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COMMITTEE ON HUMAN RESOURCES 

UNITED STATES SENATE

NINE TY -FI FTH CONGRESS

SECOND SESSION

ON

S. 2474

TO AMEND THE PUBLIC HEALTH SERVICE ACT TO EXTEND 

THROUGH THE FISCAL YEAR ENDING SEPTEMBER 30, 1983, 

THE ASSISTANCE PROGRAM FOR COMMUNITY HEALTH CENTERS ; MIGRANT HEALTH SERVICE S; TO EXTEND THROUGH 

THE FISCAL YEAR ENDING SEPTEMBER 30, 1981; HEMOPH ILIA ; HOME HEALTH SERVICES; TO EXTEND THROUGH 

THE FISCAL YEAR ENDING SEPTEMBER 30, 1979, THE ASSISTANCE PROGRAMS FOR COMPREHENSIVE PUBLIC HEALTH 

SERVICES; HYPERTENSION PROGRAMS; DISEASE CONTROL 

PROGRAMS; VENEREAL DISEASE PROGRAMS; GENETIC DISEASES PROGRAMS; AND LEAD-BASED PAINT PROGRAMS, AND 

FOR OTHER PURPOSES

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FEBRUARY 9 AND MARCH 1, 1978

Printed for the use of the Committee on Human Resources

28-386 O

U.S. GO VERNMENT PR IN TING OF FIC E 

WA SHING TO N : 1978
COMMITTEE ON HUMAN RESOURCES

HARRISON A. WIL LIAMS, Jr., New Jersey, Ch airm an

JENNING S RANDOLPH, We st Vir ginia 

CLAIBORNE PEL L, Rhode Isl an d 

EDWARD M. KENNEDY, Ma ssa chusetts 

GAYLORD NELSON, Wisconsin 

THOMAS F. EAGLETON, Missouri 

ALAN CRANSTON, C alifornia 

WILLIAM D. HATHAWAY, Maine 

DONALD W. RIEG LE, J r., Michigan

JACOB K. J AVITS, New York

RICH ARD S. SCH WEIKE R, Pen nsy lva nia 

ROBERT T. STAF FORD, Verm ont 

ORRIN G. HATCH, Utah 

JOHN H. CHA FEE , Rhode Isla nd 

S. I. HAYAKAWA, Californ ia

Ste ph en J . Paradise, Gener al Co uns el an d Sta ff D irec tor

Marjorie M. Whit taker, Ch ief Cle rk

Don A. Zimme rman, M in ori ty Co uns el

Gregory F usco, M in or ity S ta ff D irec tor

Subcommittee on Health and Scientific Research

EDWARD M. KENNEDY, Ma ssa chuse tts, Chairman

CLAIBORNE P ELL, Rhode Islan d RICH ARD S. SCH WEIKE R, Pen nsy lva nia

GAYLORD NELSON, Wisconsin JACOB K. J AV ITS , New York

WIL LIAM D. HATHAWAY, Maine JOH N H. CHAFEE, Rhode I sland

HARRISON A. WILLIAM S, JR., New Je rsey

(ex officio)

Lawrence Horowitz, Pro fess iona l Sta ff Mem ber

David W inst on, M in or ity Co unsel

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CONTENTS

Text o f: P ag e

S. 2474 ______ _ _ ___ __ _ 4

CHRONOLOGICAL LIST OF WITNESSES

Thursday, February 9, 1978

Richmond, Julius B., M.D., Assistan t Secretary of Health, Departm ent of 1 Health, Education, and Welfare, and Surgeon General of the Public 

Health Service, accompanied by Joyce Lashof, M.D., Deputy Assistant

$

Secretary for Hea lth ; George Lythcott, M.D., Admin istrator of the 

Health Services Ad ministration; William Foege, M.D., Director, Center It

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for Disease Control, and Karen Davis, Ph. D., Deputy Assistant Secretary for Planning and Evaluation _ _ _' _ 18 Davis, Danny K., Ph. D., president, National Association of Community

Health Centers, Inc., Washington, D.C., and special ass istant to the 

president of Mile Square Health Center of Chicago, Ill, accompanied by 

L. Jerom e Ashford, executive dire ctor of the National Association of 

Health Centers _ _ _ _ _ _ _ __ 110 Romero, Basilio F. Tom, executive director, Rancho, Inc., Seattle, Wash_

Block, Jam es A., M.D., director, Ambulatory Services Department, Genesee 133

Hospital, Rochester, N.Y., and director, Community Hospital-Medical 

Staff sponsored primary care group practice program, Robert Wood

Johnson Foundation _ _ _ _ _ _ _ _ __ _ Kerr, Lorin E, M.D., M.S.P.H., director, Department of Occupational 150

Health, United Mine Workers of America, and member, Steering Committee, Rural Health Council of Rural America _ __ 157 Outcalt, Doug, national president, American Medical Student Association, 

and fourth-y ear medical student, University of Arizona, accompanied by 

Paul R Wright, executive director, American Medical Stud ent Association and American Medical Stud ent Association Foundation; John Barrasso, truste e-at-large, and fourth-year medical student, Georgetown 

School of Medicine; and Rich Roberts, National Health Service Corps

scholarship student, and second-year student, George Washington University School of Medicine _ _ _ _ _ _ _ _ _ _ _ 202 Aledort, Louis, M.D., medical director, Natio nal Hemophilia Foundation,

and vice chairman of the Departm ent of Medicine, Mount Sinai Hospital, 

New’ York, N.Y __ _ __ _ _ _ _ _ _ _ _ _ _ __ _ 214

Wednesday, March 1, 1978

Bamberger, Lisbeth Schorr, consultant, Children’s Defense Fund, Washington, D.C., accompanied by Donald A. Comely, M.D., American

Academy of Pediatrics, Johns Hopkins University Community Pediatric 

Section, Baltimore, Md., and C. Arden Miller, professor and chairman of

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the Department of Maternal and Child Health, University of North

• Carolina, Chapel Hill, N.C., a panel _ __ _

Whalen, Robert P., M.D., Commissioner of Health. New York State,

Albany, N.Y., accompanied by Joseph E. Cannon, M.D., directo r, Department of H ealth, Providence, R.I., James E. Word, deputy commissioner, 

State Department of Health, Nashville, Te nn.; and Donald Wallace, 

M.D., health officer, Prince George’s County Health Departmen t,

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Cheverly, Md., a panel _

Rosenberg, Dr. Leon E., chairm an, Department of Human Genetics, Yale 300

Un iversity; Dr. Robert F. Murray, chief, Division of Medical Genetics, 

Howard Un iversity; Mrs. Joan Marks, director, Genetic Associates Program, Sara h Lawrence College; and Mrs. Marjorie Guthrie, presidentemeritus, Committee to Combat Hun tington's Disease, a p a n e l__ _ 321 Gorman, Mike, executive director, Citizens for the Tre atm ent of High

Blood Pre ssu re___ __ ___ ___________ i _______________ 358

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STATEMENTS

Aledort, Louis, M.D., medical director, National Hemophilia Foundation, 

and vice chairman of the Department of Medicine, Mount Sinai Hospital, 'P ag e

New York, N.Y________________________________________________ 214

American Academy of Pediatrics, prepared statem ent-------------------------- 28(5

American Hospital Association, Washington, D.C., prepared statem ent----- 381

American Medical Association, prepared state ment------------------------------ 252

American Medical Student Association, Doug Outcalt, national president,

prepared statement____________________________________________ 20(5

Association of State and Territorial Health Officials, prepared statem ent- 315

Bamberger, Lisbeth Schorr, consultant, Children’s Defense Fund, Washington, D.C., accompanied by Donald A. Comely, M.I)., American Academy 

of Pediatrics, Johns Hopkins University Community Pediatric Section, 

Baltimore, Md, and C. Arden Miller, professor and chairma n of the Department of Material and Child Health, University of North Carolina,

Chapel Hill, N.C., a panel------------------------------------------------------------ 2(57

Block, James A., M.D., director, Ambulatory Services Departmen t, Genesee

Hospital, Rochester, N.Y., and director, community hospital-medical 

staff sponsored prim ary care group practice program, Robert Wood

Johnson Foundation------------------------------------------------------------------ 150

Prepared stateme nt------------------------------------------------ - --------------- 154

Citizens for the Treatment of High Blood Pressure, Inc., Mike Gorman,

executive director, prepared statem ent------------------------------------------- 3(51

Council of Home Health Agencies and Community Health Services, prepare d statement------------------------------------------------------------------------ 217

Davis, Danny K., Ph. D., president, National Association of Community 

Hea lth Centers, Inc., Washington, D.C., and special ass istant to the 

president of Mile Square Health Center of Chicago, Ill., accompanied by 

L. Jerome Ashford, executive director of the National Association of

Community Health Centers---------------------------------------------------------- HO

Prep ared state ment----------------------------------------------------------------- 115

Gorman, Mike, executive director, Citizens for the Treatm ent of High

Blood Pressure, Inc____________________________________________ 358

Prepared statement___________________________________________ 361

Kennedy, Hon. Edward M., a U.S. Senator from the State of Massachusetts, prepared statem ent------------------------------------------------------------- 264

Kerr, Lorin E., M.D., M.S.P.H., director, Department of Occupational 

Health, United Mine Workers of America, and member. Steering Committee, Rural Health Council of Rural America------------------------------- 157

Prep ared statement__________________________________________ 100

Marks, Joan H., director, human genetics program, Sarah Lawrence College, prepared statem ent------------------------------------------------------------- 337

Murrary, Dr. Robert F., chief, division of medical genetics, Howard University, prepared statem ent___________________________________ — 329

Natio nal Association of Community Health Centers, Inc., Danny K. Davis,

Ph. D., president, prepared statem ent-------------------------------------------- 115

National Association of Farmworker Organizations, prep ared statement— 238

Natio nal Foundation-March of Dimes, The, Charles L. Massey, president,

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prepared statem ent____________________________________________

National League for Nursing, prepared statem ent-------------------------------

Outcalt, Doug, national president. American Medical Student Association, 

and fourth-year medical student. University of Arizona, accompanied by

Paul R. Wright, executive director. American Medical Student Association and American Medical Student Association Fou ndation: John Barrasso, trustee-at-large, and fourth-year medical stud ent. Georgetown 

School of Medicine; and Rich Roberts, National Health Service Corps 

scholarship student, and second-year student, George Washington University School of Medicine----------------------------------------------------------

Joint prepared statem ent_____________________________________

Rancho, Inc., Basilio F. Tom Romero, executive director, prepared 

state ment ____________________________________________________

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Richmond, Julius B., M.D., Assistant Secretary of Health, Depa rtment of

Health, Education, and Welfare, and Surgeon General of the Public 

Health Service, accompanied by Joyce Lashof, M.D., Deputy Assistant 

Secretary for Hea lth ; George Lythcott, M.D., Administrator of the 

Health Services Administration; William Foege, M.I)., Director, Center 

for Disease Control, and Kare n Davis, Ph. D., Deputy Assistant Secretary Pa ge

for Planning and Evaluation _ _ _ _ _ _ _ _ _ __ _ _ _ 18 Prep ared statem ent _ _ ____ _ _ _ 30 Romero, Basilio F. Tom, executive director. Rancho, Inc., Seattle, Wash__ 133 Prepared stateme nt _ 130 Rosenberg, Dr. Leon E., chairman, Departm ent of Human Genetics, Yale 

Un ive rsity; Dr. Robert F. Murray, chief, division of medical genetics, 

Howard University; Mrs. Joan II. Marks, director, Genetics Associates 

Program, Sara h Lawrence College; and Mrs. Marjorie Guthrie, president-emeritus, Committee to Combat Huntington’s Disease, a panel___ 321 Prepared statemen t _ _ _ _ _ _ _ 323 United Mine Workers of America, Lorin E. Kerr, M.D., director, Dep artment of Occupational Health, prepared state ment 100 Whalen, Robert I’., M.D., Commissioner of Health, New York State,

Albany, X.Y., accompanied by Joseph E. Cannon, M.D., d irector, Departof Health, Providence, R.I., James E. Word, deputy commissioner, State 

Depa rtment of Health, Nashville, Te nn.; and Donald Wallace, M.D., 

health officer, Prince George’s County Health Depa rtment, Cheverly,

Md., a panel _ _ _ _ . _ _ _ 300 Prepared statement _ __ _ _ _ _ _ 315

ADDITIONAL INFORMATION

Articles, publications, etc.;

Road We Have Come: Rural Health Needs and Non-Response, The, by 

Lorin E. Kerr, M.D., M.S.P.II _ _ _ _ 108

Community Health Centers (Rura l Health Report No. 2 ), from Rural 

America, Washington, D.C., August 1977 _ 182

RIII and IIURA Projects (Ru ral Health Report No. 3), from Rural 

America, Washington, D.C., August 1977- _ _ _ 192

Replies to questionnaire on State hypertension programs, from the 

Citizens for the Treatment of High Blood Pressure, Inc. _ _ 372

Have a He art—The story of an atte mpt to enroll three children in a 

heart clinic, by Judy Barber, social services director. Combined 

Community Child Development Services, Inc __ _ _ _ _ _ _ 378

Communications to :

Kennedy, Hon. Edward M., chairman, Subcommittee on Health and 

Scientific Research, from James II. Sammons, M.D., executive vice 

president, American Medical Association, March 8, 1978 251 Javits, Hon. Jacob K., a U.S. Senator from the State of New York, 

from Charles L. Massey, president, the National Foundation March 

of Dimes, W hite Plains, N.Y., March 7, 1978 _ __ __ __ 344

Selected tabl es :

Community Health Centers—Rural/Urba n ______ 27 New York State Department of Health, Comprehensive State Health 

Plan—(block gra nt) Slid, fiscal year 1977 sta tistics _ 303

Percent of liveborn whose mothers began pre nature care each trimester and percent weighing 5y2

 pounds or less, by race, 42 S tate s 

and D.C., 1974, from the National Foundation March of Dimes___ 297

Rural and urba n breakout of the community health centers 20

Questions and answers:

Depa rtment of Health, Education, and Welfare, responses to questions

from Senator Edward M. Kennedy, a U.S. Senator from the Sta te of 

Massachusetts _ _ _ _ _ ___ _ ____ 55

Department of Health, Education, and Welfare, responses to questions 

from Senator Jacob K. Ja vits, a U.S. Senator from the State of New 

York _______ _______ _ ______ ________ ___ __ __ 90
VI

Questions and answers—Continued

Department of H ealth, Education, and Welfare, responses to questions 

from Senator William D. H athaw ay, a U.S. Senator from the State

of Maine__________________________________________________ 91

Guthrie. Marjorie, foun der/presiden t emeritus, Committee to Combat

Huntington’s Disease, New York, N.Y., from Senator Jacob K.

Javits, a U.S. Senator from the State of New York--------------------- 355

Marks, Joan H., director, human genetics program, Sarah Lawrence 

College, Bronxville, N.Y., from Senator Jacob K. Javits, a U.S.

Senator from the State of New York__________________________ 352

Murray, Robert F., Jr.. M.D., professor, pediatrics and medicine, chief, 

division of medical genetics, College of Medicine, Howard University, resi>onses to questions of Senator Jacob K. Javits, a U.S. 

Senator from the State of New York__________________________ 347

*
HEALTH SERVICES EXTENSION ACT OF 1978

THURSD AY , FE BRU ARY 9, 1978

U.S, Senate,

Subcommittee on Health and Scientific Research

ofthe Committee on Human Resources,

Washington, D.C.

The subcommittee met, pursuant to notice, at 10:15 a.m. in room 

6226, Dirksen Senate Office Building, Senator William D. Hathaway 

presiding pro tempore.

Present: Senators Hathaway and Javits.

Senator Hathaway. The subcommittee will come to order. This 

morning, we are holding hearings on the Health Services Extension 

Act. Senator Kennedy is unable to be here this morning, and his 

statement will be included in the record at this point.

[The opening statement of Senator Kennedy follows:]

Opening Statement of Senator Edward M. Kennedy

Senator Kennedy. I am pleased to open the first of 2 days of hearings on S. 2474, the “Health Services Extension Act of 1978,” which 

I introduced last week together with Senators Schweiker, Javits, 

Williams, Pell, and Hathaway. These amendments extend various 

health services grants programs administered in the Public Health 

Service.

Last November, our subcommittee had the opportunity to review 

many of these programs in operation throughout the country. Senators Javits, Schweiker, and I were in Atlanta to review the work of 

the Center for Disease Control. We were privileged to tour their 

modem facilities and laboratories, to talk personally with the dedicated staff of the Center, and to learn firsthand about the vital and 

important work tha t the Center performs in disease control and preventive health services.

The legislation we will be considering this morning would extend 

currently expiring authority for many of these CDC programs, including initiatives in immunization, rodent control, venereal disease, 

lead-based paint, hypertension, and others. Our legislation proposes 

only 1-year extensions of these programs and of the program under 

314(d) for comprehensive public health services. This is not because we are unhappy with the thrust of these initiatives, or with 

their administration, but because we recognize t ha t as a group they 

comprise a significant portion of the Federal Government’s investment in services directed a t prevention of disease. Disease prevention 

is one of my paramount concerns in health, and later this year I 

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intend to introduce comprehensive proposals aimed at expanding the 

Federal Government’s commitment to preventing illness. In order 

to have the flexibility to integrate statutory authority in this important area, we are reserving the option of reviewing these expiring 

authorities later in the context of a broad prevention effort.

In our subcommittee’s travels last November, we also visited community health centers in Miami, Fla., Houston, Tex., and Los 

Angeles, Calif. I was impressed with the modern new facilities and 

equipment in these centers, and with the very dedicated and hardworking people who staff the centers. I had the chance to talk with 

many of the people who use the centers. Without exception these 

people felt tha t in the absence of this grant program, they would 

not have access to the kind of care which they have a righ t to expect 

in this Nation of ours. They were satisfied with the services they ?

received. They felt their participation in the governance of the centers 

helped to make the services more responsive to their needs and desires. And they expressed to me their feelings that the support for 

the centers must continue and be expanded. *

I also visited a migrant health center and a migrant camp in Homestead, Fla. The contrast between the modern facilities available 

through the community health center in Miami, and the old, crowded, 

ill-equipped health facility used by the migrants, was startling. The 

migrants told me they could use the modern facility in Miami, but 

preferred the migrant health center which was closer to their camp, 

and where the staff seemed more sensitive to their special needs and 

problems. The migrants made it very clear to me th at they felt they 

needed the special migrant health program, and would oppose any 

consolidation of that program with the broader community health 

center program. They also pleaded for increased funding of the migran t health program and continued requirements for migrant control of the projects.

The legislation we are considering today supports the findings of 

the subcommittee from its field hearings and visits, and we will hear 

testimony this morning on the community and migrant health center 

programs.

These programs have demonstrated over the last 8 years tha t they 

deliver comprehensive health services at a cost less than or comparable 

to services provided through other health care delivery systems.

Moreover, they have been effective in reducing use of hard-pressed 

emergency room facilities, they have provided preventive services 

to an extent which exceeds the traditional health care delivery systerns, and they have made health services available to urban and 

rural communities previously without health professionals or health 

care facilities.

The bill before the subcommittee today reauthorizes both of these 

programs for a 5-year period. It is an expression of the view of this 

subcommittee that federally supported health centers have reached 

the point where their very existence no longer has to be reexamined 

every year. For example, since 1974—

—Physician productivity in health centers has increased by 30 

percent;
—The cost per patient visit has declined by 5 percent—at a time 

when similar costs in other health care delivery settings have 

increased at a rate of 30 percent;

—Administrative costs incurred by health centers have declined 

by 15 percent,

S. 2474 authorizes $364 million for Community H ealth Centers for 

fiscal year 1979, including $34 million for the conversion of outpatient departments in urban hospitals into primary health care 

centers. In each of the four succeeding fiscal years, funding for Community Health Centers will increase by 10 percent.

The sum of $50 million is authorized for Migrant Health Centers 

for fiscal year 1979, including a doubling of the funding available 

for hospitalization. These amounts will also increase by 10 percent in 

each of the 4 succeeding fiscal years.

We will also hear testimony today on increasing the authorization 

for the National Health Service Corps, as requested in the President’s budget. I have been a strong proponent of the National Health 

Service Corps since it was created in 1970. The Corps has expanded 

greatly from 20 filed assignees in 1971 to a projected 1,725 in 1979.

The Corps, however, has several important issues th at they must 

study closely in the coming months. Is the Corps a manpower program 

or a service delivery program ? Is the Corps meeting the needs of the 

populations it is legislated to serve? What are the best projections 

available for the Corps’ future? All these questions and other related 

issues are ones tha t S. 2474 is asking the Department and the National Advisory Council to the National Health Service Corps to 

address in a special report to this committee.

And finally, this morning we will hear testimony on the small but 

important program which provides funds for treatm ent centers for 

hemophilia victims and also supports blood separation centers. The 

activities in this program are proposed by S. 2474 to be extended for 

3 years with some increase in authorization levels. We hope to hear 

this morning of the needs these programs are meeting and how effectively the needs are being met.

[A copy of the bill S. 2474 follows:]
4

95th C ONGRES S 

2d Session S. 2474

IX TH E SEN ATE OF TH E UN ITED STATES

F ebruary 1 (legislative day, J anuary 30), 1978

Mr. Kennedy (fo r himself, Mr. Sciiweiker, Mr. Williams, Mr. J avits, Mr. 

P ell, and Mr. Hathaway) intro duced the following bill; which was 

rend twice and ref erred to the Committee on Human Resources

A BILL

To amend the Public Health Service Act to extend through the 

fiscal year ending September 30, 1983, the assistance program for community health centers; migrant health services; 

to extend through the fiscal year ending September 30, 1981; 

hemophilia; home health services; to extend through the 

fiscal year ending September 30, 1979, the assistance programs for comprehensive public health services; hypertension programs; disease control programs; venereal disease 

programs; genetic diseases programs; and lead-based paint 

programs, and for other purposes.

1 Be it enacted by the Sena te and House of Bepresenta2 tires of the United States of Ame rica in Congress assembled,

3 SHORT TIT LE

4 Sec. 101. (a) This Act may be cited as the “Health

5 Services Extension Act of 1978”.

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(b) Except as otherwise specifically provided, whenever in this title an amendment or repeal is expressed in 

terms of an amendment to, or repeal of, a section or other 

provision, the reference shall be considered to be made to a 

section or other provision of the Public Health Service Act. 

COMPREHENSIVE PUBLIC HEALTH SERVICES

Sec. 102. (a) Section 31 4(d) (7) (A) (relating to 

authorizations for formula grants to States for comprehensive 

public health services is amended by striking out “and” 

after “ 1977,”, and inserting before the period at the end of 

the sentence thereof the following: “, $107,000,000 for the 

fiscal year ending September 30, 1979” .

(b) Title III is amended by adding at the end thereof 

the following new section (relating to authorizations for 

formula grants to States for hypertension programs) : 

“grants for hyp ert ens ion programs

“Sec. 315. (a) (1) The Secretary may make grants to 

States (which have submitted and had approved State plans 

in accordance with regulations and guidelines issued by the 

Secretary) for the purpose of establishing and maintaining 

programs for the screening, detection, diagnosis, prevention, 

and referral for treatment of hypertension.

“ (2) The Secretary shall, in accordance with such regu24 lations as he may prescribe, allot the sums appropriated
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under subsection (4 ), among the States on the basis of the 

population and financial need of the respective States.

“ (3) Nothing in this section shall be construed to prohibit the use of funds for hypertension programs which may 

be authorized and made available under any other provision 

of law.

“ (4) To carry out the purposes of this section, there 

are authorized to be appropriated $15,000,000 for the fiscal 

year ending September 30, 1979.” .

DISEASE CONTROL PROGRAMS

Sec. 103. (a) Section 317(g) (1) (A) (relating to 

authorizations for grants to States for disease control programs to immunize children against immunizable diseases) is 

amended (1) by striking out “and” after “ 1977,” , and (2) 

by striking out “for fiscal year 1978” and inserting in lieu 

thereof the following: “for the fiscal year ending September 30, 1978, and $35,000,000 for the fiscal year ending 

September 30, 1979” .

(b) Section 317 (g) (1) (B) (relating to authorizations 

for grants to States for disease control programs for diseases 

borne by rodents) is amended (1) by striking out “and ” 

after “ 1977,” , and (2) by striking out “ for fiscal year 1978” 

and inserting in lieu thereof the following: “for the fiscal

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year ending September 30, 1978, and 814,500,000 for the 

fiscal year ending September 30, 1979” .

(c) Section 31 7(g) (I ) (C) (relating to authorizations for grants to States for disease control programs, and 

other programs with authorizations under subparagraphs 

(A) and (B) ) is amended (1) by striking out “and” after 

“ 1977,”, and (2) by striking out “for fiscal year 1978” 

and inserting in lieu thereof the following: “for the fiscal 

year ending September 30, 1978, and $5,500,000 for the 

fiscal year ending September 30, 1979” .

PREV ENTIO N AND CONTROL OF VENE REAL DISEASE

Sec. 104. (a) Section 31 8(b) (2) (relating to authorizations for grants for projects for the conduct of research, 

demonstration, education, and training programs for the 

prevention and control of veneral disease) is amended (1) 

by striking out “and” after “ 1977”, and (2) bv striking 

out “for fiscal year 1978” and inserting in lieu thereof the 

following: “for the fiscal year ending September 30, 1978, 

and $8,000,000 for the fiscal year ending September 30, 

1979”.

(b) Section 31 8(e) (2) (relating to authorizations for 

project grants to State programs for prevention and control 

of venereal disease project grants) is amended (1) by striking out “and” after “ 1977”, and (2) by striking out “for 

fiscal year 1978” and inserting in lieu thereof the following:
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“for the fiscal year ending September 30, 1978, and $43,- 

500,000 for the fiscal year ending September 30, 1979” . 

MIGRANT HEALTH

Sec. 105. (a) Section 31 9(h) (1) (relating to authorization for project grants for planning and development 

of migrant health centers) is amended by striking out “and” 

after “ 1977,” and inserting before the period at the end of 

the first sentence the following: “, $4,000,000 for the fiscal 

year ending September 30, 1979, $4,000,000 for the fiscal

year ending September 30, 1980, $4,000,000 for the fiscal

year ending September 30, 1981, $4,000,000 for the fiscal

year ending September 30, 1982, and $4,000,000 for the

fiscal year ending September 30, 1983” .

(b) (1) Section 31 9(h) (2) (relating to authorizations for operation of migrant health centers) is amended by 

striking out “and” after “ 1977,”, and inserting before the 

period at the end of the first sentence thereof the following: 

$40,000,000 for the fiscal year ending September 30,

1979, $44,000,000 for the fiscal year ending September 30,

1980, $48,400,000 for the fiscal year ending September 30,

1981, $53,240,000 for the fiscal year ending September 30,

1982, and $58,564,000 for the fiscal year ending September 30, 1983”.

(2) The third sentence of section 31 9(h) (2) is 

amended by striking out “and” after “ 1977,” , and insert-

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ing before the period at the end thereof the following: 

“, the fiscal year ending September 30, 1979, the fiscal 

year ending September 30, 1980, the fiscal year ending 

September 30, 1981, the fiscal year ending September 30, 

1982, and the fiscal year ending September 30, 1983” .

(c) Section 31 9 (h )( 3 ) (relating to authorizations 

for inpatient and outpatient hospital services) is amended 

by striking out “an d” after “ 1977,” , and inserting before 

the period at the end of the sentence thereof the following: 

“, $6,000,000 for the fiscal year ending September 30,

1979, $6,600,000 for the fiscal year ending September 30,

1980, $7,260,000 for the fiscal year ending September 30,

1981, $7,986,000 for the fiscal year ending September 30,

1982, and $8,784,600 for the fiscal year ending September 30, 1983” .

COMMUNITY HEALTH CENTERS 

Sec. 106. (a) Section 33 0(b) is amended by adding 

at the end thereof the following new paragraphs:

“ (4) The term ‘community hospital’ means cither a 

public general hospital owned and operated by a State, 

county, or local unit of government located in an urban area 

and primarily serving a population designated by the Secretary as having a shortage of personal health sendees, or a 

private, nonprofit community hospital located in an urban
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1 area and primarily serving a population designated by the

2 Secretary as having a shortage of personal health services.

3 “ (5) The term ‘primary care center’ means a unit of

4 a community hospital which—

“ (A) delivers primary health services to a catchment area (as determined by the hospital and approved 

by the Secretary) through a group of health professionals 

composed of primary care physicians and allied health 

personnel; and

(B) provides both (1) referral to emergency 

medical services and (ii) access to patient medical records on a twenty-four hours a day, seven days a week 

basis; and

“ (C) provides referral to supplemental health services.”.

(b) Section 330 is amended by adding at the end

17 thereof the following:

18 “ (h) (1) The Secretary may make grants, to commu19 nity hospitals to assist such hospitals in planning, develop20 ing, and operating primary care centers in urban areas.

21 “ (2) To be eligible for a grant under this subsection, the

22 community hospital must submit an application which con23 tains or is supported by the following assurances, satisfactory

24 to the S ecretan7

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“ (A) that, to the extent practicable, facilities anti 

equipment located in existing emergency rooms, outpatient departments, and other sections of the hospital 

shall he converted or have been converted for use in the 

primary care cente r; and

“ (B) that appropriate emergency room and outpatient services will be maintained or have been maintained after the conversion; and

“ (C) that the primary care center will be maintained as a separate and distinct cost unit, from such 

community hospital.

“ (3) Funds for grants under this subsection may be 

used for covering costs associated with (A) planning, (B) 

developing (including modernization, renovation of space, 

and construction), and (C) operating primary care centers.

“ (4) The Secretary may not approve an application 

for a grant under this subsection unless the application contains assurances that the primary care center will be operated in accordance with all the requirements for community health centers in subsection (c ), except for subsection (e) (2) (G).

“ (5) The Secretary may not approve an application 

for a grant under this subsection unless the application contains, in addition to the assurance pursuant to paragraph

28-3 86 0 - 78 - 2
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(4 ), the following assurances: the primary care center must 

have an advisory board which is composed of individuals a 

majority of whom receive their medical care at the center. 

The board shall meet regularly, hut no less than six times 

per year, to review the operations of the center and to 

develop recommendations to the hospital’s governing board 

concerning the types of services to be provided and the 

operation of the center.

“ (6) There are authorized to be appropriated for the 

purpose of making payments for grants under this subsection $34,000,000 for the fiscal year ending September 30,

1979, $72,000,000 for the fiscal year ending September 30,

1980, and $114,000,000 for the fiscal year ending September 30, 1981. No more than 30 per centum of the funds appropriated in any fiscal year may be used for planning and 

development (including construction, modernization, and 

reno vation) .”.

(c) Section 33 0(g) (1) (relating to authorizations for 

the planning and development of community health centers) 

is amended by striking out “and ” after “ 1977,” , and inserting before the period at the end of the sentence thereof the 

following: “, $10,000,000 for the fiscal year ending September 30, 1979, $10,000,000 for the fiscal year ending 

September 30, 1980, $10,000,000 for the fiscal year ending 

September 30, 1981, $10,000,000 for the fiscal year ending

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September 30, 1982, and $10,000,000 for the fiscal year 

ending September 30, 1983” .

(d) Section 33 0(g) (2) (relating to authorizations for 

the operation of community health centers) is amended by 

striking out “and” after “ 1977,” , and inserting before the 

period at the end of the sentence thereof the following: 

“, $320,000,000 for the fiscal year ending September 30, 

1979, $352,000,000 for the fiscal year ending September 30, 1980, $387,200,000 for the fiscal y ear ending September 30, 1981, $425,900,000 for the fiscal year ending 

September 30, 1982, and $468,500,000 for the fiscal year 

ending September 30, 1983” .

NAT IONAL IIE AL TII SERVICE CORPS 

Sec. 107. (a) Section 33 8(a) (relating to authorization for the National Health Service Corps) is amended by 

striking out “$57,000,000” and substituting in lieu thereof 

$64,000,000”.

(b) Section 336 (relating to annual reports to Congress) is amended by (1) inserting after “Sec. 336.” 

“ (a )”, and (2) by inserting at the end of subsection (a) 

thereof the following:

“ (b) In addition to the report required by subsection 

(a ), the Secretary shall submit a special report, developed 

through consultation with the National Advisory Council on 

the National Health Service Corps (as defined in section
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337), to the Committee on Human Eesources of the Senate 

and to the Committee on Interstate and Foreign Commerce 

of the House of Representatives on February 1, 1979. Such 

special report shall delineate the present and future directions of the National Health Service Corps particularly its 

relationship as a health manpower program and as a health 

services delivery program, analyze the use of corpsmen in the 

various settings defined in section 332, address the use of 

the Corps in meeting urban and rural health needs, and 

project the estimates of the Corps’ manpower and their use 

through 1985.” .

GENETIC DISEASES

Sec. 108. Section 110 1(b) (relating to authorizations 

for grants and contracts for testing and counseling, information and education programs to genetic diseases) is 

amended (1) by striking out “and” after “1977,” , and (2) 

striking out “for fiscal year 1978” and inserting in lieu 

thereof the following: “for the fiscal year ending September 30, 1978, and $30,000,000 for the fiscal year ending 

September 30, 1979” .

HE MO PH ILIA

Sec. 109. (a) Section 1131(f) (relating to authorization for hemophilia programs) is amended by striking “and” 

after “1977,” , and inserting before the period at the end of 

the sentence thereof the following: “, $5,000,000 for the fisr
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cal year ending September 30, 1979, $5,500,000 for the 

fiscal year ending September 30, 1980, and §6,500,000 for 

the fiscal year ending September 30, 1981” .

(b) Section 113 1(e ) (relating to authorizations for 

blood separation centers) is amended by striking “and” after 

“ 1977”, and inserting before the period at the end of the 

sentence thereof the following: “, §3,900,000 for the fiscal 

year ending September 30, 1979, $4,290,000 for the fiscal 

year ending September 30, 1980, and $4,712,000 for the 

fiscal year ending September 30, 1981” .

home health services

Sec. 110. (a) Title 111 is amended by inserting after 

section 319 the following new section:

“home hea lth services

“Sec. 320. (a) (1) For the purpose of demonstrating 

the establishment and initial operation of public and nonprofit private agencies (as defined in section 1861 (o) of 

the Social Security Act) which will provide home health 

services (as defined in section 1861 (m) of the Social Security Act) in areas in which such services are not otherwise 

available, the Secretary of Health, Education, and Welfare 

may, in accordance with the provisions of this section, make 

grants to meet the initial costs of establishing and operating 

such agencies and expanding the services available through 

existing agencies, and to meet the costs of compensating
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j professional and paraprofessional personnel during the initial 

2

 operation of such agencies or the expansion of services of 

2 existing agencies.

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 “ (2) In making grants under this subsection, the Sec5 retary shall consider the relative needs of the several States

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 for home health services and preference shall he given to

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 areas within a State in which a high percentage of the popug lation proposed to be served is composed of individuals who *

9 are elderly, medically indigent, or both.

1 0 “ (3) Applications for grants under this subsection

11 shall be made in such form and contain such information

12 as the Secretary shall prescribe by regulation.

13 “ (4) Payment of grants under this subsection may be

14 made in advance or by way of reimbursement or in install15 ments as the Secretary may determine.

16 “ (5) There are authorized to be appropriated $8,000,-

17 000 for the fiscal year ending September 30, 1978, $12,-

18 000,000 for the fiscal year ending September 30, 1979,

19 $12,000,000 for the fiscal year ending September 30, 1980,

20 and $12,000,000 for the fiscal year ending September 30,

21 1981, for payments under this subsection.

22 “ (b) (1) The Secretary of Health, Education, and Wel23 fare may make grants to public and nonprofit private entities

24 to assist them in demonstrating the training of professional

25 and paraprofessional personnel to provide home health serv-
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ices (as defined in section 1861 (m) of the Social Security 

A ct ).

“ (2) Applications for grants under this subsection shall 

be in such form and contain such information as the Secretary shall by regulations prescribe.

“ (3) Paym ent of grants under this section may be made 

in advance or by way of reimbursement, or in installments, 

as the Secretary shall determine.

“ (4) There are authorized to be appropriated $2,000,- 

000 for the fiscal year ending September 30, 1978, $2,- 

000,000 for the fiscal year ending September 30, 1979, 

$2,000,000 for the fiscal year ending September 30, 1980, 

and $2,000,000 for the fiscal year ending September 30, 

1981, for payments under grants under this subsection.”.

(b) Section 602 of Public Law 94-63 is repealed.

LEAD-BASED POISONING PREVENTION 

Sec. 111. Section 503 of Public Law 91-695 (relating 

to authorizations for lead-based paint poisoning prevention 

programs) is amended (1) by striking out “and” after 

“ 1977.” , and (2) striking out “for fiscal year 1978” and 

inserting in lieu thereof the following: “for the fiscal year 

ending September 30, 1978, and $14,000,000 for the fiscal 

year ending September 30, 1979” .
18

Se na tor Kennedy. I am hopef ul th at the witn esse s tod ay, and at 

he ari ng s schedule d fo r Ma rch 1, will discuss con struct ive im pro vements in these ex pi rin g au tho rities , so th at we can move forw ard to 

str en gth en the he alt h services deli very systems ava ilab le fo r un de rserved are as and population s, and fo r con trol an d pre ven tion of 

spec ial diseases.

Se na tor H athaway. Our firs t witn ess is Dr . Ju lius Ric hmo nd, 

acco mpa nied by Dr. Joy ce La sho f, Geo rge Ly th co tt, W illi am Foeg e, 

and Ka ren Davi s. Doc tor, go ah ead.

STATEMENT OF JULIUS B. RICHMOND, M.D., ASSISTANT SECRETARY OF HEALTH, DEPARTMENT OF HEALTH, EDUCATION, AND

WELFARE, AND SURGEON GENERAL OF THE PUBLIC HEALTH

SERVICE, ACCOMPANIED BY JOYCE LASHOF, M.D., DEPUTY ASSISTANT SECRETARY FOR HEALTH; GEORGE LYTHCOTT, M.D.,

ADMINISTRATOR OF THE HEALTH SERVICES ADMINISTRATION;

'WILLIAM FOEGE, M.D., DIRECTOR, CENTER FOR DISEASE CONTROL, AND KAREN DAVIS, PH.D., DEPUTY ASSISTANT SECRETARY FOR PLANNING AND EVALUATION

Dr . Richmond. We ll, th an k you, Mr. Ch air ma n. I am pleas ed to 

hav e the op po rtu ni ty to ap pe ar before th is subcom mittee ag ain th is 

mo rning. Yo ur he arin g conc erns sta tu to ry au thor iti es fo r Fe de ral 

pro gra ms pr ov idi ng he alt h servic es and disea se pre venti on and contro l. The se pro gra ms includ e the com munity he alt h centers, migrant 

he alt h centers, com preh ensi ve pub lic he alt h gr an ts to Sta tes , hy pe rtension, im mu nizatio n, venerea l disease, and othe r diseas e control 

pro gra ms.

F o r th e mos t pa rt, the y are adm ini ste red in two agenc ies of the 

Pu bli c He alth Serv ice: the He alth Serv ices Ad minist ratio n and the 

Ce nte r fo r Disea se Control. Acc ord ing ly, Mr. Ch air ma n, I am accom pan ied th is mo rning by Dr . George Ly th co tt and Dr. Willi am 

Foe ge, resp ecti vely , Adm in ist ra to r and Di recto r of those two age ncies. In ad dit ion , I am acco mpa nied by Dr . Joy ce La shof, De puty 

As sis tan t Se cre tar y fo r He alth Pr og ram s, and Dr . Ka ren Dav is, 

De puty As sis tan t Se cre tar y fo r Pl an ni ng and Ev alua tio n fo r He alth 

Pr og ram s.

In my prep ared sta tem ent, I will briefly desc ribe the cu rre nt sta tus 

and achievem ents of, and leg isla tive pro posal s for, ou r service deliv ery , cap aci ty build ing , and public he alt h and dise ase con trol activ itie s. Follo wing t ha t, my colle agues a nd I will be h ap py to r espond 

to yo ur questions.

in the inter est of tim e, Mr. Ch air ma n, I wi ll sum marize variou s 

po rti on s of my tes tim ony, and sub mit th e fu ll sta tem en t fo r the 

rec ord , so th at we w ill t ry to be brief.

As the mem bers of th is subc omm ittee kno w, the se service deli very 

and disea se pre ven tio n pro gra ms pro vid e us wi th some of th e mos t 

di rect Fe de ral lin ks to th e eve ryd ay he alt h car e pro blems of in di ­

vid uals. Due in lar ge m easure t o the com pass iona te lea dersh ip of this 

subc omm ittee , the acc omplis hme nts of the subcom mittee can be meas-
19

ured by the improved quality of health for the populations in our 

country in greatest need.

I would first like to discuss our capacity building programs. Our 

federally funded primary care programs include community health 

centers, migrant health, health underserved rural areas, maternal and 

infant care, and children and youth programs. As of 1977, a total of 

5.7 million persons were being reached through the Health Services 

Administration’s capacity building programs. This represents an increase of over 75 percent since 1975. Eighty percent of these people 

are poor; 85 percent of them are members of minority groups.

However, these programs do not yet fill the needs of all underserved areas, Mr. Chairman. An estimated 45 million Americans live 

in approximately 7,200 medically underserved areas; 56 percent of 

» these persons are in rural areas, and 44 percent are in urban areas.

During a relatively short life span, the capacity building efforts 

have demonstrated their flexibility in providing health care w’hich 

integrates health services, health and nutritio n education, social serv-

* ices, mental health counseling, and environmental services into a 

more efficient and cost-effective delivery system.

We will propose 3-year extensions for the community health center 

and migrant health programs, Mr. Chairman, at an authorization 

level of $301 million for community health centers, and 34.5 million 

for migrant health for fiscal 1979, and such sums as may be necessary for the following 2 years.

Closely linked to our capacity building programs is the National 

Health Service Corps, which will provide significant staffing, as we 

expand the number of centers. The National Health Service Corps 

scholarship program assignees, as well as other Corps recruits will 

also provide health services in manpower shortage areas to patients 

in a variety of settings. Those include public health facilities and 

Indian Health Service facilities.

We are using National Health Service Corps personnel, including 

nutritionists, public health nurses, and medical social workers, on 

assignment with local and district health departments to assist them 

in planning and carrying out programs.

For the National Health Sendee Corps, we request an increase in 

the 1979 authorization from $57 million to $64 million to accommodate the number of corps personnel who will be available for assignment in fiscal year 1979. The existing authorization level for fiscal 

year 1980 is considered adequate for an anticipated field strength of 

up to 3,000 in the corps.

Before I move on to the discussion of our disease control and prevention activities, I would like to speak to the urban health care

• problems addressed in section 106 of your bill, Mr. Chairm an; in 

particular, you address the need to enhance the ability of urban hospitals in underserved areas to provide comprehensive primary care 

services.

As you know, the poor in these underserved areas often use the 

hospital outpatient department and emergency room for the delivery 

of primary care, rather than for the specialized services for which 

they were designed. Not only has this resulted in many individuals
20

no t receiving ap prop ria te prim ary care services, bu t it has also contri bu ted to the gen eration of considerable deficits in these hospita ls.

We supp ort the conceptual basis of yo ur sulx?ommittee’s proposal, 

because we believe the com mun ity healt h cen ter program provides 

the flexibility necessary to relate the hospital set ting. Yo ur app roa ch 

wou ld greatly enhance our cap acity to dem onstrate more effective 

way s to delive r com preh ensive pr im ary servic es to the inner-city 

poor, and to pro vide a degree of fiscal rel ief to thes e hospita ls.

How ever, the ad mi nis tra tio n is still consider ing an urban in itia ­

tiv e in healt h, and we would thus be opposed to any addit ion al specific earm ark ing in cu rre nt pro gra ms. We believe there are sufficient 

funds to begin to work with the urban hospita ls in 1979. How ever, 

we must aw ait the Pr esiden t’s decision before com mentin g on the 

high er aut horization level proposed in y ou r bill.

Sev eral o the r legislative autho rities are u nd er c onsideration, which 

I describe in more detail in my statem ent. They include home health 

care, hyperten sion, hemophilia, and gen etic diseases.

I would ju st like to make on final com men t rega rd ing the im portan ce of our cap acity bu ild ing pro gra ms in meeting the needs of 

special initiatives underway to imp rove immu nizatio n levels and 

adolescent h ealth. W e expect the B ure au o f Comm unity He alth Se rvice pro gra ms to be a major delivery resource fo r imp roved fam ily 

plan ning services, ma ter nal, and child healt h pro gra ms , and increasing imm unization rate s. We also an tic ipa te prov idi ng necessary 

servic es fo r the CH AP program when it is enacted by the Congress.

