-1.

                                              b.. -  Option         3     more              effective
                                                     T h c  I I I,,'[ I  a n d  Bf     1) 1-0 9 I-aE'l S  I','C) LI I d  b e  's p 1 i t!,,i tii
                                                     activities  assi(ii-.,@rJ  to  sc,;)arcitc-@  agencic@s.                         Data
                                                                                                                                      C)!
                                                                                                and di r,,! g  ::-, Liu s e  a!-, -a   clo    Sri
                                                     activities     i.,:oL,,Id     li,,.v-.     to  be  -,--laligtied  fro;-,i  their
                                                     current  organizations.

                                              c.     Option         4     less              effective
                                                     This  op'tion  is                   identical  -L-o  option  3,        in  addition  to
                                                     which  it  would            i-,-,q,,iire  the  transfer  of                      from  S!@S.






                                           d.      Option I             least        effet'ive
                                                   This                                                                                  s i     e
                                                   i t i,i o u 1 d    i  t r  i    t e  t-.     E.  c   i v          o t    t@,!           c u r I- e I I
                                                                                                                                         --o  sevel-c-il
                                                   health  s,-,)-vices  and                                                              t.
                                                   different                                            to                                     r o:,. i
                                                   [))-Oi cc  t  g  1-Zl,@    S  L.'PnO'("L'  ii  reSO L@ !'C(-,                               II  d
                                                   v@lould  seDai-a-1--e  delta  (!-i4l'i                         'S Lir,,lc.      i  r-,, iS  Joel]
                                                                                        ., , L r,,- r   ,i g  a I,. t-t                I-- - .
                                                   as  healt'fi  c-(-v-icc-s                            ac'L,4,,ti   ties    'ro:il    (jlr,    :n
                                                                                                         III  --@(!r i 1-icn
                                                   grant  ai,,-d     c,,-)ntr--:,ct                                               i      @.,-ol id
                                                                                                    L
                                                   require     tlic,      ti-atisfe-i-      of'      both        arid  bllil             t,iL:lir
                                                   current      1)      i-,eilt

                              3.      NEED     F02     A     COI@iBTiil':D


                                                     -e
                                      As  tli2  p)   -,editor.,  z,,r;,-tlysis                                   (,..de       i,, e  et  s c@  P, n t c@ gs
                                                                                                                            L .  i       L.
                                      inherent     in     each     ol'     the      fo,,@i-                             options @-iiat ,-iei,e
                                      develop,-,d.          I,!Iiile  'L-@-ie  first  option,  fo,,-             -ii,is'L-aiice,    ai,,,),,2-@.rs
                                      prefei-6@,[)Ie  accot-cli,,-,c.,  to  r,,-.os6  (Di@                                  it  i-l@-ould  be  the
                                      most  disrLIPtive  to  iiiiple;-,,.ei-it.
                                      In  addition,  any  of  the  optio@is  contaiii-ii-ig  a  sep;,ii-a'L-.L,  he@,ltli
                                      resot@-f-ces  age!ic,                   a  hpal'L-!,,                                                    inherent
                                      prob*l              'Fhey                               cc-t@  s  i      ;i) '@ 2  Po IIc@,/                 t I-'-!!
                                      bet%,i.2c,ii the sei,vice  resource                                    ai,!"!                            "C)
                                                                                                    z;                                                1-Y
                                      develo:),-I-.,-ni-it  activi '(-,-,es   in                    o  f a , -i I     t c   ti@,c
                                      of         service          delivery
                                      mecliciiiis,-.is  other                  gran-Ls.             i-,e  hea'i      resources
                                      place  all  curreii,6  resource  aC-L-i@,!4, "-,ic-s                                    s,,-.;
                                      teriiii ri(@.'L-.ion or cc:i,.ersi-u,,i to                        l@C).-i-,,S  Of  SUD@--;C)-t  ii-I   ;I,-i
                                      that
                                                                              ai-ti    CLI]         1 o-, ri           resioi-l,,i!)i  1  i   i@-Y for
                                      health i-c-soui-cc-7.              i@l                             4L-.',,
                                      service (1--livc-r),              c-ci v -I @.-i es               e            c c)  cil
                                      act i v i      e s a re s c @i:-%        c-      o
                                      there                be  a  co,-i4--ii-,!.iing                1',,) r  ac      'L) i 1 -1 t,v to                  rl
                                      status     of     h-,altii      c;--,,,-e i-esoLji-cos        in         Li.S.  in  oi-r,'!@),  'Lo
                                      responsive                                                                                         p',)Iicies,
                                      incl LI-J 41 1     @LIIOSC-  1-C   I    -L                '-I. i-ia'IC'i I       s  n;T-1 .
                                                                                                                         L-
                                      Upon       )-(,c!xciminii,sg        tii@-                I    Flr)pr--"@t'l-,Ol  @.esi,-LibIc!  -'L-lo
                                      the      street      fea'L'L,",,"@-,    of  the                                      to  i@                  Lil,-,
                                      role               i-c-,spec'L,      'Lci                                      L'  O'- g -!!I I "a 'L@ .@t o 1'. a
                                      re c o!il@@@,L     t i o,,i , tl  1     -,,D                            @l  c
                                      resh@il)iii(i  of                            O:,, I       f oL,,  r op-t@, oi!s    as  t.'-,,,?y   1,:c).re