I would now like to add ress the are a of disease pre ven tion and 

control. As you know, Mr. Chairma n, th is ad mi nis tra tio n is committed to inco rporati ng preven tion as the he art of a comprehensiv e 

str ateg y fo r improving the healt h of the Am eric an people. Both 

Secre tary Ca lifano and I are c omm itted to bringing more knowledge 

to the area of preven tion, and at t he same tim e ap plying most effectiv ely w hat we do know.

Pe rh ap s nowhere is the challenge be tte r evidence d th an in our 

com munity preven tion pro gra ms, which are charg ed with carry ing 

ou t outreach, ep idem iologic assessment, surveillan ce, community orga ­

niz ation and health edu cation, and insurin g th at hig h-r isk po pulation gro ups receive ap prop ria te preven tive services. We are de termin ed to creativ ely str uc tur e the most effective and responsible 

delive ry of th ese services.

In my prepared sta tem ent at this point, I set out certain accomplishm ent s of the Ce nte r fo r Disease Control in the are a of im ­

munizatio n, venereal disease control , lead base pa in t poisoning, and 

ra t control. I will no t pre sen t th at section now, in the intere st 

of tim e, Mr. Ch airma n, bu t will be ha pp y to answ er any questions you 

may have, and I will move on int o the prep ared sta tem ent to ap ­

pro xim ate ly pag e 15.

Yo ur su bcom mittee cu rre ntl y has a bill un de r con sideration which 

prop oses a 1-year exte nsion of the disease control and preven tion 

autho riti es. While we wou ld be opposed to enact ing a simp le 1-yea r 

extension of thes e autho rities at this time, it is our underst andin g 

th at the leg isla tion was introd uce d in its prese nt form prim arily to 

pro vid e tim e to deve lop a more com preh ensive preven tion initiative 

late r t his sp ring.
21

We understand that you are in the process of consulting with 

interested outside groups, and tha t you will be proposing legislation 

in the near future. Accordingly, rather than commenting further on 

the 1-year extension, I will outline our own prevention proposals 

and express the hope tha t we can work closely together in this vital 

health care area.

We will soon be submitting legislation to you, Mr. Chairman, proposing a consolidation of existing disease prevention and control 

programs into a single annual grant to the States. This comprehensive grant will consolidate existing authorities for disease control— 

lead based paint poisoning, venereal disease control, rat control, 

immunizations, and the comprehensive public health services gran t 

to States. Except for hypertension and mental health planning, we 

are proposing that consolidation.

We believe tha t States should be assisted in meeting the costs of 

providing required disease control and prevention programs of high 

national priority. We would expect to require the States to specifically earmark a portion of their grant for childhood immunization 

activities.

With regard to other disease prevention and control activities, 

however, States must be given sufficient flexibility so that they can 

determine which priority problems should be addressed with these 

Federal funds. While States will thus be afforded considerable flexibility to set their own prevention spending priorities for the Federal 

dollars they receive, flexibility will have to be balanced with the 

need for accountability.

In order to achieve such balance, we will recommend tha t State 

health planning activities under Public Law 93-641 and, in par ­

ticular, the requirement for development of a coordinated State 

health plan, address the extent of the need for preventive health 

programs and services and tha t States submit plans to spend the 

money they would receive from this program in accordance with the 

needs identified in those plans.

The Secretary would approve the plan prior to allocating these 

funds. We also favor incorporating audit and reporting mechanisms 

so tha t the Congress and the Secretary can review and examine 

whether funds are spent for appropriate preventive services identified in the State’s plan and approved application.

Incorporating the section 314(d) authorities into this comprehensive State gran t would allow the States to continue to spend tha t 

money on needed preventive health activities. It recognizes tha t certain of those traditional activities may require Federal funding in 

some States, but not in others.

I want to emphasize tha t we are looking forward to working 

closely with this subcommittee in further refinement of this legislation. I and my colleagues thank you for the opportunity to testify on 

these vital health care delivery and prevention issues today. We will 

submit a table, including the administration’s proposed authorization levels for fiscal year 1979 for the subcommittee to review. We 

will shortly be submitting extension legislation.

We will welcome, Mr. Chairman, any questions.

Senator Hathaway. Doctor, are you saying that under the block 

grant proposal which you are going to make, there are no national
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priorities and tha t we just give it to the States to do what they want, 

and tha t they are going to set all the priorities ?

Dr. Richmond. No, Mr. Chairman. We would certainly want to 

ask the States to focus on national priorities tha t we think are of 

importance; for example, the immunization initiative tha t we now 

have underway. We want to be certain that certain national priorities 

of tha t nature are well attended to. On venereal disease control—a 

current epidemiologic problem—we certainly would look hard at 

their plans. We would certainly want to see to it tha t the individual 

States are attending to the important national priorities, and that is 

the reason for asking for a State plan, tha t we so review and the 

Secretary can approve the State plan.

Senator Hathaway. They have to submit to you a State plan, but 

tha t cannot be too specific, because they do not know what the problems are going to be in the future. So if they spend a whole lot of 

money on something tha t you do not think they ought to be spending 

money on, there is nothing much you can do about it, is there, once 

you approved the States plan ?

Dr. Richmond. Well, again, we would be asking, Mr. Chairman, 

for audits and reports as to how the funds have been expended. I 

should also mention, Mr. Chairman, tha t we are in the process of 

developing a rather close liaison program with all of the State health 

officers. Dr. Lashof, as my deputy for health programs, and I have 

invited all of the S tate health officers to design a plan through their 

organization, the Association of State and Territorial Health Officers, to meet with us on a regular basis. And we would hope, through 

such communication processes and through the review of their plans 

and the audit of what they do, th at they would not be off target in 

terms of the public health priorities of the Nation.

Senator Hathaway. Now, for how long a period of time are you 

recommending this—3 years?

Dr. Richmond. Three years, yes, sir.

Senator Hathaway. The apprehension I have is once you start 

down that road, it is very difficult to go back to a categorical program, once you start on a block gran t program. I would think tha t 

we would go very slow’ with respect to that, to make sure tha t our 

priorities are guarded, and not just by some agreement tha t you may 

have with the State. They do not have anything over their heads to 

prevent them from doing whatever they want to do, which may or 

may not be in the national interest.

Dr. Richmond. Well, Mr. Chairman, your concerns have been 

concerns we have discussed in the Department rather extensively, 

and we do feel that national priorities need to be set, and we 

think, through a continuing dialog, the States will be responsive. 

We do feel tha t since there are individual variations in States—that 

is, not all of the problems are equally distributed across the 50 

States—that it becomes important to try to introduce some flexibility.

We think tha t we need to learn how’ to fine-tune our efforts at the 

State and local level to really target our efforts more effectively, and 

tha t is the reason we are moving in this direction.

Senator H athaway. Well, w ill there be any retained funds at the 

Federal level for special priorities?
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Dr. Richmond. Well, we have not as yet made a judgment about 

that.

Senator Hathaway. I would hope you would consider that, because I think it might be necessary. It seems to me th at if you are 

worried about the States having flexibility, tha t we ought to continue on a categorical basis and put the onus on the States to come 

back to us for approval to transfer funds, and in th at way, we would 

have better control, and at the same time we would provide for 

flexibility. I understand tha t various States are going to have different problems and tha t they would like to transfer funds, and I am 

not against that, but I think tha t it ought to be done on an ad hoc 

basis, rather than just giving them all the money and saying, “You 

can spend it any way you want.”

* You know we had problems under 3 14 (d); no information of how 

the funds were being spent. I assume tha t you recall that, and that 

there is something in your recommendation to take care of tha t 

accountability.

Dr. Richmond. Yes, sir. I think your suggestion is a good one and 

it is one that I think we would want to consider.

Senator Hathaway. Now, the Kennedy bill extends the community 

and migrant health center program for 5 years, and you are proposing 3. I t seems to me that if you believe that these are good programs, tha t the longer period of time is warranted. "Why are you 

cutting it off to 3 years?

Dr. Richmond. Well, Senator Hathaway, it is our view tha t the 

3-year period provides enough operational time to warrant a review 

of how effectively the programs are operating, to really assess how 

they are functioning. While we certainly would not look forward to 

discounting these programs at the end of 3 years, we think an opportunity to reassess at the end of 3 years would be very useful.

We are learning a good deal about how to deliver these services 

more effectively. We are certainly learning how to improve the comprehensive nature of these services. We are learning, certainly, how 

to build preventive services into these programs and as we learn 

more, I think we may want to take the opportunity at the end of a 

period like 3 years to see if we can redirect these programs to become even more effective.

Senator Hathaway. Well, lengths of time, I suppose, are always 

debatable, anyway. I suppose it is very difficult to come up with the

* right answer. It just seems tha t a 5-year period would give these 

programs a better chance to grow, and then evaluate them. You 

know, it is just those two programs we are talking about; others are 

of shorter duration.

* Let me ask you something about the National Health Service 

Corps. How many new scholarship recipients will there be in 1979?

Dr. Richmond. We expect to add at least 450 scholarship people to 

the Corps in 1979. In terms of the specifics concerning scholarship 

recipients, do you have that number, Dr. Lvthcott ?

Dr. Lythcott. We are at about half and half righ t now, sir.

Dr. Richmond. About fifty percent serving in the Corps in 1979 

will be scholarship recipients, and 50 percent will be volunteers.

Senator H athaway. How many?
24

Dr. Richmond. F ift y-fif ty.

Se na tor H athaway. New ones, I am talk ing ab ou t; new sch ola rships.

Dr. Richmond. We will have 1,725 assignees.

Se na tor H athaway. Those are no t all new, tho ugh. How many of 

those a re new ?

Dr . Richmond. 300 will be new scholarships fo r exce ptio nally needy 

studen ts.

Se na tor H athaway. 300 ?

Dr. L ythcott. Yes, and in addit ion 900 new contr act s will be 

aw ard ed in 1979.

Se na tor H athaway. It will be 300 new sch ola rships th at will be 

aw ard ed in 1979 ?

Dr. L ythcott. Th ere will be abo ut 300 sch ola rsh ips aw ard ed to >

persons who received th eir firs t year of su pp ort un de r a special pr ovision fo r sch olarships fo r students of exceptional fina ncia l need.

Th is will be th eir firs t ye ar of su pp ort un de r th e Na tio nal He alth 

Serv ice Corps sch olarship prog ram so, I guess they could be con- *

side red new awards. In addit ion to thes e 300 aw ard s there will be 

anoth er 900 new awards.

Se na tor H athaway. I s th at a reasonable figure, or could th at be 

increased ?

Dr . L ythcott. Well, I think it is a reaso nable figure for now altho ugh we a re con stantly reassessing our needs. Th e numb er of scholars hip men and women will increase as th e yea rs go by. W e anticipa te 

a larg er num ber of sch ola rship people as com pared to volunteers as 

we go do wn the line.

Se na tor H athaway. H ow does th at com pare with th e pa st year?

Dr . L ythcott. I t has been more volunteer, and the sch olarship is 

becoming about equal, sir.

Dr . L ashof. I t migh t he lp to clarify a lit tle bit the difference in 

yo ur question as to wh eth er you were talk ing about new sch olarship 

awardees th at were actua lly aw ard ed sch olarships in school versu s 

those com ing out of the prog ram and ready fo r field placeme nt. I 

think th at is where some of the confusion on figures is.

Th ere will be. in 1979, 900 new aw ard s made to stu dents in school 

fo r sch ola rship aw ard; actua lly coming out, ha ving finish ed their 

schooling and ha vin g done th ei r po stg radu ate residency trai ni ng 

and ava ilable for field assignment in 1979 will be 450. Tha t is where 

the differences in figures are. .

Se na tor H athaway. I see. Th an k you. Now, it has been alleg ed 

th at a dispropo rtion ate sha re of the com munity healt h cente r fun ds 

pro vid ed un der section 330 are allocate d to urban he alth centers.

Can you give us a brea kdo wn fo r the most recent fiscal ye ar of the .

numb er of pro iec ts th at hav e been fun ded and the amount of fun ds 

exp ended in, first, urba n comprehensive com munity he alth centers, 

then ru ra l com preh ensive com munity health centers, and ru ra l health 

in itiative pro jec ts and urba n he alt h initiati ve pro jects? Do you have 

th at wi th you, or can you su pply it fo r the re cord ?

Dr . L ashof. We hav e all the figures here, bu t maybe you would 

pr efer fo r us to sub mit a table to you with them broken down, rath er 

than t ry in g to read them all off to you ?
25

[The information referred to appears on p. 91.]

Senator Hathaway. Well, can you answer my question as to 

whether or not the allegation is true that a disproportionate share 

of the money is going to urban, rather than rural ?

Dr. Lashof. I do not know how you define “disproportionate.” 

The urban projects-----

Dr. Richmond. Dr. Lythcott has those figures.

Dr. Lythcott. I do not know how you define “disproportionate” 

but the ratio of dollar expenditures is about 8 to 5 now, sir, of the 

urban versus rural, in numbers.

Senator Hathaway. Eight to five?

Dr. L ythcott. Yes, approximately.

Senator Hathaway. Eight dollars to every five ?

Dr. L ythcott. Actually, for CHC, the ratio we anticipate for fiscal 

year 1979 expenditures is 68 percent urban and 32 percent rural. But, 

for health services projects overall, including migrant health, health 

underserved rural area projects and the National Health Service 

Corps the ratio is closer to 55 percent urban and 45 percent rural.

Senator Hathaway. I see. How about on the basis of service on 

the number of people involved? Do you have any breakdown along 

that line?

Dr. Lythcott. We have it here. We have to provide it for the 

record; I would have to dig it out.

[The information follows:]
Ta ble 1

Ru ral and Urban Breakout of the Community He alth Ce nte rs

1977_________________ ________________ 1978________________ 1_____________ 1979 ______________

P ro je cts Funding Proj ects Funding Proj ec ts Funding

2 of 2 of 2 of 2 of 2 of Z of

Cocununitv Hea lth Cen ters No. ' s T ota l $ T ot al N o.'s T ota l $ T ot al N o.'s Tot al $ Tot al

On-going CUC's

Ru ral 45 10Z $ 40,47 0 192 45 82 5 44,40 8 182 45 62 5 52.347 182

Urban 113 252 $143,484 672 113 20Z 5157,445 642 113 162 5165,767 582

RHI 262 582 $ 23,5 99 112 356 622 5 31,18 7 132 441 632 5 39,688 142

m I 35 72 S 7,595 32 60 102 5 13,9 60 52 106 152 5 28,198 102

CHC T ot al 455 1002 5215,148 1002 574 1002 5247 ,000 1002 705 1002 $286,000 1002

Ru ral 307 672 5 64,069 302 401 702 5 75,5 95 312 486 692 5 92,035 322

Urban 148 332 5151,079 702 173 302 5171 ,405 692 • 219 312 $193,965 682

K05

V i
27

Co mn unity H ealth Cen te rs 

Rura l/U rb an

1977______________ . ___________1978

P ro je cts Pe ople

Se rved 0 0 0 's

Funding

000's

P ro je cts Pe ople

Served OC

Funding

10's 000 's

Ongoing CHCs

Ru ral 45 504 $40,4 70 45 537 $44,40 8

Urban 113 1,59 6 143,4 84 113 1,69 9 157 ,445

Subto ta l (158) (2 ,1 00) (1 83 ,9 54 ) (158 ) (2 .2 36) (2 01 ,8 53 )

RHI 262 1,14 9 23 ,599 356 1,85 4 31,187

UH I 35 175 7,59 5 60 475 13,960

T o ta l a ll Ce nters 455 3, 42 4 21 5,14 8 574 4,56 5 247,0 00

w

Ru ral (307 ) (1 ,653 ) (6 4,0 69) (401 ) (2 .3 91) (7 5,5 95)

Urban (148 ) (1 .7 71) (1 51 ,0 79 ) (1 73 ) (2 .1 74) (171 ,405)

NHI Stud y da ta in d ic a te us er s and t h e ir fa m il ie s in :

Ru ral area s - 97X B la ck, 57% fe m a le , 43X un de r 17 , 62X BCHS f a c i l i t y us ua l so urce 

o f ca re

Urban area s - 81X B la ck, 59X fe m ale , 47X un de r 17 , 71X BCHS f a c i l i t y us ua l so urce 

o f ca re

28 -386 0 - 78 - 3
28

Senator Hathaway. I s it roughly equivalent ?

Dr. Lythcott. Larger numbers are served in rural areas, generally, 

then are served in the urban areas.

Senator Hathaway. Larger numbers are being served ?

Dr. Lythcott. Yes, in 1978 in the CHC program we anticipate that 

2,391,000 persons will be served in rural areas and 2,174,000 persons 

will be served in urban areas.

Senator Hathaway. Now, as you know, Senator Javits has introduced an amendment calling for the establishment of an urban health 

initiative as a part of the community health program. Would the existing need for such services in rural medically underserved areas 

justify the broadening of this proposed program to include both 

urban and rural community hospitals as recipients of this financial 

assistance, or the establishment of a similar program to meet the 

special needs of rural communities?

Dr. Richmond. Well, Senator Hathaway, we still have large underserved or unserved populations in urban centers, and our considerations in the urban initiative reflect our concern for the need to extend 

those services and, there, we are considering the potentialities, of 

course, of using hospitals in central cities, their outpatient departments, and also developing satellite units in addition to the existing 

community health centers.

In the rural areas, in addition to the development of centers, we 

think tha t the National Health Service Corps approach does provide 

us with a great deal of flexibility to meet the needs of rather sparsely 

settled areas where the population is rather thinly distributed. So, 

we see ourselves as going in both directions, because there are great 

needs in both the rural and the urban areas.

Senator Hathaway. Let me ask you a question on the migrant 

health centers. The administration budget includes $3 million for 

hospitalization for migrants. I t does not seem to me that that is going 

to be sufficient, because what happens with migrants who cannot 

meet the residency requirements for State-funded programs that 

need to be hospitalized? I am just wondering why no additional 

funding has been requested in that particular area.

Dr. Richmond, senator, we are proposing some legislation—I 

might ask Dr. Lashof to comment on it—that would deal with this 

matter of residency requirements. Do you want to comment on that, 

Dr. Lashof ?

Dr. Lashof. Just briefly, the Health Care Financing Administration will be proposing some legislation to deal with the problem of 

resident status as a barrier to services for the migrant population. 

If tha t legislation is successful, we would assume tha t the problem 

of hospitalization for the migrants would be addressed in tha t way 

and that it would be able to be picked up under the medicaid program. I f that is not successful, then I think you have, indeed, identified a problem. But we are, at this point, expecting tha t that legislation will deal with that problem.

Senator H athaway. Now, when will this proposal be before us?

Dr. Lashof. It is in the hands of the Health Care Financing Administration, so I cannot tell you exactly. I assume it is going forward. We met with them about it, and it is to deal specifically with
29

the problem where one State claims tha t the m igrant is not a resident, 

so that State will not pick it up, and the other State says, “They are 

not a resident here either and we will not pick it up.” The exact wording and the exact methodology they are planning to use, I do not 

know, but that is the problem they intend to address.

Dr. Richmond. Dr. Davis has a comment.

Senator Hathaway. Yes, Karen?

Dr. Davis. That proposal has been approved by the administration ; 

it is part of the President’s budget. We estimate tha t it would cost 

about $8 million in fiscal 1979. There are legislative amendments 

being forwarded to the appropriate authorizing committees to deal 

with tha t problem.

Senator Hathaway. I see. Thank you. Now’, in the New York 

Times last week, it was reported tha t you are sending at least 20 

physicians from the National Health Service Corps into New York 

City next year. So far, almost all members of the corps have gone to 

rural areas; approximately 94 percent. Your new policy would put 

60 percent in the inner city. How can you make such a rapid switch 

in placement ?

Dr. Richmond. Senator Hathaway, I do not know’ where your 60- 

percent figure comes from.

Senator Hathaway. I guess it comes from the New York Times.

Dr. Richmond. There is no policy on that. It was in the New York 

Times, but I do not know’ where that reporter got tha t figure. There 

has been no policy decision.

Senator Hathaway. It is part of all the news tha t is fit to print; 

I do not know th at that necessarily means it is true. So, the 60 percent is off ?

Dr. Richmond. Oh, yes.

Senator Hathaway. What kind of a switch, percentagewise, do you 

intend to make ?

Dr. Richmond. Well, w’e are moving slowly on this matter of 

redistribution. This issue is more complex than at first meets the 

eye, Senator Hathaway, because we do take into the Corps volunteers, and we try to make a match between the volunteer and the 

area of need. A number of people are volunteering who prefer to 

serve in urban areas, and we do not deny them tha t opportunity.

So, we cannot be absolutely certain as to how many we will ult imately have in urban areas. I think it is fair to say that, as a policy 

matter, we do not want to lose the concentration on the rural areas, 

because we think w’e have really made some impact there and we 

would not want to diminish that.

Senator Hathaway. Yes, I think you have, too, and I do not want 

to see that neglected, understanding full well the problems of the 

inner cities. I think the figure was that 60 percent of the new assignments would be to urban areas. Even tha t is not true?

Dr. Lashof. That is not correct.

Dr. Richmond. That is not the policy.

Senator Hathaway. Well, you mentioned th at some of them volunteer for this, but do you have any plan for an orderly transition, or 

increase in urban over rural ?
30

Dr. Richmond. We ll, we are proje cti ng—an d, of course, we have 

to mak e some guesses abo ut this—b ut in 1979, we would think it 

would be 85 per cent ru ral and about 15 percen t ur ba n; and in 1980, 

pe rhaps 80 pe rce nt r ur al and 20 perc ent urban .

Se nator Hathaway. Do y ou think th at that is a fa ir m ix?

Dr . Richmond. Yes, I think th at is a reasonable mix, no t because 

we wa nt to neglect the urban area s, Se na tor Ha thaw ay , bu t we do 

th in k th at since the re are healt h pro vid ers in urban are as who may 

no t curre ntl y be worki ng amo ng the underse rve d population —in 

othe r words, in the centr al city area s—we are looking at ways by 

which we can provide ince ntives fo r those peop le, no t necessarily 

throug h the Corps exclusively, to work in those areas.

So, it does no t mea n we are minim izing the problem of prov idi ng 

services to people in the centr al cities, bu t we do not th in k it will 

hav e to come pre dominat ely from the Corps.

Se nator H athaway. Now, alo ng the same line, I know t hat you are 

me etin g the needs of the In di an healt h service un it, bu t how about 

some others, like com munity men tal healt h cen ters and State mental 

hospitals and federal prisons ?

Dr . Richmond. We are looking at the needs th at are develop ing 

the re, Senator Ha thaw ay , pa rti cu larly if one looks at the poten tial 

need in pub licly financed hospitals , as we c ut off th e inflow of foreig n 

medical gra duates. Such graduates have been staffing some of those 

hospitals in relatively significant num bers . It may well be th at t here 

will be some critical needs there fo r phy sician s, and if th at does 

become acute, we would certainl y con sider the assi gnm ent of Natio nal He alth Service Corps phy sician s and othe r healt h pro vid ers 

to those settings .

Senator H athaway. Y ou do not think the re is a need righ t at the 

pre sen t tim e ?

Dr. Richmond. W ell, fo r example the St ate menta l hospitals have 

tra ditio na lly been poo rly staffed, so th at th ere is a need. How ever, the 

needs are ve ry vast and we are not sure th at a st rat egy using the Corps 

would be a relevant solu tion to the State hospital problems. But we 

would be wa nting to look at critical areas where there are some real 

problems. A nd, a gain, we are no t insensitive, I m igh t say, to the needs 

of the State mental hos pitals, bu t our Alcohol, Dru g Abuse, Mental 

He alth Ad ministratio n is look ing at those problems. And our commu nity m enta l h ealth ce nter pro grams, we hope, w ill begin to de al with 

the State m ental h ospit al needs more effectively.

Se nator H athaway. I s the re an ove rall pla n fo r taking car e of 

thes e needs ?

Dr. Richmond. Well, we hope th at with the recommen dations th at 

we discussed yeste rda y, which will be com ing from the Pr es id en t’s 

Commission on Mental He alth, t hat we will be dev eloping more comprehensive design fo r m ental health services.

Se nator H athaway. Th at will be out in Apr il ?

Dr. Richmond. Yes, in Ap ril. As you may recall, we are looking 

forw ard to lin king those services with the healt h service system 

much more intima tely.

Se nator H athaway. W ha t abo ut the Fe de ral prison prob lem?

Dr. Richmond. We ll, this is an are a where we are review ing the 

needs. Some National He alt h Service Corps personnel could be as-
31

sign ed to those areas, because there are some c ritica l needs. It has not 

been a p artic ularly p op ular area f or healt h provide rs to work. We m ay 

well have to rely on our Corps personnel f or some of those services. W e 

are looking a t th at.

Se na tor H athaway. You are looking at it, bu t is there some kin d 

of a plan to do somethin g about i t ?

Dr . Richmon d. W e will be dev eloping a pla n, Se na tor Ha tha wa y. 

Pe rh ap s D r. Ly thco tt wants to comment on tha t.

Dr . Lythcott. T he Bu rea u of Medical Serv ices, sir, has been pr ovidin g medical supp ort fo r the Bu rea u of Prisons. We have h ad the 

total respon sibility for th at. Fa irly recently, we were asked to reduce 

th at int ere st over a 3-y ear per iod un til it is phased out. We have 

requ ested th at we be allowed to sta y in the are a, and th at is in the 

mill now and I am hopeful th at we will be able to con tinu e full 

su pp ort fo r the Federal prison s h ealth p rogra m, w ith o ur own service 

officers and , if need be, N ational Hea lth Service Corps people, as well.

Se na tor H athaway. Now, le t me ask you a question on the admi nistration of this pro gra m. The Na tional He alth Service Corps is 

un de r the Burea u of Comm unity Hea lth Services, bu t the sch ola rship program is administered in the Burea u of Hea lth Man power. 

Does t hat cause any problem s ?

Dr . Richmond. I migh t ask Dr . Ly thco tt to com men t on that.

Dr . Lythcott. Th e two agencies, both at staff an d at senior level, 

work very closely tog eth er, sir , and we have had no problems at all 

in do ing this.

Se na tor H athaway. Th ere is no need fo r a cons olid atio n or a sep arate agency ?

Dr. L ythcott. No, sir.

Se na tor Hathaway. Now, one las t question on this gen eral prob ­

lem : Man y stu dents come o ut of medical school with excellent clinical 

know ledge, bu t lit tle knowledge of the sit uatio n th at the y are goi ng 

to face. I ju st won der wh at you are pre sen tly doing to help to ease 

the tran sit ion for them.

Dr . L ythcott. We ll, Se nator , most, if no t all, of ou r un its are 

relate d eit he r to tea ching centers or to other ho spita ls where pa tie nts 

can be hos pita lize d. An d with th at relationship between th e more 

sen ior phy sician and the younger men who come in, we inten d to 

bridg e the ga p between wh at the y do no t know when the y come in, 

and pe rhaps to learn what it is a ll about.

By the time a physician is place d in a C orps site he o r she has generally completed resid ency tr ai ni ng and h as had several year s experience 

in responsible pa tie nt care. In addit ion , we pro vide dir ectly and 

throug h c ontracts a variety of assistance in clu din g pr e-a ssignme nt conferences, and assistance in setting u p a practic e and medical ma nagement systems. In addit ion , conti nuing rel ati onships wi th edu cational 

institut ion s are bein g deve loped to reduce pro fessional isolation and 

continu e the professional edu cation of the Corps assignees. Area 

He alth Ed ucati on Cen ters assist in this also. Also, we a re wo rking on 

the identif ication and eliminat ion of spouse displeasure, cu ltu ral and 

perso nality clashes to help us to beg in to work on eas ing these typ es 

of p roblem s in C orp s assignments.

Dr. Richmond. D r. Davis wou ld like to comment on th at.

Dr . Davis. W e also have several program s to tr y to acquain t students w ith ru ral areas du rin g th ei r period of tra in ing. We are spon-
32

soring, of course, the area health education center program which 

establishes training centers throughout the States so tha t medical 

students and other types of health professional students can rotate 

through the centers and get some experience with rural areas prior 

to that time.

We also have, of course, the family practice residency and primary 

care residency programs, so the students do have an opportunity 

through this period of their training to become acquainted with rural 

areas.

Senator Hathaway. Are these keyed to certain geographical areas, 

or are you just saying rural areas, in general ? Could a doctor find 

out what the problems are in Alaska or North Dakota or Maine, or 

wherever?

Dr. Davis. That is right. They have had, particularly in the area ”

health education center program, a very strong rural focus to try to 

acquaint students with these areas during their training.

Dr. Richmond. In the health manpower legislation, too, that requires, ultimately, 50 percent of the training physicians to go in the 

direction of primary care, there is the specification that some of that 

training be in remote sites from the medical centers, so that the ultimate pressure is there to get the students out into places at some 

distance from the medical centers so tha t they gain some experience 

in other kinds of communities.

Senator Hathaway. One last group of questions; I just wanted 

to find out what you are doing with respect to the Russian flu. I suppose Dr. Foege could better answer that.

Dr. Foege. We do have isolates now on the Soviet flu from Wyoming, from Colorado, from West Point, New York, and from Michigan. And then, of course, this morning we have clinical evidence 

tha t has been submitted from Annapolis. A series of meetings have 

been held, starting in December, and the last one was held Monday 

of last week, with flu experts from university centers and also people 

from State health departments as well as representatives from a variety of groups—NIH, COC, the Food and Drug Administration.

They met to look at this and they have made some recommendations to the Department that a program on influenza be contemplated, 

not specifically for Soviet flu, but a program tha t w’ould provide 

ongoing influenza immunizations for high-risk groups each year, but 

starting this fall with the Soviet flu as one of the components.

Senator Hathaway. But does this high-risk group not change?

This is just newspaper talk, but I understand the Russian flu has 

affected more young people, who are normally not in the high-risk 

group.

Dr. Foege. There is one high-risk group tha t does not change for »•

any strain of influenza A. It consists of two types of people—those 

who have a chronic medical condition, and those who are over the age 

of 65. With the current Soviet strain, the individuals under the age of 

about 24 have had no previous experience w’ith this strain, so they 

are considered to be at a different risk than older people. Therefore, 

the first priority, we feel, should be given to persons under 24 who 

have a chronic medical condition. That is what the group recommended last week.
33

We have now gone to all State health officers and asked them for 

comments on the recommendations of this group, and specifically 

what recommendations they would have for carrying out an annual 

program aimed at high-risk groups. We expect the comments by the 

end of this week, and the Department will then look at the recommendations from last week and the recommendations from the State 

health officers, and present a proposal.

Senator Hathaway. I see. What percentage of the population do 

you think would have this available to them ?

Dr. Foege. The committee last week listed three priorities, the 

first priority being persons under the age of 24 with chronic medical 

conditions, which would be about 4i/2

 million people; the second 

priority being persons over the age of 25 with chronic medical con- 

* ditions, which would be an additional 14 ^ million people; and,

finally, persons over the age of 65, which would be an additional 23 

million people. So, the high-risk group would consist of about 43 or 

44 million people.

Senator Hathaway. About 20 percent of the population.

Dr. F oege. Tha t is right.

Senator Hathaway. And you think tha t is going to be sufficient ?

Dr. F oege. Traditionally, we have only been able to reach about 

20 percent of the high-risk group in the country. The committee feels 

tha t it is probably not an attainable goal to reach the entire highrisk group this year, and they are proposing th at we begin a program 

which would double the population reached from 20 percent to 40 

percent of the high-risk group during the coming year.

Senator Hathaway. What is the likelihood of side effects from 

the immunization? I know tha t there were some a year or so ago on 

the immunization program.

Dr. F oege. We would expect tha t the new vaccine containing the 

Soviet strain would have about the same risk of side effects, and side 

effects can be listed in two categories: minor side effects—sore arms 

and fever for the first 24 hours—and the major ones, which would 

included allergic reactions. We find that this happens only about once 

every 4 million influenza immunizations. The second major complication would be Guillain Barre Syndrome, and we find this happens 

about once every 105,000 immunizations, and about 5 percent of the 

people getting Eon Boray do, in fact, die, which means about 1 

death per 2 million immunizations.

_ So, I think we are in a position of having a better idea of what

the risks are and being able to compare this to influenza. For people 

who are in high-risk groups of influenza, the risk from disease is many 

times greater than the risk of death from Guillain Barre.

« Senator Hathaway. Well, as far as allergic reactions, I suppose

the individual knows whether he is going to be subject to tha t or 

not, but how about on the Guillain Barre Syndrome? Can you determine ahead of time whether that would be likely to happen in an 

individual ?

Dr. Foege. We know of no way to screen out people for likelihood 

of Guillain Barre Syndrome. We do know that it is more likely to happen in the older age groups; that is also the age group most likely 

to have complications from the flu. But we know of no way to spe-
34

cifically look a t an individual and make a decision on whether they 

would have a high risk of Guillain Barre.

Senator Hathaway. And is that from the vaccine itself, or is it 

just from the innoculation?

Dr. Foege. It is associated with people who get the vaccine. We 

really do not know the mechanism. We also do not know whether 

influenza itself carries a high risk of Guillain Barre, and this year we 

are hoping to do surveillance on what is the risk of Guillain Barre 

after natural influenza.

Senator Hathaway. What is the projected cost of this program?

Dr. Foege. If, in fact, we attempted to reach 20 percent of the 

high-risk group, we believe this would cost about $15 million during 

the current year.

Senator Hathaway. But then you said at the beginning that you »

are going to have a program that will be ongoing from year to year.

So, will it be roughly the same or will it be increasing?

Dr. Foege. I t would increase, and let me back up just a moment 

on those figures. The recommendation th at has been made is th at the 

Federal Government would assist the States, not pay for the entire 

program, and the $15 million would represent about two-thirds of the 

cost for reaching 40 percent of the high-risk group.

Senator Hathaway. Thank you all very much. I have some ad ditional questions that I will submit to you in writing Senator Javits?

Senator J avits. Dr. Richmond, I will not keep you but 2 minutes, 

but I did have this question. I am naturally very much interested in 

what this bill does about the urban hospitals, especially the problem of the use of emergency rooms, et cetera, for clinic purposes.

And I notice in reading your testimony t hat you are opposed to earmarking. We are not trying to earmark, but we are tryin g to raise 

the aggregate authorization. In addition, I see th at you wish to await 

the determination of the President.

My problem with tha t is how much time do you want?

Dr. Richmond. Well, Senator, as the person who was the first director of the program tha t preceded what we now call community 

health centers—the neighborhood health center program was in the 

Office of Economic Opportunity, back in the 1960’s—I share your 

concern about movement. I can assure you that we are in the process 

of planning. We have certainly been communicating with people on 

your staff concerning the matter of extending community health 

services in the urban setting.

We do hope that the President, as pa rt of the overall urban initiative of his administration, will be persuaded tha t we have got to 

move quite rapidly. But we certainly are essentially in agreement 

with the principles tha t you and your staff have enunciated in terms 

of directions in which we ought to go.

Senator J avits. Well, how very kind of you, and it is terribly 

helpful. So you feel the President’s views will come within the total 

of what he offers to the urban community ?

Dr. Richmond. Yes.

Senator J avits. Well, all I can say in response to tha t is that I am 

not committed to waiting, but will certainly give a modest opportunity to see what the President comes up with. I am going to write
35

the Pr esiden t and urg e him to include th is pro posal in his urban 

ini tiativ e.

Th e othe r question I would like to ask you is a questio n rais ed by 

Dr. Davis. He raised the point abo ut the fact th at in my bill, we 

allow c onstruction , whereas in the com munity he alt h centers , we only 

allow fo r ren ova tion , and he asked why. Can you tell me if you believe we would need con struction au thor ity to accomp lish thes e pr ogram ’s objectives?

Dr. Richmond. We ll, I think, Senator , th at as we move int o the 

gr ea ter expansion of services, it pro bably will be necessary to hav e 

some con stru ctio n fun ds. Whil e we realize th is does consume ra th er 

lar ge amounts, nonetheless fo r some of the reasons Dr . Da vis in di ­

cates—th at is, the need to have physicians and othe r he alth pr oviders wo rki ng in ap prop ria te kin ds o f settings— we think th at some 

new constru ctio n w ould become necessary .

Se nator J avits. My reason fo r inc lud ing it was th at the difficulty 

wi th emergency room use was th at it was in hos pitals. If you are 

going to hav e some kind o f a clinic and you are goi ng t o avo id cloggin g the emergency facil ity , you have to pu t i t somewhere. You m igh t 

pu t it in the same hospital, bu t it would still be con struct ion , no t a 

renovation .

But I promise you, Dr. Dav is, because I very much su pp ort the 

com munity h ealth c enters—I promise you th at we w ill do our utm ost 

to see that th ere is no und ue expend itu re on bricks and m or ta r which 

would tak e money away from anybody. Th e idea is to rea lly separate 

the clin ical facility from the emergency facil ity , so th at the em ergency f acility can do its job.

Th e last th in g I would like to say is th at I than k you very much, 

Dr. Richmond , fo r your supp ort of the exte nsion of th e genetic 

diseases bill fo r 3 y ears, and we will proceed with th at wi th con sidera ble encouragemen t, now th at you have fe lt th at th at is the righ t 

way t o go. If we have a ny othe r questions, I will sub mit the m to you 

in wr iting.

Dr. R ichm ond. Tha nk you very much.

[The prepared statem ent of Dr. Ric hmond and his responses to 

wr itten questions sub mitted by the subcommittee fo llo w:]
36

DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE

STATEMENT

BY

JU LIU S B . RICHMOND, M .D .

ASS ISTA NT SECRETARY FOR HEALTH

DEPARTMENT OF HEALTH , EDU CAT ION, AND WELFARE

BEFORE THE

COMMITTEE ON HUMAN RESOURCES

SUBCOMMITTEE ON HEALTH AND S C IE N T IF IC RESEARCH

UNITED STA TES SENATE

THURSDAY, FEBRUARY 9 , 1978
37

MR. CHAIRMAN, MEMBERS OF THE SUBCOMMITTEE:

I am p leas ed to be here again today. This morn ing your 

hearing concerns statutory authorit ies for Federal programs 

providing health services and dise ase prevention and control.

These programs include the comm unity heal th centers, migrant 

health centers, comprehensive public health grants to States, 

hypertension, immunization, venereal disease, and other 

disease control programs.

For the most part, they are admi nistered in two agencies of 

the Public Health Service: the Health Services Administration, 

and the Center for Disease Control. Accordingly, I am 

acco mpanied this morning by Dr. Geor ge Lythcott and Dr. William 

Foege, respective Administrator and Director of those two 

agencies. In addition, I am acco mpanied by Dr. Joyc e Lashof, 

Depu ty Assi stant Secretary for Hea lth -Pr ogr ams , and

Dr. Karen Davis, Deput y Assista nt Secretary for P lanning 

and Evaluation/Health.

In my prep ared statement, I will brie fly describe the current 

status and achiev ements of, and legislative proposals for, 

our service delivery, capa city building, and publ ic health 

prevention and disease control activities. Foll owing that, 

my colleagues and I will be happy to respond to you r questions.
38

- 2 -

As the members of this Subcommittee know, these service 

delivery and disease prevention programs provide us wit h 

some of our most d irect Federal links to the everyday 

heal th care problems of individuals. Due in large measure 

to the compassionate leadership of your Subcommittee,

Mr. Chairman, their a ccomplishments can be measured

by the improved qual ity of health for the populations in w

greatest need.

Capacity Building Programs *

I w ould like first to discuss our capa city building progra ms .

Our Federally funded primary care programs include Community 

Healt h Centers, Migran t Health, Healty Underser ved Rural 

Areas, Maternal and Infant care, and Children and Youth programs.

As of 1977, a total of 5.7 million persons were being reached 

through the HSA capacity building programs. This represents 

an increase of over 75 perce nt since 1975. Eighty percent 

of these people are poor. Eighty-five percent of them are 

members of minority groups.

However, these programs do not fill the needs of all und erserved areas, Mr. Chairman. An estimated 45 million 

Americans live in a pproximately 7200 m edically underserved 

areas; 56 percent of these persons are in rural areas and 

44 percent are in urban areas.
39

- 3 -

Betwe en 1975 and 1977 HSA establis hed a total of 350 new

centers, increasing access to services for 2.5 million 

persons. During 1977 alone, we establis hed a total of 200 

new centers providing access to app roximately 1.25 million 

residents of medically unde rserved areas and heal th manpower 

shortage areas.

Of the 836 health services grantees, 520 are in rural areas 

and 316 are in urban areas. Based on the 1978 appr opriations 

and our requests for 1979, we hope to de velo p 150 additional 

community health centers this year and 131 in 1979.

These centers are located in areas of medi cal underservice, 

characterized by above -average poverty and infant mort ality 

rates, higher than average proportions of the aging and a 

shortage of ph ysicians and other providers.

They have focused on preventive health measures, subs tituting 

less expensive ambulatory care for more costly, sometimes 

unnecess ary hospitalization.

During a relatively short life span, the c apacity building 

efforts have demo nstrated their flexibility in provid ing 

healt h care whic h integrates heal th services, health and 

nutr ition education, social services, mental healt h 

counseling and environmental services into a mor e efficient 

and cost -eff ective d elivery system.
40

- 4 -

These programs have proved successful in improving health 

status and health services distribution at reasonable costs.

A nationwide study showed that heal th cente r users experienced 

24 percent less hospital ization than those in the same income 

category among the general population.

We will propo se three-year extensions for the comm unity healt h 

center and m igrant health programs, Mr. Chairman, at an 

auth orization level of $301 mi llion for c ommu nity health centers 

and $34.5 millio n for migran t heal th for fiscal 1979, and such 

sums as may be nece ssary for the following two years.

In addition, I should note that our recent efforts to improve 

the a dministration and management of these centers have 

generated consider able savings. Admini str ati ve costs have 

gone from 25 percen t to 20 percent of the cost of the program, 

resulting in increased spending for patient care. Moreover, 

collection of third-pa rty reimbursement has risen from 17 percent 

of total costs in 1974 to 36 percent in 1977.

Over the past three years, we have more than doubled the 

numbers of patients served (from 1.4 millio n to 3.4 mi llion 

between 1975 and 1977) with a relatively small increase in 

appro priations (from $197 million to $215 m il li on ). The cost 

of a comprehensive visi t is now often signifi cantly less than 

a visit to an outpatient department or emergency room.
41

- 5 -

The objective of ma ximi zing third-party reimbur sement has 

further sharpened the busine ss management, billing, and 

administ rative skills of the centers.

Closely linked to our capacity building programs is the 

National Health Service Corps, which will provi de 

signific ant staffing as we expan d the number of centers.

The NHSC Scholarship Program assignees as well as other Corps 

recruits will also provide health services in man power 

shortage areas to patients in a variety of settings. Those 

include public health facilities, State menta l hospitals 

and Indian Health Service facilities. We are usin g NHSC 

personnel, including nutritionists, public health nurses, 

and medical social workers, on assignment wit h local and 

district health departments to assist them in planning and 

carrying out programs.

Up to this time we have emphasized rural settings in our 

assignment of Corps personnel. Now a greater emphasis on 

urba n p roject s will complement our long-range intentions to 

meet manpower requirements in all areas of great need. We 

support the provision in your bill mand ating a r eport of NHSC 

manpower projections, and presen t and future directions.

We believe we can meet the dead line specified in that 

provision.
42

- 6 -

For the National Health Service Corps we request an increase 

in the 1979 auth orization from $57 million to $64 milli on 

to accommodate the number of Corps personnel who will be 

available for assignment in fiscal year 1979. The existing 

authorization level for fiscal year 1980 is consi dered 

adequate for an anticipated field strength of up to 3,000.

Before I move on to the discussion of our disea se control 

and prevention activities, I would like to speak to the 

urba n health care problem addressed in s ection 106 of your 

bill, Mr. Chairman* In particular, you address the 

need to enhance the ability of urban hospitals in

unde rserved areas to p rovide comprehensive primary care 

services.

As you know, the poor in these underserved areas often use 

the hospital outpatient department and emer gency room for 

the delivery of p rimary care rather than for the specialized 

services for wh ich they were designed. Not only has this 

resulted in many individuals not receiving appropriate 

primary care services, but it has also cont ributed to the 

generation of huge deficits in these hospitals.
43

- 7 -

Mr. Chairman, we support the conceptual basis of your 

proposal, because we believe the community

health center program provides the flexibility necessary to 

relate the hospital setting. Your approach 

would greatly enhance our capacity to demonstrate 

more effective ways to deliver comprehensive primary services 

to the inner city poor and provide a degree of fiscal relief 

to these hospitals. However, the Administration is still 

considering an urban initiative in health, and we would thus 

be opposed to any additional specific earmarking in current 

programs. We believe there are sufficient 

funds to begin to work with the urban hospitals in 1979; 

however, we must await the President's decision before 

commenting on the higher authorization level proposed in 

your bill.

Several other legislative authorities are under consideration: 

The Bureau of Community Health Services administers 

home health grants to public or nonprofit private 

organizations to: (1) meet the initial costs of establishing 

and operating a home health agency in areas where such services 

are not otherwise available, (2) expand services provided by 

existing home health agencies, and (3) meet the costs of 

compensating professional and paraprofessional personnel 

during the initial operation of such agencies or the expansion 

of such services through existing agencies. In 1976 and 1977

28 -38 6 0 - 78 - 4
44

- 8 -

we developed 30 new home healt h agencies and assisted in the 

expansion of 82 existing sites, prov iding home health services 

to over 30,000 persons. In 1978 and 1979 we plan to expand 

the program by 40 new developmental grants and 20 training 

gr an ts .

Assistance is provided to the States under section 31 4(d) for 

the screening, detection, diagnosis, prevention and referral for 

the treatment of hypertension; currently all States have operative 

programs. We will propose the extension of this program for 

three years to s trengthen the efforts of the States in follow-up 

for treatment. We also propose a three -year extension of the 

hemop hilia program, which awards grants for

comprehensive hemophilia diagnostic and treatment centers 

to provide services, train professional and paraprofessional 

personnel in hem ophilia diagnosis, research, and treatment, 

and to offer social and vocational counseling for hemopiliacs 

and their families.

We are proposing a three-year extension of the Genetic Diseases 

authorities, which includes sickle cell anemia, Cooley's anemia, 

Tay-Sachs disease, cysti c fibrosis, dys autonomia, hemophilia, 

retinitis pigmentosa, Huntington's chorea, and muscular 

dystrophy. We estimate that six percent of the population 

suffers from severe genetic disease; our studies indicate
that about 30 percen t of hospital ized children have diseases 

of genetic origin, 40 percent of all infant m ortality results 

from genetic factors and that up to 80 percent of ment al 

retardation due to medical organic causes is ge netically 

related.

While time is not available to dwell on the accomplishments 

of these programs, I wish to underscore our belief in their 

imp ort ance.

I would like to make just one final comm ent regarding the 

importance of these programs in meetin g the needs of special

init iatives underway to improve immu nization levels and
46

- io -

adolescent health. We expect the Bure au of Community Health 

Services programs to be a majo r delivery resource for 

improving family planning services, maternal and child health 

programs, and increasing immun ization rates. We also anticipate 

providing necessary services for the CHAP progra m when it is 

enacted by the Congress.

DISEASE PREVENTION AND CONTROL

»

I woul d now like to address the area of disease prevention 

and control. As you know, Mr. Chairman, this Administ ration 

is committed to i ncorpor ating prevention as the heart of a 

comp rehensive strategy for improving the health of the A merican 

people. Both Secretary Califano and I are committed to bringing 

more knowledge to the area of p revention and at the same time 

applying most e ffectively what we do know. Perhaps nowhere is 

this challenge b etter evidenced than in our community prevention 

programs, which are charged wit h carrying out outreach, 

epide miologic assessment, surveillance, community orga nization 

and healt h education, and ensuring that high-risk

population groups receive appropriate preventive services.

We are determined tg creatively structure the most effective 

and responsible deli very of these services.

•

I believe it wou ld be useful to cite certain accomplishments

which merit mention. «
47

- n -

Immunization

Late in fiscal year 1977, Secretary Califano announced the 

implementation of a program to raise immunization levels of the 

Nation's children under age 15 from 60 percen t to 90 percent, 

and to establish an effective, ongoing system to provide 

appropriate, comprehensive immunization services to the 

appr oximately 3 million children born in America each

year. Major progress has already been made in heightening 

public awareness of our children's immunization needs, 

and in gal vanizing the resources and energies of government 

agenci es and v olunteer groups into a unified program to 

achieve these goals. Procedures have been established for 

the systematic identification of incompletely immunized 

pre-school and school age children. Remedial action programs 

are under way to provide appropriate immunizations to those 

children. These efforts are accomplishing results, as 

evidenced by the significant increases in the number of 

doses of v accine administered in public programs during 

the last three months of 1977 compared with the same 

period in 1976. The gains in doses of vaccin e administered 

nationwide wer e 40 percent for measles vaccine, 34 percent 

for rubella, 42 percent for polio, 91 percent for mumps,

and 38 percen t for diphtheria-tetanus-pertussis.
48

- 12 -

Venereal Disease Control

We are also seeing impressive signs that the cooperative 

national effor t to control v enereal disease is producing 

favorable results. In fiscal year 1977, the number of 

reported cases of g onorrhea declined very slig htly— this 

mark s the first time in almost 20 years that we have not 

witnessed an increase in gonorrhea. This slight decrease 

occurred in concert w ith a continuation of intensive

casefinding activities. Over 8.5 million women were 

tested for gonorrhea through our screening pr og ra ms , 

of who m 394,000 were found to be positive.

In early 1976, cases of gonorrhea caus ed by a new strain 

of gonococcus resistant to penicillin suddenly emerged 

in the United States and England. To meet the threat 

of importation and spread of this new strain for which 

the standard treatment of choice is ineffective, the 

Cent er for Disease Control, work ing c losely with State 

and military health authorities, rapid ly developed and 

implemented an intensive control strategy which has con tri ­

buted to the containment of this orga nism to date.

For the second consecut ive year, and into the first quarter 

of fiscal year 1978, we have seen a de cline in the number •

of reported cases of infectious syphilis. Again, this
49

- 13 -

reflects the greatly intensified case detection and 

prevention measures carried out by State and local health 

departments with grant support and national leadership 

from CDC. The downward trend holds true for all stages 

of syphilis as well, including congenital syphilis 

among children, which decreased by more than 11 percent 

in fiscal year 1977.

Lead-Based Paint Poisoning

As you are well aware, Mr. Chairman, childhood lead 

poisoning has long been recognized as a health problem

which can result in serious behavioral disorders and 

even death. Once considered a problem primarily of the 

inner part of large cities in the so-called "lead belt" 

of the Northeast, the lead hazard is now known to be 

endangering children in all sections of the country— 

North and South, East and West, and in rural as well

as urban environments.
50

- 14 -

In fiscal year 1977, 58 grant supported local programs 

screened some 380,500 children, of w hom more than 28,000 

were found to need pediatric followup. At least 95 perce nt 

of these children are receiving the necessary pediatric 

man agement services to completion, and the lead haza rd 

has been abated in 61 percent of their houses. We 

estimate that 65 grant supported programs will t est 500,000

¥

children in fiscal year 1978, 42,500 of whom will be 

identified with undue lead absorption.

«

The childhood lead poisoning prevention gran t program 

has been instrumental in the rapid dis semination and 

broad appl ications of technological innovations, such 

as the hematof lou rom ete r, which allows a child to be 

tested on site, provides a screening test result in 

four seconds, requires no chemical manipulations, and 

costs less than 10 cents per test in consumable 

supplies. Furthermore, a normal test rules out not 

only lead poisoning, but iron defic iency as well.
51

- 15 -

Rat Control

By the end of fiscal year 1978, as a result of grant 

supported programs, an estimated 6 million Americans 

will be residing in communities which nave been 

rendered essentially free of rats. Over 23,500 residential 

blocks will no longer require intensive rat reduction 

activities. The maintenance activities required for those 

blocks can be totally supported with local resources, 

thus freeing up Federal grant funds to be applied in 

new target areas. In conjunction with funding from other 

Federal sources such as CETA, these grant funds currently 

provide employment for approximately 2,000 individuals, 

of whom over 60 percent are residents of the program 

target area.

Your Subcommittee currently has a bill under consideration 

which proposes a one-year extension of disease control 

and prevention authorities, Mr. Chairman. While we would 

be opposed to enacting a simple one-year extension of these 

authorities at this time, it is our understanding that the 

legislation was introduced in its present form primarily to 

give you time to develop a more comprehensive prevention 

initiative later this spring.
52

- 16 -

We understand you are in the process of consulting with 

interested outside groups and that you will be proposing 

legislation in the near future. Accordingly, rather than 

commenting further on the one-year extension, I will outline 

our own prevention proposals, and express the hope that we 

can work closely together in this vital health care area.

*

We will soon be submitting legislation to you, Mr. Chairman,

proposing a consolidation of e xisting disease prevention and

control programs into a single annual grant to States. »

This comp rehensive grant will consolidate existing authorities

for disease control, lead-based p aint poisoning, venereal

disease, rat control, immunization, and the comprehensive

public health services grant to States (section 314(d)),

except for hypertension and mental heal th planning.

We b elieve that States should be assisted in meeting the 

cost of providing required disease control and prevention 

programs of high national priority. We woul d expect 

to require States to specifically earma rk a portion of their 

grant for childhood immunization activities.
53

- 17 -

With regard to other disease prevention and control activities 

however, States must be given sufficient flexibility so that 

they can determine which priority problems should be 

addressed with these Federal funds.

While States will thus be afforded considerable flexibility 

to set their own prevention spending priorities for the 

Federal dollars they receive, flexibility will have to be 

balanced with the need for accountability. In order to 

achieve such a balance, we will recommend that State health 

planning activities under P.L. 93-641, and in particular the 

requirement for development of a coordinated State health 

plan, address the extent of the need for preventive health 

programs and services, and that States submit plans to spend 

the money they would receive from this program in accordance 

with needs identified in those plans. The Secretary would 

approve the plan prior to allocating these funds. We also 

favor incorporating audit and reporting mechanisms so that 

the Congress and the Secretary can review and examine whether 

funds are spent for appropriate preventive services identified 

in the State's plan and approved application.
54

- 18 -

Incor porating the section 314 (d) authorities into this 

comprehensive State grant would allow States to contin ue to 

spend that m oney on needed preventive heal th activities. It 

recognizes that certain of those traditional activities may 

require Federal funding in some States but not in o th er s.

I want to emphasize that we are looking forward to working

*

closely with this Subcommittee in further refinement of 

this legislation.

•

Thank you for the oppo rtunity to testify on these vital 

health care delivery and prevention issues today. We have 

attached a table including the A dministration's proposed 

authorization levels for fiscal year 1979. We will shortly 

be submitting extension legislation. My colleagues and I 

welcome any questi ons you may have.

♦
Senator Kennedy - Commun ity Heal th Center s - Q uest ion No. 1

The Adminis tration’s budget proposes to increase funding for C ommu nity 

Heal th Centers from $247 mi llio n to $301 million. Given the fact that 

these programs now reach 9.5 p ercent of the 45 mi llion people living in 

medical ly underser ved areas, why are you requestin g so little additional 

funding?

An sw er :

Approximat ely 49 mil lion people c urrently resi de in me dically underserved 

areas. Whil e Community Healt h Cente rs are servin g an esti mate d 3.7 

million or 7.5 percent of these people, an additional 2.5 mi lli on persons 

who reside in these areas are served by other projects (Migrant, Health 

Underserve d Rural Areas, etc.). Therefore, appr oximately 12.6 percent 

of the residents of medic ally u nder serv ed areas will be served by Bureau 

projects this year.

Program em phasi s over the past year has been on c onsolid atin g and integrating the resources of all Bure au programs so that we can m ore effectively mee t the health needs of the m axi mum populat ion with the m inimum 

resources. The FY 1979 budget reques t woul d allo w us to continue and 

stre ngthen this approach. The proj ecte d n umber of people to be served 

by Communi ty Healt h Center s in FY 1979 is 4.2 mil lion or 4.7 m illion 

whe n the P resi dent 's Urban Initiative is included. This latter figure 

represen ts almost 10 percent of the resid ents of medically underser ved 

areas. This amount of growth is in conso nanc e w ith D epartme ntal p riorities 

and current budget constraints.
56

Senator Kennedy - C ommu nity Health Centers - Que stio n No. 2

2. Since 1975 the cost per patient served b y Comm unit y Health Centers has 

dropped by 50 percent. This is truly remar kabl e at a time when 

double-digit inflation has char acterized the cost of health care 

services in other sectors. What part of this redu ctio n in cost can 

be attributed to increa sed admi nist rati ve efficiency, and what part 

results from the fact that of the 574 center s established, only 

158 are provi ding c ompr ehensive service s— wit h the remaining 416 

provid ing little mor e than the pre senc e of a phys icia n or physic ian 

extender and a very limited range of services.

Answ er :

The 50 percent reduction in the cost per patient served by Commu nity *

Health Centers can be attributed to two factors — increased efficiency 

among the on going centers (those op erat iona l m ore than 2 years) and 

modif ied funding strategy for ne w centers. The 574 centers estimated for fiscal year 1978 can be distribu ted among the following w

categories: 158 ongoing CHCs, 356 Rural Health Initiative centers 

(RHIs) and 60 Urb an Health Initiative center s (UHIs). For the on going 

CHC, increased efficiency has been a ccompli shed primarily by reducing 

admi nistrative overhead costs and increasing physi cian and other 

provider productivity. Between 1975 and 1977, ongoing CHCs have shown 

a relative reduction of 10 percent in their admin istr ativ e costs while 

having a 13 percent relative increase in their provider productivity.

The end result of this increased effi cien cy is service being provided 

to more people in the on going CHCs. Thes e saving s have been used to 

assist in initial fundin g of RHI and UHI projects.

With the funding of centers under the RHI and UHI, the PHS embarked 

upon a fund ing strategy that en couraged an incre mental approach to 

the d evel opment of ne w centers. This approac h emphasized the 

establ ishment of centers that i nitia lly woul d provide only primary 

ambulatory health services (including preve ntiv e health and p reventive 

dental services). After the pri mary services are in place, then the 

centers will expand to provide m ore comp rehe nsiv e health services. By 

the end of fiscal year 1977, all but about 13 percent of these newly 

funded center s were provi ding or w ere p repared to provide the required 

primary heal th services.

ft
Senator Kenned y - Co anunlty Healt h Cent era - Q ues tio n No. 3

3. What perc entage of the commun ity heal th centers and mig ran t health 

projects meet the g overni ng board requ ire men ts spelle d out in 

sections 319 and 330? Und er wha t circ ums tan ces and aut hor ity d oes 

HEW grant waivers of the govern ing b oard req uir emen ts? Of the center s 

funded as rural or u rban hea lth ini tiat ives (RHI/UHI), wha t per centage 

have governing boards?

Answe r :

In fiscal year 1977, a total of 455 com mun ity hea lth center s (CHC) 

grants w ere funded. Of this number, 85.5 percent (389 projects) 

meet the governing board req uir eme nts spelled out in sectio n 330 as 

the following table Indicates. Of the 66 p roje cts not mee tin g the 

governing board requirements, 8 CHC proj ects are in the process of 

meetin g the governin g boa rd require men ts during fiscal year 1978,

45 (43 RHIs and 2 UHIs) are pla nning and deve lop ing p roj ect s w hic h 

will meet the governing boar d requ ire men ts once they become fully 

oper ational and the remain ing 13 proj ect s (7 RHIs and 6 UHIs) will 

be in comp liance wi th the govern ing bo ard requ iremen ts wit hin the 

next 2 years. The statute and the regu lat ion s sti pula te that 

entities w hich do not meet the govern ing board requir eme nts m ay be 

awarded up to 2 operat ion al grants (2 years) to d eve lop com plia nce 

with all CHC requirements.

Section 330 Grants

Meeting Gove rni ng Board 

Requir eme nts

Not Meet ing G over ning 

Board Requ iremen ts

66 Total 455 389

CHCs 158 150 8

RHIs 262 212 50

Pla nni ng & Devel. (43) (0) (43)

Operation al (219) (212) (7)

UHIs 35 27 8

Pla nni ng 4 Devel. (2) (0) (2)

Operation al (33) (27) (6)

In fiscal year 1977, the m igrant hea lth centers progr am funded 102 service 

delivery grants. Of these, 70 perce nt are operat ion al migr ant health 

centers which meet the govern ing board requi reme nts. The rema inin g 

30 percent of the service del ive ry grants are operat ion al migran t health 

projects which are not required to mee t the govern ing bo ard requireme nts.
58

Senator Kennedy - Community Health Centers - Question No. 4

4. What procedure does HEW follow at present when a Community Health 

Center is run by a public agency which, under State law, cannot 

have its programs determined by a consumer governing board. In 

how many instances has this been a problem, and how has it been 

resolved?

Answe r:

There is nothing in our current regulations which prohibits State 

or local governments from becoming community health center grantees. 

Experience with the program since enactment of P.L. 94-63 has indicated that the requirement that the applicant for community health 

center grant funds establish a consumer majority governing board 

with the authorities specified in law may unduly restrict the ability 

of some public agencies to apply for center grants. The regulations 

were revised on November 25, 1977 (Federal Register, Volume 42,

No. 227) to permit joint applications, where, for example, a public 

agency itself may not be able to meet the definition of a community 

health center but the entity sponsored by the public agency to provide 

the services may, in fact, meet the governing board requirements.

This change in the community health center’s regulations allow a 

public entities to become co-applicants and avoid delegating their 

statutory responsibilities to another entity. There are currently 

109 grantees under section 330 that are public agencies, county 

health departments, hospitals or medical schools, and 101 of these 

projects have met and 8 of these projects are in the process of meeting 

the governing board requirements. (8 of these projects are planning 

and developmental projects.)

We have no way of knowing how many public entities have in the past 

been discouraged from applying for grants because of the governing 

board requirement.

«»
S en ato r Kennedy - Community H ealt h C en te rs - Q ues ti on No. 5

5 . Yo ur fig u r e s show an avera ge re im bu rs em en t r a te o f 30 p e rc e n t fro m 

th ir d p a r ti e s fo r se rv ic e s pro vid ed th ro ugh Community H ealt h C ente rs 

How much o f t h is p erc en ta g e comes fro m (1 ) M ed ic ai d, (2 ) M ed ic ar e, 

an d (3 ) th e p a tie n ts th em se lv es ? Is i t r e a l i s t i c to expect su ch 

pa ym en ts to in c re a se s u b s ta n tia lly in th e coming y ears ?

Answe r:

Our FY 1977 re im bu rsem en t r a te fo r Community H ealt h C en te rs i s 31 

p e rce n t ($ 114,9 92,8 96) o f th e t o t a l o p e ra ti n g c o s ts . Of t h is amo unt 

17 p e rc e n t ($ 63,0 60,6 22) i s fro m M ed ic ai d; 3 p e rce n t ($ 11,1 28,3 44) 

fro m M ed ic ar e; 9 p e rc e n t ($ 33,3 85,0 34) fro m p a tie n ts and 2 p erc en t 

($ 7,4 18,8 96) from o th e r so u rc e s. We have be en p ro v id in g e x te n siv e 

te c h n ic a l a s s is ta n c e to p r o je c ts in d ev elo p in g and im pr ov in g t h e ir 

p r o je c t and b i ll i n g and c o lle c tio n sy st em s. Our c u rre n t e sti m a te s 

f o r FY 1978 and FY 1979 of 35 p e rce n t and 36 p e rce n t re s p e c tiv e ly 

a re ba se d on expec te d im provem ent in p ro je c t man agement and th e 

re v is e d B ure au ’s Common R eport in g R eq ui re m en ts which fo cus a tt e n ­

tio n on th e re ven ue and acco u n ts re c e iv a b le r e p o r ts . T his w ill 

lo w er t o t a l o p e ra ti n g c o s ts an d, co re sp o n d in g ly , c o lle c tio n s w ill 

re p re s e n t a r e la ti v e ly h ig h er p e rc e n t of o p e ra ti n g c o s ts . We have 

a ls o worke d e x te n siv e ly w it h M ed icaid and M ed ic ar e pr og ram s in 

c la r if y in g re im bu rs em en t is s u e s r e la te d to f e d e r a lly fu nd ed p ro je c ts 

Th es e e f f o r t s ha ve hel ped c e n te rs to n o t only d e a l e f f e c tiv e ly w it h 

c u rre n t f in a n c ia l e n ti tl e m e n t pr og ram s but a ls o to g a in ex p eri en ce 

to ta k e advan ta ge o f new e n ti tle m e n ts as th ey become a v a ila b le .

The se a c t i v i t i e s and re im bu rs em en t pr og ram ch an ge s su ch as th e 

pass age o f P.L . 95 -2 10 fo r th e re im bu rs em en t of r u r a l c li n i c h e a lt h 

s e rv ic e s a re a ls o expecte d to in c re a s e re im burs em en ts to c e n te r s . 

Beyond FY 1979 th e re i s no p ro je c ti o n f o r In c re a se d re im burs em ents . 

We f e e l th a t th e maximum c o lle c tio n i s 36 p e rc e n t o f t o t a l o p e ra ti n g 

c o s ts fro m th e th ir d p a r ti e s . We b e li e v e th a t an in c re a s e much 

be yond 36 p e rc e n t would only be r e a liz e d a f t e r m aj or ch an ge s 

in h e a lth se rv ic e s fin a n c in g o r re im bu rs em en t a u th o r i t ie s in th e 

U nit ed S ta te s .
60

Senator Kennedy - Conatjnlty Health Centers - Q ues tio n No. 6

6. Legislati on has been introduced in the House to re quire HEW to base fundin g 

for Community H eal th Centers on the amount by wh ich a Ce nter's pro ject ed 

cost of operat ion excee ds its p roj ecte d receipts from third p arty rei mbu rse ­

ments and state, local and other funds. Ho w does this differ from the way 

such funding is d etermined now? How mu ch a ddi tio nal budge t aut hority would 

be n eed ed to fulfill this requ irement if it we re enacted into law?

An sw er :

This proposed leg islation does not dif fer from curr ent HEW funding pol icy . 

In addition, Com munity He alt h Service regula tio ns prov ide that the Secr etar y 

wil l consider the following factors in det erm ini ng the perc ent age of 

project costs to be borr.e by the grantee:

a. The ability of the grantee to finance its share of proje ct 

costs from non -Feder al sources;

b. the need in the area for the serv ices pro vid ed by the project:

c. the extent to which the proje ct will prov ide servic es in an 

Inn ovative ma nne r to further dev elo p effect ive h ealth servi ce 

del ive ry systems in me dic all y und ers erv ed areas.

Therefore, no add itional funds are required.

4
61

a n a to r Ken ne dy - Co mm unity H e a lt h C e n te rs - Q u e sti o n No. 7

1 . As yo u may kn ow , S. 133, th e new A m eri cans H e a lt h S e rv ic e A ct in tr o d u c e d by 

S e n a to rs In ouye an d M atnu r.a ga i s a ls o p e n d in g -b e fo re o u r su b co m m it te e. To 

w hat e x te n t a re e x i s t i n g h e a lth c e n t e r s r e a c h in " g r a n ts and hav e yo u 

c o n s id e re d th e e s ta b li s h m e n t o f s p e c i a l h e a l th c a r t e r s d e s ig n e d to m ee t t h e i r 

n e e d s i n th e s i x s t a t e s in w hic h th e y a r e c o n c e n tr a te d ?

A nsw er :

U nd er e x i s t i n g l e g i s l a t i v e a u t h o r i t y , th e B ure au o f Co mm unity H e a lt h S e rv ic e s 

ma ke s a v a i la b le a w id e ra n g e o f h e a l th s e r v i c e s . P u r ir g 19 77 a t o t a l o f 455 

Comm unity H e a lt h C e n te rs p ro v id e d h e a l t h c a r e s e r v ic e s to 3 .4 m illi o n p e rs o n s 

an d 102 M ig ra n t H e a lt h p r o j e c t s s e rv e d 4 9 9 ,0 0 0 m ig r a n ts an d s e a s o n a l fa rm ­

w o rk e rs an d t h e i r f a m ilie s . Th e fo rm er pro gra m fo c u s e s on m e d ic a ll y u n d e rs e rv e d p o p u la tio n s in b o th u rb a n an d r u r a l are -" - w h il e th e l a t t e r i s 

s p e c i f i c a l l y m an dat ed to p ro v id e a c c e s s to s e r v ic e s f o r a s p e c i f i c p o p u la ti o n 

g ro u p . We b e lie v e th a t a nu mbe r o f th e s e p r o j e c t s a re a d d r e s s in g th e h e a l th 

n eed s o f im m ig ra nt g ro u p s . In c a s e s w her e th e im m ig ra n ts a r e

u n a b le to pay f o r s e r v ic e s b u t m ee t th e e l i g i b i l i t y c r i t e r i a , M ed ic aid i s 

a v a i l a b l e f o r fin a n c in g th e s e r v i c e s .

The D e p art m e n t, i n FY 1 9 7 '', p la n s to i n v e s t i g a t e th e h e a l th c a r e n eed s o f 

im m ig ra n ts in th e te n S ta te s w it h th e h ig h e s t p r o p o r tio n o f im m ig ra n ts to 

th e t o t a l p o p u la tio n . Th e D epar tm ent e x p e c ts to d e v elo p an d fu nd th r e e to 

fo u r p r o j e c t s in th e s e h ig h p r i o r i t y a r e a s d u rin " FY 1978, u s in g a v a i la b le 

fu n d in g u n d er S e c tio n 330 o f th e P u b li c H e a lt h S e rv ic e A c t. B as ed on i t s 

e x p e r ie n c e w it h t h i s a sse ssm e n t an d th e d e v elo p m ert o f a d d i t i o n a l p r o j e c t s 

th e D epart m ent w i l l r e p o r t to C o n g re ss and make re com m endati ons f o r f u tu r e 

a c t io n .
Senator Kennedy - Commun ity Healt h C enters - Question No. 8

In the Conference report whic h acco mpani ed the fiscal year 1978 appropriation for the Depa rtment of Health, Educ atio n and W elfare the 

Confer ees stated their posit ion that, begi nnin g in fiscal year 1979, no 

furthe r Medica id funds would be provided to begin new projects under the 

Health Unders erve d Rural Areas (HURA) program. The Conferees further 

stated: "In future years rural health activ itie s of this type are to be 

funded under the c ommu nity health centers authority of the Public Health 

Service Act where there is alread y an on goin g rural health initiative." 

What steps has the Department taken to as sure th at , as a result of this 

directive, there is not a $15 mill ion shortfall in this area and what 

recomm endations can you make to the Subcom mitt ee as to ho w this problem 

should be ad dressed?

An sw er :

The Conference Report directed that fiscal year 1978 be the last year in 

which new starts be mad e under the H URA program as authorized under the 

Medicaid progr am and that in futu re years acti viti es of this type are to 

be funded under the C ommu nity Health Center authority, Section 330 of 

the Public Health Servic e Act.

The Department has included $15 million in its fiscal year 1979 budget 

request to continu e the H URA program. This reques t has been made under 

the Community Health Centers Program based on the research and demonstration a uthor ity of Section 1110 of the Social Secur ity Act, pending passage 

of a separate authority. The Department has also proposed that a new 

section be added to the Public Health Service Act to establish a statutory 

autho rity for this program. This prop osal reque sts auth orization of 

$15 million for fiscal year 1979 and such sums as may be necessary for 

two subsequent years.
63

Senator K enne dy - Migrant Heal th Progr ams - Q ues tion No. 1

1. The Congress has provided separ ate legislativ e aut hor ity for the 

Comm unit y Heal th Center Pro gra m and the Mi gran t Hea lth Center 

Program. It is m y und erstanding that there is good coordination 

between the two pr ogra ms and that they are even adm inistered out 

of the same suite of offices. In the three year extensi on you 

are requ esting for these programs do you see any need to change 

the present legislat ive framewo rk for these prog rams ? Isn't it 

true that the differenc e in the two p rograms are difference s 

specifi call y designed to meet the special cultura l and health 

needs of the migrant populati on?

t An sw er :

It is true that there is good coor dination between these two 

programs. Coor dina tion and services integra tion a re key com ­

ponents of the c apac ity bui lding strateg y whic h relates resou rces

• of several Bureau programs to more effectivel y address the probl ems

of medical underse rvic e through coordina ted sites an d services in 

both rural and urba n areas. We expect this type of program sharing 

to contin ue and w ould not, therefore, see any need to change the 

present legislative framewo rk for these programs. The difference s 

in the two programs are indeed spec ific ally designe d to meet the 

specia l cultu ral and hea lth ne eds of the m igrant population. It is 

because of the c ultural and related barr iers that such a separate 

legislat ive authority is useful. For the foresee able future we 

woul d expect the ne ed for this legi slat ivel y base d advoc acy role 

to continue.
Senator Kennedy - Migrant Health P rograms- Q ues tion No. 2

2. The admi nistration ha s requested a 20 percent Incre ase In funding 

for C ommunity Health Centers. No increase at all has been 

reque sted for Migrant Health Programs. How was this decisio n 

reached? What will this mean to the 80 percent of the migrant 

and seasonal wor k force w hic h does not now have access to 

migrant health programs?

Answ er :

The Depa rtme nt is faced wit h the p rob lem of mak ing hard choices 

during a time of fiscal constraint. The app roach has been to 

maintai n the Migrant Heal th Program at its 1978 level while finding 

effective alternat ive ways of providing servi ces to migrants. The 

Migrant Health Pro gra m is an integral part of the Bureau's capac ity 

building strategy to address probl ems of medical underse rvic e in 

areas of greatest need. Thro ugh this effort, a portion of the 

resources of the Migran t Prog ram is linke d with those of other 

Bureau P rograms (Community He alth Centers, Nationa l Health Service 

Corps, etc.) so that incre ased access to compr ehensive services 

is prov ided to mig ran ts and seasonal farmwork ers and their 

dependents through a larger number of access points b eing d eveloped 

throughout rural areas.

In additi on to these integrat ed relat ions hips , the Migra nt Health 

Prog ram is also affi liat ed wit h other federally- supp orte d programs 

which have a uthorit y to provid e servi ces for migrants . Thirty- four 

projects have referra l or staff affi liation with commu nity mental 

heal th center s through a joint agre emen t with the A lcohol Drug 

Abus e and M ental Health Adm inistration (ADAMHA), 48 migrant projects 

serve as grantees or referral points for services under the 

Depar tmen t of Agriculture's Women, Infants and Children (WIC) Nutri tion 

Program, and 47 migran t projects are affi liated with State Title I 

Migrant Educ ation Program whi ch provides summer education al and 

suppleme ntal servi ces to migrant school children. It is expected 

that these types of linka ges w ill improve the scope of services 

provi ded and incre ase capacity to pro vide servi ces to migrants.
Sen ato r Kennedy - M ig ra nt H ealt h C ente ra - Q ues ti on No. 3

3. The Dep artm en t of Labor ha s fu nds a v a ila b le fo r m ig ra nt h e a lt h 

in co n n ecti o n w it h i t s employment and tr a in in g pro gra m s. I t is 

my u n d ers ta n d in g th a t in D el aw ar e, M ar yl an d, and V irg in ia , fo r 

ex am pl e, th e re i s no c o o rd in a ti o n and th a t th e Dep artm en t of 

La bo r pr og rams in th o se S ta te s ha ve more money fo r m ig ra nt h e a lt h 

th an HEW sp onso re d pr og ra m s. How a re you r e f f o r t s c o o rd in ate d 

w it h th o se of th e La bo r Dep ar tm en t?

Ans we r:

At th e p re se n t ti m e, c o o rd in a ti o n be tw ee n HEW's and th e Dep artm en t 

o f L ab o r' s h e a lth se rv ic e e f f o r t s i s ac co m plish ed p rim a ril y a t th e 

p r o je c t le v e l. A pp ro xim at el y 60 HEW m ig ra nt h e a lt h p r o je c ts have 

arr angem ents w it h Dep artm en t o f La bo r CETA p r o je c ts to pro vid e jo b 

p o s itio n s and tr a in in g o p p o rtu n it ie s fo r CETA e n r o ll e e s .

In o rd e r to more e f f e c tiv e ly u t i l i z e th e h e a lt h r e la te d re so u rc e s 

o f both a g e n c ie s, we a re i n i t i a t i n g c o n ta c t about de ve lo pm en t of 

an in te ra g e n c y ag re em en t which would en co ur ag e or re q u ir e in cre ased 

co o p era ti o n a t th e p ro je c t le v e l. We w ill pro v id e a re p o rt of p ro g re ss 

to th e Comm itte e by Ju ly 1, 1978.
S e n a to r Ke nn edy - M ig ra n t H e a lt h C e n te rs - Q u e s ti o n No. 4

In re sp o n s e to a q u e s tio n fr om S e n a to r Hatha way c o n c e rn in g th e ad eq uac y 

o f c u r r e n t fu n d in g fo r h o s p i t a l i z a t i o n o f m ig ra n ts , yo u t e s t i f i e d th a t 

th e A d m in is tra tio n in te n d s to su b m it l e g i s l a t i o n to r e s o lv e M edic aid 

re s id e n c y re q u ir e m e n ts w hi ch hav e s to o d i n th e way o f m ig ra n ts r e q u ir in g 

h o s p i t a l i z a t i o n . When w i l l t h i s l e g i s l a t i o n be s e n t to th e C ongre ss ? 

What a s s u ra n c e do yo u hav e t h a t th e F in an ce an d Ways an d Me ans C om m itte es 

w ou ld be a b le to co m p le te a c tio n on t h i s m ajo r ch an ge in M edic aid l e g i s ­

l a t i o n b e f o re th e en d o f th e 9 5 th C ongre ss ?

A ns w er :

The p ro p o s a l to d e a l w it h th e M edic aid " i n t e n t to r e s id e " pro ble m h a s 

b een fo rw ard ed to th e Hou se Commerce C om m it te e, a t t h e i r r e q u e s t, an d 

h a s been in c o r p o ra te d as an amend me nt by t h a t Com m itte e to H .R . 13 61 1, 

th e A d m in is tr a tio n 's C h il d H e a lt h A ss ess m ent A c t. We f u l l y a n t i c i p a t e 

f i n a l Ho use an d S e n a te a c tio n on t h i s am endm ent in th e c u r r e n t s e s s io n
67

Senator K enne dy-C ompr ehen sive Public Health S ervices (314(d))-Questlon No. 1

You ar e aware of the As sociation of State and Terr itorial Health Officials' 

prop osal to mod ify 314(d) from a formula grant pro gra m to a cost-sharing, 

Federal enti tleme nt prorgram? Wha t is your posi tion on tis proposal?

An sw er ;

(1) The Departme nt's positio n o n 314(d) is that it should be combined 

wit h current activities relat d to rat control, lead based paint, 

tuberculosis, venerea l disease and immuniz atio n and formed into a 

new grant to States require d to be focuse d on preventive health

* activities.

(2) The Depa rtment is opposed to the A ssociation of State and Territo rial 

Health Officials' proposal to mod ify 314(d). In ad dition to budge tary 

concerns wit h the a uthorization levels it sets for a mo difi ed

* section 314(d), we question that aspec t of the ASTHO proposal which 

woul d elim inat e the finan cial need factor in the c urrent statute 

whe reb y States wit h a lower per capita Income receive a proporti onat ely 

high er allotment.

a
Senator Ken ned y - C omp reh ens ive Public Hea lth Servic es (314(d)) - Ques tio n No. 2

2. What specific State p ublic health pr ogra ms do you see bene fit ing from 

such increased Federal mat chi ng funds? How much of the mo nies go into 

the support of State laborato ries and gen era l public health activ itie s?

Answer

The programs, projects, or activities whi ch are supp orte d w ith funds 

under section 314(d) are determined b y each State, refl ect ing Its own 

needs, priorities, and goals. An In cre ase in funds is likel y to be 

used to support those services which have the high est prio rit y in 

each State. The State Health Coo rdi nat ing C omm itt ee must be given an 

opportuni ty to review and approve or dis app rov e an appl icatio n for 

these funds and the H eal th Systems Agenci es must have an opp ortu nity 

to approve or disapp rov e the use of the funds wi thin their planning 

areas.

The Public Health R eporti ng Systems showed that in fiscal year 1975 

the State hea lth agencies expended $12,74 4,0 00 of secti on 314(d) funds 

for State laboratories, $7,3 87,000 to a dmi nistrat ion, and $53,0 08,0 00 

was expended on all other activities.
69

Senator Kennedy - Comprehensive Public Health Servic es (314(d)) - Qu estion No. 3

3. Have the monies provided over the last three years through secti on

314(d) been used in a way that makes furthe r expa nsio n of the program 

immediat ely desirable?

Answe r

The monies provided under section 314(d) over the last years have been 

used in accord wit h the leg isla tion and the apparent intent to bro adl y 

support c omprehensive public h eal th services. Except for that portion 

of the funds used t o support State inst ituti ons operate d by the State 

health agencies, the 314(d) funds, in the aggregate, supporte d a wide 

range of personal healt h services, envi ronm enta l health services, 

health resources development, State labora torie s, and general health 

administration. The Dep artment has not recom mend ed an increase in the 

section 314(d) authorization. Increased suppor t of capacit y b uild ing 

programs specific ally directed to med ica lly under serv ed areas is 

expected to have a more immediate impact on h ealt h p robl ems in areas 

of identified need.

«
S enato r Kennedy - Co mprehensiv e P ubli c H ealt h S e rv ic e s (3 14( d) - Q ue st io n No. 4

4. Do you expec t th e v o lu n ta ry ASTHO re p o rtin g prog ram to me et yo ur 

d a ta nee ds in t h i s are a?

An sw er:

The A sso c ia ti o n o f S ta te an d T e r r i t o r i a l H ea lt h O f f i c i a l s ' re p o rti n g 

prog ram ha s s u f f ic ie n t f l e x i b i l i t y to p ro v id e a d e s c rip tio n o f th e 

co m pr eh en sive p u b li c h e a lt h s e rv ic e s in ea ch S ta te , as re q u ir ed 

un de r se c ti o n 3 1 4 (d ). We hop e to ad va nc e th e re p o rtin g to be ab le 

to ha ve d a ta sum ma rized more pr om pt ly fo ll o w in g ea ch f i s c a l year and 

to all ow th e S ta te ag en cie s to p re p are fo r d a ta c o lle c tio n in ad va nc e 

o f ea ch f i s c a l y e a r. We a ls o pla n to o b ta in more d e ta ile d re p o rt in g 

fro m lo c a l h e a lt h d ep art m en ts . Our e x p e c ta ti o n is th a t th e ASTHO 

R ep ort in g Sy ste m w ill me et ou r nee ds.

I t i s th e D epart m ent's in te n t in co mbining 31 4( d) pr og ra m s in to a 

p re v e n ti v e h e a lt h i n i t i a t i v e to fo cu s a g re a te r em ph as is on Federa l 

d ir e c tio n and management of t h is a c t i v i t y . A ga in , we b e li e v e th e 

ASTHO sy st em ca n be ta ilo r e d and be u s e fu l fo r m ee ting th ese nee ds.
71

Senator Kenned y - Preve ntio n and P ubli c Health Services

1. Are you suggesting that the Adm inis tration will introduce legislati on 

to consolidate a number of the pre sent categori cal disease control 

programs into one program.

— H ow wo uld you propose under such a co nsol idation to assure an 

ability to target funds toward nationa l priorities?

Answer

Under our proposal the State woul d be required to submit a State plan 

for approval by the S ecret ary in advance of receipt of any funds. The 

State woul d be required to address high prior ity nationa l programs 

specifically in the plan.

— How would you propose to set national p riorities?

Answe r

The establishment of nation al prio riti es w ould be b ased on the extent 

of the problems caused by the di sease or adverse health conditions, and 

on the a vailability of effec tive mea ns of preventing or ameliorating 

them.

— What woul d be the Federa l role and resp onsi bili ty under such a 

consolidation? Does the Federal level retain funds for special 

priori ties?

Answer

It would be the responsib ilit y of the F edera l G overnme nt to:

(1) establ ish national priorities; (2) require that these be addressed 

in the State plan in advan ce of funding; this State plan could be 

disapproved in whole or In part; (3) establ ish a list of optional preventive programs for which States could use those funds not required 

to meet national priorities; and (4) monit or and audit both expenditures 

and program accomplishments.

The Federa l Government would retain up to 20 percent of any additional 

funds appropriated for the initi atio n of new programs or for 

demonstration s to develop and evalu ate meth odologies to apply to 

other diseases or conditions.
72

Page 2 - Senator Kennedy - Prev ention and Pu bli c H ealt h Services

Do y ou see any problems with assuring accou ntab ilit y for 

expendit ure of funds? Recall that under the bloc k g rant under 

314(D) for many years we had no Informa tion on how the funds wer e 

being spent. There was no accountab ility . How under a new block 

grant approach would you assure acco untabilit y?

Answer

We believe that with the State plan requ irem ents in our proposa l that 

we w ill be able to assure accountabilit y. The plan would have to address 

Federal priorities; it would also have to address optional prev enti ve 

health programs. The Secretary w ould h ave the authority to approve 

the plan in w hole or in part, and final ly the States would be required 

to report bot h expenditures and pro gra m a ccom plis hmen ts on a yearly 

basis.

— Would you be willing to wor k with us in devel opin g a more comp rehensive 

approach to authori ty for pre ventive health?

Answer

We w ould be delighte d to work with the Subcom mitte e, as wel l as wi th 

other interested parties in de velopin g a comprehe nsiv e strategy for 

prevention. We are anxious to obtain the broadest possibl e range of 

viewpoints and expertise, including those of State and local government, 

the medical community, the Acade mic community, and the Congress.

t
73

Res ponses to Senato r Kennedy's Questi ons re: IMMU NIZA TION PR OGR AMS

1. We hear a* lot about the target of 90X level s of immu nizat ion. How di d that 

target get established? Should the targe t be the same for eac h o f the di seas es 

against wh ich we are immunizing. Ho w man y ye ars will it take to achieve that 

target? Ho w much will it cost in 1980 and 1891 to mainta in it. What immediate 

impact should we expect on the h eal th of Am eri can children ?

QUESTION: How did that target get estab lish ed?

ANSWER: A n umber of factors w ere con sidered in esta bli shi ng the 90

percent immu nization level target: (1) The higher the level

♦

of immunizations, the less sign ific ant is the p ubl ic health

pro ble m posed by a disease. (2) A 90 percent imm uniz atio n

» level is achievable. Aft er polio v acc ine first became ava ilable and the threat of annual polio epi demi cs was percent,

fjmnunlzation levels agains t polio appr oac hed 90 per cen t (3)

Iaaninlzatlons in excess of 90 percent would be ver y diff icul t

if not impossible to achieve. (4) An immu nizati on level

of 80 percent or lower is una cceptable .

A 90 perce nt iom uniz atlon level is a h igh goal and one w hic h

will be d iffi cult to reach. It is based on a proj ecte dil eve l of

Federal support, enthusias tic suppo rt of State and local health

agencies and volunteers, and hard work.
74

Senator Kennedy - Immuniza tion -2-

QUESTION: Should the target be the sane for each of the disea ses

against which w e are immunizing?

ANSWER: As menti oned above, an Immun izat ion level of 90 p ercent Is one #

which is desira ble and w hic h we believ e can be reached. The

age group Included In the target varie s by antigen and is based

<

on the Ad visory Co mmit tee on Immuniza tion Pr actices (ACIP),

recommendations. For example, the target for polio Includes

children age three mont hs to 14 years. For rubella the target

includes childre n ov er age one through 12 years. For mumps,

becau se of difficulty in de termining s uscepti bles in the s choolage populat ion and the high cost of mu mps vaccine, we feel the

goal of 90 percent should appl y o nly to the prescho ol-a ge

population. The Inclusion of mu mps va ccine for school-ag e

child ren would increase cost by more than $20 million.

t
75

Senator Kennedy - Immu nization - 3 -

QUESTI ON: How ma ny years wi ll it take to achie ve that target?

ANSWER : Original estim ates were that an average Immu nization level

of 90 percent could be reached by October 1979. These estimate s we re base d on the ass umption that pro jected funding

woul d be avai labl e at the beginn ing of fiscal year 1978.

It has not been d etermined whether or not delays in receiving

the 1978 proje cted fundi ng app ropriation (October to December)

will signi fica ntly d elay our attai nmen t of that goal.

28 -386 0 - 78 - 6
76

Senator Kennedy - Immunization - 4 -

QUESTION: How much wil l it coat in 1980 and 1981 to maint ain it?

ANSWER: The Secretary's immuniz atio n initiative inclu des as one of

its goals, the establis hmen t of a continuing pr ogr am which

is capable of p rovidin g immuniza tion aga inst m easles, rubella,

*

polio, mumps, diptheria, pertussis, and tetanus to all children

enter ing the population. The annua l cost of this program is

estima ted to be $18.5 million.

I

«
Senato r Kennedy - Im mun ization

QUESTION

ANSWER:

Based on

- 5

What im med iate Im pa ct sh ould we expect on th e h e a lt h of 

Am eri can c h il d re n ?

We have e s ta b li s h e d th e fo ll o w in g as h e a lt h t a r g e ts :

1. M ea sles - q u a r te r ly in cid e n ce in FT 1978 w ill be 33 p e rc e n t 

lower th an in co m pa ra bl e q u a rte r FT 1977 .

lo wer th an in co m pa ra bl e q u a rte r FT 1977.

2. R ubell a - q u a r te r ly in cid e n ce in FY 1979 w ill be 25 p erc en t 

lower th an in co m pa ra bl e q u a rte r FT 1977 .

- q u a rte rly in cid en ce in FT 1979 w ill be 33 p e rc e n t 

lo wer th an in co m pa ra bl e q u a rte r FT 19 78 .

3. Mumps - q u a rte rly in cid e n ce in FY 1978 w ill be 25 p e rc e n t 

lower th an in co m pa rabl e q u a rte r FT 1977.

- q u a rte r ly in cid en ce in FY 1979 w ill be 33 p erc en t 

lo wer th an in co m pa ra bl e q u a rte r FY 1978.

4. D ip h th eri a - m ain ta in 80 p e rc e n t o f S ta te s fre e o f d ip h ­

th e r ia in th o se un de r 15 in CT 19 78 , 85 p e rce n t in CT 1979.

5. Tet an us - m ain ta in 85 p e rc e n t o f S ta te s fr e e o f te n ta n u s in 

th o se un de r 15 in CY 19 78 , 90 p e rc e n t in CY 19 79 .

6. F o li o - c o n ta in o u tb re a k s in no more th an on e g e n era ti o n 

fo ll o w in g i n i t i a l c a se .

d eath to case r a ti o s , s im il a r re d u c ti o n s in d e ath s a re a n t i c i ­

p ate d .
Senato r Kennedy - H ypert en si on - Q uest io n No. 1

1. P rio r to th e en ac tm en t of 31 4( d) (7 )(B ), wh at was th e e x te n t of

S ta te prog rams in h y p e rt e n sio n I d e n tif ic a tio n , sc re e n in g , d ia g n o sis 

and r e f e r r a l fo r tr eatm en t?

An sw er;

As re p o rt e d th ro ugh th e A sso c ia ti o n of S ta te and T e r r i t o r i a l H ea lt h 

O f f ic ia ls (ASTHO) P u b li c H eal th R eport in g Syste m fo r f i s c a l year 

19 75 , only th re e S ta te h e a lt h agen cie s (A labama, M is s is s ip p i, and 

New Me xico) had se p a ra te h y p e rt e n sio n pr og ra m s. F o rty -fiv e S ta te s 

re p o rt e d th a t sc re e n in g fo r h y p ert en sio n was in clu d ed in v a ri o u s 

o th e r pr og ra m s.
Senator Kenn edy - Hyp ert ens ion - Que sti on No. 2

What effect has the Feder al formula grant pro gra m had over the last 

two ye ars in stimulati ng exp ansion and improving the effecti vene ss 

of the State hype rtension progr ams?

Answe r

Inasmuch as data is not yet availab le .on a na tionwide basis describing 

State hype rten sion services prio r to the separate aut hor iza tio n of 

funds under section 314(d)(7)(B), funds for hyp ertension control, we 

cannot m easu re the extent of expansi on the funds have stimulated.

The funds were used, in some cases, to start new separate hype rtension 

programs and, in other cases, to suppleme nt the pre existing activiti es 

in the State. One State indi cate d that the 314(d) hyp ertension monies 

more than doubl ed the usua l level of pro gram support. These funds were 

descr ibed as the "key to prog ram devel opme nt, and in providing direct 

financ ial aid to local health agen cies ."
80

Senator Kennedy - Hype rtension - Que stion No. 3

3. If hyper tension we re not a separate cat egorical pro gram but were

organ ized as part of a genera l preve ntio n package, and if the States 

had greater flexibility in fundin g the e arl y dete ction pro gram with 

Federal funding, what develop ment s do y ou see in State support of 

hyperte nsio n scree ning programs?

Answer

Under a broad prev ention authority, having a flexible autho riza tion 

and appropriation, States wou ld have the latitude to use amounts for 

hyperte nsio n which are greater or lesse r than are now spec ifically 

allocated toward hyp ertension un der the exi sting specifi c authority.

We know of no way to forecast what approac h the States w oul d take.

However, the cur rent appr oach does provide a mi nimum level of 

resources for hyp ertension p rogr amming in each State. Unlike many 

diseases hype rten sion is not readily apparent until it reaches

advanced and criti cal stages. This specific level of reso urce s *

insures that no State will ignore h ypertension problems.

t

«
Senato r Kennedy - H ypert en si on - Q uest io n No. 4

4. What d a ta do you ha ve co ncern in g th e e x te n t to wh ich th e S ta te

pr og rams In h y p e rt e n sio n a re e f f e c tiv e in id e n tify in g and r e f e r r in g 

In d iv id u a ls w it h h y p ert en si o n ? How many people a re bein g sc re en ed 

in th e S ta te s? At a c o st of app ro x im ate ly $.5 0 p er sc re e n in g t e s t , 

how w ell i s th e F edera l money b ein g us ed in te rm s o f th e numb ers of 

in d iv id u a ls a c tu a lly b ein g exam ine d?

An sw er:

At th is p o in t d a ta i s n o t a v a ila b le re g ard in g th e num ber of people 

b ein g sc re ened fo r h y p e rte n sio n . B eg in ni ng w it h f i s c a l year 1977 , 

w it h th e appro val of th e O ff ic e of Management and B udg et , th e 

S ta te s w ill be as ke d to r e p o rt th e num ber of people sc re ened by 

se x and ag e gr ou ps (u nder 18 , 18-4 4, 45 and over) and num ber of 

new ly dia gnose d h y p e rte n siv e s by se x and ag e gro ups. In a d d it io n 

to sc re e n in g , fu nd s are bein g ex pe nd ed fo r p u b li c e d u ca ti o n , 

p a tie n t e d u ca ti o n , p ro fe s s io n a l e d u c a ti o n , d ia g n o s is , and fo r 

p a tie n t m o n it o ri n g , in clu d in g fo ll o w -u p , a l l of which a re e s s e n tia l 

fo r c o n tr o l of h y p e rte n sio n .
Senator Kennedy - Hypertension - Question No. 5

5. If you are not presently receiving this data, how effective do 

you believe the voluntary reporting system of the ASTHO will be 

in providing these data?

Answ er:

The Public Health Program Reporting System of the Association of 

State and Territorial Health Officials (ASTHO) has sufficient 

flexibility and capability to collect requested data regarding 

the hypertension control program. Some States are likely to have 

difficulty in reporting unless the reporting requirements are 

determined in advance. Otherwise, the necessary records and data 

for State reporting may not be kept. Clearance from the Office of 

Management and Budget has been requested for data collection for 

fiscal year 1980 and beyond.
83

Senator Kennedy - Hypertension - Question No. 6

6. Considering the total cost of treatment of hypertension In this 

country is approximately $4 and one-half billion-annually, early 

detection and treatment seems to be the correct and most realistic 

approach to preventive care for cardiovascular disease. Do you 

support a vigorous, categorical approach to hypertension as is 

presently contained in 314(d)(7)(B)? If not, why not? The present 

program allows State flexibility within the development of a screening 

program, does it not?

Answer

In order to develop and establish programs for the screening, detection, 

diagnosis, prevention, and referral for treatment of hypertension, a 

categorical approach, such as presently contained in section 314(d)(7)(B) 

is warranted and desirable. When such programs have been adequately 

developed and become fully operational, a categorical approach may no 

longer be the most desirable approach to accomplish the objectives of 

the program within the overall health mission of the State. The present 

program does allow States sufficient flexibility for the development 

of screening activities.

I

«
Senato r Kennedy - H y p ert en si o n - Q uest io n No. 7

7. Do you su p p o rt fo ld in g in th e p re se n t fo rm ula g ra n t h y p e rt e n sio n 

pr og ram in to a g e n e ra l p re v e n ti v e d is e a s e g ra n t a u th o r ity , w it h 

th e S ta te fre e to pro pose th e le v e l o f t h e i r S ta te e x p e n d it u re s 

as be tw ee n a num ber o f p re v e n ti v e d is e a s e pr og ra m s? What e f f e c t 

do you se e t h is havin g on h y p e rte n sio n sc re e n in g , i d e n t i f ic a t i o n , 

d ia g n o s is , and r e f e r r a l to tr e a tm e n t pr og ram s in th e S ta te s?

Ans we r:

We su p p o rt an e x te n sio n of th e h y p e rte n sio n pr og ram under a se p a ra te 

l e g i s l a t i v e a u g h o riz a ti o n and not a s a p a r t o f th e p re v e n ti v e 

s e rv ic e s g ra n t a u th o r ity . Sh ou ld th e h y p e rte n sio n pr og ram be in ­

clu ded in a g e n e ra l p re v e n ti v e d is e a s e g ra n t a u th o r ity , w it h th e 

S ta te fr e e to pro pose th e le v e l of t h e i r e x p e n d it u re s a s be tw ee n a 

num ber o f p re v e n ti v e d is e a s e pro gra m s, i t i s p o s s ib le th a t some 

S ta te s wo uld not devel op and e s ta b lis h h y p e rte n sio n c o n tr o l pr og rams 

to .t h e e x te n t th ey wo uld un de r a s e p a ra te a ll o tm e n t fo r t h is pr og ram
85

Senator Kenne dy - National Health Service Corps (NHSC) - Qu estion No. 1

Approxi mate ly 94 percent of the NHSC is present ly in rural areas. I 

unde rsta nd that as of FY 1979 sixty percent of the new assig nees will 

be going to urban areas, and that by 1985 the ur ban/ rura l assignments 

should be divided evenly. How are you able to make such a rapid switch 

in placement? Where will these doctors be placed in the ci ties? What 

is your polic y in regard to urba n vs. rural placement?

An sw er :

Our curren t expectations for 1979 are that half of the n ew Corps staff 

will be assigned to urban areas. Takin g this into account, when we 

combine the new staff with ex isti ng assignments, our overall staffing 

distribu tion for 1979 should run 30-35 percen t urba n an d the remaining 

65-70 percent rural. Our expectatio n for 1983 is a 35 percent urban 

and 65 per cent rural distribution. The change in distri bution for 1979 

can be accompli shed by emphasiz ing urba n ma tche s w ith the n ew assig nees 

and not by moving any person s pres entl y in NHSC sites. This is possible 

becaus e of the large numbers of perso ns who will become avail able in the 

next few ye ars from the schola rship program. In the u rban areas, doctors 

will be a ssigned to Commun ity Health Centers, and other ambulat ory health 

care facilities wh ich serve the resid ents of health m anpower shortage 

areas. This is similar to the recent rural placements. One differen ce is 

that n ow with P.L. 94-484,it is possibl e to des ignate facilities and mo re 

urba n he alth man powe r shortage areas.

The poli cy wi th regard to the urban/ru ral place ment s is to follow the 

intent of the law. Prior ity in ass ignm ent is to be toward the areas of 

greatest need - whereve r they are - in urban or rural areas. However, it 

should be under stoo d that e ffective mat chi ng of assignees to sites must 

conti nue to be taken into conside rati on as well.

I
Senator Kenne dy - Nati ona l Health Service Corps - Ques ti on No. 2

What has been the ret ention in NH SC for pra ctitioners, i.e., perma nent

settl ing out in a comm unit y? This does net include those wh o extend

an extra year for their convenien ce.

Answer

The rate for NHS C pra cti tioners settlin g per man ent ly in a communi ty

has for the past two or three year s been abou t 12 percent of the

assig nees wh o compl ete thei r tour of duty that year.
87

Senat or Kennedy - National H ealt h Service Corps (NHSC) - Question No. 3

What should be done- to enhance reten tion and heal th services stability 

in those communiti es w hich are having consistent turnover?

An sw er :

Failure of communities to retain their assi gnee s is g enerall y attributed 

to one or more of such factors as profess iona l isolation, spouse dissatisfaction, social and/or cultural differen ces and deficien cies and personality conflict. We believe that it is essent ial now to begin to analyze 

those communities that have a c onsisten t turnover to deter mine exactly 

why the turnover occur s a nd to begin to take steps to counterac t this.

For example, we belie ve that for those communit ies that have social and/or 

cultural deficiencies that a careful search and an extra careful matching 

effort w ill enhance the opp ortu nities of retai ning professionals. We 

believe that a very carefu l and comprehens ive analysis of the individual's 

desires and the commun ity's resources, will help avoid m any turnover 

problems. For those communit ies where there is profe ssional isolation 

we believe that by provi ding the assignees wi th even greater involvement 

with a teaching facility or a State medical teaching institu tion and by 

provi ding him wi th v ariou s othe r services such as are now provi ded by 

contract with the AMA Re ference Library in Chicago or the dial access 

tapes throug h the Univer sity of Wisconsin, we can beg in to reduce the 

feeling of professional isolation. Among the c ommunit ies with highest 

turnover are those with a single provider. The NHSC will attempt to 

assign mor e than a single provider to all sites which have a poten tial 

patien t popul atio n to sustain more than o ne provider. Sites with only 

one provi der may be terminated or combined when the sole provi der decides 

not to remain.

We now make and expect to continu e effort s to involve spouses in the 

proce sses of learning about NHSC activities, asse ssin g communities, and 

identify ing prefe rred assignments. We expect to maintain a vig orou s 

moni toring program in orde r to identi fy and resolve, at the earliest 

possible time, personali ty conflicts.

X

9-
88

Senato r Kennedy _ N ati o n al H ealt h S erv ic e Co rps - Q uest io n No. 4

4 . I s th e re a ch an ge of pr og ram in te n t and p h il osophy in th e Co rps? .That 

i s , is i t moving fro m an em ph as is of h o p efu l lo n g -t erm com mitment o f a 

p r a c titio n e r to a com munity toward an expecte d o r pla nned two y ear 

tu rn o v er of NHSC pers o n n el?

Answer

Th ere i s no ch an ge of in te n t and p hil oso phy in th e NHSC pr og ram . The re 

i s th e p o s s ib i l it y th a t t h is co uld occ ur bec au se o f th e in c re a s e in 

s iz e and em ph as is bro ught ab out by P.L . 94- 48 4. T h ere fo re , we are 

ma kin g s p e c ia l e f f o r t s to co n ti n u e to p ro v id e a h ig h le v e l of a s s is ta n c e 

in m at ch in g NHSC p ers o n n el to s i t e s and in su p p o rt in g them on ce th ey 

a re pla ced in a comm unity . We hope th ro ugh th ese e f f o r t s to co n ti n u e 

to pro vid e a p o s itiv e ex p eri en ce fo r NHSC a ssig n e e s to improve th e 

q u a li ty of s e rv ic e s th ey p ro vid e and to en co ura ge them to re m ain in 

co mmun iti es when t h e ir as si gnm en t p e ri o d i s com ple te .

The sc h o la rsh ip p ro v is io n s in th em se lv es w ill r e s u l t in a fo u r year 

commitm ent fo r s c h o la rs h ip r e c ip ie n ts . We a re h o p efu l th a t th e 

ch an ce s of r e te n tio n w ill be ev en g r e a te r bec au se many a ssig n e e s w ill 

be sp en di ng fo u r y e ars in a com munity r a th e r th an two.

The r e te n tio n r a te of sc h o la rs h ip r e c ip ie n ts co uld pro bably be 

impro ved to th e e x te n t th a t s p e c ia l c are i s ta k en in th e aw ardi ng 

of sc h o la rs h ip s to ensu re th a t s tu d e n ts w it h r e la te d e th n ic 

c h a r a c t e r i s ti c s and ex p eri en ce in sh o rt a g e ba ck gro unds a re giv en 

s p e c ia l c o n sid e ra ti o n .

C u rre n tl y , we ha ve had so few sc h o la rs h ip r e c ip ie n ts se rv e in th e 

f ie ld th a t th e re i s l i t t l e ex p eri ence on which to e s ta b lis h a 

r e te n tio n r a te fo r them . In th e mea nt im e, fo r p la n n in g purp ose s 

we e sti m a te th a t t h e i r r e te n tio n r a te w ill be about 20 p e rc e n t.

Our r e te n tio n r a te of v o lu n te e rs who ha ve co m pl et ed t h e i r se rv ic e 

o b li g a tio n ha s s te a d ily improved so th a t we ex pec t th a t t h is year 

50 p e rc e n t of a ssig n e e s fin is h in g o b li g a te d s e rv ic e w ill re m ain in 

th e are a in th e NHSC or in p r iv a te p r a c tic e .

X

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89

Senator Kennedy - National Health Service Corps - Question 5.

5. Does the Administration feel that NHSC recruits are adequately prepared

to deal with their field responsibilities through present levels of

orientation and field support?

Answer

We believe that the assistance provided through orientations for NHSC

personnel snd through contracts and direct technical assistance provided

to NHSC personnel for setting up practices, and for practice management

and patient management is adequate. We hope to add greater emphasis to

the preparation and continuing capability of NHSC personnel through such

programs as are now being conducted at the University of New Mexico

and Hershey, Pennsylvania wherein the continuing medical education of

NHSC assignees is closely scrutinized by faculty members from these

institutions. Also, improved utilization of the capabilities of the

Area Health Education Centers (AHECs) could assist in this regard.

Elements of the answer to Senator Kennedy's retention question (No. 3)

are relevant to this inquiry.

t

a
90

Senator Kennedy - National Health Service Corps - Question No. 6

6. The President’s budget for FY 1979 allocates $60 million for the NHSC

scholarships In the Bureau of Health Manpower. How many students will

get scholarships for the first time under this sum?

Answer

P.L. 94-484 has added a new category of expenses which the scholarship

program will pay — all other reasonable educational expenses. We

estimate that the total cost per student per year of support will be

$11,000. That estimate will yield about 5,400 scholarships. Based on

the FY 1978 request for scholarships of $60 million and the large number

of 1978 awards which will go to students who will be continuing into

1979, It Is expected that there will be little money left for new awards

in 1979. The estimated distribution of awards at the 60 million scholarship funding level is 4,600 continuations and 1,200 new awards.

3

>
91

Senator Hathaway - Community Health Centers - Question No. 1

1. It has been alleged that a disproportionate share of the community health

center funds provided under section 330 are allocated to urban health

centers. Could you provide for this subcommittee a breakdown, for the

s»st recent fiscal year, of the number of projects funded and the amount

of funds expended In the following categories:

a. Urban comprehensive community health centers

b. Rural comprehensive community health centers

c. Rural Health Initiative projects

d. Urban Health Initiative projects

Answer

Data are for FY 1977:

w

Number of Projects Funding (000's)

Total 455 $215,148

a. 'Urban comprehensive

community health centers 113 143,484

b. Rural comprehensive

community health centers 45 40,470

c. Rural Health Initiative

projects 262 23,599

d. Urban Health Initiative

projects 35 7,595

4

28-386 0 - 78 - 7
92

Senator Hathaway - Co mmunity Heal th Centers - Que stio n No. 2

As you know, Senator Javits has introduced an amendment calling for the 

estab lish ment of an Urban Health Initiative as a part of the community 

health program. In your opinion, woul d the exist ing need for such 

services in rural medicall y unders erve d areas jus tify the broadeni ng of 

this p ropo sed program to include both urban and rural comm unit y hospitals 

as recipients of the financ ial assistance, or the estab lish ment of a 

similar program to meet the specia l needs of rural communiti es? If "no" 

to both questions, why not?

An sw er ;

Senat or Javits' proposal, section 106 of S. 2474, provi des for establishing primar y ambulatory care centers using, as a base, urban hospital 

outpati ent depart ments and emergen cy room services and facilities. This 

proposa l w ould allow e xisting com muni ty providers to reorganiz e themselves 

to provide care m ore efficiently, reduce inap propr iate utilization, and 

redirect resources to needed compr ehen sive a mbul ator y primary care 

services. (This proposal is not the same as the exist ing Urba n Health 

Initiati ve w hic h the Bureau of Community Health Servi ces is implementing 

under current section 330 authority.)

Because of the differ ence in the mo des of health care delivery between 

rural and urban areas, Senator Ja vi ts ’ proposal is ge nerally not suitable 

for applicat ion in rural areas.

While rural commun ities ofte n lack resources, espe cial ly manpower, to 

provide care, they usually do not have the problems of improper utiliza ­

tion and overspe cial izat ion comm on in urb an comm unities whi ch result in 

the p rovisio n of care to large segments of the p opul atio n through inappropria te utilizatio n of emergency rooms and speci alty oriented clinics.

In general, rural comm uniti es requi re addit iona l resources while urban 

communit ies tend to need reor gani zati on of the am ple resources wh ich 

already exist. In many urb an communities, this requires extensive 

remodel ing of facilities.

More flexi ble progr amming is currently being carried out in rural areas 

under the H URA (Health U nderserv ed Rural Area) aut hority of the Social 

Security Act, section 1110. However, the conferenc e committe e on the 

FY 1978 appropri atio n h as said no further funding wi ll be provid ed under 

the section 1110 a uthority and directs DHEW to seek authoriza tion under 

Section 330 of the Public Healt h Service (PHS) Act. This could be 

accompl ishe d simply t hroug h the addit ion of a new section in the PHS 

Act which woul d provid e the necessar y flexibili ty to develop appropria te 

system s for rur al areas whe re current section 330 a uthorities are 

inappli cabl e or inappropriate.
93

-2-

The Admi nist ration has propo sed that formal auth orit y for H URA be 

incorpor ated into the PHS Act as a new se ction 329. This new section 

would provid e support for the deve lopm enta l and demo nstration activities 

which are nee ded to meet the unique p rimary health care needs of rural 

areas in those instances where section 330 fundi ng is not appropriate.

In addition, If conversion of hospital outpa tien t servi ces were uniquel y 

appropr iate in any p articular rural area, this conversion could be 

accomod ated either under section 330 or the n ewly proposed devel opme ntal 

and demonst rati on section.

4
Senator Hatha way - Commun ity Health Centers - Que stio n No. 3

What modifications, if any, would be required in existing regulations 

governin g the funding of compr ehen sive c ommu nity healt h centers to 

enable a larger numbe r of smalle r rural communi ties to develop and 

operate commu nity health center programs? For example, it has been 

suggested that existing requ irements for the provisi on of the full 

range of p rimar y healt h care services outlined in section 330(b) of 

the Act restricts part icip atio n by smaller communi ties in the program.

Do you believe that the curren t regulations reflect an urba n bias in the 

wa y the program is administered?

An sw er :

The regulations gover ning the Community H ealth Centers program are 

based o n the legislati ve requirem ents of Section 330 of the Public Health 

Service Act. The regulat ions descr ibe the full range of health care 

services required by the Act at a level we cons ider ad equate for effective 

health care. The legi slati ve and regu latory require ment s may present 

problems to some rural communities, espec iall y those that are sparsely 

populate d and remote. Wher e the Commun ity is remote and the population 

base is too small to main tain full time staff locally, special arrange ­

ment ma y be made to delive r servi ces by mak ing use of other area resources
95

Senator Hathaway - Community He alth C enter s - Question No. 4

It has been al lege d that c urrent fundin g prio riti es wit hin the Department 

restrict fundin g under the s ectio n 330 progra ms to the p rovisio n of 

primary health care services, and that the Depa rtment has not actively 

enco urag ed and suppor ted funding for supplemen tal and environ ment al as 

outlined in the Act? Have exist ing Departme ntal polic ies rest ricted 

funding to on ly primary care services, and if so, on what basis?

An sw er :

Wit h respec t to estab lished community heal th centers, the D epar tmen t has 

not restr icte d funding to the provisi on of primary healt h care services 

but rather has suppor ted a fairly br oad array of health services. With 

4 respec t to Ur ban Hea lth Initiative (UHI) and Rural H ealth Initiati ve (RHI)

projects, the Department has conc entr ated o n p rima ry health care services 

which i nclud e physician services, diag nost ic labo rato ry and radiologic 

services, preve ntiv e heal th services, emer genc y medical services, transw portati on services and prev entive dental services. Whe n these projects

have deve lope d the capacity to deliver primary health care services, the 

Departm ent may initiate support of suppleme ntal he alth services.

»

4
S en ato r J a v i ts - Comm unity H ealt h C en te rs - Q uest io n No. 1

1 . Would you p le a se d e sc rib e th e H eal th U nd er se rv ed R ura l Are as 

pr og ram (HURA)? Co uld a prog ram o f t h is n a tu re be ex pa nd ed to 

urb an a re a s? (P le ase in clu d e ex am pl es o f th e k in d s of p r o je c ts 

which wo uld be fu nd ed under su ch a pr og ram i f th e a u th o r ity we re 

a v a ila b le .) I f on e as su m es th a t s e c tio n 330 i s th e lo g ic a l 

s ta tu to r y bas e fo r su ch an e f f o r t , wh at ch an ges wo uld have to be 

made to s e c ti o n 330 to a ll o w you to 'a c c o m p li sh th e d e sir e d o b je c ti v e s?

Ans we r:

The H ealt h U nde rs er ve d R ura l A re as (HURA) Prog ram i s a comp onent 

of th e c a p a c it y b u il d in g s tr a te g y of th e Bur ea u o f Comm unity H eal th 

S e rv ic e s. I t i s fu nd ed by T it l e XIX o f th e S o cia l S e c u rit y Act 

under S e c ti o n 11 10 , G en er al R es ea rc h A u th o rit y . I t e s ta b lis h e s 

devel opm en ta l and te s ti n g p r o je c ts in h e a lth und ers erv ed r u r a l a re a s 

fb r th e fo ll o w in g p u rp o ses:

. a t t r a c t p h y sic ia n a s s i s t a n ts an d n u rs e p r a c t it i o n e r s to 

r u r a l a re a s to su pp le m en t and a t t r a c t a d d itio n a l p h y sic ia n s

. em ph as ize pr og ra m s o f h e a lth e d u ca ti o n and p re v e n ti v e 

h e a lth c are

. g a in f u l l u t i l i t y fro m th e a v a ila b le m ed ic al re so u rc e s in 

r u r a l a re a s

. c o o rd in a te w it h M ate rn al and C hild H e alt h , E arl y and 

P e rio d ic S c re en in g , D ia gnosi s and T re atm ent, and can cer 

sc re e n in g pr og ra m s o f th e N a ti o n a l Can ce r I n s t i t u t e to 

all o w a l l th ese re so u rc e s to be b ro u g h t to b ear to in c re a se 

h e a lth c a re to m oth ers and c h il d r e n in m ed ic all y under ­

se rv ed a re a s

. devel op m etho ds o f o rg a n iz a ti o n th a t u t i l i z e th e b a sic 

m ed ic al fu ndin g pr og rams and new metho ds o f d e li v e ry

The HURA Prog ram works w it h a lr e a d y e s ta b lis h e d p ro v id e rs o f c a re 

who wis h to expand t h e i r s e rv ic e in r u r a l a re a s o r devel op p a r tic u la r 

o rg a n iz a tio n a l o r te c h n ic a l d em o n str ati o n s aim ed a t im proved se rv ic e 

o r fin a n c in g s tr u c tu r e s .

The pr og ram co uld be ex pa nd ed to urb an a r e a s . Un der su ch an ur ba n 

pr og ram , h o s p ita ls , p r iv a te n o n p ro fit gr ou p p r a c tic e s , m ed ic al 

sc h o o ls , e t c . , co uld devel op com munity h e a lth s e rv ic e p r o je c ts 

se rv in g urb an a re a s in ne ed of h e a lth s e rv ic e s d e li v e ry im pr ov em en t. 

Such p r o je c ts could in clu d e th e use of n u rs e p r a c t it i o n e r s , p h y sic ia n 

a s s i s t a n t s , new o rg a n iz a ti o n mod els o r o th e r a p p ro p ria te te ch nolo gy 

to dev el op sy st em s o f c a re .
97

Senator Javits - Com munity Healt h Cent era - Ques tio n Mo. 2

2. It Is my u nderst and ing that, accor din g to H EW calcula tion s, It curr entl y

costs app rox imately $1.5 m ill ion to establ ish a consnunlty h ealth cente r

In an u rban area and $150,000 to establ ish one In a rural area. Would

you explain this cost different ial and supply, for the record , any

Information regardin g h ow funds under sect ion 330 are bei ng spent (i.e.

ho w mu ch for planning, ho w much for ren ova tio n a nd mode rnizat ion , how

muc h for direct patient services, how mu ch for Indir ect costs like

overhead, salaries, etc.).

Answer

Since 1975, the Public Healt h Service (PHS) has been funding n ew centers

under the Rural Health Init iative (RHI), and since 1977, the PHS has been

funding new centers under the Urb an Health Init iati ve (UHI). Exper ienc e

wi th these two initiatives indicat es that the average grant for the first

year of funding, whi ch is prim ari ly to cover d eve lop men t and Initial

ope rations costs, was $150,0 00- $20 0,0 00 for the RHI cent ers and $285,000-

$325,000 for the UHI centers. The cost diff erenti al of approx ima tel y

$125,000 can be att ributed to the following:

A. Differ enc e In Group Pract ice Mod el :

The UHI model consists of 5-6 prim ary care phy sic ian s with

1 to 2 nurse practitio ner s and a d enta l hygien ist and Is

designed to s ervi ce a mi nimum patie nt pop ula tio n of app rox imately 10,000 person s (In the first year of ope rat ion about

5,000 and the second year on, about 10,000) wh ile the RHI

mod el consists of 3 to 4 pr imary care p hys ici ans w ith abo ut

the same ratio of other allied health person nel to serve

approxima tel y 6,000 persons (In the first yea r of ope ration

serving about 3,000 a nd the secon d year on, abo ut 6,000).

B. Int egration of R es ou rc es :

The assi gnment of the Nation al Health Service Corps (NHSC)

per sonnel to the RHI proj ect s and UHI proj ect s is one of the

priority objectives of the capacit y bui ldi ng activity. To

date, however, we have had more succ esse s in the place ment

of the NHSC personnel In the deve lopm ent of pri mar y care

group practices of health pr ofe ssi ona ls wit hin the rural

und erserved areas than In the urban areas. Over 100 RHI

projects currently are mat che d w ith the NHSC person nel

whe rea s only 6 UHI projects are curr entl y m atc hed w ith the

NHS C personnel.

A
C. Space A c q u is it io n , R en ov at io n and M odern iz ati on C o sts :

I n i t i a l In vest m ent and s ta r t- u p c o s ts (In c lu d in g li m it e d 

c a p ita l and re n o v ati o n c o s ts ) a s s o c ia te d w it h devel opin g 

a prim ar y c are h e a lth p ro je c t in urb an a re a s ha ve be en 

assumed to be s l i g h tl y h ig h er th an in r u r a l a r e a s .

As of 19 77 , th e d is tr ib u tio n of t o t a l o p e ra ti n g c o s ts of Community H eal th 

C en te rs (CHCs) was as fo ll o w s. The am ounts shown a re th e t o t a l fu nd s 

a v a ila b le to su p p o rt a l l CHCs which we re $370,9 44,8 27, of wh ich 

$2 15 ,1 48 ,0 00 re p re se n t s e c ti o n 330 a p p ro p ri a te d fu nds (58 p erc en t of 

th e t o t a l o p e ra ti n g c o s ts ) ; $114,9 92,8 96, th ir d p a rty re im burs em en ts 

(31 p e rc e n t of th e t o t a l o p e ra ti n g c o s ts ) ; and $40,8 03,9 31, S ta te , lo c a l, 

and o th e r c o n tr ib u tio n s (11 p e rc e n t of th e t o t a l o p e ra ti n g c o s ts ) .

A pp ro xi m at el y 70 p e rc e n t o f th e t o ta l o p e ra ti n g c o s ts a re fo r s a l a r i e s :

D ir e c t P a tie n t S erv ic e

(M ed ic al , D en ta l, Lab , X-Ray, 

Pha rmacy and o th e r H ealt h)

Support in g S erv ic es

(O utr ea ch, T ra n s p o rta ti o n , and 

M ed ical Rec or ds )

Ov erh ead

A d m in is tr a ti o n 

Hou se ke ep ing and M ai nt en an ce 

(In clu d in g d e p re c ia tio n of 

f a c i l i t i e s )

P e rc en t D o ll crc

65 $2 41 ,1 50 ,0 00

11 $ 40,8 10,0 00

24 $ 89 ,0 40,0 00

(1 7) $ 63 ,0 70,0 00

( 7) $ 25 ,9 70,0 00

Of th e $215,1 48 ,0 00 a p p ro p ri a te d fu nd s in 19 77 , a t o t a l of $2 3, 59 8, 52 4 

was ex pe nd ed to su p p o rt 262 RHI p r o je c ts , of wh ich 43 p r o je c ts we re 

fu nd ed as ri annin g /D ev elo p m en ta l p ro je c ts w it h $1,9 1 7 ,2 5 3 , and a t o ta l 

o f $7,5 95,0 31 was expend ed to su p p o rt 35 UHI p r o je c ts , of wh ich 3 p ro je c ts 

wer e p la n n in g /d ev elo p m en ta l p r o je c ts w it h $5 0,0 00.
99

Senator Javits - Commun ity Hea lth Centers - Que stion No. 3

3. Please provide a det aile d b rea kdo wn of currently approved projects 

(including RHI and UHI) by category as they relate to u rban and 

rural areas. I would like for you to include a per capita allocat ion 

of grant moni es per eligi ble medic all y underse rved recipie nts in urban 

and rural areas. Also pleas e indicate how yo u a nti cipate spending 

any new funds, as pr opos ed for aut hor ization under S. 2474, in urban 

and rural areas. Be specific.

Answer

A detailed b rea kdown of the pro jects and per capita all ocations of 

grant funds are disp laye d in the attached Tables 1 and 2.

Table 1 (attached)

Table 2 (attached)

The adm ini stration’s budge t request for FY 1979 of $286 ,000,000 for 

the C ommu nity Heal th Centers incl udes $27,700, 000 to fund an addi tional 

131 projects. Eigh ty-fi ve (85) of the proj ecte d 131 new pr ojec ts will 

be establis hed in the rural areas ($12,750,000), and 46 project s in 

the urban areas ($14,950,000).

A

*
Tabla 1

Rural and Urban Breakout of the Coaaunlty He alth Centers

1977_________________ ______________ 1978________________ _________________ 1979

•

Cocaunlty He alth Centers No.'

Pro ject s

Z of

'a Tota l

Funding

Z of

$ Tota l

Pro ject s

Z of

No.'a To ta l

Funding

Z of

$ Tota l

Pro jects

Z of

N o.'a To ta l

Funding

Z of

$ Tota l

On-gotng CHC's -

Rural 45 10Z $ 40 ,47 0 19Z 45 8Z $ 44,40 8 18Z 45 6Z $ 52,347 18ZUrban 113 2SZ $143,484 67Z 113 20Z $157,445 64Z 113 16Z $165,767 S8Z

RKI 262 58Z $ 23,599 11Z 356 62Z $ 31,187 13Z 441 63Z $ 39,688 14Z

UKI ' 35 7Z $ 7,595 3Z 60 10Z $ 13,960 SZ 106 15Z $ 28,198 10Z

CMC Tota l 455 100Z $21 5,146 100Z 574 100Z $247,000 100Z ' 705 100Z $28 6,000 100Z

Rural 307 67Z $ 64,069 30Z 401 70Z $ 75,595 31Z 486 69Z $ 92,035 32Z

Urban 148 33Z $151,079 70Z 173 30Z $171,405 69Z 219 31Z $,193,965 68Z

> * a v
101

Table 2

Per Capi ta Us e of Section 330

Grant Funds In Ur ban and Rural Proj ect a

1977 1978 , 1979

Rural Urb an Rural Urban Rural Urban

Total Section 330 •

Grant Dollars:

Con tin uat ion Projects $40.5 $143. 5 $44.4 $157. 4 $52.3 $165. t

RHI $23.6 — $31.2 — $39.7 —

UHI — $7.5 — $14.0 — $28.1

Grant Dol lar s per

capita 1/ $41 $81 $33 $75 $31 $73

1/ Using only Section 330 funds. Not Include d In this compu tati on, part icul arly

for RHI projects, are other federal res ources such as Mig ran t grant funds

and Natlona l»H eal th Service Corps resources . Comput ati on of per capita use

of sec tio n 330 funds Is based on persons served in CHCs.

<

*
102

Sen at or J a v its - Community H ealt h C ente rs - Q ues tion No. A

A. P le a se pro vid e a " c u rre n t p o li c y budget " (c o n ti n u a ti o n of c u rre n t 

a c t i v i t y p lu s I n f la tio n ad ju stm en t) fo r c u r re n tl y ap pr ov ed p ro je c ts 

(In clu d in g RHI and UH1) by cate g o ry fo r f i s c a l 19 79 , 19 80 , and 19 81 , 

co mpa rin g th ese fig u re s (I n a d ja c e n t co lumns ) w it h (a ) fu nd s 

re q u est ed by th e A d m in is tr ati o n fo r c o n ti n u a ti o n of t h i s pr og ra m , and 

(b ) fu nd s pr op ose d fo r a u th o riz a tio n un der S. 2A7A, and (c ) fu nd s 

pr op os ed fo r a u th o riz a ti o n un de r H.R . 10 55 3.

Answer

(a ) C o n ti n u ati o n c o s ts fo r c u rre n tl y ap pr ov ed p r o je c ts p lu s in f la tio n 

ad ju stm en ts :

C o n ti n u ati o n c o s ts fo r c u rre n tl y 

ap pr ov ed CHC p r o je c ts ($ In m illio n s )

1979 1980 2 / 1981 2 /

On -going CHCs $2 18 .1 A/ $2 30 .5 $2A3.A •

R ura l H ealt h I n i t i a t i v e 39 .7 A2.0 AA.3

Urban H ealt h I n i t i a t i v e 28. 2 29 .8 31 .5

H ealt h fl nder se rv ed R u ra l Areas 15.0 15 .9 16 .8

T o ta l - c u rre n t p o li c y p ro je c tio n $3 01 .0 $3 18 .2 $3 36 .0

(b ) Funds pr op ose d fo r a u th o riz a tio n un der S. 2A7A fo r Con nu nity H ea lt h 

C e n te rs:

1979 1980 1981

P la nnin g $ 10,0 00, 000 $ 10,0 00,0 00 $ 10 ,0 00 ,0 00

O pera ti ons 32 0, 00 0, 00 0 35 2, 000,0 00 38 7, 20 0, 000

Urban H o sp it a l 

I n i t i a t i v e 3A,00 0,00 0 72,0 00,0 00 11A ,000 ,000

T o ta l $36 A, 00 0,00 0 $A 3A,00 0,0 00 $5 11 ,2 00 ,0 00
103

- 2 -

(c ) Funds proposed for au th or iz at io n under H.R. 10553 fo r Community

Health Centers :

Plan ning

Operations

Total

1979

$ 6, 30 0,00 0

308,7 00,00 0

1980

$ 7,5 00 ,000

367,5 TM, "00

1981 -

$ 9,0 00 ,000

441,0 00,00 0

$315,00 0,0 00 $375,00 0,0 00 $450,00 0,0 00

-4 1/ Does not inc lude in fl ati onary adjustment

2/ 5.7X of in flationary adjustment

3/ 5.6X of in flationary adjustment

4/ Inclu des ad olescent he al th se t- a si d e funds and othe rs

«
Se na to r J a v it s - Secti on 31 4( d) - Unnumbered Que sti on

How much Is known about th e accomplish men ts o f S ta te program s which

spend fund s under Sec ti on 31 4( d) ? Why has DHEW no t Imposed more

s p e c if ic re p ort in g re qu irem en ts?

Answe r;

Through th e Hea lth Program Re po rting System o f th e A sso cia ti o n of Sta te

and T e r r it o r ia l Health O f f ic ia ls (ASTHO), supp orted by th e Hea lth

S ervic es A dm in is tr ati on, th e ex pen dit ure s by S ta te h ealt h agencie s of

se c ti o n 31 4( d) fun ds ar e re por te d by th e fo ll ow in g program are as and

c a te g o r ie s: per so nal healt h programs (g en eral, mater na l and ch il d

h ea lt h , communicable d is e a se , denta l h e a lt h , ch ro ni c d is e a se , o th e r ),

en vi ro nm en ta l healt h programs (g en era l, consu mer p ro te cti o n and sa n ita tio n , ra d ia ti o n co n tr o l, publi c dr in kin g wa ter and wa ter p o ll u ti o n

c o n tr o l, o th e r ), healt h res ourc es programs (h ealt h pla nnin g, healt h

f a c i l i t i e s and se r v ic e s de ve lopm en t, h ea lt h manpower de ve lopm en t,

h ealt h f a c i l i t i e s and se r v ic e s r eg u la ti o n , hea lt h manpower r eg u la ti o n ,

h ealt h s t a t i s t i c s , eme rgency m ed ical se r v ic e s , g e n e ra l) , S ta te la b ­

o r a to r ie s , gen er al adm in is tr ati on and se r v ic e s , and fund s to lo c a l

h ealt h de partm ents no t a ll o c a te d to program a reas. T ota l ex pen diture s

o f S ta te and Fe de ra l fund s by th ese program c a te g o r ie s ar e a ls o

re por te d as ar e a ls o th e number o f pe rs on s se rv ed , w ith a fu rt her

breakdown in c er ta in per so nal h ealt h pro grams. A s ig n ific a n t in cre ase

in rep ort in g fo r materna l and ch il d h ea lt h and cri p p le d c h il d re n ’s

program be gi nn in g with f i s c a l ye ar 1977 and an in c lu sio n o f more

d e ta il e d rep ort in g from lo c a l h ealt h departm ents i s ex pe ct ed be gi nn in g

in f i s c a l ye ar 19 78 .

Pre vi ou s to March, 1976 two major r ep o rts , th e FAR and FAST ta sk fo rces

were de ve lope d w ith th e o b je c ti v e s o f s ig n ific a n tly re du cing th e tim e

and e ffo r t de vo ted to pl an pre para tion and re port in g re qui re m en ts.

As a r e s u lt o f th ose e f f o r t s , d e c is io n s were made to r a d ic a ll y reduce

pl an ni ng m a te ria ls .

Si nce March 1 , 19 76 , th e Department has bee n su b je ct to a P re sid e n ti a l

d ir e c tiv e to redu ce publi c re p ort in g to Fe de ra l agencie s in or de r to

imp lement th e Fed er al Re ports Act (44 U.S.C . 3501-3 512). The O ff ic e

of Management and Bud get has th e r e s p o n s ib il it y fo r th e cle ara nce of

a l l rep orti n g re qu irem en ts a ffe c tin g 10 or more re sp onden ts . The

Departm ent curren tl y has as an o b je c ti v e th e re duct io n o f th e re port ­

in g burden a ss o cia te d with HEW r e p e tit iv e re p ort s by 50 pe rc en t by

May 31 , 19 78 . The burden re duct io n i s measured in terms of hours of

burd en ass ig ned to a rep ort in g form in th e June 30 , 1976 OMB

in ven to ry or upon i t s en tr y in to th e OMB in ven to ry , i f a fte r th at date .
105

Senator Javits - Migr ant Heal th Centers - Unnumb ered Question

Duri ng the question period follo wing your testimony, the issue of 

establi shin g Me dica id eligibili ty for migrants based o n "intent to 

reside " w as raised. Would you please elabo rate on how the determination of this intent would be made?

An sw er :

Presently, when a person is interviewed with regard to his request for 

certifi cati on for State M edicaid benefits, man y States ask if the 

person intends to reside wit hin the State. Ofte n Medicaid benef its are 

denie d wh en the person states that h e does not intend to become a State 

resident. This is p articul arly true of migrant workers who by the ve ry 

natu re of their w ork cannot claim perman ent State residence.

The Depar tmen t has under conside rati on an approach removing these restric 

tions by p rohi biti ng States from denying Medicaid bene fits to migrant s 

on this basis.

The propo sal woul d specific ally ad dress the migr ant pro blem and make 

migrants eligible for Medi caid reimbursa ble health services within the 

income limits and service benefit package of the State. It wou ld not 

involve billi ngs between States but w ould me an that mi grants would have 

var ying eligibil ity for differ ent levels of services as they traveled 

from State to State.
Senator Javit s - Miscellan eous - Unnumbered Que stion

It Is my understanding that the National Assoc iation of Neighborhood

Health Centers and Rural America, each re pr esen tin g the In te res ts of

or ga ni za tio ns funded under the Community Health Centers program,

re ce iv e support from the Bureau of Community Health Ser vic es . Could

you ad vise how much support is di re ct ed to th es e and re la te d orga nizati ons and from what program(s) th is money is obtained? Is there a

c o n fl ic t of in te rest in trade ass oci ati ons re pr esen tin g those who

re ce iv e pr oject grants from your o ffic e als o re ce iv in g support funds

fo r th ei r a c tiv it ie s? Is i t appropriate that the same agency that is charged

wi th ev alua tin g the eff ecti v en ess of such programs giv es fi nancia l

support to ass oci ati ons re pr esen tin g th ese groups?

Answer:

The Nationa l Assoc iatio n of Community Health Centers (NACHC) is an

or ga nizatio n whose sta ff and membership have expe rie nc e in the pla nning ,

development, and operation of community and migrant he al th ce nte rs .

Their exp erience is d ir ectl y re la te d to the ar ea s—underserved ar ea s—

which frequently lack the te ch nic al ex per tise and resour ces wi thin the

community to plan and dev elop ambulatory he alth care se rv ic e de live ry

programs. As such, th es e in div id ual s are uniqu ely qu alifi ed to provide

as sist an ce to community and migrant he alth ce nte rs .

The NACHC has been awarded a te ch ni ca l ass is ta nce grant of $875,000 for

fis c a l year 1978. The grant is funded from the fo llo win g sources:

$765,000 from Se ction 330 of the Pu blic Health Se rv ice Act and $110,000

from Sec tion 319 of the same Ac t.

The Ca lifornia Rural Health Feder ation and the Rio Grande Feder ation of

Health Cente rs, In c. are oth er or ga ni za tio ns th at a s s is t communities

in the developm ent of primary car e programs in th eir re sp ec tive rural

ar eas. The membership of the or ga ni za tio ns are primary care ce nt ers

ser vin g larg e migrant and season al farmworker po pu latio ns .

The Bureau of Community Health Se rv ices (BCHS) has awarded grants of

$70,000 to the Cal ifor ni a Federation and $104,000 to the Rio Grande

Feder ation.

The work pla ns submitted by these or ga niza tio ns and approved by BCHS

contain obje ct iv es that supp ort the pr ov isi on of te ch ni ca l ass is ta nce

to migrant and community he alth ce nte rs . The au th or ity for the Sec ret ary

to provide ne cessary te ch nic al ass is ta nce is giv en in Se ction 33 0( f) and

Se ct ion 319(g ) of the Ac t, fo r community he alt h ce nt er s and migrant

he al th ce nte rs , res pect iv el y. Assista nc e may be giv en fo r develop ing

pla ns fo r, or op er ating as, a community he alth center or migrant he alth

ce nte r. Spec if ic a c tiv itie s con tained in the NACHC workplan fo r 1978

in clud e:
107

1. To assist "high priority" Medically Underserved Areas to develop 

applications for urban and rural health initiative grants.

2. To Improve health service program effectiveness by providing onsite 

technical assistance to community health service programs. Assistance 

shall include, but not be limited to, the following areas:

a. Financial Management

b. Clinical Management/Quality Assurance

c. Administration

d. Board Training

e. Facility Development

f. BCHS Initiatives (Adolescent Health etc.)

3. To provide opportunities for continuing education for health care

-4 administrators, providers, board members, and consumers of member

and non-member health service programs by conducting one national 

and ten regional Community Health Institutes.

4. To help alleviate health manpower shortage problems in medically

• underserved communities by assisting MUAs to request and obtain 

designation as Critical Health Manpower Shortage Areas.

5. To improve the long term financial viability of certain community 

health service programs by developing strategies for converting 

such programs to prepayment financing mechanisms and disseminating 

this information to member and non-member community health service 

programs.

6. To educate nationally, the persons involved with the community health 

center movement by producing and disseminating information on program 

policy, development and operation.

7. To provide a forum for the discussion of specific health care Issues 

of national and regional significance by conducting a series of 

National Health Policy Issues Conferences on the following topics:

a. Continuity of Care for Migrant Populations

b. Quality Assurance Issues in Ambulatory Care

c. Solving Environmental Health Problems through Community Health 

Services

d. Rural Health Care Consortia and Regional Health Delivery Systems: 

Models for Meeting Health Care Needs of Rural Populations

e. Strategies for Improving Program Management

f. Partners in Health Care Delivery, Consaunity Health Centers and 

General Hospitals

Rural America was awarded a 6 month contract in fiscal year 1977 of 

$28,260 to Identify and prepare a directory of non-Federal national and

* regional organizations concerned with rural health care or actively 

involved in Improving rural health conditions and to plan and conduct, 

as part of their Third National Conference on Rural America, a session

28-386 0 - 78 - 8
108

-2-

on how to coordinate and maximize and integrate these resources to 

improve rural health care. Copies of this directory, when finalized, 

will be distributed to communities interested in developing health 

care systems to aid them in indentifying resources.’ This contract was 

supported with National Health Service Corps funds and was part of the 

overall Bureau of Community Health Services capacity building strategy 

designed to integrate resources and develop linkages between health 

care providers.

It is our understanding that Rural America is not a trade organization 

but a rural membership organization whose interest has been in agriculture, housing transportation, and more recently, health. Their work

with and knowledge of the many rural organizations interested in W

Improving health care delivery, but not directly associated with health care

delivery, enabled this Bureau to obtain valuable information which will

contribute to the further identification of non-Federal health care

resources available to rural communities and aid these communities to

develop their capacity to provide health care. The Third National *

Health Care Delivery Conference brought together persons with knowledge 

of the many areas of rural life.

It is our view that activities such as those described above, are appropriate and essential to the work of this Bureau and do not present any 

conflict of interest. We believe that subsidization of such organizations would be inappropriate; but we regard making use of their special 

capabilities to carry out specified activities to further the development 

or improve the operation of health centers as a sound management practice.
109

SENATOR JAVITS - NATIONAL HEALTH SERVICE CORPS - Unnumbered Question

It has come to my attention that the National Health Service Corps has

a very limited program to support the development of State health

service corps activities. Given the generally favorable reception of

the National Health Service Corps and the demonstrated Interest of States,

to become more active in this type of program, why has not mo.re been done

'to decentralize Corps activities through State participation? What action

would be needed by the Congress to demonstrate its commitment to the support

- 'of Increased State activity in this area?

Answer *

Some activity in this area Is under way at the present time. Contracts to

■a support the development of State Health Corps operations In Oklahoma,

Mississippi and Arizona were awarded in 1976. We are currently negotiating

for such programs with several other States including Arkansas, Pennsylvania

and Alabama and we have inquiries from West Virginia and North Carolina.

The Health Services Administration has plans to launch an aggressive program

• this year .to foster better relationships between the more than 20 States

with some form of a Health Service Corps and the National Health Service

Corps. The California operation is particularly interesting inasmuch as

their law was essentially a reproduction of the National Health Service

Corps authority.

One of the problems remaining to be Ironed out is the question of the

potential conflict of dual service obligations. For example, when a

student with an obligation to a State applies for and receives a National

Health Service Corps scholarship, can a placement in that State be

arranged and thereby satisfy both obligations? This becomes a problem

when there are more students with State obligations than can be assigned

to a State on the basis of greatest need.

Serious discussions are under way now to attempt to resolve these problems

in a mutually satisfactory manner and if this can be arranged it is likely

that emphasis will be placed on establishing and Improving the State Health

Service Corps operations.

At this point, we do not believe that any action is required on the part

of the Congress. It may be useful to have the report contain an expression

of Interest in this activity, as well as an indication that efforts in this

regard should continue.
110

Se na tor J avits. Th an k yo u very m uch.

Se na tor Hathaway. Th e next gro up of witnesses is a panel on 

healt h cente rs: Dr. Da nie l Davis, Bas ilio F. Rom ero, Dr. Lo rin 

Ker r, and Dr . Jam es A. Block.

Dr. Dav is ?

STAT EMENT OF DANNY K. DAVIS, PH.D., PRESIDEN T, NATIONA L

ASSOCIATION OF COMMUNITY HEALTH CENTERS, INC., W ASHING ­

TON, D.C., AND SPECIAL ASSIS TANT TO T HE PR ESIDEN T OF MILE

SQUARE HEALTH CEN TER OF CHICAGO, ILL., ACCOMPANIED BY

L. JEROME ASHFORD, EXECUTIVE DIRECT OR OF TH E NATIONA L

ASSOCIATION OF COMMUNITY HE ALTH CENTERS

Dr. Davis. Mr. Ch air ma n, my nam e is Da nn y Da vis and I am 

special assistan t to the preside nt of the Mile Square Hea lth Cente r 

in Chicago , a nd preside nt of the N ational Associatio n of Com munity 

Hea lth Centers. I am accomp anied tod ay by Mr. Jer om e As hford , 

who is executive direc tor of the National Ass ociatio n of Com munity 

Hea lth Centers. An d Ja ck Crado ck fro m the Massac husetts Lea gue 

of Hea lth Centers was supposed to be here, bu t the weath er con ditions in Boston pre vente d him fro m doing so. However, he will be 

subm itting testimony.

On behalf of the Na tio nal Associa tion of Comm unity He alth 

Centers and the tho usa nds of med ically uns erved and underserved 

fam ilies who benefit fro m thes e pro gra ms , I wa nt to than k you and 

members of the subcommittee for this op po rtu nity to sha re with you 

our views on Sen ate bill 2474. We sha re yo ur concerns fo r this Na ­

tio n’s unserved and underserve d, and comm end yo ur subcomm ittee 

for its efforts to tra ns late th is mu tua lly share d concern int o effective 

legisla tion .

Th e membersh ip of our assoc iatio n is rep res entat ive of the dive rse 

com munity and m igra nt healt h center models designed to meet the 

he alth service needs of Ame rica’s medic ally unserved and und erserved 

pop ula tions. Th roug h th ei r repres ent atives , these organiz ations have 

ha d th e o pp ortunity to review S. 2474.

I would like to tak e this op po rtu nity to sub mit to you our assessme nt of the me rits and deficiencies of the proposed legisla tion, as 

well as some recommendations r eg arding bro ader healt h-rel ate d issues.

One, th at com munity healt h cen ter and migrant healt h pro gra ms 

be extend ed for a 5-year period throug h fiscal year 1983; we wholehe art edly su pp ort you r recent floor sta tem ent th at , “The healt h cen ter 

program s have now reached a po int where Congres s should pro vide 

an exp ression of its confidence and reflect th is in a 5-year au tho riz atio n.”

Sh or t period autho riz ati ons ten d to give a sense of tran sience to 

the prog ram . More impo rta nt, however, is the fact that in the pas t the 

result has been disrup tio ns in prog ram fu nd ing as approp ria tio ns 

were delayed due to lack of autho riz ing legislation. At the cen ter 

level, it has m ade plan ning most difficult, and all too often employees 

have been dismissed because o f uncertain or delaye d funding .

Rec ommen dation I I : T hat e lig ibility fo r gr an ts un de r sections 330 

and 319 be res tricte d to c ommunity-bas ed, pr ivate, nonprofit organi-
Ill

zations. Community and migrant health centers have developed over 

the last decade as community-controlled ambulatory health providers 

with emphasis on prevention. They have shown themselves to be 

effective both in delivering services to those previously unserved by 

traditional providers and in being responsive to the unique needs of 

their target populations, needs which traditional providers have not 

understood or met. Congress enunciated its support of the community 

health center model when it eliminated section 314(e).

Senate bill 2474 weakens this commitment to community-based 

ambulatory care by permitting grants to public general and other 

nonprofit hospitals. We are sympathetic to the needs of “community 

hospitals” and agree that many may require Federal support. However, we do not feel tha t section 330 is an appropriate means of

• providing support to public hospitals, because section 330 is intended 

to support consumer-controlled ambulatory care centers.

There already exist numerous resources upon which public hospitals can draw, such as section 314(d) of the Public Health Service 

Act, and categorical programs, such as community development under HUD, Economic Development Administration, and Comprehensive Employment and Training Act funds under Labor. In addition, 

Mr. Rogers bill, H.R. 10553, is proposing to increase the authorization 

for 314(d) to $300 million from the current appropriation of $90.

The proposed legislation—refer to section 330(b) (3) (6 )—would 

not only permit funding grantees who are not part of the community 

health center model, but also would permit such grantees to construct 

facilities, while community health centers are limited to renovation. 

One wonders if this discrimination implies a commitment to the 

permanence of public hospitals, while regarding community health 

centers as temporary.

Moreover, public hospitals would merely be required to have an 

advisory board—refer to section 330(h) (4) (5) which implies no 

community control and little consumer input, an issue which is central to section 330.

Three. Tha t the list of mandatory primary services be expanded 

to include a broad range of preventive health services and those 

services which eliminate barriers to access. Further, the Secretary 

shall assure that centers are adequately funded for the provision of 

such services.

Specifically, the following services should be added to the primary 

« category: First, preventive health services for children and adults;

second, public health services, including nutrition education and social services; third, health education services; forth , environmental 

health services as may be appropriate for particular centers; fifth,

* primary mental health services; sixth, outreach services and other 

services which promote and facilitate optimal use of primary health 

services; and, seventh, information on the availability and proper 

use of health services.

In addition to those services already defined as prim ary, the above 

services compliment a range of health care and a philosophy which 

have led these programs to their successful track record; tha t is, 

accessability, quality, prevention, and substantial reductions in costly 

inpatient care.
112

Mr. Ch air ma n, we would hope this committee will tak e a lead in 

est ablishin g a healt h policy of this na ture by gu ara nteeing th at 

th roug h these program s, a certain minimum of he alt h servic es will 

be ava ilable to all people. Th e services th at we con tend should be 

manda tory fall int o thr ee grou ping s: Fi rs t, basic medical and den tal 

ca re; second, preven tive services; and , th ird , ancillary servic es which 

remove ba rri ers to access.

I should point out th at we are not ask ing th at all services cu rrently defined in the law become ma ndato ry. Th e need fo r th is kind 

of policy is eviden t when one exam ines wh at has happened to the 

healt h cen ter pro gra ms recently. Gra nt levels to ong oin g pro gra ms 

have in some cases been reduce d, and in oth ers no t adjus ted to keep 

up wi th increased costs. Th is has resulte d in red uctions of service 

levels, and in the case of new pro gra ms —rur al and urban healt h *

ini tia tiv es—services beyond those which are man da tory are seldom 

fun ded , if at all. Th is is ap pa rent when one examines HSA figures 

fo r cost pe r person served and pro jected cost pe r new st ar t, refer to 

chart s C and D.

We recognize the need to reach more of the 49 millio n med ically 

und erserv ed Americans. We also app rov e of e ffor ts to imp rove ma nagement and increase prod uctiv ity . How ever, we do no t believe th at 

the com munity and m igra nt healt h cen ter model sho uld be dow ngraded th roug h reduction o f services.

Fo ur , we believe th at the definitio n of “m edically underserved 

po pu lat ion ” should be ame nded to allow fo r inclusion of small areas 

or pockets of poverty wi thin a larg er are a no t pre sen tly defined as 

und erserved. Th ere cu rre ntly are a numb er of such are as which do 

no t meet the crite ria fo r des ignatio n as a medically und erserved 

are a, acco rding to regu lati ons.

One are a, fo r example, may hav e a large tea ching hospita l, and 

therefore an “ad equ ate” supply of phy sicians, even tho ug h these 

phy sician s may not be ava ilab le to local residents. Or, in ano the r 

instance, t here may be a numb er of phy sicians, none of whom accept 

med icaid, thus cre ati ng an access ba rri er. Al thou gh thes e areas are 

no t und erserv ed by D H EW definition, significant numbers of the 

popu lat ion m ay no t have access to health care.

As the cu rre nt law speaks to population s and no t areas, we feel 

th at the Congress should spell ou t th at such are as or pock ets no t be 

exclude d, bu t ra th er incl ude d as areas which may ap ply fo r gr an t 

fun din g. We hav e sub mitted recommended lan guage to your staff. ,

Of cours e, priorities and areas of gre ate st need wou ld still be ta rgeted by H EW region al offices.

Fiv e, we believe th at new gr an ts should go to the poo rest medically 

under ser ved are as; whenever possible th at the y may be fun ded 

throug h existing com munity a nd m igrant h ealth centers. Th e gre ate st 

single ba rrie r to access is poverty . A pr iority sho uld be esta blished to 

assu re th at areas of greatest poverty are given precedence . We would 

recommend those med ically und erserved areas with a poverty rate in 

excess of 30 percen t be fu nded first.

Fur th er , where existing comm unity and migrant c enters pro xim ate 

medically underserved areas, pr iorit y should be given to these centers to exp and th ei r service areas. It is logical to utilize their adm in-
113

istrative capacity and expertise to assure tha t new projects develop 

both effectively and efficiently. Further , it would be prudent in view 

of everyone’s concern with reducing administrative costs.

Six, we feel that not less than 5 percent of the funds appropriated 

under sections 330 and 319 should be made available for purposes of 

construction or renovation of facilities. Too many of our facilities are 

less than adequate; some still operate out of trailers. The fact is that 

although money has been appropriated under other programs, little 

has ever reached health centers. Under Hill-B urton, for example, 

hospitals received the lion’s share, and under community development 

corporation or economic development assistance programs, new roads 

and police stations have been priorities.

We are not asking tha t new or refurbished facilities be luxurious, 

• but construction and renovation are necessary for three reasons. One,

inadequate facilities can impair productivity. For example, having 

too few examining rooms impedes physician efficiency, or having 

inadequate laboratory facilities may mean sending tests to other 

laboratories and require an additional patient visit when the test 

results return. Two, community health centers should not appear to 

be “second class” health care if they are to be acceptable to their 

potential patients. This is particularly important as we look at prepaid and voucher models of financing care. And, three, adequate facilities imply a permanence and a commitment to community health 

centers as important parts of the total health care system. Lack of 

permanent facilities has led providers, patients, and the general public to regard community health centers as temporary.

Seven, we feel that health centers should be permitted to use any 

income which exceeds operating costs to generate funds for development. Projects are, and should continue to be, awarded grants based 

on projected reasonable costs, less projected reasonable income from 

State, local, and other funds; fees; premiums; and third party reimbursements. However, projects are well aware tha t any savings 

tha t accrue through efficiency of program administration will be 

offset by a reduced grant in the following year. The present system 

reinforces a “spend it or lose it” mentality, project dependence on 

DHEW, and a feeling of transience.

We recommend that projects be permitted to retain savings they 

generate by either reducing operating costs or increasing reimbursement. In other words, the following year’s grant should not be offset 

w

by the amount of excess income. This retention of a development fund

would be the same as tha t currently permitted HMO’s, and would 

provide additional incentive for efficiency.

Development funds would be restricted to expenditure on one of the 

following, as the project assessed its community’s needs: (A) to increase the number of persons served; (B) to increase the number or 

range of services provided; (C) to improve the quality of services; 

(D) to develop and maintain a reserve fund to be used in offsetting 

underestimates of funding needs for approved project activities, ana 

for purposes of complying with State regulations for prepaid health 

care services; (E) to improve management and operational capabilities, including those related to the maximization of third party reimbursement revenues; (F) to constitute a capital improvements
114

fund as a means of addre ssing the problem of ina dequate fac ilities 

which inhibit prod uctiv ity and acceptance of com munity he alth center s as im po rta nt an d perm anent p ar ts of th e to tal healt h care system.

Mr. C hairm an, the above reco mmendations refe r t o b oth com mun ity 

and m igrant he alt h centers. I would like to tu rn to those concerns 

which affect only the migrant he alt h pro grams.

[Wher eup on, Senator Ja vi ts assumed the chair .]

Se na tor J avits. Dr . Davis, would you sum marize the res t of your 

pr esen tatio n; it w ill a ll go into the record.

Dr. Davis. Al l rig ht. Th en, in terms of sum ma rizing , we are concerned th at the committee br ing abo ut closer prox im ity between authoriza tio n and ap prop ria tio n levels. Senate bill 2474 would increase 

autho riz ati ons fo r fiscal years 1980 to 1983 by 10 perce nt pe r year. 

We th in k th at this is barely enough to offset inf lat ion ary costs, let 

alone exp and prog ram s.

So, wh at we would propose is th at the increase be gre ate r. We 

recommend fo r fiscal ye ar 1980 to fiscal ye ar 1983 an increase of 25 

perce nt each year.

We are sorry th at we hav e gone over ou r time. We would like to 

th an k you f or th is op po rtu nity to s hare thes e feelings.

Se na tor J avits. Than k you very much.

[T he prepared s tatem ent of Dr. Davis follo ws :]
115

NATIONAL ASSOCIATION of

COMMUNITY

HEALTH CENTERS, inc.

I62S “I" Street, N.W. I Suite 420 I Washington. D. C. 20006

(202) 833-928 0

STATEMENT OF 

DANNY K. DAVIS> PHD

NATIONAL ASSOCIATION OF COMMUNITY HEALTH CENTERS 

1625 "I" STREET. NW 

2 0 0 0 6

TO THE

SENATE COMMITTEE ON HUMAN RESOURCES 

SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH

FEBRUARY 9. 1978

RE: S.2A7A HEALTH SERVICES EXTENSION ACT OF 1978
116

Mr. Chairman:

My name is Dr. Dan ny K. Davis, Special A ssi stan t to the President 

of M ile Square Heal th C enter of Chicago, Illinois, and Presiden t of the 

National Associati on o f Comm uni ty Health Centers. I am acc ompa nied today by 

Mr. Jac k Cradock, repr esen ting the Mass achuset ts Leagu e o f Neighbo rhoo d H eal th 

Centers, and Mr. L. Jerome Ashford, Executiv e Dire cto r of the National A ss oc iati on of Community Health Centers.

On behalf of the National Assoc iat ion of Comm uni ty Health Cente rs 

and the thousands of medic all y unser ved and u nde rse rve d fami lies w ho benefit 

from these programs, I want to thank you and the m embers of the Subco mmit tee 

for this opp ortunity to share with you ou r views on Senate bill S.2474.

We share your concern, Mr. Chairman, for this nation 's unse rve d and 

unde rse rve d and commen d yo u on your effort to tra nslate this mutua lly shared 

con cer n into effective legislation.

The mem ber shi p of our Associ ati on is re pres ent ati ve of the d iver se 

commun ity and migran t health center model s d esi gne d to me et the health service 

needs of America's medi cal ly u nse rved and und ers erv ed populations . Thro ugh 

their representatives, these orga nizatio ns have h ad the opport uni ty to review 

S.2474.

I would like to take thi s oppo rtu nit y to submit to yo u our ass essmen t of the merit s and deficiencies of the prop osed legis lation, as well as 

some recomm endations r ega rding broader h ealt h-r ela ted issues.

-1-
117

RF.CChWENLlATIONS

I. That Community Health Center and Migrant Health Programs be extended fo r a

fi ve year pe rio d, through fi sc al year 1983 (r ef er to Sections 330(g)(1),

1

(g )(2) , and Sections 319(h)(1), (h )(2) , and (h )(3) .

We who leheartedly support your recent flo or statement th at, "the 

he alth ce nt er programs have now reached a po int where Congress should pr ovid e an expre ssion of its confide nce and re fl e ct th is in a fi ve yea r au th or ­

iz ati on."

Short period au thor izat ions ten d to giv e a sense of tran sien ce to 

the program. More imp ortant, however, is the fa ct th at in the pa st the 

re su lt has been di srup tio ns in program funding as ap prop ria tio ns were delayed 

due to lac k of autho riz ing le gis la ti on. At the ce nt er le vel, i t has made 

planning most d if fi c u lt , and a ll too of te n employees have been dismis sed 

because of un ce rta in or delayed fund ing.

II. That e li g ib il it y fo r gran ts under Sections 330 and 319 be re str ic te d to 

conwiunity-based pr iv at e no n- pr of it orga niza tio ns (r ef er to Section 33 0(c)( 1), 

(d )( 1 ), 1

 and 319 (c )( 1), (d )( 1)1

 and proposed new Sections 330(b) and (h ).2

Community and Migrant Health Cen ters have developed over the la st 

decade as community-controlled ambulatory he alth provide rs with emphasis on 

pre venti on. They have shown themselves to be eff ec tive both in de liv er in g 

services to tho se prev iou sly unserved by tr ad it io n al prov ide rs and in being 

responsive to the unique needs of th eir ta rg et popu latio ns, needs which tr a ­

ditio nal provide rs have not understood or met. Congress enunciated its

1

PL 94-63 as amended by PL 95-83.

2

Proposed in S.2474

-2-
118

support of the co mmu nit y h eal th cen ter mod el when it eliminated Sec tio n 314(e).

S.2474 wea kens this co nmitment to c ommuni ty- bas ed ambula tor y c are by 

per mitting grant s to publ ic general and othe r n on-profit hospitals. We are 

sympathetic t o the nee ds of "co mmu nit y h ospi tals" and agree that many may re quire 

Federal support. However, Sec tio n 330 is an inappropriate mea ns of provi ding 

suppo rt to public ho spitals bec ause Sectio n 3 30 is inte nded to support consu mer 

contro lle d ambulator y c are centers. The re alr ead y e xist num ero us resources 

upo n w hic h public hospitals can draw, such as PHS Act 314(d) and categorical 

progr ams, Conmun ity Development under HUD, Eco nom ic "Development un der HUD and 

Com prehensive E mployment and Tra ini ng Act funds u nd er Labor. Mr. Rog er's bill, 

HR 10553 is propo sing to incr ease the aut hor iza tio n for 314(d) to $300 mill ion 

from the current appro pri ati on of $90 million.

The prop ose d leg islation (refer to Sec tio n 33 0( b) (3),(6)-) wou ld not 

onl y permit funding grantees wh o are not part of the Co mmu nit y H eal th Center 

model, but also wo uld p ermit suc h gr antees to constr uct facilities whil e c om ­

mun ity health cen ters are limi ted to re no vation. One 'wonders if this d is crimination implies a comm itm ent to t he permanenc e o f public hosp itals whi le regarding 

Con munity Health Cen ter s as temporary.

Moreover, pub lic hosp ita ls would me rely be re qui red to ha ve an 

"advis ory bo ard," (refer to Sec tio n 33 0( h) (4),(5)^)which implies no c omm uni ty 

con trol and little c ons ume r input, an issue centr al to Sec tion 330.

III. That the list of m and atory pri mar y servi ces be expanded to i n cl u d e , a . b r o a d

range of p rev ent ive h eal th services and thos e ser vices which el imi nate barriers

to access (refer to Sec tio n 330( b)(l)and 31 9( a) ( 6 ) ) . Further, the Secretary 

shall assure that cen ter s are ade qua tel y f unde d for the p rov isi on of such

servic es .

-3-
Sp ec ifically , the following serv ices should be added to the primary

category:

A. Preventive health services for children and adu lts;

B. Public health serv ices (including nu tri tio n education and soci al 

serv ices);

C. Health education services;

D. Environmental health services as may be appropriate for pa rti cu lar 

centers.

E. Primary mental health ser vices;

F. Outreach serv ices and other services which promote and fa cil it ate 

optimal use of primary hea lth ser vices; and

G. Information on the av ai la bi lity and proper use of health services.

In addition to those serv ices alrea dy defined as primary, the above

services compliment a range of health care and a philosophy which have led 

these programs to thei r succe ssful tra ck record: i. e. acce ssab ility, qu ali ty, 

prevention, and substan tial reductions in co stl y inp atient care.

Mr. Chairman, we would hope th is Committee wi ll take a lead in establishin g a health policy of th is nature , by guaranteeing tha t through these programs a ce rta in minimum of health serv ices wi ll be ava ilable to a ll people.

The serv ices tha t we contend should be mandatory fa ll into three

groupings:

1) Basic medical and dental care ,

2) Preventive services, and

3) Ancillary serv ices which remove ba rriers to access.

I should point out we are not asking tha t a ll serv ices currently defined in the 

law become mandatory. The need for th is kind of policy is evident when one 

examines what has happened to the health center programs rec ently. Grant lev els
120

to on-going programs have in sone cases been reduced and in others not ad jus ted 

to keep up with inc rea sed co sts. This has re su lted in red uctio ns of service 

le ve ls . In the cas e of new programs, Rural and Urban Health In it ia ti v es,s erv ic es 

beyond those which are mandatory, are seldom funded, if at a ll . This is apparen t 

when one examines HSA figu re s fo r co st per person served and pr ojec ted co st per 

new sta rt, (see ch ar ts C and D)

We reco gnize the need to reac h more of the 40 m ill ion medically und erserv ed Americans. We al so approve of eff o rt s to improve management and increase 

pr od uc tiv ity . However, we do not be lieve th at the Community and Migrant Health *

Center model should be downgraded through redu ction of se rv ices .

IV. That the def in it io n of "Med ically Underserved Population " be amended to allow «

fo r inclu sio n of small areas or "pockets of poverty" wi thin a larg er area not 

pr es en tly def ined as underserved, (r ef er to 33 0(b)(3))1

There cu rren tly are a number of such areas which do not meet the c rit e ria 

fo r de sig natio n as a Medically Underserved Area, according to re gula tions. 3

One ar ea , for example, may have a large tea chi ng hosp it al , and therefor e an 

"adequa te" supply of ph ysicians, even though these physi cians may not be avail ­

able to local re si de nt s. Or, in another instan ce , th er e may be a number of 

ph ysician s, none of which acce pt Medicaid, thu s cr ea tin g an acc ess barr ie r.

Although the se area s are not underserved by DHEW defi nit io n, si gnif ic an t numbers 

gf the population may n ot have access to he al th ca re.

As the cu rre nt law speaks to population s and not ar ea s, we fe el 

Congress should sp ell out th at such are as or pockets not be excluded, but 

ra th er included as areas which may apply fo r gran t funding. We have subm itted

"Med ically Underserved Areas" were determined through a weighted "index of 

medical underservice" which used 4 in di ca to rs :

A) in fa nt m or ta lit y ra te s

B) population to physi cia n ra ti o «

C) % population aged 65 and over

D) % population below p ove rty le ve l

-S-
recommended lang uage to you r staff. Of course, prioritie s and areas o f g re at ­

est need wo uld still be tar geted by HE W reg ional offices.

That new gra nts go to the poorest Med ically Unde rse rve d Areas; wherever possible that they ma y be funded thr ough existing c omn unity and mig ran t hea lth 

centers, (no refe rence)

The greatest single bar rie r to acce ss is poverty. A priority should 

be est abl ish ed to assu re that a reas of grea tes t p overt y are given precedence.

We wo uld rec onmend those Med ically Under ser ved Areas w ith a poverty rate in 

exce ss of 304 be fund ed first.

Further, whe re existi ng co mm unity and mi grant centers pro xim ate m edically underser ved areas, pri ori ty s hould be g ive n t o the se c ent ers to expand 

their service areas. It is logic al to u tilize th eir administra tiv e cap acity 

and e xpe rtise to a ssu re that ne w pr oje cts d eve lop both effec tiv ely and ef fi ­

ciently. Further, it woul d b e pr ude nt in vi ew of eve ryone's c oncer n wi th 

reduci ng admini str ati ve cost.

That not less than 5% of the funds approp ria ted un der Secti ons 330 and 319

be made av ail abl e for pur poses of co nstru cti on or renova tio n of a facility,

(refer to Sec tion 330(c)(1), (d)(2) and Sec tio n 319(c)(1), (d)(2).)

Too ma ny of our fac ilities are less than a dequate, some still o per ate 

out of trailers. The fact is that alt hog h mo ney has been app rop ria ted under 

other programs little has ever r eac hed h eal th centers. Und er Hil l Burton, for 

example, hos pitals rece ived the lions' share a nd und er CDC or ED A pro grams, 

ne w roads and po lic e stati ons have be en prior ities.
122

We are not asking th at new or refurbish ed fa c ili tie s be lux uriou s, 

but constru cti on and renovatio n are neces sary fo r th ree rea son s: 1) Inadequate 

fa c il it ie s can impair pr od uc tiv ity . For example, having too few examining rooms 

impedes physi cia n ef fici en cy , or having inadequate labo ratory fa c il it ie s may 

mean sending te sts to other la bo ra to ries and requ ire an ad ditio na l pat ie nt 

v is it when the te st re su lt s re tu rn ; 2) Community Health Centers should not 

appear to be "second cl as s" he alth care i f the y are to be acc ept able to th eir 

pote ntial pat ie nts . This is part ic ula rl y important as we look at pre pai d and 

voucher modes of fin anc ing ca re ; and 3) Adequate fa c il it ie s imply a permanence *

and a commitment to Community Health Cen ters as important par ts of the to ta l 

he alth care system. Lack of permanent fa c ili tie s has led prov iders, pati ents , 

and the gen era l pu blic to regard Community Health Centers as temporary. *

VII. That he alth ce nt ers be permitte d to use any income which exceeds opera tin g

co sts to generat e funds fo r development, (no references)

Pr oj ec ts are and should con tinue to be awarded gran ts based on 

projected rea son abl e cost s, le ss pr ojec ted rea son able income from sta te , lo ca l, 

othe r funds, fe es , premiums, and th ir d pa rty reimbursements. However, pr oj ec ts 

are well aware th at any savings they accrue throu gh ef fici en cy of program 

ad minist ratio n w il l be off se t by a reduced gran t in the following year. The 

present system re in fo rc es a "spend i t or lose it " men ta lit y, pr oj ec t dependence 

on DHEW, and a fe elin g of tra ns ienc e.

We recommend th at pr oj ec ts be permitted to re ta in savings they 

generat e by eit her reducing opera ting expenses or incre asing reimbursement.

In other words, the follo wing year 's gran t should not be off se t by the amount 

of the exce ss income. This re te nt io n of a development fund would be the same

4
123

as that curr ently permi tte d t tO' s a nd wou ld pr ovi de add itional ince ntive 

for efficiency.

Development funds w oul d be restricte d to e xpe ndi tur e on one of 

the following, as the proj ect a sse sse d its com munity's needs:

a) to increase the num ber of p ers ons served

b) to increase the num ber or range of s ervices provided.

c) to improve the qua lity of services.

d) to deve lop and maintain a rese rve fund to be u sed in offset tin g 

underestimates of f undi ng needs for approved p roj ect a ctivities, 

and for pu rpo ses o f co mpl yin g w it h stat e r egulat ion s for pre pai d 

healt h care services.

e) to improve manage men t and operat ion al capabilities, including 

those relate d to t he max imization o f thi rd par ty re imburs eme nt 

revenues.

f) to constit ute a cap ita l imp rovements fund as a me ans of add ressin g 

the pro ble m of ina dequate facilitie s w hich inhibit prod uctivity 

and ac ceptan ce of Comm uni ty Healt h C ente rs as important and p erman ent parts of the t otal healt h care system.

28-386 0 - 78 - 9
124

Mr. Chairman, the above recommen dations refer to both Commu nity 

and Migr ant H ealth Centers. I w oul d like to turn to those concerns whi ch 

affect onl y the Migr ant He alt h programs.

VIII. That elig ible recipients include those m igr ant and seasonal farmworkers 

who can no longer me et the wo rk re quir ement becau se of age o r d isability

as well as members of their fam ilies. (Refer to S ect ion 31 9( a) (2)(3) ).

Present de fin itions specify that agri cultural workers must m eet 

cer tain r esidence and wor k cri teria in or der to qualif y for services. The 

present definit ion exclu des workers who bec aus e o f age or disabilit y c an no 

longer p erfor m rigor ous agricultural labor, the refore dis qualif yin g them ­

selves and their famil ies from health benefi ts. Mig rant and seasonal far mworkers receive minimal benefits under M edicaid and other third-party 

programs. They are thus par tic ula rly dep end ent o n Section 319 and 330 

pr og ra ms .

IX. That the definitio n o f "h igh jm pa ct area" be cha nged from 6,000 migrant 

and seasonal farmworkers to 4.000 migra nt and seaso nal farmworkers.

(Refer to Sec tion 319(a )(5 )1 ).

At this time, 125 grantees serve migrant and seas onal ag ri ­

cult ural workers in 250 se rvice sites. Ma ny of these servic e sites are 

"pro jects" rat her than "cent ers" b eca use the pre sen t d efini tio n o f "h igh 

impact areas” pre cludes their b ecoming "centers". "Pr ojects" w oul d 

ben efit b y becomi ng "centers" in that they w ou ld be r equ ire d to of fer a 

broad er range o f serv ices and would be govern ed by a consum er- bas ed board. 

Currently, a high impact area is an area whic h has not less than 6,000 

migra tor y and seasonal worke rs. Wit h 967 counti es in the Uni ted States 

wi th migr ant populations, less than 26t pr esently q ualif y as high impact 

ar ea s.

- 9 -
By changing the n umber of work ers neede d to iden tify a n area 

as high impact, a greater numbe r o f areas w ou ld be a ble to qu ali fy to 

pro vid e additional, improved servi ces to the target pop ula tio n through 

mig rant healt h centers. Qui te frankly, our co nce rn is that mig ran ts away 

from home base areas receive more than just emerge ncy care.

That a governing boar d b e manda ted for all Mig ran t Hea lth Centers and

Proj ects w ith no waiv ers perm it te d. (Refer to Sec tion 31 9( c) (2) ,(d )(1) (B)1 ^ ‘

Commu nit y and mig rant health c ente rs hav e d emo nst rat ed that com munity 

boar ds mai ntain sensitivity to cons ume r n eeds, oft en taking into acco unt 

factors frequentl y overloo ked by traditional hea lth pr oviders, i.e. language, 

cultur al attitudes. The activ e involvement of consu mers also enco urages 

the t arget p opula tio n to accept ne w an d inn ovative methods for d eli ver ing 

healt h services. Consum er involvement mo tiv ates users of the centers to

det erm ine for themselves how and when services in t hose c ente rs sho uld be

offered.

In the p revious legislation, up to two-year waiver s w ere all owed 

for pr ogr ams w hi ch the Secret ary deter min ed cou ld not m eet all of the re ­

quirement s and conditions of Sections 330 and 319.

The biggest problem was meeting the gov erning bo ard requirement 

by those traditional agen cies which were reluctant to tra nsfer p olicy ma kin g 

autho rit y to consum er boards. Sin ce that time, gran tees hav e been forced 

into com pli anc e w it h these requirements. As this transitional period has 

passed, w e n o long er see the n eed for such waivers. Acc ordingly, each 

app licant should meet the gov erning b oard re qui rem ent befo re receipt of 

grant funds.
126

XI. That special project author iza tio n be limited to not mor e than 2% of

appropriations. (Refer to Sect ion 319 (e)1 ).

Currently, up to 10% o f the funds appropria ted for o per ating grants m ay be 

use d for contracts in the imp lementation and enf orcement of en vironmental 

health standards. As funds for servi ces are meager, we be lieve that the 

authorization should be reduced to 2i. While it is a wor thwhile activity, 

we be lieve oth er prog rams could assume gre ater respo nsi bil ity in this area 

if they were mo re ade qua tel y funded.

XII. That not m ore than 301 o f the total funds be made availa ble to projects in

non-high-impact areas (Refer to S ection 319( h) (1),(h)(2)1 ) .

*

Wit h respect to ope rating an d plan ning and dev elo pme nt gr an ts , present 

legislation restricts alloc ati on to no n-high -im pac t area s to n ot m ore 

than 25% of the total or 90% of the previous year's grant. The real 

pro blem is a shorta ge of funds. Howe ver, in or der to ma intain the capacit y 

of upstr eam programs, we bel iev e that the alloc ati on should be increased to 

"not more than 30% o f the total funds."

XIII. That not less than 15% shall be used for hos pit ali zat ion 

(Refer to Section 319 (h) (3)1 ).

Hosp ital services, bot h inpatient and out patient is an area which has not 

had adequate funding. In ord er to be effe cti ve in of fer ing comprehensive 

services, inpatient an d out pat ien t hospital services sho uld not be less 

than 15%. We furth er belie ve that current leg isl ati on sho uld specify that 

pri ority should be giv en to areas in whic h those servic es are not currently 

being provided.

4

- 11 -

♦
127

XIV. That the Nati onal Adv iso ry Cou ncil be s trengthened 

(Refer to Section 319(b) (g)1 ^

While we und ers tan d that the National Adv isory Counc il was c reate d to 

adv ise the Sec retary in mat ters regard ing mig rant health centers and 

other entiti es having grants and con tra cts unde r Sec tion 319, we be lieve 

that the following powers and responsib ili tie s should s pec ifi cal ly in ­

clude:

1. to reconmend general policy

2. to revi ew a nd adv ise on federal regulations and 

adm ini strative recommend ati ons rela ting to p ro ­

gra m pol icies and development

3. to rev iew fundi ng allocations to the regions a nd 

basi s thereof

4. to revi ew a nd adv ise federal initiatives whic h 

rela te to ac tivities perfor med un der this Act.

We a lso be lieve all proje cts funded un der this Act shall be adv ise d a nd 

notif ied in wri ting of:

A. a listing o f all adviso ry council membe rs, and

B. cop ies of findings, reports and recomnend ations 

of the Council.

Mr. Chairman, I w ould like t o turn no w from the a bov e reco mmendati ons to our proposed autho riz ati on levels.

XV. That a uthori zat ion levels for fiscal yea r 1979 be set as follow s:

- Com munity Health Centers $366,000 ,000

- Migrant H eal th $ 66, 950,000

and for fiscal year s 1980, 81, 82, and 83, an incr ease o f 254 eac h year -

(See Charts A and B (refer to S ections 330(g)(1), (g)(2), and 319(h)(1), 

(h)(2), and (h)(3)1 -

- 12 -
128

Mr. Chairman, we realize th e co nce rn of this Committee to 

b bri ng about a closer p rox imi ty betwee n a uthori zat ion and appr opr iat ion

levels. S.2474 would increase authorizations for 1979 by 101 per year.

Thi s is bare ly enough to of fset inflatio nary costs, let a lon e e xpand 

the programs. Yo u must recognize we cannot abs orb inc reased costs for 

labor, mal pra cti ce insurance, and supplies. Ma ny he alt h c ent er employees 

are union ize d and the n ew mini mum wage w ill hav e a n impact. Infl ation 

in the amb ulatory he alt h sect or has rema ined at 9-11% in ea ch of the last 

three years. While cente rs hav e been abl e to of fse t some o f this in the 

past, most prog rams are app roaching maxim um efficiency. The opt ion then, 

is to reduce services. I am sure this is not w hat yo u inte nd to h appen

Mr. Chairman, I wis h to e xtend to yo u our s inc ere thanks for yo ur 

support a nd personal lea dership in advan cin g the commu nit y and m igr ant 

hea lth center progra ms. We a re dee ply indebted.

Sho uld you h ave a ny question s, I would be hap py to respond.

- 13 -

*

♦
« ♦ » 4

Recommended Autho rization

Chart At Community Health Centers

I . Support to on-going CHC's

- fi s c a l 78 level of $247,000,000 

a d j u s t e d f o r i n f l a t i o n a t 10%

I I . New Starts

- Add 1,100,000 new pa tie nts at a per ca pita gra nt of $54 through 

200 CHC's or $300,000 average grant

I I I . In it ia ti v e s :

A. CHAP

- would provide 10 new sta rts at $300,000 and an ad ditio na l 150 

pedia tric & nurse pra ctitioner s ta ff fo r centers alre ady at fu ll 

ca pa city. I t would als o permit 

the outreach services cru cial to 

the success of th is program.B. A d o l e s c e n t C a r e

- same as ad ministra tio n request

C. Construction and Renovation

TOTAL

FY 79 FY 80 FY 81 FY 82 FY 83$271 m

$ 60 m

$ 10 m

$ 15 m$ 10 m

$366 m $ 4 5 7 .5 m $5 71 .9 m $ 7 1 4 .9 m $ 8 9 3 .6 m

►—* 8
C h a r t B Rec om m en de d A u t h o r i z a t i o n

M ig r a n t H e a l th P ro g ra m s

\ FY 79 FY 80 FY 81 FY 82 FY 83

I . O n -g o in g s u p p o r t $3 7.9 5 m

- to fu n d th e e x i s t i n g 12 5 g r a n t e e s w ith

10Z fo r in f la tio n .

I I . New S ta rts

- to fund 80 new s t a r t s a t $2 00 ,000 ea ch . To serv e 

an a d d iti o n a l 26 2,29 5 far mwo rk ers a t th e c u rre n t c o st o f $6 1/p ers on.

$16 m

I I I . I n it ia t iv e s o r New Program s $13 in

A. H o sp it a li z a ti o n - $3 m

I t is ou r b e lie f th a t th e p re se n t $3 m ap p ro p ria ti o n 

fo r h o s p ita liz a tio n must be ra is e d to $6 m to o f f e r 

more ad eq ua te s e rv ic e s . P re s e n tl y only 1/ 10 of 1Z of 

th e ta r g e t p o p u la ti o n i s b ein g se rv ed .

B. CHAP - $4 m

Thi s fig u re wou ld pro vid e fo r a d d iti o n a l p e d ia tr ic & 

nurs e p r a c titio n e r s (150 ) wh ich would be re q u ir ed fo r 

c e n te rs alr ead y a t f u l l ca p a c it y in hig h im pa ct are as an d /o r fo r s a t e l l i t e a c t i v i t i e s in ad ja cen t a re a s. ♦ P re s id e n t' s bu dg et im p li es fu nd s a re ta rg e te d fo rCHAP s e rv ic e s . Thi s is not tr u e .

C. A do le sc en t - $2 mThi s fi g u re wou ld p ro vid e co m pr eh en sive h e a lt h se rv ic e s 

fo r ad o le scen ts (p ro je c te d 19 ,5 50 ) e s p e c ia ll y pr eg nan cy , 

v e n e ra l d is e a se , dr ug & alc o h o l abuse , and em otion al d is o rd e rs .

D. D em on st ra tio n - $2 mThi s fi g u re wou ld al lo w fo r th e m ai nt en an ce and ex ­pan si on o f p re p aid p la n s, su ch as th ose c u rre n tl y 

in o p e ra ti o n , El V all e, La redo and E ast C oa st . The 

amount would pro vid e co ve ra ge fo r a t le a s t 10 .80 0 

m ig ra nt w o rk ers /f ara il y members a t $185 p er p ers o n .*

♦ fig u re co mpu tated from FY 76 a t $139 per per so n in f la te d and compounded an n u all y fo r 3 y e a rs .

E. C o n str u cti o n and Ren ov at io n - $2 m

TOTAL $ 66 .9 5 m $ 83 .6 9 m $104 .61 m $130 .76 m $163.45 m

♦ • * 4
♦

CO TO N ITY HEALTH CENTERS CHART C

P R O G R A M A C T I V I T Y

Community Health Centers

FY 74* FY 75* FY 76** FY 77* FY 78(e st)* FY 7 9(p ro j)*

1. Funding Level (BA) (i n m illi o n s ) $ 196.7 $ 196.7 $ 196,648 $ 215.15 $ 247.0 $ 286.0

2. To tal Pro jects 157 204 302 455 574 705

(a) CHCs 157 158 158 158

(b) RHIs(c ) UHIs - 26235 35660 441 106

3. Number o f Persons Served 1,235,000 1,425,000 2,539,160 3,424,000 4,565,000 5,604,059

4. Number o f Encounters 5,600,000 6,555,000 9,984,304 12,612,600 17,376,500 21,640,560

5. To tal Cost Per Person Served $238 $204 $129 $108 $100 $96

6. Grant Funds Per Person Served $159 $138 $ 75 $ 62 $54 $51

7. To tal Funds Ava ila ble - $290,648,000 $327,282,000 $370,944,827 $457,407,407 $539,622,642

(a) Third-P arty(b) Other

$ 62,000,000 $ 93,685,000 $114,992,896 $160,092,592 $194,264,151 - $ 32,000,000 $ 36,949,000 $ 40,803,931 $ 50,314,815 $ 59,358,491

8. Cost Per Encounter (T ota l) - $44.30 $33.00 • $29.40 $26.30 $24.90

9. Cost Per Encounter (Gran t) $35.00 $30.00 $20.00 $17.00 $14.00 $13.00

* Budget J u s ti fi c a tio n -Revised A p ri l 15,"1976 

♦‘ J u s ti fi c a tio n o f Appro priat ion ^ 7 T #
MIGRANT HEALTH P R O G R A M A C T I V I T Y

M ig ra n t H e a lt h CHART D

FY 75* FY 76** FY 77* FY 78(e st)* FY 79 (p ro j. )*

I. Funding Level (BA) m illio n s $23.75 $25.0 $30.0 $34.5 $34.5

2' To tal Pro jects 105 97 125 138 138

3. Number o f Persons Served 390,000 400,000 499,000 557,000 557,000

4. Number o f Encounters 640,000 800,000 998,000 1,114,000 1,114,000

5. To tal Cost Per Person Served $100 $98 $94 $96 $96

6. Grant Funds Per Person Served $ 61 $63# $60 $62 $62

7. To tal Funds A vaila ble $39,000,000 $39,000,000 $47,000,000 $53,000,000 $53,900,000

(a) Th ird Pa rty - $ 3,120,000 $ 3,800,000 $ 4,300,000 $ 4,300,000

8. Cost Per Encounter (T ota l) $61.00 $49.00 $47.00 $48.00 $48.00

9. Cost Per Encounter (Gran t) $37.00 $31.00 $30.00 $31.00 $31.00

t<

* In corr ect fi g ure by HSA

* Budget J u s ti fi c a tio n - Revised A p ri l 15, 1976 

** J u s ti fi c a tio n o f App ro pr iatio n

A
133

Senator J avits. Our next witness is Basilio Romero, executive director of RANCHO, Inc. of Seattle, Wash. And may we ask you, 

Mr. Romero, if you would be kind enough to summarize your statement, and it will all be included in the record.

STATEMENT OF BASILIO F. “TOM” ROMERO, EXECUTIVE DIRECTOR, 

RANCHO, INC., SEATTLE WASH.

Mr. Romero. I will. Thank you, Mr. Chairman. I would like to 

thank you for the opportunity to appear before you today and submit 

this statement. I will summarize this statement, which is a compilation of concerns of several community health organizations located 

throughout the country; farm labor advocates, as well as those tha t

* are part of the coalition of RANCHO.

We are especially grateful to the migrant legal action program, and 

the other agencies, such as Rural America, for their assistance in 

preparing this statement. RANCHO and the farm labor advocates 

greatly appreciate the strong commitment of the subcommittee and 

its chairman fo r the cause of migrant health.

This commitment has led to the creation and maintenance of very 

efficient migrant health centers since the program’s inception in 1962. 

We agree with some of the statements made by Dr. Davis in relation 

to the community-based programs, and so forth. I will not elaborate 

on that. However, I would like to zero in on some of the constraints 

tha t are particular and specific to migrant health; namely, the inadequate, current funding for farmworker health.

The current funding meets between 22 and 28 percent of the health 

needs of farmers, which results in approximately 29 counties in 6 

States, with a 6,000 or more farmworker population, unserved by 

migrant health facilities. Twenty of these counties are also unserved 

by the more urban-oriented community health centers.

Our proposal is tha t full ambulatory care service to the Nation’s 

eligible farmworkers and dependents requires between $65 and $95 

million. Providing adequate hospitalization coverage requires at 

least an additional $60 million. These unmet needs will not likely be 

addressed outside the Migrant Health Act. We urge the subcommittee to accept a figure of $125 million, as a threshold cost for minimal adequate migrant health care, and to adopt that figure as a 

funding goal.

«. It is not unrealistic to augment the m igrant health program in $15

million annual increments for the next 6 years in order to reach tha t 

threshold in health delivery by 1984.

We just heard from HEW when they talked about capacity build-

* ing programs. This is not the case with respect to migrant health as 

it relates to a comprehensive system of health care for farmworkers 

under this act. One of the pressing and most urgent issues in terms 

of migrant health is the continuing HEW attempt to divert scant 

moneys from migrant health programs into a “consolidated” health 

care delivery package as p art of the rural health initiative program.

When we talk about our objection to rural health development, we 

are not talking about the areas outside of the agricultural community. 

We do support, in principle, the theory and the approach of the rural
134

he alt h initiative pro gra m. How ever, we believe th at the problem s of 

migrants are uniq ue to war rant special legi slation.

Presently , the lure o f t he ru ra l health initiative prog ram is enough 

to tempt even the most conscientious admi nistr ator. By pooling 

moneys from variou s small and specialized program s, an ad minist rato r could develop a large, unifiea, and com preh ensive pro gra m. An 

R H I, so the arg um ent goes, can pro vide a gr ea ter va rie ty of services 

to migrants over a more continuous p eriod.

Th e consolidation the ory does not ma tch its rea lity. Draining 

money from a ru ral migrant health proje ct into a sem i-urban healt h 

cente r has many adverse effects. It becomes inaccessible, a bil ing ual 

staff, which has been effective in servin g the farm wo rker, becomes 

dispensa ble. He alth outrea ch efforts, which hav e been so crucial to 

the success of m igrant health pro jects, become costly frill s to the *

sem i-urban center.

We urg e th at H E W mu st not dive rt scarce m igra nt he alt h resources to large com munity healt h enterprises , in a cav alier hope 

a

th at migrants will c ontinue to receive a fa ir sha re of healt h services.

Indeed, the fundam ental prem ise un de rly ing the M igrant He alth 

Ac t of 1962 is “In recognition of the failu re of existing priva te 

he alt h services or Gov ernment pro gra ms to pro vid e adequate health 

service to the N ation ’s m igrant far mw orker.”

An othe r issue th at I would like to zero in on is in resp ect to the 

in pa tie nt hospital needs. We heard fro m H E W th at the y are pr oposing a change in th ei r residency req uir em ent to allow fo r more 

pa rti cipa tio n in med icaid. Well, $3 million, th e cu rre nt m oneys av ail ­

able fo r inpa tie nt care, is ha rdly enough to meet the needs of fa rm ­

workers. The best estim ates th at we have—H E W e stim ates —are th at 

cu rre nt levels de fra y less th an 5 percen t of the migrant hospita liz atio n needs each year. We propo se an increase to at leas t $6 million

An othe r issue which is of gr ea t concern to the migrant healt h center s is the definition of “high impac t are a.” Th is issue, as it rela tes 

to capacit y build ing , as migrant health centers gr ad ua lly expan d 

int o unserved area s, th e 6,000 m igra nt/2 mo nth fund ing formu la 

may become unn ecessarily restric tive. We sug gest, the ref ore , th at 

Congres s delete the form ula and ret ain its principle in the general 

lan guage of subsection (b) (1) . Th is would enable H E W to continue 

fu nd ing those established farm worker healt h fac ilities th at have 

developed efficient cost-effective progra m services, specifically orie nted 

at meeting th e needs of fa rmworke rs. «

F or example, the Un ite d He alth Centers of San Joaq uin Cou nty 

in Orange Grove , C alif., w hich serves a lar ge far mwo rker population 

in Fresno County, has been faced with cutb acks because of the definition al cha nge of m igra nt to seasonal farmw ork er. Th e dem and ♦

fo r services, however, increases or rem ains the same fro m the same 

pop ulation. We believe th at seasonal far mwo rker subjected to the 

same wo rki ng e nvironm ent as a migrant is also faced wi th the same 

ba rri ers to he alt h care.

Th e funds th at were secured by the he alth centers , for exam ple, 

to main tai n the level of services were no t new moneys to be used for 

me eting increased dem and fo r services from the farm wo rke r po pu lation. Th is kind of disru ption prec ludes the dev elopment of a com-
135

prehensive health care fac ility in a planned, orderly, and progressive 

manner.

Mr. Chairman, I would like to also cite the issue of coordination. 

We have heard consolidation, in terms of pooling moneys, but we 

have not heard about consolidating these programs tha t serve farm 

workers which should be par t of a total comprehensive package for 

farm worker health delivery systems. We believe that the reauthorization bill can provide the necessary impetus for interagency cooperation.

The other concern we have is the National Advisory Council on 

Migrant Health—we recommend tha t it be retained and tha t the 

authority and role of the National Advisory Council for Migra nt 

Healt h be expanded. One of the modifications tha t we would like to 

see made is t hat the selection process be changed to assure maximum 

input from migrant health centers.

Mr. Chairman, I want to thank you for being here. In closing, we 

feel th at comprehensive health care is a fundamental righ t of every 

farmworker. Our professional goal for migra nt health is to see tha t 

HEW—BCHS , in particular—and this Nation is f ully committed to 

an integrated comprehensive health care system fo r the more t han 5 

million farmworkers in this country. Thank you very much.

Senator J avits. Thank you very much, Mr. Romero.

[The prep ared statement of Mr. Romero follows:]
136

STATEMENT TO SENATE SUBCOMMITTEE ON HEALTH 

AND SCIENTIFIC RESEARCH

RE: HEALTH SERVICES EXTENSION ACT OF 1978

Mr. Chairman and members of the Subcommittee, 

my name is Basilio F. Tom Romero, Executive Director of 

Rancho, Inc. I would like to thank you for the 

opportunity to appear before you today and submit this 

statement on S.2474, a bill to reauthorize the Migrant 

Health Programs under the statutory authority of 

Title 42 U.S.C. § 247d.

The Regional Associations of non-profit 

Community Health Organizations is a coalition of the 

Northwest Chicano Health, Inc., the California Rural 

Health Federation and the Rio Grande Federation of

Health Centers.

The membership of the three Federations 

total 93 migrant and rural health centers and clinic 

sites which are located throughout the states of 

Washington, Oregon, Idaho, California, Arizona, New 

Mexico and Kansas. They represent health care entitlement 

to the more than 734,835 migrants and 1,451,402 seasonal 

farmworkers that reside in those areas.

We are grateful to Migrant Legal Action Program, Inc., 

for their assistance. MLAP is a Legal Services Corporation 

support center located in Washington, D.C., that provides 

assistance to farmworker clients, client groups, attorneys
137

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and other farmworker representatives located in over 

130 offices in 29 states. They also engage directly in 

litigation or other advocacy on behalf of farmworker 

clients.

Rancho and farm labor advocates greatly 

* appreciate the strong commitment of the Subcommittee and

its Chairman to the cause of migrant health. This 

commitment has led to the creation and maintenance of 

very efficient migrant health centers since the program's 

inception in 1962. Our criticism of the program is its 

inadequate level for meeting the health care needs of 

the more than five million farmworkers in this country.

Presently, less than one-quarter of the health 

needs of farmworkers and their families is met by this

program for eligible population of 700,000 migrants and 

two million seasonal farmworkers and their dependents.

Three examples will suffice. Last year in 

Arizona a migrant suffered a p ermanently broken thumb 

when his migrant status caused a denial of medical 

attention from the county hospital. Last year in central 

California a seasonal farmworker was advised by his 

physician to undergo hospitalization for pneumonia but 

> was denied admission for several days because he was

medically uninsured; he was ultimately admitted under 

threat of a lawsuit. Last year the minor son of a migrant 

worker was denied hospital care for a cardiac problem 'in 

Colorado because of his suspected illegal alien status.

The boy was shipped to Mexico where he died for lack of
138

-3-

prompt medical attention. These three incidents reflect 

problems common to all farmworkers. All three incidents 

occurred in communities having efficient but meager 

migrant health facilities. And all three incidents arose 

from health care gaps generic to the migrant population.

We urge the Subcommittee to consider the 

following in their deliberation regarding the reauthorization 

of the Migrant Health Program:

1. Minimally adequate health care for the 

migrant population requires funding at 

$125 million.

2. A separate program for migrant health. 

Consolidation Means Dilution; require 

that HEW fund programs through Section 319 

only.

3. Support services be an integral part of the 

service delivery mode of a migrant health 

center and that funding be flexible to 

allow for development of alternative 

approaches for providing health care.

4. Coordination among federal agencies that 

provide health care for migrants and their 

families.

5. Increase In-Patient Hospitalization Funds.

6. Definition of High "Migrant Impact". On 

new starts, priority be given to areas 

with the greatest number of migrants.

That established centers that serve farmworkers be able to maintain their level of 

funding from 319 funds in the event their 

"high impact" status is changed. Priority 

funding be given to established migrant health 

centers and community based organizations.

7. Retain the National Advisory Committee on 

migrant health except to modify the selection 

process to assure the migrant health center 

more input in who gets selected.

8. Require that services be comprehensive and 

that they be consistent with the language, 

cultural and ethnic backgrounds of the migrants 

to be served.
139

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1• Minimally adequate health care for the

migrant population requires funding at

$125 million.

This Subcommittee surely appreciates the 

chasm between existing migrant health services and actual 

migrant health needs. By HEW population surveys, over 

1.7 million farmworkers and dependents — two-thirds of 

the farmworker population — remain medically unserved.

The largest farmworker home-base areas 

such as Hidalgo County, Texas, Fresno County, California, 

and Collier County, Florida, continue to be designated

medically underserved areas. Twenty-nine counties in six

*

states each have migrant and seasonal farmworker populations 

exceeding 6,000, and yet are totally unserved by migrant 

health facilities. Twenty of these counties are also 

unserved by the more urban-oriented community health 

cente rs.

Providing full ambulatory health service 

to the nation's farmworkers and dependents requires 

between $65 million and $95 million; providing adequate 

hospitalization coverage requires at least an additional 

$60 million. Thus, current funding reaches from 22 to 

28 per cent of the minimum medical needs of the target 

population.

* California, Florida, Michigan, New Jersey, Oregon and 

Texas.

28-386 0 - 78 - 10
140

-5-

These unmet needs will not likely be addressed 

outside the Migrant Health Act. We urge the Subcommittee 

to accept the figure of $125 million as the threshold 

cost of minimally adequate migrant health care, and to 

adopt that figure as a funding goal. It is not unrealistic 

to augment the Migrant Health Program in $15 million 

annual increments for the next six years in order to 

reach that threshold in health delivery in 1984.

2. Consolidation Means Dil uti on.

The most urgent migrant health issue 

facing this Subcommittee is the continuing HEW attempt 

to divert scant monies from the Migrant Health Program 

into a "consolidated" health care delivery package as 

part of the Rural Health Initiative (RHI) program.

The Rural Health Initiative Program has 

been instituted in HEW by the Bureau of Community Health 

Services by combining various elements of rural health 

care, including migrant health money, into larger 

integrated units. Initial grants for RHI have gone to 

areas of low-population density and high numbers of poor 

or elderly citizens, and low physician-patient ratios.

In fiscal 1977, HEW set aside $4.5 million which Congress 

had appropriated for migant health and instead earmarked 

this money for the Rural Health Initiative Program.

Although only $1 million of this money was used actually 

to fund RHI projects, HEW has set aside another $4.5 

million for migrant health money for RHI projects in fiscal

1978.
141

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The lure of R HI P’s is enough to tempt 

even the most conscientious Administrator: By pooling 

monies from various small specialized programs, an 

Administrator could develop a large, unified and 

comprehensive program. An RHI, so the argument goes,

w can provide a greater variety of services to migrants

over a more continuous period.

The consolidation theory does not match 

its reality. Draining funds from a rural migrant health 

project into a semi-urban health center has many adverse 

effects. The rural health project located next to a 

grocery store in a small town moves 30 miles away to a 

shopping center in a small city and thereby becomes 

virtually inaccessible to migrants. The bilingual staff 

which had been so effective in servicing the farmworker 

population becomes dispensible in the larger semi-urban 

operation. Health outreach efforts which had been so 

crucial to the success of the migrant health project 

become costly frills to the semi-urban center.

These fears are not fanciful. Time and 

again migrant health providers related situations like that

# in one area of the Eastern Seaboard where a migrant

health center and an RHI project operate in the same area.

The RHI tends to ignore community education and bilingual

w

outreach, and instead fosters a pervasive attitude of 

treating local residents first, and migrants second, if

at all.
142

-7-

HEW must not divert scarce migrant health 

resources to larger community health enterprises in the 

cavalier hope that migrants will continue to receive a 

fair share of health services. Indeed, the fundamental 

premise underlying the Migrant Health Act is "In 

recognition of the failure of existing private health 

services or government programs to provide adequate health 

services to the n ati on’s migrant worker."

First, HEW must assure that a fair percentage 

of community health centers under Section 330 are located 

in rural areas. Second, HEW must reverse its direction by 

assuring that rural groups and migrants receive their fair 

share of a myriad of other programs wh ich historically are 

absorbed by urban areas. These programs include Maternity 

and Infant Care, Children and Youth, Family Planning, HUVA 

Community Health Centers, Hypertension, National Health 

Service Corp., and Title I, Migrant Education, and that 

HEW should assure the delivery of some of these resources 

to migrant health in supplement of existing migrant health 

progra ms.

We urge the Subcommittee to preclude HEW

from draining migrant health resources into consolidation

adventures. If such a preclusion is impossible, then at

the very least the following safeguards must be imposed:

(a) that HEW's consolidation plans

be considered "experimental" subject 

to a prudent annual dollar sealing and 

subject to annual reporting to Congress;
143

-8-

(b) that migrant health funds be 

available to an RHI program only

in areas where the migr ant population 

is significant enough that it merits 

service but small enough that no 

separate migrant health facility is 

feasible;

(c) that any RHI program using migrant health 

resources strictly report to HEW on the 

nature and extent of services provided to 

migrants and their dependents; and

(d) that governing boards of such RHI 

programs have migrant representation 

in porportion to the number of 

migrants in the target population 

selected under procedures materially 

similar to those applicable to the 

governing boards of migrant health 

cen ter s.

3. Support Services are Vi ta l.

HEW is reluctant to fund migrant health 

projects for social services outside the direct delivery 

of health care, in order to conserve the scant resources 

available. This reluctance causes problems in many remote 

areas, however, where certain support services are crucial 

to the success of a migrant health project. These services 

include outreach, the transportation of workers to the 

project from labor camps, adequate community education or 

* special provisions for bilingual staff.

HEW's chary approach causes projects to 

hide support service costs in their administrative budgets, 

which itself creates problems in a grant review. We urge 

Congress to make it clear that a budgetary item for support
144

-9-

services must be funded by HEW to the extent that any such 

service is necessary to provide effective health care 

delivery to the target population, and must be weighed on 

its merits with respect to any grant proposal.

4. Coordination Among Federal Age nci es.

Federal agencies having money available for 

farmworker health frequently lack cooperation. Several 

programs invite integration into migrant health, such as 

the Women, Infants and Children Feeding Program (WIC, 

Department of A gricult ure) ; the Pre-Screening and Record 

Transfer System under Title I of the Migra nt Education 

Program (HEW); health money under the Comprehensive Employment and Training Act (Department of La bor ); and money 

for rural transportation (Department of Tran spor tati on).

These programs offer financial resources 

which have not been used. For .example, some $450 million 

earmarked for rural transportation exists within the 

Department of Transportation; although this fund goes to 

capital purchases rather than operating expenses, it could 

underwrite the cost of a modest migrant transportation system 

for many health projects. A National Record Transfer 

System already is in place under the Migran t Education 

Program, whereby a child’s school records are stored on a 

central computer and are easily available to any school
145

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in which the migrant child is subsequently placed.

Adaptation of this existing network for storage of migrant 

health records must be explored.

Accordingly, the reauthorization bill can 

provide the necessary impetus for inter-agency cooperation.

The bill should require HEW to develop a plan to coordinate 

the activity of each federal agency performing statutory 

function with respect to migrant health, in order to assure 

the maximum level of health care delivery. Coordination 

must include .the Office of Migrant Education, the Office of 

Child Development, the Employment and Training Administration, 

the Food and Nutrition Service, and the Department of 

Transportation, and to submit the plan to Congress within 

eighteen months thereafter.

5. In-Patient Hospitalization N eeds.

HEW currently earmarks about $3 million 

annually to meet the in-patient care needs of the nation's 

farmworker population. HEW understandably does not wish 

to dissipate its scarce resources by underwriting an 

elaborate health care prog ram which diverts monies to 

private hospitals and physicians without adequate cost

controls.

Nonetheless, migrant hospitalization remains 

as a critical unmet need. HEW estimates that current 

levels defray less than 5 per cent of migrant hospitalization 

needs each year.
146

-liFor example, in Northern Santa Barbara 

County, California, farmworkers are deprived of minimal 

health care even though they live in an area having two 

private hospitals and one county hospital. They have 

no health care plan provided through their employment.

Eligibility for Medicaid (called "Medical" in California) is 

unavailable to any household whose head is employed more

than 100 hours during the month — a provision excluding >

virtually all farmworker families during the nine to ten

month season. The county hospital w hich normally provides

services to indigents having no public or private insurance

repeatedly refuses to assist migrant workers because they

are not considered "residents" for whom the county has

a legal obligation of care. Althou gh one of the two private

hospitals had received federal construction funds under

the Hill-Burton Act, it consistently refuses to honor any

obligation under Hill-Burton to provide services to indigents.

The sad upshot is the repeated exclusion of farmworker 

families from adequate hospital care although they reside in 

a medically well-served area.

In Colorado, a farmworker must travel to 

Colorado General Hospital in Denver from any other point *

in the state in order to receive in-patient care. In

Oregon, other hospitals deny care to migrants on the premise #

that the University of Oregon Hospital in the Northwestern 

corner of the state is available to service migrants. Common
147

-12-

medical needs among migrants and their dependents during 

the season include pneumonia, tuberculosis, polio, 

arm and leg injuries and maternity care.

6. Definition of "High Impact Are a".

Subsection (d)(1)(C) provides for funding of 

projects in areas in which not more than 6,000 migratory 

agricultural workers and their families reside for more 

than two months. We agree with this concept especially 

for new starts. We also suggest that this concept is 

sufficiently set forth in Subsection (b)(1) requiring 

funding priorities in "areas in which reside the greatest 

number of migratory agricultural workers and the members 

of their families for the longest period of time." HEW 

should be authorized to fund, if otherwise appropriate, 

a project covering 4,000 migrant workers and dependents 

over a six-month season. Alternatively, HEW should be 

authorized to fund, without restriction, a state-wide 

program having considerable numbers of migrants but who 

are dispersed among numerous small pockets in the state.

As migrant health gradually expands into 

unserved areas, the 6,000 workers/two-mont h funding formula 

may become unnecessarily restrictive. We suggest, therefore, 

that Congress delete the formula and retain its principle 

in the general language of subsection (b)(1). This would 

enable HEW to continue funding those established farmworker 

health facilities that have developed efficient cost
148

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effective program services specifically oriented at 

meeting the needs of migrants.

For example, United Health Centers of San 

Joaquin County, Orange Cove, California which serves a 

large farmworker population in Fresno County, has been 

faced with cutbacks because of the definitional change 

of migrant to seasonal farmworker.

The demand for service, from that same 

population, remains the same and often increases, a 

population whose needs for health care is unchanged 

despite the definitional reclassification.

The funds that the were sec ured by the United

Health Centers to maintain the same level of services 

were not "new" monies to be used for meeting the increased 

demand for services from the farmworker population. This 

kind of disruption precludes the development of a 

comprehensive health care facility in planned, orderly 

and progressive manner.

7. National Advisory Council for Migrant H eal th.

In order to insure accountability and 

responsiveness to farmworkers in this Nation, we recommend 

the retention and expansion of the authority and role of 

the National Advisory Council for Migrant Health (NACMH).
149

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1. Modify the selection process to assure 

maximum input from migrant health centers.

2. NACMH should be recognized as the central 

focal point for dialogue with HEW and 

the farmworker community.

3. NACMH should be provided the necessary 

staff to facilitate an ongoing planning, 

review and oversite capability.

4. NACMH should be provided resources to 

conduct four (4) Regional Meetings per 

year in order to assess the effectiveness 

of H EW ’s efforts on behalf of farmworkers 

in the Health Services.

5. NACMH should provide an independent 

assessment each year of the progress 

of HEW's total effort in farmworker 

health services to the Secretary of DHEW.

6. In order to ensure representation of 

farmworkers throughout the Nation NACMH 

should be composed of active migrant

and seasonal farmworkers from each of the 

ten (10) federal regions selected by 

farmworker-governed health projects within 

each Region, five (5) representatives from 

various health professions and occupational 

areas, and a representative from Migrant 

Division of BCHS and a representative 

from the Secretary.

7. This advisory council should be concerned 

with existing farmworker programs, and 

also be the vehicle for input to any 

National Health Insurance program, as it is 

refined and implemented in the next year

or two.

In closing, we feel that comprehensive health 

care is a fundamental right of every farmworker. Our 

professional goal for migrant health is to see that HEW/BCHS 

and this notion is fully commited to integrated comprehensive 

health care system for the more than five million farmworkers 

in this country.
150

Senator J avits. Our next witness is Dr. James Block of the Genesee 

Hospital in Rochester, N.Y. Would you, Dr. Block, summarize your 

statement within 10 minutes.

STAT EMENT OF JAM ES A. BLOCK, M.D., DIRE CTOR, AMBULATORY

SERVICES DEP ART MEN T, GEN ESEE HOS PITAL, ROCHESTER, N.Y.,

AND DIREC TOR, COMMUNITY HOSPITA L-MEDICAL STA FF SPONSORED PRIMAR Y CARE GROUP PRA CTICE PROGRAM, ROBERT

WOOD JOHNSON FOUNDATION

Dr. Block. I am Dr. James Block. I am director of ambulatory 

services at the Genesee Hospital in Rochester, N.Y., and I am also 

the director of the Community Hospital-Medical Staff sponsored 

primary care group practice program of the Robert Wood Johnson 

Foundation. I am here today to testify as an individual in support 

of the amendment to the Community Health Center Act introduced 

by Senator Javits which would permit the funding of community 

hospitals to establish primary care centers.

I thought tha t the most effective way for me to indicate my support for this amendment would be to share with you the experience 

tha t we have had in Rochester, N.Y., at Genesee Hospital in establishing a primary care center. I would add parenthetically tha t we 

have received support through HE W’s Community Health Centers 

grant to the Rochester Health Network to establish this primary 

care center.

We initiated this effort in 1970, because we were facing problems 

which were similar to those seen throughout the United States. We 

had an increasing demand in our emergency department by patients 

who, in essence, were unable to find physicians in their neighborhood. 

Not only did we find total visits to our emergency department increasing, b ut it was our impression th at the percentage of visits to 

our emergency department by nonemergent patients was also increasing.

We estimated tha t as many as two-thirds of the patients who 

came to our department were nonemergent and were there because 

they were seeking primary care services. In addition, we saw similar 

increases in the outpatient clinic of our hospital. We looked at the 

visit data which these patients generated and we found some very 

interesting figures.

We found tha t those patients who were coming to our emergency 

department three or more times—and we felt tha t this indicated 

they were looking to the department as their source of care—that 

over half of those patients were medicaid recipients. In addition, 

those patients were also using our outpatient clinic. We found, in our 

outpatient clinic, 5,000 patients who were using both the emergency 

department and the outpatient clinic, who had made a total of 25,000 

visits to the hospital.

We also found a very interesting group of patients tha t I would 

mention. One thousand patients who used the emergency department 

and the clinic made a total of 17,000 visits in 1 ye ar; once again the 

majority of these patients were medicaid recipients. I would like to 

qualify that, however, with one very important observation. We
151

found tha t black patients who utilized our emergency department 

three or more times did so regardless of the source of payment for 

their care. What this indicated to us was t hat it was not only the 

low-income patient in our community who was relying on the emergency department as a regular source of medical services.

I would like to speak for a moment about our outpatient clinic. 

It was organized as other traditional outpatient clinics in this country 

are organized. We had 33 different specialty clinics. We had no appointment system, which meant tha t patients normally appeared at 

8 in the morning and might not be seen for several hours, or they 

appeared at 1 in the afternoon and might still be there at 5:30.

Patients did not have their own physician; there was no one coordinating their care. The clinic charge was expensive; the collec-

* tions were abyssmal. The facilities were inadequate, and in the last 

analysis, a system of care had evolved incapable of responding to 

the medical needs or basic dignity of the patient.

We asked ourselves what might be a more appropriate response 

of a hospital to demands for on-going medical care being made upon 

it by low income and other patients in our community who were 

turning to us. At Genesee, we made the decision to close our outpatient clinic entirely. We felt tha t a necessary first step was to rid 

ourselves of the concept. We reminded ourselves that the outpatient 

clinic was the only department within the hospital which was intended 

to serve one socio-economic class. We felt it was inappropriate for 

a hospital to house a service that was defined in this manner.

Having made a decision to close the clinic we decided to establish 

at our hopsital a group practice for the delivery of primary care. The 

objective of the primary care center was to serve all patients, regardless of income, socio-economic status, or race. We wanted to move the 

concept of outpatient care to one of serving all patients in the community in need.

Second, we felt it was critically important to organize the service 

so that we would have success in recruiting and, more importantly, 

retaining excellent physicians. We were well aware of the difficulties 

tha t were inherent in establishing new programs in urban areas; the 

difficulties tha t were reflected primarily in their inability to recruit 

and retain physicians.

Third, w’e wanted to have community involvement in the entire 

process. We worked with organized community groups located near 

» the hospital. They participated with representatives of the hospital

board in planning the transition. They also formed an ongoing advisory board to the group practice, made up of consumers, as well as 

hospital representatives and physicians.

* I would now like to summarize our experience since closing the 

outpatient clinic in 1970. At tha t time the outpatient clinic was 

serving 80 percent medicaid recipients. There were approximately 

25,000 visits a year. Today, our medical group practice consists of 15 

fulltime physicians. We are seeing approximately 100,000 patient 

visits a year. Medicaid patients make up about 45 percent of the 

visits to our medical practice. However, I would emphasize tha t we 

have increased the number of medicaid patients cared for at our 

institution fourfold in the process, and substituted 24-hour, 7-day 

telephone coverage for many former ED or OPD visits.
152

Today our hospital is one of the major providers of care to our 

state’s medicaid patients outside of New York City. I would also 

like to emphasize th at our cost for providing comprehensive primary 

care to medicaid patients is comparable to our community’s private 

sector fee structure.

It is also important to know tha t our primary care center essentially runs as an organized medical group; tha t each patien t has 

his/her own physician; tha t we have an appointment system; tha t 

we have physicians on call 24 hours a da y; tha t we have office hours 

6 days a week; tha t we have evening office hours at least 4 days a 

week.

I would also like to mention two other critical points t hat fall into 

the area of financing. First, we have a prepayment plan which we 

offer in the community, both a Blue Cross plan and a medicaid *

plan, and patients come to the group whose care is financed through 

these plans. Second, one of the problems we have faced in further 

reducing our costs for care has been the result of medicare reim- a

bursement policies which result in the allocation of excessive costs 

to our out-patient activities.

Certain cost accounting requirements and cost allocation requirements of the medicare program make it unnecessarily difficult for 

hospitals to reduce to the lowest level the cost of outpatient care.

If the legislative intent is to enhance the role of hospitals in ths provision of ambulatory care, the existing regulations must be re-evaluated.

Before concluding my remarks, I would like to also mention tha t 

I presently have the honor of directing a national program for the 

Robert Wood Johnson Foundation, directed at establishing primary 

care centers at community hospitals throug hout urban and rural 

areas in the United States. I regret tha t your interest in our past 

achievements at Genesee Hospital coupled with the need for brevity 

have prevented me from sharing with you the importance and excitement of this effort by private philanthropy.

To date, the Robert Wood Johnson Foundation program has 

funded over 45 such hospitals, and we are very pleased with the 

results of tha t program. Many of these hospitals are pursuing the 

same kinds of concerns tha t Senator Jav its reflected in his earlier 

statements; tha t is to say, they also are facing increasing demand 

in thei r emergency departments and are realizing the inadequacies 

of their outpatient clinics, as traditionall y conceived, and of their 

emergency departments to effectively address the problems. #

Three years ago, The Robert Wood Johnson Foundatio n announced 

a national gran t program designed to assist community hospitals and 

thei r medical staffs strengthen the insti tution ’s role in ambulatory 

care by developing primary care group practices. This program was >

designated the community hospital-medical staff sponsored primary 

care group practice program. The announcement followed a 3-year 

examination of the role of community hospitals in ambulatory care 

and an assessment of the impact of pilot hospital-sponsored group 

practices throughout the country.

The Foundation committed $30 million to support as many as 60 

hospital-sponsored group practices. Gran t awards of up to $500,000 

have been made available to each participa ting hospital to offset
153

planning and operating deficits of the new practices over a 4-year 

period. With this level of management, the program has become the 

largest single effort of the foundation to expand public access to primary care.

Nine hundred of the country’s nearly 6,000 community hospitals— 

in all 50 States and the District of Columbia—were invited to submit 

applications that would meet the requirements set forth in the program’s protocol. Almost half of these hospitals formally indicated 

interest in the program, and more than 200 completed applications 

were received, Between March of 1976 through December of 1977, 

42 grants have been awarded to hospitals in 34 States. Total gran t 

awards exceed $20 million. It is expected that additional grants will 

be awarded during 1978, primarily in the remaining 16 States.

In January of this year, 31 of the 42 funded group practice programs (74 percent) were in operation and providing primary care 

services. Resourceful and innovative hospital and medical staff 

leaders have developed practices which vary with regard to location 

relative to the hospital, populations served, organizational structure, 

staff composition, leadership dynamics, and facility design; 13 practices are located within their sponsoring hospitals or in professional 

office buildings on or near the hospital grounds; 14 others are housed 

in satellite locations in communities as far as 25 miles from the hospital. The remaining four operational projects have hospital-based 

facilities and one or more satellites. About half the practices are 

located in metropolitan areas; the remainder are evenly distributed 

between suburban and rural sites. Community economics range from 

middle-to-upper-income neighborhoods to low-income and poverty 

areas.

Senator J avits. Thank you very much, Dr. Block. I am very proud 

tha t a New York hospital in my State is engaged in such innovative 

procedures. Your experience is terribly helpful to what I have proposed. Again, I repeat, as I said to Dr. Davis, we will be scrupulous 

to see tha t this is not at anyone’s expense—the community health 

centers, or anybody else’s—but really operates on its own and is 

simply a methodological way to facilitate what obviously needs to 

be done.

I will not ask you any further questions now, but we will feel 

free, if we choose to, to write to you and, without objection, include 

whatever reply you make for the record.

[The prepared statement of Dr. Block follows:]

*
TESTIMONY BEFORE TIE

SUB-COMMITTEE ON HEALTH AND SC IEN TIF IC RESEARCH OF H E UNITED STATES SENATE

J sr.e s A. B lo c k , M.D.

D ir e c to r , A m bula to ry S e rv ic e s D e p art m e n t, The G enes ee H o s p i ta l ,

R o c h e s te r, New Y or k

an d

S e n io r Pro gra m C o n s u lt a n t an d D ir e c to r , Co mm unity H o s p ita l-M e d ic a l 

S t a f f S p o n so re d P rim a ry C are Group P r a c t i c e P ro gra m o f th e R o b e rt 

hood Jo h n so n F o u n d a ti o n

F e b ru a ry 9 , 1978
155

I ar.i Dr. Jam es Block, Direc tor o f Am bul ato ry Serv ice s at the Gen ese e 

Hospital in Rochester, New York. I also ser ve as a Sen ior Prog ram 

Consult ant to The Robert W ood Jolmso n Fou nda tio n o f Pr inceton , Ne w Je rsey 

and as Director o f the C omm uni ty Hos pit al- Med ica l Sta ff Spo nso red Pri mar y 

Ca re Grou p Pract ice Pr ogram of Ihe Robe rt Wo od John son Foundat ion.

I am her e today to tes tif y as an ind ivid ual in suppor t o f S ena tor 

Javits' amendm ent to the C omm unity Health Cent er A ct w hi ch woul d est abl ish 

hospi tal aff ili ate d pr imary care centers in me dic all y un der scrved areas.

For the p ast seven year s w c at The Gen ese e Hospi tal in R oche ster ,

Ne w Yor k have be en ac tively inv olv ed in the dev elo pme nt of a ho spi tal 

affiliated primary care pract ice desig ned to mee t the ne eds of an ur ban 

medica ll y und erscrve d population. Like m any o the r hospi tal s w e had 

experienced a r apid rise in u tilizat ion of o ur emerge ncy depa rtm ent and 

out patient clinic as patie nts una ble to find family p hys ici ans turned to 

the hospital as their source o f care. Nat ion al data s ubs tan tia te this 

trend. Few er than 10 mil lion e mer gen cy visits w ere report ed by all 

community hospitals in the U nit ed S tate s in 1954, more than 62 mill ion 

in 1975. A large num ber of these visit s are ma de by pat ien ts wi th pro ble ms 

that do n ot fit the con ven tio nal d efi nit ion of a medi cal emerg ency ; to a 

great extent they represent patie nts w ho rely on the eme rge ncy de partme nt 

as the ir " fam ily doctor." Similarly, there has bee n a fou rfo ld ris e in 

the volume of outpatien t visits to comm uni ty hos pit als in the last two 

decades, from 42 mil lio n in 1955 to 180 m illion in 1975. On an aver age 

day, 87,000 people are adm itt ed as inpa tien ts to co mmu nit y hosp ital s, 

wh il e eac h day nearly ha lf a million peo ple c ome to the clinic s and 

eme rge ncy rooms of these hos pit als for trea tment , tests and advice.

28 -38 6 0 - 78 - 11
156

Page 2

Today I w ou ld like to share wi th you the exp eri enc e we ha ve had at 

The Gen esee Hospital in our efforts to improve the care p rovided to patient s 

wh o wer e see kin g care through ou r outpatie nt cli nic s and em erg enc y d epa rtment. In addition to ray wor k in R ocheste r, I hav e als o h ad t he oppo rtunit y 

to a ddress the se probl ems in othe r areas of the c oun try t hro ugh my work 

wi th the R obe rt Woo d Joh nso n Foundation. In 1975 the Fou nda tio n initiated 

a $30 m ill ion nati ona l p rogra m d esigned to st ren gth en the rol e o f c ommu nity 

hospi tal s in ambulat ory car e by devel opi ng aff ili ate d pr imary care group 

practices. Ou r exp eri enc e wi th this pr ogram wil l also be dis cus sed durin g 

my testimony.

I antici pat e submit tin g a more extens ive wr itten statem ent to the 

commi tte e subsequ ent to my testimony.
157

Sen at or J avits. N ow, D r. K err , could we he ar from y ou , an d wo uld 

you be good en ou gh t o bri ef y our s ta te m en t to 10 m inute s.

STATEMENT OF LORIN E. KERR, M.D., M.S.P.H. DIRECTOR, DEPARTMENT OF OCCUPATIONAL HEALTH, UNITED MINE WORKERS OF

AMERICA, AND MEMBER, STEERING COMMITTEE, RURAL

HEALTH COUNCIL OF RURAL AMERICA

D r. K err. I fu lly su pp or t yo ur pr op os al to ex pa nd th e fu ndin g 

av ailable to lo cal comm un ities t hro ugh sec tion 330 an d 319 pr og ra m s, 

an d to exp an d th e ra ng e of pri m ar y su pp lem en tal an d en viro nm en tal 

he al th ser vic es th at can be fu rn ishe d th ro ug h m ig ra nt an d com ­

m un ity hea lth cente rs, an d ot he r co mmun ity -based in stitu tio ns .

I am par ticula rl y ple ase d to see th e special concern s expressed by 

th e spon sors of th is legisla tio n w ith th e prev en tio n of dis eas e an d 

di sa bi lity , an d th e reco gn iti on of th e im po rtan ce of pr ev en tio n as a 

p art of a co mpreh ensiv e co mmun ity he al th servic es pr og ra m . I feel 

stro ng ly th a t an y ex istin g or new na tion al he al th care syste m must 

em ph asize pri ori ty fo r th e comp lete ra ng e of pr ev en tiv e he al th 

me asu res , inc lu di ng occ up ationa l he alth .

W hi le th e co mmun ity he alth ce nt er pr og ra m ha s de m on stra te d its 

effe ctiv ene ss in meetin g th e acute he al th ca re nee ds of peop le in 

med ically un de rserve d areas, th e ex pe rie nce to da te de m on strates at 

leas t th re e m aj or defic iencies. Br iefly , th ey are, (1 ), lim ite d fu ndin g; 

(2) re strict iv e fu ndin g re qu irem en ts; an a, (3) a serio us im ba lanc e in 

th e alloca tio n of fu nd s bet ween ur ba n an d ru ra l med ically under ­

ser ved a reas.

The fu nd s mad e av ailable un der th e co mmun ity an d m ig ra nt 

he al th ce nt er pr og ra m s ha ve been wh olly inad eq ua te, in vie w of th e 

m ag ni tu de an d scope of th e he al th pr og ra m s co nf ro nt in g ou r m ed ­

ically un de rserve d po pu latio n. I st ro ng ly ur ge th at we rec og niz e th e 

ser iou s sh ortcom ings of proc eeding alon g th e lin es of w ha t I wo uld 

ch ar ac terize as a m ed ig ap ap pr oa ch to mee tin g th is society’s he al th 

nee ds, an d be gin to move in th e di re ct io n of ex tend in g a fu ll ra ng e 

of nee ded medica l an d he al th ser vic es to all in di vi du al s wh o ar e 

cu rr en tly exclu de d from ou r he al th ca re service.

As pr es en tly ad ministered, th e co mmun ity he al th ce nt er pr og ra m 

is co nc en tra ted on the p rovision o f a co mpreh ensiv e ra ng e of pri m ar y 

he al th c are servic es, ne glec tin g im port an t su pp lem en tal an d en vi ro nm en tal services. By m an dat in g a prov ision of specified pri m ar y care 

services, m an y sm aller ru ra l co mmun ities have b een de nied access to 

CHC fu nd s because of th ei r in ab ility to prov ide all of th e re qu ire d 

serv ices . T his “a ll or no th in g” ap pr oa ch ha s serio usly re st rict ed th e 

deve lopm en t of c om mun ity he al th ce nters in ru ra l are as.

A dd itio na lly, th e exc lusive foc us on pri m ar y ca re ser vic es ha s 

wo rked to th e real di sa dv an ta ge of m an y ru ra l co mmun ities whose 

serio us hea lth prob lem s are closely lin ke d to in ad eq ua te dome stic 

water , sa nitat io n fa cilit ies, po or ho us ing, a nd m al nu tritio n.

In recent wee ks, increa sing at te nt io n ha s been paid to t he nu mbe rs 

of he al th ce nters wh ich ha ve been deve lop ed in ur ba n an d ru ra l 

are as. I ha ve seen , fo r exam ple, re por ts which sho w th at more th an
158

65 percent of the community health centers financed under the Section 330 program operate in rural areas, leaving the clear impression 

tha t only limited attention has been paid to urban health.

According to a recent report prepared by Rural America, roughly 

75 percent of the comprehensive community health centers, accounting for more than 80 percent of the funds, were located in the cities. 

For example, of the 158 centers funded in 1977, 122 operated in 

urban areas, and 36 centers, or less than one-fourth, were rural. Although rural areas account for roughly 60 percent of the nation’s 

medically underserved population, they receive less than 25 percent 

of the available funding.

Under the community health center program, HE W currently 

spends more than $7.50 for every medically underserved urban resident, but only about $1 for every rural person residing in a medically 

underserved area. Even when the supplemental projects funded under 

the rural health initiative and HURA grants are added, the per 

capita expenditure in rural areas rises to only about $2.25.

In an attempt to rectify the imbalance, HE W recently established 

the rural health initiative program. During fiscal year 1977, more 

than 260 rural health projects were funded under the RH I program. 

However, it is to be kept in mind that these 260 ru ral health projects 

operated on a total budget of less than $23 million, while the 160 or 

so predominately urban community health centers received approximately $185 million.

Finally, I would like to make three specific recommendations and 

additions to the suggestions covered earlier.

(1) To assure a more equitable allocation of existing Federal resources among medically underserved areas, the Secretary of HEW 

should be required to set aside no less than 40 percent of all funds 

appropriated for community health center programs for the development and operation of health centers in rural areas.

(2) In view of the special health needs of migrant and seasonal 

workers, and the limited access many farm workers have to existing 

community health services, authorization and funding for migrant 

health programs should continue to be separate from the section 330 

programs.

(3) In view of the importance of the community health center 

program and the limited hearings surrounding its extension, I would 

urge tha t additional time be scheduled for other public witnesses.

I respectfully request, Senator Javits, that a statement th at I made 

this fall to the National Rural Health Council, as well as three reports 

on rural health tha t have been prepared by Rural America, be appended to my statement and included in the record.

Senator J avits. Without objection, it will be done, Dr. Kerr. And 

may I say to you tha t I am very sympathetic to the problem of 

extending my concept to medically underserved rural areas. I am 

not sure tha t I want to go 40 percent; tha t is a pretty big slice when 

you consider tha t almost 75 percent of all our people live in urban 

surroundings. But, tha t apart, we will study tha t carefully and do 

what needs to be done. I am certainly sympathetic to that.

Dr. K err. I think that would be extremely helpful, Senator Javits.
159

Senator J avits. Now, gentlemen, Senator Hathaway has not returned. I am compelled to recess this hearing momentarily, as I must 

be elsewhere. But I am told by his staff th at you may be excused, and 

we thank you very much, with the understanding that if there are 

any questions, they will be addressed to you in writing and your 

reply and the questions will be incorporated in the record in connection with your testimony, without objection.

[The prepared statement of Dr. K err and additional material subsequently supplied follows:]

*
160

STATEMENT OF LORIN E. KERR, M.D. , M.S.P.H.

BEFORE THE

SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH

UNITED STATES SENATE 

February 9, 1978

I am Dr. Lorin E. Kerr, Director of the Department of 

Occupational Health of the United Mine Workers of America.

I am also a member of the Steering Committee of the Rural 

Health Council of RURAL AMERICA, a national association of 

indiv iduals and organizations active in the health care field 

and particularly concerned with improving healt h conditions in 

our small towns and rural areas and access to health services 

by rural people. I appreciate the Subcommittee's invitation 

to appear here this morning, and to par ticipate in the review 

of community health pr ogra ms provided under the Public Health 

Service Act. As requested, I will confine my remarks this 

morning to the proposed extension of the Comm unity Healt h 

Cent ers program from the perspective of that program's 

effectiveness in address ing the health care needs of our 

rural citizens.

Proposed Extension

In prepari ng for these hearings, I have read with 

interest the proposed amendents to the P ublic Health Service 

Act contained in S. 24-74, and recently introduced by Senators 

Kennedy, Schweiker and other members of this Subcommittee.

I ce rtainly concur wit h the sponsors of this legislation that
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the c ommunity health and migrant heal th programs established 

unde r S ections 350 and 319 respectively of the Act have been 

effective in deli vering needed health services to medic ally 

underserved people. For many people residing in both urban 

and rural "underserved" areas, publicly supported community 

health centers provide the only organized form of critically 

needed health services, and constitute an important part of 

the existing heal th delivery system.

I therefore fully support the proposal to expand the 

funding available to local communities through the Section 

330 and 319 programs, and to expand the range of primary, 

supplemental, and environmental health services w hich can be 

furnished through migrant and community health centers and 

other community-based institutions. I am also p articula rly 

pleased to see the special concerns expressed by the sponsors 

of this legislation for the prevention of illness and disease, 

and the reco gnition of the importance of prevention as a part 

of a comprehensive community health services program. I feel 

strongly that any existing or new national healt h care system 

must emphasize priority for preve ntive community health efforts 

It will certainxy pa y off in the long run, both in terms of a 

heal thier nati on and reduced costs, since preventive services 

are far less expensive and more cost effective than sickness 

services.

Comm unity Health Centers and Rural People

While the Commu nity Health Cent er program has demonstrated

its effe ctiveness in meetin g the acute health care needs of
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people in many m edically underserved areas, I believe that the 

experience to date demon strates at least three major 

deficiencies. These can be summarized as follows: 1) limited 

funding; 2) restrictive funding requirements; and 5) a serious 

imbalance in the allocation of funds b etween urban and rural 

medically underserved areas. Since I believe that these issues 

have particul arly serious consequences for people residing in 

small town and rural America, as well as important national 

implications, I would like to briefly discuss my concerns in 

these areas.

1. Available Resources: As has been pointed out by 

Senator Kennedy in in troducing the Health Services Extension 

Act of 1978, the funds made available under the community and 

migra nt health center programs have been whol ly inadequate in 

view of the magnitude and scope of the health problems 

confronting our medically u nderserved population. As documented 

by the Administration itself, and confirmed by the Subcommittee, 

fewer than 10 percent of the medically un derserved people in 

this natio n are currently being reached through community and 

migrant centers. Even under the most generous proposals 

curr entl y under consideration, including the Subcommittee bill 

S. 2474-, it is estimat ed that community health services would 

be provided to only 12.5 percent of those indivi duals who are 

considered to be medi cally underserved. I s trongly urge that 

we recognize the serious shortcomings of procee ding along the 

lines of what I have characterized as a "Medi-Gap" approach to 

meeting this soc iety’s health needs, and begin to move in the
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direction of ex tending a full range of needed medical and health 

services to all individuals who are currently excluded from our 

heal th care system. The community health center p rogram has 

and can make an important contribution toward meeting those 

needs, but substantially greater resources must be made,available 

than those presently contemplated.

2. Restrictive Fu nd in g: As p resently administered, the 

Comm unity Heal th C enter program has concentrated on the p rovision 

of a co mprehensive range of pr imar y health care services, and 

neglected important supplemental and environmental services.

This has had a critical impact on the allocation of CHC funds 

and the ability of many rural communities to pa rticipate in the 

prog ram or otherwise meet community health needs. In the first 

place, by mandating the provision of specified primary care 

services, which include such requ irements as laboratory and 

radiologic services, transpo rtation services, and preventive 

dent al services, many smaller rural communities have been 

denied access to CHC funds because of their inability to 

provide all of the required services, or because the p rovi sion 

of the full range of such services would be pro hibitively 

expensive or otherwise impractical. This "all or nothing" 

approach has seriously restricted the d evelopment of commun ity 

heal th centers in rural areas.

Additionally, the exclusive focus on prima ry care services 

has worke d to the real disadvan tage of many rural communities 

whose serious health pr oble ms are closely linked to

environmental factors such as in adequate domestic water and
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sanitation facilities, poor housing, and m alnutrition. Existing 

Administ ration policies affecting the funding of community 

health centers has denied many rural cente rs the resources 

necessary to furnish needed supplemental and environmental 

services, even though such services are clearly authorized by 

the Public Healt h Service Act, and were clearly intended by the 

Congress to become integral parts of commu nity health efforts.

3. Funding Alloc ati ons : In recent weeks, increasing 

attention has been paid to the numbers of health centers which 

have been develope d in urban and rural areas. I have seen, 

for example, reports w hic h show that more than 65 percent of 

the community health centers financed under the Secti on 350 

program operate in rural areas, leaving the clear impression 

that only limited attention has been paid to urban health 

needs. The truth, of course, is that the health needs of 

medi cally underserved people, both urban and rural, have been 

neglected, but that if we look at the allocation of funds 

rather than the number of projects, we find that rural areas 

have received only a small proportion of the Section 350 funds, 

although they conta in a disproporti onately large share of the 

medi cally underserved population.

Since its inception, the Community Health Center program 

has been largely geared to the health needs of people residing 

in our large urban centers, and has failed to provid e anything 

close to equitable funding for rural centers. According to a 

recen t report prepared by RURA L AMERICA, INC., a national 

nonprofit organization r epre senting people in small towns and
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rural areas, roughly 75 percent of the comprehensive community 

heal th centers, accounting for more than 80 p ercent of the 

funds, were located in the cities. For example, of the 158 

centers funded in 1977, 122 operated in urban areas, and 36 

centers, or less than one fourth, were rural.

Looked at from another perspective, although rural areas 

account for roughl y 60 percent of the na ti on ’s m edically 

underserved population, they receive less than 25 percent of 

the available funding. Under the Comm unity Heal th Center 

program, HEW currently spends more than $7.50 for every medically 

underser ved urban resident, but only about $1.00 for every 

rural p erson residing in a m edically underserved area. Even 

whe n the supplemental projects funded under the Rural Health 

Initiative and HURA grants are added, the per capita 

expen diture in rural areas rises to only about $2.25.

In an attempt to recti fy the imbalance, and in order to 

address special rural health problems, HEW recently established 

the Rural Heal th Initiative (RHI) program. Duri ng fiscal year 

1977, more than 260 rural health projects were funded unde r the 

RHI program. However, it must be kept in mind that these 260 

rural heal th projects operated on a total budget of less than 

23 million dollars, while the 160 or so pre dominantly urban 

comm unit y health centers received appro ximately 185 m illion 

dollars.

Urban Health Initiative

Before closing, I wanted to comment brie fly on the proposal 

submitted by Senator Javits to establish an urban health 

initiative as a part of S. 24-74. The needs of me dically
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underserved urban areas whic h Senator Javits identifies are 

certainly critical. I am in full agreement with the intent 

of this proposed demonstration program which, as I understand 

it, would provide needed financial assistance to community 

hospitals for the conversion of excess space and facilities 

for the provision of needed primary care services.

I am troubled, however, that the proposed amendent would 

restrict such assistance to urban areas. Many of the health 

problems confronting urban underserved areas, including the «

effective utilization of existing local resources such as 

community hospitals, are equally great in rural areas. In 

rural America, we find a serious shortage of effective primary 

heal th care facilities and other resources, while a number of 

our smaller rural hospitals suffer from unde rutilized capacity 

and/or facilities. The potential for expanding p rima ry care 

services in rural areas throu gh the expanded utilizat ion of 

existing community hospital facilities is significant, and I 

woul d urge this Subcommittee to give consideration to either 

1) expanding the existing proposal to include eligible 

participants in both urban and rural areas, or 2) enacting a 

similar measure with c omparable resources for assistance in 

medi cally underserved rural communities.

♦
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Conclusion

Finally, I would like to make a couple of specific 

recommendations in addition to the suggestions covered earlier.

1. To insure a more equitable allocation of existing 

federal resources among medically underserved areas, consideration 

should be given to requiring the Secretary of H EW to set aside

no less than 40 percent of all funds appropriated for; community 

healt h center programs for the development and opera tion of 

healt h centers in rural areas.

2. In view of the special healt h needs of migrant and 

seasonal farmworkers, and the limited access many farmworkers 

have to existing community health services, authorization and 

funding fo r migrant health programs should continue to be 

separate from the Section 550 programs. However, some mec hanism 

should be established to assure that increases in the funding 

levels for the migrant programs keep pace with increased 

fundin g of community health centers u nder Section 550.

5. In view of the importance of the commu nity health 

center program, and the limited hearings surrounding its extension, 

I would urge that additional time be scheduled for other public 

witness. This would provide the Subcommittee with an oppor tunity 

to un dertake a more detailed review of the operations of these 

commun ity healt h programs, and to hear from additional witnesses 

before a five year extension is adopted.

I have appreciated the o pportunity to appear before you 

today, and hope that my testimony will be useful as you co nsider 

the extens ion of these programs.
168

THE ROAD WE HAVE COME: RURAL HEALTH NEEDS AND NON-RESPONSE * 

by Lorin E. Ke rr, M.D., M.S.P.H. **

F io re ll a H. LaGu ardia in 1944 sta te d with his in im itable vi go r 

"When knowledge is no t ap pli ed , i t ' s wi ck ed ." In the same p re se n ta ti o n 

a t th e Annual Meeting of the American Pu blic Health A ss oc ia tion in New 

York, Mayor LaGuardia went on to say "Peop le have a rig h t to me dical c a re ."

During the same meeting th er e was dis cu ss io n of th e prob lem of 

me dical se rv ic e fo r migrant workers and th e excell ent way in which i t had 

been handled by th e Farm Sec uri ty and War Food A dm in is tr at io ns. The APHA 

al so adopted as i t s o ffic ia l poli cy a landmark re port on Me dical Care in 

a Nationa l He alth Program.

Th is ac ti on pu t APHA sq ua re ly on re co rd in fa vo r of a nati onal 

program which would make avail able fo r a ll peop le of th e United S ta te s 

com plete and ade quate medica l ca re of a ll e s se n ti a l ty pes . I t made i t 

cle ar th a t such an end can be att ain ed on ly by a decentr ali zed bu t fed era ll y 

aide d program ; th a t i t must be su pp or ted by compulsory in su ra nc e plu s 

ta xati on or by ta xati on al on e; and th a t i t should be ad m in iste re d by a 

si ngle public healt h agency a t th e fe d e ra l, s ta te and lo ca l le v els .

Th is ac tion was b u ilt upon the long and oft en is o la te d st ru g g le s to 

so lve th e onerous problem of payin g do ct or and h o sp it al b i l l s . Many of 

th es e invo lved ru ra l groups ban ding to get her in h ealt h co -o per at iv es such 

as the One formed i t Elk C it y , Oklahoma in 1929. While healt h co-ops were

* Pr es en ted at Nationa l Rural Health Conference he ld in co nj un ct io n wi th 

th e Th ird Na tio na l Con ferenc e on Ru ral America, Shoreham -Americana 

H ote l, Was hing ton, D.C., December 5, 1977.

** D ir ecto r, Departmen t of Oc cu pa tio na l H ea lth, Un ited Mine Workers of America.
169

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given impetus by some urban workers they became the mainstay of the 

Farm Se cu rit y Adm inis tration in working with low income farm fa mili es 

throughout the na tio n. Eve ntually th er e was an amalgam of the FSA program 

with the fede ral eff o rt to overcome the unhea lthy plight of migra tory farm 

workers, part ic ula rl y during World War II .

What has happened in the ensuing jea rs? We have stud ied, re po rte d, 

recorded and proved beyond a do ub t-- in fa ct the documentation is tr uly 

mountainous—that very l it t le has changed. The lita ny of death and d is ab il it y 

is ess enti all y the same. The he alth fa c ili tie s are in sh or t supply and the 

same is tru e of a ll types of he alth pe rso nnel. The co sts are astr ono mic al and 

there is no in di ca tio n th at they w ill les sen or lev el off at any po in t in the 

fores eeable fu tu re .

Two yea rs ago at the F ir st Nation al Conference on Rural America 

i t was the con sidered opin ion of the 1500 attend ees th at "Nowhere in the United 

St ates is the need fo r an improved he alth system more pressin g and nowhere 

is i t le ss adequate than in ru ra l America." It was agreed the si tu at io n is 

ge tti ng worse, not b e tt e r, de sp ite the ch eerfu l re po rts of the American Medical 

Assoc iation and some government o ffic ia ls . In the la st 30 years the net 

eff ort s of tardy and miserly government eff o rt s have not improved co nditions 

so much as they have ju st barely pre ven ted them from becoming sca nda lous.

An impressive array of he alth experts at the 1975 Conference de lin ea ted one 

aft er ano ther the nation's ru ra l he alth problems. Today, cond ition s are 

s t i l l the same. For example, in fa nt m or ta lit y ra te s in ru ra l me dic ally 

underserved are as are double and tr ip le the na tio na l norm, ranging in some 

cas es up to 35 and 40 dea ths per thousand liv e b ir th s. Twenty percen t of 

a ll women of ch ild -bea rin g age are ru ra l, but the y account fo r f if ty percen t of 

a ll materna l de ath s. The message of the se figu re s on in fa nt and maternal 

mor talit y is qu ite cle ar- -r u ra l America off er s a more hazardous environment

than urban America.
170

3

Rural re side nt s have a hig her incidence of chr onic cond ition s inc lud ing 

dig es tive, re sp irat ory and ci rc ula to ry he alth problems. They have 22 per cen t 

more ulc ers , 26 perce nt more cases of hyperte nsion , and 29 pe rce nt more 

str ok es than cit y re si de nt s.

Work re la te d death and d is a b il it y in ru ra l communities have long 

co ns tit ut ed a major he alth problem which has only re ce nt ly begun to a tt ra c t

serio us na tio na l at te ntion. S ta ti sti c s fo r seve ral decades have shown th at

♦

tr adit io nal ru ra l occupations such as mining, lumbering and ag ricu lture are

among the most dangerous to working people. Although our system of co llec ting

inform atio n concerning a ll work re la te d in ju ri es is ina dequate , i t is •

part ic ula rl y tru e fo r farm accid en ts and the ef fe cts of pest ic id es on humans.

The m or talit y ra te fo r ru ra l workers is almost double th at of th eir urban 

co un terp arts. Ov erall, our na tio na l rec ord is extremely poor compared to 

other in dust rial iz ed nations of the world.

In other are as of pre venti on 30,000 communities lack a ce nt ra lize d 

sa ni ta ry water system and th is does not inc lud e is ol at ed po pu latio ns ; sewer 

fa c ili tie s are a serio us problem fo r m ill io ns . In West V irgi ni a, 60 perce nt 

of a ll homes have dangerous sewer syste ms. Six ty perce nt or le ss of ru ra l 

ch ild ren are immunized ag ainst communicable di se as es .

One of the most serio us he alth problems confronting the ru ra l poor is 

un de r-nu triti on and hunger. It is est imated th at less than on e-ha lf of the 

26 mill ion Americans who cannot afford an adequate die t are rece ivin g as sistan ce 

through Federal food programs. A majority of the se Americans live in ru ra l

♦

America.
171

4

Briefly, this is the stat us of hea lth in r ural Americ a. In this 

centur y we have managed to reve rse the tra ditional relat ion shi p between urba n 

and rural areas as far as the p ub li c’s heal th is concerned. Today , on 

the basis of most indicators rura l America is far less hea lt hy t han the 

dom inant more urb anized p art of society.

Most of us kno w that the distribution o f heal th res ources and per son nel 

« in rural Ame ric a is as b ad (and in some cases worse) as the di st ribution of

other vit al resources. The qui ckest way to learn w hat is wr ong wit h our heal th 

system in g eneral is to obse rve its particular ma lfunc tio n in r ural areas.

At the heart of the crisis lies the gross mal -di stribution o f phys ici ans 

and other hea lth personnel. Ove ral l the Uni ted States ave rages one doctor 

for every 665 persons. In ur ban com mun iti es the rati o is one doc tor for every 

500 pers ons, whereas in rural America for every 2400 res idents there is o nly 

one physician. Looked at anothe r way, although rou ghly a thir d of our 

nat ional populat ion resides in rural areas, the y are served by o nly 12 perc ent 

of the nati on's doctors, and just 18 p erc ent of the nurses. The shortage 

means hardships for doct ors, as w ell as p ati ents, for rural phy sic ian s must 

work longer hours and see mo re pati ents.

Exp erience indicates that decent m edi cal care can be pro vided wit h one 

doc tor p er thou sand people. There is obv iou sly a short age of docto rs and 

other health personnel, and those we have are dis tri but ed withou t muc h 

regard to need. But this is not a n ew problem.

Fifty years ago C.-E.A. Winslo w, a wi dely acknow led ged h ealth expert, stated 

that state after state was compla ini ng "of a grave lack of medic al ser vice of 

any kind in rural distr ict s." He also n oted t hat there was no att emp t to

28 -3 8 6 0 - 78 - 12
172

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meet th is need with coiranunity gr an ts to physicians who will consent to 

pr ac tice in such region s. Winslow was of the opinion th at money alone was 

not the answer. The solu tio n requ ire d good labo ratory and hosp ital fa c ili tie s 

and the ready av ail ab il it y of co ns ultatio n with ot he r well tr ai ned ph ysicians.

Nearly three generat ion s la te r st ate a ft e r sta te is s t i l l com plaining-- 

but more loudly because the si tu at io n has worsened. Today, i t is estimated 

th at to remedy the doc tor d e fi c it in ru ra l are as would re qu ire over 100 perce nt 

of the U.S. and foreign medical school gra dua tes fo r a fu ll ye ar--a lm ost 

20,000--no t counting dea ths and re tir em en t.

The re al remedy involves much more than lo ca tin g 20,000 ph ysicians-- even 

i f i t could be accomplished--in do ct or -les s ru ra l communities. These problems 

are ma nisfe sta tio ns of sorely needed changes in our enti re na tio na l de liv ery 

system which must be ef fected in the immediate fu tu re . More than 60 yea rs 

ago Congress f ir s t held hearings on na tio na l he alth ins uran ce. It was nearly 

25 years la te r bef ore the next Congressional heari ngs occurre d. Since 1943 

numerous proposals have been introd uced but none achieved passage u nti l 

Medicare and Medicaid were enacted in 1966. Today, th er e is , as you know, a 

wide vari ety ,o f measures again before Congress which bea r the labe l of na tio na l 

he alth insura nce . The major pro posal supp orted by organized lab or and many 

othe r groups is the Kennedy-Corman Health Se cu rit y B il l. This b ill has been 

improved by two se ts of e a rli e r he ari ng s. While i t will assure the payment 

of doctor and ho sp ita l b ill s i t does not resolve the ba sic problems which are 

s t i l l the prevent ion of di se as e, reorga niza tio n of de liv er y of se rv ices and 

fin ancin g. The absence of adequate cost co ntro ls such as con tinuance of the
173

6

fe e-f o r- se rv ic e method of payin g docto rs w il l un do ub tedly pe rm it th e cost of 

me dic al ca re to ris e from i t s curr ent le vel of n earl y 9 perc ent o f th e Gro ss 

Nationa l Prod uct to somewhere aro und 12 to 15 perc ent in a ve ry sh o rt ti m e.

On Oc tob er 18, 1976, in a h is to r ic stat em en t fo ur form er p resid en ts 

of th e American Pu bl ic Hea lth A ss oci at io n de cl ar ed th e ir convic tion th a t on ly 

a nati onal h ealt h se rv ic e act ra th e r th an n a ti o n al h ealt h in su ra nce co uld 

so lv e Am erica 's h ealt h prob lem s. They sta te d :

"We ar e fe arf u l th a t a n ati o n al h ealt h in su ra nc e measure 

w il l be en ac ted in to law th at w il l re pea t th e se ri ous 

m istake s of Medicare and Med icaid, and th a t w il l f a i l to 

ad dr es s the re a lly c r it i c a l is su es confr onti ng th is nati on 

with re sp ect to heal th ca re fo r th e pe op le . All of th e 

many pro po sa ls in trod uc ed in Congress th a t ar e des cr ib ed 

as n ati onal h ealt h in su ra nc e b i ll s are e s s e n ti a ll y fin an c ia l 

mechanisms fo r pr ov id in g gu ar an teed paym ents to th e pro vid er s 

of h ealt h ca re se rv ic es. They conta in v ir tu a lly no pro vis io ns

fo r th e ref orm or a lt e ra tio n of th e American h ealt h ca re

system . I t has become more and more ap par ent, no t on ly to 

h ealt h pro fe ssi o n als and sc hola rs but to much of th e gen er al 

p u b li c, th at th er e ar e fund am ental fla ws in ou r sys tem of 

pr ov id in g h ealt h se rv ic es which must no t be in co rp ora te d in to 

a new h ealt h sy stem ."
174

- ' 7 -

They then pro ceeded to identify the five major prob lem s as follow :

1. Inflation of heal th costs is literall y out of control.

2. Shortages of heal th workers are agg rava ted by giant increases 

in the costs of training.

3. The nearly complete exclusion of the con suming pub lic from 

the d ecisio n making process of health pol ici es wou ld never 

be acceptable in any oth er sphere of Americ an life.

4. The special needs of major segments of the Ame ric an public 

are largely neglected. The se include people in small towns 

and rural areas, ethnic and min ori ty groups and m an y others.

5. Episodic m edic al care for sickness and dise ase is the prim ary 

characteristic of our health system.

The former presidents ended their statement as follows:

"We therefore call upo n Congress to enact leg isla tion to creat e 

a national health service w hic h would be financed thro ugh prog ressiv e 

taxation, provide comprehensive health care with an e mpha sis on 

preventio n and positive healt h promot ion to all pers ons in the United 

States without charge and withou t any form of d isc riminat ion, to be 

controlled by the p ubl ic in local comm unit ies with safe guar ds over 

qualit y and efficienc y of health services del ive ry and expen se, and 

wit h remunerat ion o f provi der s based not on fee-fo r-s erv ice s but 

on adequate salaries, as in all other pu bli c servi ces. "

Two days later APH A at its annual meet ing called for a com nunity- base d 

national health service progr am e mbod ying the rec omm end ati ons of the four 

former presidents.

♦
175

8

Congressman Ronald V. Dellum s on May 4, 1977 in troduce d th e Nat io na l 

Hea lth Ser vi ce Act H.R. 6894. The b i ll is now be ing re vis ed and w il l be 

re -i ntr oduced when Con gress reconv en es a f te r th e f i r s t of th e year. The major 

pro vis io ns of the b i ll as su re th a t a ll re sid en ts of th e United S ta te s w il l 

be in clud ed with ou t ex ce pt io n; a ll h ealt h serv ic es fo r p re v enti on, d ia g n o sis , 

tr ea tm en t and re h a b il it a ti o n w il l be in cl ud ed and th ere w il l be no ch ar ges ;

« and ca re w il l be prov ided pri m ari ly in p u b li cly owned community healt h cente rs

equip ped wi th modern dia gnost ic and tr ea tm en t f a c i l i t i e s .

Spec ia l e ffo rts w il l be made to clo se th e gap betwee n urban and ru ra l 

ar ea s by gi vi ng p rio rit y to the const ru cti o n and sta ffin g of h ealt h cente rs in 

th e sm all towns se rv in g ru ra l comm unities. Improved tr an sp o rta ti o n and 

communication f a c i li t ie s w il l be develop ed to make th e serv ic es of th es e h ealt h 

cente rs e a s il y accessi b le .

Where th e problem is beyond the cap aci ty of th e community healt h cente r 

s t a f f , th e in div id ual w il l be re fe rr e d to a h o sp it al or sp e c ia li z ed cente r 

and i f nece ss ary , to th e s ta f f of th e neare st U niv ers ity Medica l C en te r.

Should th ey be un ab le to ha ndle th e problem the in div id ual w il l be se nt wi th 

a ll tr a n sp o rta ti o n co st s p aid , to th e n ati o n al cen te r th a t is equip ped to 

ha nd le th e co ndit io n. These arrang em en ts as su re th a t th ere w il l be a two way 

flow of pe op le and doct ors betwee n th e community h ealt h cen te rs and th e 

nati o n al sp e c ia li ty cen te rs , such as th e N at io na l In s titu te s o f He alth he re in 

clo se -b y Be the sda. For the f i r s t tim e ru ra l America can be as su re d of th e 

read y a v a ila b ili ty and a c c e s s ib il ity of q u a li ty medica l ca re be cause physi ci an s 

* and oth er heal th workers w il l work to g eth er in group and team m ed ic in e, and

w il l be st im ula te d by th e ir co llea gues to kee p up to date .
176

- 9 -

The Delluras Health Service Act states that all health p ers onn el will 

be salaried. Fee -fo r-service pra cti ce will be elimi nat ed in the nati onal healt h 

service. For those doctors who wish to rema in in p riv ate pra ctice there 

und oub ted ly will be a small part of the popul ati on wil ling to p ay their fees.

Traini ng for the health prof ess ion s will be tuiti on- fre e and graduates 

will serve for several years in u nders erv ed rural areas. Living all owances

and free child care services, as n eede d, will rem ove major barri ers to #

training. Admission p olicies for medi cal schoo ls will favo r n ot onl y those

pre vio usl y u nd errepresented--minorities, women, rural and working class stud ents--

but will draw a considerable por tio n of the student bod y from health workers,

such as, nurses and tec hnicians who alr eady h ave d emonstrated their commitme nt

to improving the health o f people.

The b asic unit of the national hea lth servi ce will be the commun ity 

serv ed by a single heal th center, with a pop ulation v aryi ng con sid era bly 

according to circumstances but usually of 25,000 to 50,000.

The adm inistration will be at each level- -f ed er al , state, local— by a 

Department of Health. Each Dep art men t will be respons ibl e to a govern ing board 

of whi ch two-thirds of the m emb ership will truly repre sen t the peopl e bein g 

serv ed and one-third of the healt h w ork ers provi din g the service. All hea lth 

centers, hospitals and other health faci lities will like wise be govern ed by 

these citizen dom inated boards.

The keystone of the nat ional hea lth service will be the pro motion of 

healt h and p revent ion of d isea se. At every level there will be strong divisions 

of dise ase preven tio n in the health dep artments whic h wil l take all available 

measur es for the prevent ion and control of infectious, non -in fec tious, occupatio nal 

and environmental diseases. Pri ori ty in r esearch w ill be given to p reve ntion.
177

* io -

The national health service will be consumer- ori ent ed rathe r than 

pro vider-oriented. Health wor kers will be expected to h ave the welfare of the 

peo ple they serve as their pri mar y aims. In f act a port ion of the hea lth 

service bill will be devoted to t he pro vis ions necessary to ass ure the observ anc e 

of these hea lth rights.

The exact met hods of financing the nati onal healt h ser vic e are still 

« to be worked out. They will, however, use the princ ipl e of p rogressive taxation,

that is e veryon e's con tribution wi ll be based on abi lit y to pay. Thi s is v ery 

dif ferent from the regres siv e tax ati on of the social sec urity system. The 

social securi ty ceiling on the payrol l tax means that worker s and rural 

people with low incomes will pay a hi ghe r pro portion of t hei r income for 

national health insurance than do h ighly pai d executives.

The n ear ly 9 percent of the Gross Nation al Prod uct (GNP) which we now 

spend for health services in the U.S. is too much for what we get. Muc h of 

it goes for unn ece ssa ry operati ons, unnecessarily hig h incomes of pri vat e 

practi tio ner s and unnec ess ary was te and dupl ication. For 8 pe rce nt of the GNP, 

which is the limit on exp enditures set by the Dellums National Health Ser vice 

Act, a national service w ill assu re the provision of a high quality of gene ral 

services. In addition, it will also ass ure the provi sio n of all the serv ices 

badly neg lected at the p res ent time, such as, dental care, mental heal th and 

servi ces for the chroni cal ly ill and aged.

A half cen tury ago Win slo w p roposed that essenti all y the same 

pro gra m we are dis cussing today w oul d solve the hea lth proble ms he was obser vin g 

in 1926. He anticipated criticism of the pro jec ts for organiz ing the med ica l 

service he outlined. Some he felt woul d be soun d and sig nificant, oth ers

♦

merely super ficial and frivolous. Then he adde d "The h abi t of condemning any
178

ii

attempt at intelligent com munity a cti on by labe lling it as "social ist ic" 

and "bu reaucratic" is for examp le, unw ort hy o f serious m inded men. Some 

thin gs are better d one by the individual, some better b y the state; and 

catchwords will not help us to d ete rmi ne to w hic h class a g ive n act ivity 

belongs."

While it is likely the same cri ticisms will be leveled at the 

Dellums Bill, a national health serv ice is the onl y logical and ration al way »

to solve our count ry's heal th problems. Medica re has alr ead y taught us that

national hea lth insurance, with all the good will in the world, cannot do it.

To h elp is move forward a little fast er in r eso lvi ng the ill hea lth *

of rural America, I propose the for mation of a na tional rura l health orga nization.

There is a need to assi st rural peo ple in t hei r efforts to secure adequate 

rep res entation on all heal th polic y boards.

Of immediate urg ency is the des ignation of rural con sum er represe nta tio n 

on the boards of the Hea lth Syste ms Agenci es (HSA's). The Nation al Hea lth 

Plan ning and Resources Act of 1974 allo ws consum er organi zat ion s to concen tra te 

on one agency in each community. The law req uir es that the members and the 

executive committee of the local Healt h Systems Agency mus t be m ade up of 

"a majori ty- -wh o are cons umers of health care and who are not (nor with in 

the 12 mon ths pre ced ing appointment have been) providers of health car e and 

who are broad ly rep res entative of the social, economic, linguis tic an d racial 

pop ulations, geogra phi c areas of the healt h service area and major pu rch ase rs 

of health care."

This pro vis ion is the hea rt and cen terpiece of the health-care pla nning 

legislation that n umerous con sumer groups and organ ize d labor hav e been fighting 

for in the last 15 years. This is also wha t org ani zed me dic ine has b een

♦
179

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fighting against; this is what they have succeeded in sandbagging or watering 

down many times in order to preserve the status quo. This provision 

established the major battleground where a new people centered health-care 

system is going to take shape. It sets up a sensible and workable structure 

for community planning and community control that can serve as the model and 

nucleus of local administration for the health-care legislation Congress enacts.

The law is not perfect--it needs strengthening. But there is nothing 

more important than for consumer organizations to measure up to the opportunity 

and responsibility they have fought for so hard and so long. They must 

see to it that the consumer seats on the local Health Systems Agency and the 

state Health Planning and Development Agencies are filled by genuine 

consumers who know how to represent their fellow consumers.

A national rural health organization is needed to help bring together 

in a united front the diverse groups identified with and working for the 

development of health service programs meeting the needs of rural consumers.

A national rural health organization should also establish a center for 

the continuous exchange of relevant research, experience and opinion in the 

field of rural health. A national policy for improving the health of rural 

America should be developed by such a group. Other concerns would 

be the presentation of appropriate testimony at federal and state hearings 

on rural health legislation, assistance in the development of demonstration 

rural health projects and assistance in selecting, financing and training 

rural health personnel.

The beginnings of such a national organization identified as the 

American Rural Health Association have occurred in Alabama and will be reported
180

- 13 -

at this me eti ng by Stephen N. Barton, M.D. The Ame ric an Public Heal th 

Ass oci ati on at its recent annual meetin g here in W ash ing ton pass ed a 

policy statement calling for the format ion by APHA of a National Rural 

Healt h Coalition. The statement also calle d for the est abl ish men t of 

a National Cen ter for Rural Health. It is interesting to note that this 

is the first time the 105-year old APH A has mad e such a proposal.

I would strongly urge that we here acknowledge these other acti ons by »

forming a national rural hea lth o rga niz ati on clo sely ass oci ate d wit h Rural 

America.

The immediate task of this organi zat ion will be to seek the adopti on 

and implementation of the pol icy statement and res olu tio ns which emerge from 

this National Rural Health Conference.

To avoid jurisdictional disputes, I woul d fur the r suggest that 

Dr. Barton and APHA be not ified of our action and clos e wor kin g relationships 

be implemented.

In conclusion, I want to r eturn to p reven tio n becaus e it is the crux of 

the action needed to reo rganize the nati on's hea lth care del ivery system. It 

has never come of age becaus e m edi cal care is us ual ly limited to those servi ces 

for which p ayment is made on the arch aic fee-fo r-s erv ice basis. This m eth od 

of paying docto r bills is well suited for epis odic serv ices, like the repa ir 

of a faulty televi sio n set. But onl y when this piece work syste m o f p aying 

docto r b ills is changed can the full force of preven tiv e medicine become 

effective. A new national health care system must emphas ize priority for 

pre ven tiv e community health efforts. It would certa inl y pay off in the long run, 

bo th in terms o f a healthier natio n and red uced costs, since pre ventive serv ices 

are far less expensive and more cost effective tha n sick ness services.

♦
181

- 14 -

We must implement the phil osophy of pre ve ntion which is be st 

express ed by Milton J . Rosenau, M.D., an acclaime d pu blic he al th lead er 

who said in 1913,

"Prev entive medicine dreams of a time when th er e sh al l be 

enough fo r a ll , and every man sh all bear his share of lab or 

in accordance with his a b il it y , and every man sh al l posse ss 

su ff ic ie n t fo r the needs of hi s body and the demands of hea lth. 

These thi ng s he sh al l have as a matter of ju sti c e and not of 

ch ari ty . Preve ntive medicine dreams of a time when th er e sh al l 

be no unnecessary su fferin g and no premature de aths ; when the 

we lfare of the people sh al l be our high es t concern ; when 

humanity and mercy sh al l repl ac e greed and se lf is hness ; and i t 

dreams th at a ll the se things w ill be accom plished thro ugh the 

wisdom of man. Pre ventive medicine dreams of the se th in gs, 

not with the hope th at we, in div id ual ly , may p art ic ip ate in 

them, but with the joy th at we may aid in th e ir coming to tho se 

who w ill live aft e r us. When young men have vi sion the dreams 

of old men w ill come tr u e."
182

FEDERAL RESOURCES

■3 RURAL HEALTH

conrtiwy w t h ce/jte^ s

(p .U R ftt- HERLTh R E (t o K T *i)

1346 Connecticut Avernie NW Washington DC 20036

AUGUST, 19 77

4

♦
183

RURAL HEALTH REPORTS

NUMBER

1

2

3

4

5

6

7

8

9

TITLE

H ealth S ta tu s in Rural Am erica

Community H ealth Cen ters

Rural H ealth I n i t i a t i v e and H ealth 

Und erse rved Rural Areas P ro je c ts

H ealth Program s o f th e Appala chia n 

Reg iona l Comm ission 

H ealth Mainten an ce O rg a n iz a tio n s 

N a tio n al H ealth S erv ic e Corps 

M ig ra nt H ealth Program 

In dia n H ealth S erv ic e

P u b lic F in ancin g o f H ealth S e rv ic e s : 

Med icare and M edic aid

This s e rie s o f ru ra l h e a lt h re p o rts was pre pare d by th e 

s t a f f o f RURAL AMERICA. The p ro je c t was made p o ssib le 

th ro ugh th e assis ta n ce o f th e Ford F oundation, but th e 

Foundatio n sh ould in no way be he ld re s p o n s ib le fo r th e 

view s ex pr es se d in th ese p u b li c a tio n s .

RURAL AMERICA is a n o n p ro fit memb ers hip o rg a n iz a ti o n 

e s ta b li s h e d to se rv e as a str o n g n a ti o n a l vo ic e on 

b e h a lf o f pe op le in sm all tow ns and ru ra l are as. Our 

main go al is to as su re ru ra l pe op le e q u it y in th e 

fo rm u la ti o n and im ple m enta tion o f p u b lic p o li c ie s and 

pr og ra ms. To meet th ese o b je c tiv e s , RURAL AMERICA 

c a rrie s out an a c ti v e program o f a c tio n -o rie n te d 

re se a rc h , te c h n ic a l a s s is ta n c e and tr a in in g , le g is la ­

tiv e in fo rm a ti o n , p u b li c education and ad vo ca cy .

For a d d it io n a l p u b li c a ti o n s and fu r th e r in fo rm a ti o n , 

ple ase c o n ta c t:

RURAL AMERICA

1346 C o n n ecticu t Av enue, N.W. 

W ash in gto n, D.C . 20036
184

Community Health Center Program

History and Program Development

The Community Health Center (CHC) program is an outgrowth 

of earlier efforts by the Office of Economic Opportunity to help 

meet the primary care needs of low income people. Under the 0E0 

Initiated program, Federal funds were utilized to establish 

neighborhood clinics and other types of health centers in both 

urban and rural areas.

During 1972 and 1973, various aspects of the program were 

transferred from 0E0 to HEW. Under Section 330 of the Special 

Health Revenue Sharing Act of 1975,(RL 94-63), the funding operation of neighborhood health centers and other types of compr ehensive health centers were consolidated into the Community Health 

Center program. This program is administered by the HEW Bureau 

of Community Health Services (BCHS). Under the program, grants 

are available to public and nonprofit private organizations provid ­

ing a broad range of health services to the community. Grants cover 

the operating costs of the clinic and the provision of health services. Funds for the acquisition or construction of medical facilities 

are not available through the CHC program.

Community Health Centers emphasize comprehensive health care, 

although the number and scope of services provided varies somewhat

4

♦
185

-2 -

de pend ing upon the he a lth ce n te r. PL 94 -63 re q u ir e s Community 

Health Cen ters to pro vid e prim ary h e a lth se rv ic es such as se rv ic es 

o f physic ia ns and, where fe a s ib le , p h ysic ia n e xte nders ; d ia g n o s ti c 

la b o ra to ry and X-ray s e rv ic e s ; p re ve n ti ve h e a lth and denta l se rvic es;a nd tra n s p o rta tio n and eme rgency med ical s e rv ic e s . In additio n to thes e re q u ir e d s e rv ic e s , many he a lth cente rs als o pro vid e 

or arran ge fo r the p ro v is io n o f su pple m enta l h e a lth se rv ic es such 

as h o s p it a l s e rv ic e s , home he a lth s e rv ic e s , ex tend ed ca re f a c i l i t y

• s e rv ic e s , men tal he a lth s e rv ic e s , denta l s e rv ic e s , v is io n s e rv ic e s , 

a llie d h e a lth s e rv ic e s , pharm ace utica l s e rv ic e s , p u b li c h e a lth 

s e rv ic e s , h e a lth education s e rv ic e s , and o th e rs .

Dur ing th e past few ye ar s a co nce rted e f f o r t has been made 

by the Bureau o f Community Health Serv ic es to improve 

the management c a p a b il it ie s o f com munity he a lth ce n te rs . Ambula to ry h e a lth ca re in fo rm a ti o n sys tem s and uniform cost accounting systems have been de ve lope d. Vigor ou s e ffo r ts are be ing made 

to in cre ase th ir d - p a rty re im burs em ents. A l i s t o f fu ndin g c r it e r ia 

d e a lin g w it h management, p o li c y , fin a n c ia l and q u a l1ty -o f-c a re 

co n siO ra tions has been de ve lope d and 1s used by HEW in making 

fu ndin g d e c is io n s .

Program E xpenditure s

Funds to Ru ral CHCs

* The Ta ble on the fo ll o w in g page In d ic a te s th a t the m aj or p o rtio n o f CHC fund s has gone to compreh en sive he a lth cente rs in urb an
186

-3-

areas. In FY 1973, approximately $191 million went into a total 

of 157 CHCs. Only $36.7 million, or 19.2 percent of these funds 

went into rural health centers. In FY 1974, only $42.6 million, 

or 21.4 percent of CHC funds went into rural projects. For FY 

1977, it is projected that $36.9 million, or only about 17 percent

of the total CHC grant funds will go to ongoing rural comprehensive *

V

health centers. Viewed front) another perspective, there are currently 164 community health centers. One hundred and fifteen, or

seventy percent are urban, and 49 centers, or less than one-th1rd 

2/

are rural. Thus, since Its Inception, the Community Health 

Center program has been predominantly urban.

In an attempt to rectify the imbalance between CHC funds going

into urban and rural health centers, the Bureau of Community Health

Services created the Rural Health Initiative program in 1975. The

Bureau redirected $7.3 million of the Community Health Center funds 

3/

into the RHI in its first year. The RHI program provides operating 

funds for rural health projects. It does not provide funds for 

rural comprehensive health centers. (See following chapter for 

fuller discussion of RHI program.)

1

Z Telephone interviews 

member, Washington, D.C.

with Community Health Center program staff 

March 23, 1977 and April 29, 1977.

-

z Ibid., 7 March 1977. 

-

Z Ibid.
BREAKDOWN OF CHC FUNDING

FISC AL

YEAR

TOTAL CHC

GRANT FUNDS

(M i 1 1 i ons )

URBANCH C's

RURAL

CH C's

RHI

PROJECTS

----------m n r r r r ----------------------

OF FUNDS

RURAL

19 73 $ 1 9 1 .0 1 5 4 .3 3 6 .7 - 1 9.2 X

19 74 1 9 9 .4 1 5 6 .8 4 2 .6 - 2 1 .4

19 75 1 93 .1 1 5 4 .2 3 1 .6 7 .3 2 0 .119 76 1 9 1 .7 1 4 4 .8 2 9 .7 1 7 .2 2 4 .5 i.

197 7 * 2 1 5 .1 1 4 7 .5 3 6 .9 2 4 .7 2 8 .6

TOTAL $ 9 9 0 .3 7 5 7 .6 1 7 7 .5 4 9 .2 2 2 .9

S o u rc e : HEW /Com mun ity H e a lt h C e n te r pro gra m s t a f f in W a s h in g to n , D .C .* T h is y e a r 's f ig u r e s a re p r o j e c t io n s , and in c lu d e a p p ro x im a te ly $6 m ill io n

f o r a new ly c re a te d Urb an H e a lt h I n i t i a t i v e .
188

-5-

CHC Funding Level

The funding level for ongoing community health centers has

remained relatively constant over the past few years. As previously

noted, approximately $191 million went into 157 projects in FY

1973. Grant funds for the Community Health Center program for FY

4/ >

1977 will total approximately $215.1 million. Of this amount, 

it is projected that $24.7 million will go into the RHI program,

and about $6 million will go into a newly created urban health „

5/

initiative. The remaining $184.4 million is grant funds for the 

164 ongoing community health centers. Therefore, despite an apparent 

increase in funding for FY 1977, about $30 million will be put into 

other BCHS efforts, leaving the current traditional community health 

centers at a funding level actually below the FY 1973 level.

Commentary

The Community Health Center program has greatly increased the 

poor's access to health services in many underserved areas. Further, 

the provision of comprehensive health care with an emphasis on 

preventive care has been an extremely beneficial aspect of the program. Studies have shown that many of these projects have succeeded in reducing infant mortality rates, serious illness, and serious 

6/

hospitalization. Unfortunately, limited funding over the past 

several years has prevented this program from expanding to addi-

-

Z I b . d

~ Ibid. ,

6/ Southern Rural Health Conference. Report and RecommendatTQ.nl. 4

Washington, D.C.: National Rural Center, 1976, Page 27.
189

-6-

tional needy communities. Moreover, as previously indicated, the 

urban bias of the CHC program has meant that currently only 49 CHCs, 

or 30 percent, are rural.

Limited funding has also caused financial difficulties for 

some of the ongoing community health centers. Clinic admini strators and planners contacted during the course of this study explained 

that the requirement that comprehensive health care be provided, 

Including, 1n many Instances, financial responsibility for hospital 

and other extended care, 1s extremely costly to the health centers. 

The centers also provide a number of other essential services 

such as transportation, medical outreach, and health education.

The cost of these services is not reimbursable, however, and consequently must be absorbed by the clinics. This particularly 

affects rural centers, since a large segment of rural people do 

not have private health insurance plans. Further, the two major 

public financing programs for health care, Medicare and Medicaid, 

are strongly biased against rural areas. As an overall result, 

budget restrictions have caused many clinics to cut back on the 

range of their services 1n recent years, with preventive care and 

environmental health services often being the first ones eliminated.

A very serious problem for rural community health centers is 

Medicare's restrictions on the reimbursement of services rendered 

by nurse practitioners and other physician extenders. Under the
190

-7-

present law, the services of physician extenders are reimbursable 

under Medicare only if these services are provided under the di rect 

personal supervision of a physician. Almost two-th1rds of the 

rural community health centers have satellite clinics which use 

physician extenders, and Ineligibility for reimbursement for these 

services greatly contributes to their financial difficulties.

Health centers which continue to provide a broad range of services to low-income populations will not be able to meet their 

costs through collections or thtrd-party reimbursements for services. 

Congress is in the process of considering the funding level for 

fiscal year 1978. It ts hoped that they will appropriate a significant increase in funds to allow existing centers to continue to 

provide comprehensive health care and to expand the program into 

additional needy communities.
191

8

BIBLIOGRAPHY

RURAL AMERICA, In c ., Statemen t to the Subcom mittee on Health

o f th e Comm ittee on Ways and Means. U. S. House o f Rep resenta 

tiv e s . Feb ru ary 28 , 1977. (X ero xed).

U. S. Co ng ress. P u b lic Law 94-6 3. Specia l Health

Ac tof_l_97 _5 . J u ly 29, 1975. 94 th Con gr es s, 

197 5.

4

Revenue Shari ng

1st Sess io n,

U. S. De pa rtm en t o f H e a lth , Educa tio n and W elfare . P u b lic Health 

S e rv ic e . Pr om oting Community H e a lt h . 1975. DHEW P u b li c a ti o n 

No. HSA 75 -501 6.

S. De pa rtm en t o f H e a lth , Educa tio n and W elfare . P u b lic Health 

S e rv ic e . Community Health C ente rs . (X ero xed).

So uthe rn Rural Health Con fe re nc e. Re po rt and Recomm endation s. 

W as hing ton, D. C .: N ational Rur al C ente r, 1976.-----------

D avis , Ka ren. "A Decade o f P o li c y De velopme nts in P ro vid in g 

Health Care fo r Low -Income F a m il ie s ." W as hing ton, D. C." 

Bro okings I n s t it u tio n . 197 5. (X ero xe d).

to
192

FEDERAL RES OUR CE S

18 RUR AL HEALTH

RH1 >2 HURA PROJECTS

(RURAL. HEALTH REPORT * 3 i) *

1346 Connecticut Avenue NW Washington DC 20036

AUGUST, 1977
193

RURAL HEALTH REPORTS

NUMBER TITLE

1 Health Status in Rural America

2 Communit y Health Centers

3 Rural Health Initiative and Health 

Underser ved Rural Areas Projects

4 Health Programs of the Appalachian 

Regional Commission

5 Health Maint enance Organizatio ns

6 National Health Service Corps

7 Migrant Health Program

8 Indian Health Service

9 Public Financing of Health Services: 

Medicare and Medicaid

This series of rural health reports was prepared by the 

staff of RURAL AMERICA. The project was made possible 

through the assistance of the Ford Foundation , but the 

Foundation should in no way be held respon sible for the 

views expresse d in these publications.

RURAL AMERICA is a nonpro fit membership organizati on 

establ ished to serve as a strong national voice on 

behalf of people in small towns and rural areas. Our 

main goal is to assure rural people equity in the 

formulation and implem entati on of public policies and 

programs. To meet these objectives, RURAL AMERICA 

carries out an active program of actio n-oriented 

research, technical assis tance and training, legisla ­

tive information, public educat ion and advocacy.

For additional publications and further information, 

please contact:

RURAL AMERICA

1346 Connecticu t Avenue, N.W. 

Washin gton, D.C. 20036
194

Rural Health Initiative

Goals and Specifications

To deal with the acute shortage of rural health services 

and the failure of the Community Health Center program to effectively address this need. In 1975 the Bureau of Community 

Health Services (BCHS) created the Rural Health Initiative (RHI). 

The Rural Health Initiative 1s an administrative effort combining 

existing health resources of HEW to provide grants and technical 

assistance to local nonprofit organizations and groups for the 

development of rural health care delivery systems. Under the 

program, grants are available to nonprofit groups to cover the 

operating costs of community health clinics, satellite clinics 

and other health projects 1n underserved rural areas. The program's grant funds come from the Public Health Service Act, 

Section 330, which is the Community Health Center Program, and 

Section 319, the Migrant Health Program.

Priority has been given to placing projects in those nonmetropolitan areas with the greatest need for health services.

Some of the indicators of need considered 1n project selection 

are high proportion of migrant farmworkers, poor transportation, 

and low physlcian/patient ratios.

All rural health projects provide physicians' services, Including preventive, diagnostic, and therapeutic treatment.
195

-2-

Projects also provide emergency medical services Including transportation, laboratory and x-ray services and linkages for ho spitalization. Nurse practitioners, physician assistants and other 

physician extenders are often employed at the projects.

Health Underserved Rural Areas Program

The Health Underserved Rural Areas (HURA) Program is a project 

grant program for rural health research and demonstration admini ­

stered by BCHS as a key component of the Rural Health Initiative.

«# The program 1s funded under Title XIX (Medicaid) of the Social

Security Act. The purpose of the program is to develop projects 

to provide better health care to the Medicaid eligible population.

Program Expenditures and Growth

RHI/HURA grants up to $200,000 are available to cover the

operating costs of rural health proj ects. Funding 1s available 

for a total of three years, with decreasing amounts for the second 

and third year. Projects are expected to become economically 

self-sufficient within three years.

The Rural Health Initiative program has grown significantly 

since its inception three years ago. In FY 1975, forty-seven 

RHI and nine HURA projects were funded for a total of $10.6 million 

In 1976, $27.2 million was put into 138 RHI and 53 HURA projects. 

The FY 1977 budget 1s approximately $44.7 million, and 1t is estimated that by the end of this fiscal year a total of 353 projects
196

3-

1 /

w ill have been funded under th e pro gram .

A li m it e d number o f pla nnin g and de ve lopm en t gra nts o f up

to $25,0 00 have been made a v a il a b le re c e n tl y to co mmun ities to

aid them in as se ss ing th e ir he a lth ca re needs and deve lo pin g

g ra n t a p p li c a tio n s . A ppro xim ate ly 40 o f th ese g ra nts w ill be

a v a il a b le in FY 1977, w it h th e f i r s t awards sc he du led to be 

2/

made in May.

As a re s u lt o f the g ra n t support now pro vid ed to th e 191 

prim ary ca re p ro je c ts su ppor te d thro ugh th e RHI/HURA prog ra m,

w

459 ru ra l counties w ill re ce iv e health s e rv ic e s . In clu ded

are p a rt s or a ll o f 375 cou n ties designate d as c r it ic a l

h e a lth manpower sh ortage are as; and 180 co u nties having the

h ig h e st in fa n t m o r ta li ty . In a d d it io n , s ix o f th e th ir te e n

high m ig ra nt im pa ct areas in non-SMSAs not p re v io u s ly se rved 

3/

w ill now re ce iv e se rv ic es th ro ugh RHI p ro je c ts .

- U. S. Departm ent o f H e a lth , Edu ca tio n and W elfare , P u b lic 

Health S e rv ic e , "Backgroun d in fo rm a ti o n on th e P u b lic Health 

S erv ic e Ru ral Health I n it ia t iv e fo r Ru ral Health P o lic y Workshop , 

December 15, 19 76 ," 1976, Page 3, (X ero xe d).

2/

—' Te lephone In te rv ie w w it h Rur al Health I n it ia t iv e pro gra m s ta ff 

in W as hing ton, D .C ., March 22 , 1977.

U. S. De partm ent o f H e a lt h , Edu ca tio n and W elfa re , P u b lic 

Health S e rv ic e , "Backgroun d In fo rm a ti o n ," Pages 4 -5 .
197

-4-

Li nkages

Whenever possible, RHI projects are linked to other Public 

Health Service programs. Thus far, approximately half of the 

projects have been staffed by the National Health Service Corps. 

According to HEW officials, referrals and consultation relationships with Community Mental Health Centers have been developed or 

are in the process of being developed in 82 projects. Linkages 

with alcoholism programs have been or are in the process of being 

developed in 51 projects. Additional linkages of BCHS administered 

programs, such as the Migrant Health and Appalachian Regional Programs, are continuing, and linkages with other programs are being 

4/

initiated.

Commentary

The Rural Health Initiative represents a significant effort 

to deal with the crisis in rural health care. Many of the clinics 

established under the RHI program serve rural areas where primary 

health care has not previously been available. But a very large 

number of unde rserved rural areas have not been reached. These 

areas could benefit greatly from the continuation and expansion 

Of this program.

Unfortunately, the RHI is currently in an extremely tenuous 

position, as it is only an administra tive effort with no legislative

-

Z Ibid.
198

-5-

authorization . In addition, there are no administrative funds to 

support the development and expansion of the RHI, and there is 

very little money available for planning grants and technical assistance to needy communities. In an uncertain political environment, 

where efforts to meet urban needs have frequently taken precedence 

over rural needs, the RHI could easily come to an abrupt end.

Another problem is that the diversion of Community Health 

Center and Migrant Program funds for use 1n RHI projects has already 

provoked concern among affected groups. Spokesmen for migrant

farmworker organizations have expressed strong reservations about 

the use of Migrant Health Program funds 1n health projects that 

are not primarily designed to meet the special needs of migrant and 

seasonal farmworkers. (Rural Health Report #7 "The Migrant 

Health Program," discusses this issue in greater detail.)

Still another Issue which has caused considerable concern 

is the RHI program goal of economic self-sufficiency for its pro 

jects. Such Independence may be possible In areas with high income or where many residents are covered by private health insur 

ance or public financing programs, but extremely difficult 1n 

low-income areas where people cannot afford to pay for medical 

care. Since many rural people do not have their own health Insurance or benefit from the Medicare and Medicaid programs, 

the lack of adequate reimbursement mechanisms has made selfsufficiency next to impossible for many RHI projects.
199

-6-

The HEW Bureau of Community Health Services recognizes the

many obstacles to economic self-sufficiency for rural clinics.

According to BCHS staff, the goal of self-sufficiency should not

be interpreted as a strict requirement. They explain that an RHI

project will continue to receive Federal grant support after the

initial three-year period If it is evident that the clinic is using

its funds efficiently to deliver quality health services and is 

5/

making every effort to maximize third-party reimbursements.

Outside of HEW, however, thera is much speculation that continued 

grant support cannot be guaranteed in the absence of legislative 

authori ty.

In order to insure the continuation and strengthening of the 

RHI program, the following recommendations are suggested:

The RHI Program should be legitimized and protected 

through Rural Health Initiative legislation.

Separate funding should be sought for the program, 

with appropriation levels commensurate with the need, 

including adequate funds for planning grants and 

technical assistance.

RHI legislation should specify that RHI/HURA projects 

that fail to achieve economic self-sufficiency after 

three years should continue to receive Federal support 

as long as they are meeting legitimate low income needs.

Michael Samuels, Associate Director of BCHS, "Federal Initiatives 

1n Support of Rural Health," a speech given on April 1, 1S77 at 

the American Medical Association's 30th National Conference on 

Rural Health.
It appears that there already exists considerable Congressional

support for the Rural Health Initiative. In addition, Admini stration officials have expressed interest in the RHI program. Proponents hope that the 95th Congress will initiate legislation to protect this program for rural Americans and that the new Administration will lend support to these efforts.
201

-8 -

BIBLIOGRAPHY

U. S. De partm ent o f H e a lth , Education and W elfare . P u b lic H ealth 

S e rv ic e . B u ild in g a Rural H ealth System. 1976. DHEW P u b li c a ­

tio n No. H'SA 76-1 5028.

U. S. De pa rtm en t o f H e a lth , Education and W elfare . P u b lic Health

S e rv ic e . "Backgroun d In fo rm a ti o n on th e P u b lic Health S erv ic e 

Ru ral Health I n it ia t iv e fo r Rur al Health P o li c y Workshop, 

December 15, 19 76. " 1976. (X er ox ed )

U. S. De pa rtm en t o f H e a lth , Education and W elfare . P u b lic Health 

S e rv ic e . "R epor t on Rur al H ealth I n it ia t iv e A c tiv it ie s 

Dur ing F is c a l Year 1976." (X er ox ed )

U. S. De partm ent o f H e a lth , Educa tion and W elfare . P u b lic Health 

S e rv ic e . "In te g ra te d PHS Ru ral Health P ro je c ts ." 1975. 

(X ero xed)

U. S. De pa rtm en t o f H e a lth , Educa tio n and W elfare . P u b lic Health 

S e rv ic e . Ru ral Health I n it ia t iv e ; Program Guid ance M a te ria l 

fo r RHI/Hlj'R'A' G ra n ts . 1976.

U. S. De partm ent o f H e a lth , Educa tion and W elfare . P u b lic Health 

S e rv ic e . "Backgroun d State m en t on th e HURA Pro gra m ."

1975. (X erox ed )

U. S. De pa rtm en t o f H e a lth , Educa tio n and W elfare . P u b lic Health 

S e rv ic e . "G ra nts : P ro je c t Grants fo r Community H ealth 

S e rv ic e s ." Fed er al R e g is te r 41 (June 11 , 197 6) 114.

U. S. De pa rtm en t of H e a lt h , Educa tio n and W elfare . P u b lic 

Health S e rv ic e . P u b lic Health S erv ic e Rur al Health 

I n it ia t iv e F.Y . 1976 B rie fin q fo r th e P o lic y Bo ard.

T975”. (Xeroxed)--------------- ------------------------ ------------
20 2

Sen at or J avits. Now, th er e ar e tw o mo re wi tne sse s, M r. O ut ca lt 

an d D r. A le do rt. W ou ld you be good en ou gh to st an d by fo r ab ou t 

5 m in ut es ? I am su re Sen at or H at haw ay wi ll be ri g h t bac k. Th e 

he ar in g is recess ed unt il 12 o’clock.

[W he re up on , a bri ef rece ss wa s ta ken .]

Sen at or H ath aw ay. M r. O ut ca lt, wh y do yo u no t go ah ea d? Yo u 

ar e ac co mp an ied by P au l W ri g h t, Jo h n B ar ra ss o, an d Ric h Ro be rts .

STATEMENT OF DOUG OUTCALT, NATIONAL PRES IDEN T, AMERICAN MEDICAL STUDENT ASSOCIATION, AND FOURTH-YEAR

MEDICAL STUDENT, UNIV ERSITY OF ARIZONA, ACCOMPANIED

BY PAUL R. WRIGHT, EXECUTIVE DIRECTOR, AMERICAN MEDICAL STUDENT ASSOCIATION AND AMERICAN MEDICAL STUDENT

ASSOCIATION FOUNDATION; JOHN BARRASSO, TRUSTEE-ATLARGE, AND FOURTH-YEAR MEDICAL STUDENT, GEORGETOWN

SCHOOL OF MEDICINE; AND RICH ROBERTS, NATIONAL HEALTH

SERVICE CORPS SCHOLARSHIP STUDENT, AND SECOND-YEAR

STUDENT, GEORGE WASHINGTON UNIV ERSITY SCHOOL OF

MEDICINE

M r. Outc alt. M r. C ha ir m an , we wo uld lik e to ex pr es s ou r ap ­

pr ec ia tio n fo r th e op po rt un ity to be he re to da y. I t is an ho no r on 

beh al f of A M SA , an d we th an k yo u an d yo ur comm itte e.

I wi ll sk ip th e second p ar ag ra p h , as yo u ha ve al re ad y na med th e 

pe op le wh o ar e ac co m pa ny in g me , an d ju st say th a t my na me is 

D ou g O ut ca lt an d I am a fo urt h-y ea r med ica l st ud en t a t th e U n ive rs ity of A riz on a, cu rr en tly ta k in g a ye ar aw ay fr om med ica l school 

se rv in g as P re si de nt of th e Am er ic an Medi cal S tu den t As so cia tio n.

A M SA is a to ta lly in de pe nd en t, na tio na l or ga ni za tion w ith ov er 

20 ,000 me mb ers a t 128 al lo pa th ic an d os teop athi c med ica l scho ols. 

W e ha ve a lo ng hi st or y of co m m itm en t to im pr ov in g med ica l ed uc atio n, hea lt h ca re ser vic es, an d he al th ca re de liv er y. O ve r th e pa st 

10 ye ar s, we ha ve ru n a va ri et y of field pr og ra m s fo r he al th science 

st ud en ts wh ich ha ve exp ose d mo re th an 10,00 0 yo un g he al th pr of es ­

sion als to in no va tiv e he al th ca re de liv er y sy ste ms an d ch al le ng in g 

op po rt un itie s in un de rs er ve d are as.

M an y of the se st ud en ts ha ve re tu rn ed to the se ar ea s— in A p palach ia , on Am er ican In d ia n re se rv at io ns , in th e in ne r ci ty ne ig hb or ­

ho od s, an d in sm all ru ra l comm un iti es—to es ta bl ish a pe rm an en t 

pr ac tic e.

O ur or ga ni za tio n ha s a hi st or y of su ppo rt fo r th e N at io na l H ea lth 

Se rv ice Cor ps wh ich ex tend s back to th e or ig in al le gi slat io n. M an y 

of ou r pas t me mb ers an d officers ha ve wo rked fo r th e co rp s as p ra cti tione rs an d in ad m in is tr at iv e po sit ion s. W e cu rr en tl y re cr uit yo un g 

ph ys ic ia ns fo r th e N at io na l H ea lt h Se rvice Cor ps , In d ia n H ea lth 

Se rvice , a nd B ur ea u of Medica l Se rvice s th ro ug h th e A M SA F oundati o n ’s ad vo ca cy an d re cr ui tm en t pr og ra m , which is su pp or te d by 

th es e th re e bran ch es of th e Pub lic H ea lth Se rvi ce. W e ha ve , in th e 

pa st , ru n st ud en t pr ec ep to rs hi p pr og ra m s fo r th e N at io na l H ea lth 

Se rv ice Co rps.
203

AMS A remains very supportive of the corps and the National 

Health Service Corps scholarship program. We feel this has been, 

by far, the best attempt by the Government, or anyone else, to address the problem of physician maldistribution. We would like to 

commend those who administer the Corps at the national and local 

levels for their dedication and hard work. We are very committed 

in seeing the National Health Service Corps succeed in providing 

chronically underserved communities with a long term solution to 

their health care needs. I t is with this outlook th at we offer the following observations and suggestions.

At one time, young physicians in training viewed the Public Health 

Service scholarship program as a vehicle for accomplishing their 

goal of providing health care services in underserved areas. Today, 

there is an increasing tendency of physicians in training to view the 

program as a means of financing the ever spiraling costs of a medical education in exchange for a service obligation.

It is slowly ceasing to be an attractive option and becoming, instead, a last resort. This attitude is reflected by a decline last year 

in the number of scholarship applicants. Our perception is t hat the 

reasons for this trend are complex and include the following: (A) 

Lack of clear and regular communications from the Corps to scholarship recipients; (B) Lack of personal and professional growth opportunities, and guidance for seeking them out, for scholarship 

recipients related to their future service experience; (C) Lack of 

preparation for practice in underserved communities; (D) There is 

the uncertainty of eventual assignment as to which service, either 

the National Health Service Corps, Indian Health Service, or Bureau of Medical Services, an obligee will be placed in (E) The possibility of a $1,500 penalty for applying, being accepted, and then 

deciding not to participate in the program; (F) The discrepancy in 

incentive pay between obligated and volunteer Corps physicians; and 

(G) A general feeling of uncertainty about how young physicians 

will be treated by a Government program.

We feel tha t the scholarship program need not be viewed as a 

coercive system. It can be a positive personal and professional growth 

experience in which young physicians will want to participate. We 

suggest tha t once a medical student enters the scholarship program, 

the Corps should begin the process we refer to as acclimation— 

regular communications about the Corps; the types of placement 

mechanisms; available practice models and locations, and other general information, as well as growth experiences to prepare fo r serving.

Field experiences should be provided for all scholarship recipients 

at Corps sites, and training provided on vital nonclinical skills, working with health teams, analysis of community health problems, preventive medicine, patient education, grantsmanship, mobilizing 

resources at the Federal and State levels, working with community 

boards, and dealing with crisis situations.

Anyone not wanting to participate in these experiences should not 

be involved in the scholarship program. Those recipients who discover, through these experiences, tha t they are not suited for this 

type of program and practice challenge should be dropped, with no 

further expense to the Government. Scholarship support should only

28 -38 6 0 - 7 8 - 1 4
20 4

be fo r those ind ivi duals wi lling and incline d to meet th e to tal na tur e 

of the commitmen t.

The se non clin ical ski lls are esse ntia l fo r a successfu l pra ctice in an 

und erserv ed are a, and are no t cu rre ntl y bei ng ta ug ht in medic al 

schools or po stg rad ua te tra in in g pro gra ms . Th e Corps should seize 

the op po rtu ni ty to enha nce its image by pr ov idin g lea rn ing op po rtun ities in thes e are as to med ical stu de nts an d ot he r young ph ys ician s as po ten tial Co rps re cru its.

At the very min imu m, th e Co rps sho uld provide pro fess iona l 

gui dan ce to sch ola rship rec ipient s th ro ug ho ut th ei r tra in in g. Th is 

counsel ing could incl ude how best t o schedule elective ti me and choose 

the mos t ap pr op ria te resi dency pro gra ms , so as to pr ep are oneself 

fo r ru ra l or inne r city prac tice . Not only wou ld th is ap pro ach insure •

the Co rps of pr ac tition ers who are prop erl y pr ep ared to dea l with 

a wid e ran ge of non clin ical prob lem s whi ch hav e a dir ec t effect on 

the qu ali ty of care and desire to rem ain in a ch all engin g pra ctice 

set tin g, bu t it would also doc ume nt the need ed fact th at the prog ram *

believes in bac kin g u p and i nvest ing in its people.

Th ro ug h ou r com munity tech nical assistan ce effo rts, we hav e 

lea rne d th at the re is also cri tic al pr ep ar at or y wor k which sho uld be 

done with com mun ities to pr ep are them fo r rec eiving Corps ph ysicians . We hav e come to resp ect the com mu nit y’s role , as it is often 

the essential ingred ien t to a succes sful exp erience fo r the Corps and 

the yo ung assignee.

I t is im perat ive th at ski lls and kno wle dge be inve sted in this 

grou p so th at the pr ac tit io ne r and com munity com ponents meld into 

an effective wo rki ng force . Com munitie s need to un de rst an d th eir 

resp ons ibil itie s in crea tin g an env ironm ent cond ucive to prac tit ione r 

and health servic e dev elop men t, and to hav e a fee lin g of mov ing 

tow ard self-sufficiency in th e long term . To achie ve this, it will re ­

quire a new com mitmen t by the Corps to ana lyze its field prob lems 

and to develop and main tain an effective field-sup port system fo r its 

pract itio ne rs, th ei r fam ilie s, a nd co mmu nities.

We urg e th at young phy sician s wi th service obl iga tio ns be given 

as much choice as poss ible as to which loca tion and servic e bra nch 

the y will be pr ac tic ing in. We believe th at th e step s tak en th is ye ar 

by the Cor ps, such as the conference fo r sch ola rsh ip rec ipient s and 

th ei r spouses, as con duc ted by the AM S A Fo un da tio n’s advocacy 

pro gra m, sho uld be con tinu ed. They were a need ed, appre cia ted , and 

effectiv e step , no t only in plac eme nt, bu t in imp rov ed com mun icat ion 

betwe en the sch ola rsh ip rec ipient s and the Pu bli c Hea lth Service.

We think th at if give n the op po rtu ni ty to mak e an inform ed de ­

cisio n, young physi cia ns wil l hav e a va rie ty of pref ere nce s whi ch 

s

will include bot h ru ra l and urb an areas, as well as Fe de ral pris ons ,

Pu bli c He alth Ser vice hospi tals, and the In di an Hea lth Service. An 

open system which emph asizes ful l pa rti cipa tio n will hel p sus tain a 

high level of mo tiv ation wi thin the Co rps pro fessional commun ity.

We welcome the inter est wi thin the Co rps in ex pa nd ing int o urban 

area s. Th e need is cle ar and critical. How ever, we would advise cautio n, and str on gly recomme nd a balance in the prog ram be maintai ne d to acco mm odate both ru ra l and ur ba n need s and pr ac tit ione r 

exp ectatio ns.
205

Finally, we would also urge tha t any penalties associated with the 

application process for the scholarship program, along with any 

differences in incentive pay received by Corps physicians who are 

obligees and volunteers, be eliminated. A permanent solution needs 

to be found to the problems created by the new tax status of servicedependent scholarships effective 1980, so tha t scholarship recipients 

at high-tuition schools will not have to borrow’ money to continue 

on the scholarship program.

We would like to conclude by reiterating our strong suppo rt for 

the National Health Service Corps and the scholarship program. 

AN e offer these suggestions in the hope tha t the corps can be viewed 

by young physicians as an o pportun ity for personal and professional 

growth, and by communities as a long-term solution to thei r health 

care needs.

The corps has the o pportun ity to develop a truly innovative, model 

program for practitioners and communities to work togethe r for 

their mutual benefit. AMSA offers its continued assistance in this 

effort. Thank you.

Senator Hathaway. Have you communicated these concerns to 

the corps ?

Mr. Outcalt. Yes; we are in close communication with the corps 

through the advocacy program, which I mentioned before, and have, 

on occasion, expressed these concerns; yes.

Senator Hathaway. What has been thei r response ?

Mr. Wright. The dialog between AMSA and the corps is very 

close, and the corps is making progress on the kinds of things indicated for which they are to be commended. But I think the legislative process needs to be more specific to make sure those kinds of 

needs are met, and not to just depend on the initiative of the administr ators of the NHSC program.

Senator Hathaway. You think we ought to legislate these concerns?

Mr. Wright. I think the legislation should be as specific as possible, leaving little doubt what the inten t of Congress is in meeting 

these kinds of needs.

Senator Hathaway. Thank you very much for expressing these 

concerns, and we will do what we can to incorporate them into the 

pending amendments.

Mr. Outcalt. Thank you.

[The joint prepared statement of Mr. Outcalt, Mr. Wright, Mr. 

Barraso, and Mr. Roberts follows:]
206

AMERICAN MEDICAL STUDENT ASSOCIATION

1171 Tower Road 

Schaumburg, Illinois 60195

STATEMENT OF

DOUG OUTCALT 

NATIONAL PRESIDENT

AMERICAN MEDICAL STUDENT ASSOCIATION

AND

PAUL R. WRIGHT 

EXECUTIVE DIRECTOR 

AMSA AND AMSA FOUNDATION

JOHN BARRASSO 

SENIOR TRUSTEE-AT-LARGE 

AMERICAN MEDICAL STUDENT ASSOCIATION

RICH ROBERTS

FEDERAL LEGISLATIVE AFFAIRS COORDINATOR 

AMERICAN MEDICAL STUDENT ASSOCIATION 

BEFORE THE

SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH 

COMMITTEE ON HUMAN RESOURCES

UNITED STATES SENATE 

THURSDAY, FEBRUARY 9, 1978
207

Mr, chairman, we would lik e to express our ap prec iation fo r the 

op po rtu nity to appear here today. I t is an honor and on be ha lf of AMSA 

we thank you and your committee.

My name is Doug Ou tca lt and I am a fo ur th year medical student at the 

Unive rsity o f Arizona College of Medicine and I'm currently taking a 

year away from school to serve as President of the American Medical 

Student As socia tion. Here with me are : John Barrasso, AMSA Senior 

Trustee-at-Large; Rich Roberts, AMSA Federal Legi slat ive A ffa irs 

Coordinator and National Health Service Corps Scholarship re cip ie nt; 

and Paul Wright, Executive Dire ctor of the American Medical Student 

Assoc iation and the AMSA Foundation.

AMSA is a to ta ll y independent, na tional orga nizatio n with over 20,000 

members at 128 allo path ic and osteopathic medical schools. We have a long 

his to ry o f commitment to improving medical educa tion , health care 

services and health care deliv ery . Over the past ten years we have run 

a variety o f fi e ld programs fo r health science students which have 

exposed more than 10,000 young health professio nals to inno vative health 

care de liv ery systems and challengin g op po rtu nitie s in underserved 

areas. Many o f these students have returned to these areas -- in 

Appalachia, on American Indian rese rvations , in the inn er c it y neighborhoods, 

and in small ru ra l communities — to es ta blish permanent prac tic es .
208

- 2 -

Our orga nization has a hi sto ry o f support fo r the National Health 

Service Corps which extends back to the origin al le g is la ti o n . Many of 

our past members and off ic e rs have worked fo r the Corps as pra ctitioners 

and in ad ministra tiv e po sitio ns . We currently re cru it young physicians 

fo r the National Health Service Corps, Indian Health Service and Bureau 

o f Medical Services through the AMSA Foundation's Advocacy and Recruitment 

Program which is supported by these three branches of the Public Health 

Service. We have in the past run student pre cep torship programs fo r 

the National Health Service Corps.

AMSA remains very supportive of the Corps and the NHSC Scholarship Program. 

We fee l th is has been by fa r the best attempt by the government, or 

anyone else , to address the problem o f physician m ald is trib ution. We 

would lik e to commend those who administe r the Corps at the na tiona l and 

local leve l fo r th e ir dedic ation and hard work. We are very committed 

in seeing the National Health Service Corps succeed in prov iding 

ch ro nic ally underserved communities with a long term so lutio n to th e ir 

health care needs. I t is with th is outloo k that we o ff e r the fo llo win g 

observations and suggestions.

At one tim e, young physicians in train in g viewed the Public Health Service 

(o r NHSC) scholarship program as a vehicle fo r accomplishing th e ir goal 

of prov iding health care services in underserved areas. Today there is 

an inc reas ing tendency fo r physicians in tr ain in g to view the program as
209

3 -

a means of fin an cing the ever spir aling costs o f a medical education in 

exchange fo r a service oblig ation. I t is slo wly ceasing to be an 

a tt ra ctive option and becoming instead a la st re sort. This att itud e 

is re flecte d by a decline la st year in the number of scholarship 

ap plican ts. Our perception is th at the reasons fo r th is trend are complex 

and include the fo llo wing:

A. lack of cle ar and regu lar communications from the Corps to scholarship 

re cip ie nts ;

B. lack of personal and pro fession al growth op po rtu nitie s, and guidance 

fo r seeking them o u t, fo r scholarship re cipient s relate d to th e ir 

fu tu re service experience;

C. lack of pre paration fo r pr ac tic e in an underserved community;

D. there is the un ce rta inty of eventual assignment as to which service 

(NHSC, IHS, BMS) an obligee w il l be placed in ;

E. the p o s s ib ilit y o f a $1,500 penalty fo r ap plyin g, being accepted and 

then deciding not to partic ip ate in the program;

F. The discrepancy in ince ntive pay between ob lig ated and volun teer 

Corps physicians;

G. A general fe elin g o f un ce rta inty about how young phy sicians w il l be 

tre ated by a government program.

We feel th at the scholarship program need not be viewed as a coercive 

system. I t can be a positiv e, personal and pro fes sio nal growth experience 

in which young physicians w il l want to partic ip ate .
210

- 4 -

We suggest th at once a medical student enters the scholarship program the 

Corps should begin the process we re fe r to as acclima tion - regu lar 

communications about the Corps, the types of placement mechanisms, 

av ailable prac tic e models and loca tio ns and othe r general inform ation, 

as well as growth experiences to prepare fo r serving.

Field experiences should be provided fo r a ll scholarship re cipient s 

at Corps sites and tr ain in g provided on v it a l non-c lin ic al s k il ls such 

as settin g up a rura l or inn er c it y pr act ice, working with health teams, 

an aly sis o f community health problems, pre ven tive medicine, pa tie nt 

educa tion , grantsmanship, mob ilizing resources at the fed eral and state 

le vels , working with community boards and dealing with c ris is situations. 

Anyone not wanting to partic ip ate in these experiences should not be 

involved in the scholarship program. Inasmuch, those re cipient s who 

discover through these experiences th at they are not suite d fo r th is type 

of program and prac tic e challenge should be dropped with no fu rt her 

expense to the government. Scholarship support should only be fo r 

those in divid uals w il li n g and in clin ed to meet the to ta l nature of the 

coimi tment.

These non-c lin ic al s k il ls are esse ntial fo r a successful pr ac tic e in an 

underserved area and are not currently being taught in medical schools 

or postgraduate tr ain in g programs. The Corps should seize the op po rtu nity 

to enhance it s image by providing learning op po rtu nitie s in these areas 

to medical students and oth er young physicians as po te nt ia l Corps re cru its.
211

- 5 -

At the very minimum, the Corps should provide pro fession al guidance to 

scholarship re cipient s throughout th e ir tr ain in g. This counseling could 

include how best to schedule ele ctive time and choose the most ap propriate 

residency program so as to prepare on eself fo r ru ra l or inne r c it y 

pr actice. Not only would th is approach insure the Corps o f pra ctitioners 

who are properly prepared to deal with a wide range of non-c lin ic al 

problems which have a direct eff ect on the quality of care and desire to 

remain in a challengin g prac tic e sett in g, but i t would also document the 

needed fa ct th at the program believes in backing up and inve sting in 

it s people.

Through our Community Technical Assistance e ff o rt s we have learned that 

there is also c rit ic a l pre paratory work which should be done with communities 

to prepare them to receive Corps physicians. We have come to respect the 

community s ro le as i t is often the esse ntial ingred ient to a successful 

experience fo r the Corps and the young assignee. I t is imp erative that 

s k il ls and knowledge be invested in th is group so th at the pra ctition er 

and community components meld in to an eff ective working force. Communities 

need to understand th e ir re sponsib ility o f cr ea tin g an environment conducive 

to pra ctition er and health services development and to have a fe elin g of 

moving toward s e lf suffic ie ncy in the long term. To achieve th is , i t w il l 

require a new commitment by the Corps to analyze it s fi e ld problems and 

to develop and maintain an eff ective fi e ld support system fo r it s

pra ctitioners , th e ir fam ilies and com nunities.
212

- 6 -

We urge th at young physicians with service ob lig at io ns be given as much 

choice as possible as to which loca tio n and service branch they w il l be 

pra cticin g in . We believe th at the steps taken th is year by the Corps 

such as the conference fo r scholarship re cipient s and th e ir spouses as 

conducted by the AMSA Foundation's Advocacy Program should be continued.

They were a needed, appre ciated , and effective step not on ly in placement 

but in improved communication between the scholarship re cipient s and the 

Public Health Service. We th ink th at i f given the op po rtu nity to make 

an informed de cis ion, young phy sicians w il l have a variety of preferences 

which w il l include both ru ra l and urban areas as well as fed era l priso ns , 

Public Health Service Hos pitals, and the Indian Health Service. An open 

system which emphasizes fu ll partic ip ation w il l help sustain a high lev el 

of mo tivation with in the Corps pro fes sio nal community.

We welcome the in te re st w ithin the Corps in expanding in to urban areas.

The need is clear and c r it ic a l. However, we would advise caution and strong ly 

recommend a balance in the program be maintained to accommodate both 

ru ra l and urban needs and pra ctition er expecta tions.

F in a lly, we would also urge th at any pe naltie s associa ted with the 

ap pl icat io n process fo r the scholarship program, along with any diffe rences 

in ince ntive pay received by Corps physicians who are obligees and voluntee rs, 

be elim inated . A permanent so lu tio n needs to be found to the problems 

created by the new tax sta tus of service-dependent scholarships effective
213

- 7 -

1980 so th at scholarship re ci pie nts at high tu it io n schools wo n't have 

to borrow money to continue on the program.

We would lik e to conclude by re ite ra tin g our strong support fo r the 

National Health Service Corps and the scholarship program. We o ff e r

* these suggestions in the hope th at the Corps can be viewed by young 

physicians as an op po rtu nity fo r personal and professio nal growth and

• by communities as a lon g-term so lu tio n to th e ir health care needs.

The Corps has the op po rtu nity to develop a tr u ly inno va tiv e, model 

program fo r pra ctitioners and communities to work together fo r th e ir 

mutual benefit. AMSA offers it s continued assistance in th is e ff o rt.

Thank you.
214

Se na tor H athaway. Dr. A led ort?

STATEMENT OF LOUIS ALEDORT, M.D., MEDICAL DIRECTOR, NATIONAL HEMOPHILIA FOUNDATION, AND VICE CHAIRMAN OF

THE DEPARTMENT OF MEDICINE, MOUNT SINA I HOSPITAL, NEW

YORK, N.Y.

Dr. Aledort. S en ato r Ha thaw ay, than k you very much fo r giv ing 

me the op po rtu nity to add ress a specific elem ent in the He alth Se rvices Extension Ac t of 1978, and t hat is to deal with sections 1131 (e) 

an d (f ), the Blood Se pa ratio n Center prog ram and the He mo philia 

Dia gnostic and Com preh ensive Tr eatm en t Ce nte r su pp ort pro gra m.

I would like to add ress the Separat ion Cente r firs t by tel lin g you a

wh at has been accomplished and wh at has been done with some of 

the ap prop ria ted money over the p ast y ear and a qu art er. Th ere were 

two aspects of the work th at was done. One was to un derst and and 

define the relative supply needs and dem and s fo r factor 8 and factor *

9 fo r he mo philia pa tients.

I have sub mitted the Booz, Allen & Ham ilton repo rt th at has 

evolved out of th at study. In essense, un til 1975, the needs of fac tor s 

8 and 9 were not met. How ever, since 1975, the y have been met by 

the comm ercial indu str y th at is su pp lyi ng ma ter ial . How ever, we 

are facin g several unso lved problems. One has been a tr en d to pr op hy ­

lactic use to mak e pa tie nt recipie nts of th is tre atm en t even more 

effective, and we have seen a gro wth on use of prod uct from an av erage of 10,000 units pe r pa tie nt in 1970 to appro xim ate ly 50,000 per 

ye ar at thi s p resent time, a nd the pati en ts are living longer.

In addition , we have inf lation ary costs, and several oth er areas 

rel ate d to the production of this ma ter ial . One is th at we have some 

knowledge as to how to bre ak up blood into its m ult ipl e components, 

so th at h emo philiacs, leukemics, cancer pa tie nts can get those pieces.

How ever, we have no t ye t seen a significant enough move in th at 

direction th roug ho ut the country.

Technology at prese nt is very poor, and the yield from original 

source plasma to final prod uct is a major prob lem. In addit ion , the 

major resources fo r fac tors 8 and 9 are wi thin the Un ite d Sta tes, and 

there is inc reasing exporta tio n of this mate ria l to the res t of the 

world.

In addit ion , we hav e a pilot proje ct th at has been support ed by 

some of these fund s to see wh eth er a vo luntary prog ram can use 

com pon ent the rapy in a more effective fashio n to make this ma ter ial 

available. A t presen t, we can not meet t he e ight and nine dem and s b y 

bleedi ng people only wi th whole blood, and therefore have resorted to «

plasmaph eresis, and there is very lit tle evidence in th is country th at 

we can move t hat to a volu nta ry prog ram .

Th ere fore, we rea lly do need, and su pp ort wholehearted ly, the 

recomm endation to continu e th is separat ion cente r for at least 3 

more yea rs, so th at fund s could be used to encourage the uti lization 

of com ponent therap y, and to increase the yield of this m ate ria l from 

source plasma, so th at we are not ca ug ht in a major commercial 

cru nch where plasmaph ere sis is the only source of material.
215

In terms of the Hemophilia Diagnostic and Comprehensive Treatment Center, the first year tha t the funds were made available, 17 

centers were funded throughout the United States, with few of them 

going to areas without previous experience. However, in the second 

year, which started October 1, 21 centers have been funded, and now 

there are several areas where neophytes in the treatm ent programs 

have actually received funds and are cooperating with those established programs to make available this comprehensive care.

Some of the major accomplishments th at we can actually measure, 

and which have been done on five of the centers being evaluated 

since October, have shown that in the five centers, there has been an 

increased patient identification within the region tha t they cover, 

by 25 percent. The comprehensive care which only got to 10 percent 

of those patients already identified, was now increased to 25 percent. 

The utilization of home care—that is, the ability to get the patient 

out of the hospital, self-treating, and back a t work and school—has 

increased by 25 percent.

In addition, a marked increase in services giving comprehensive 

care has evolved. We have been able to get more patients detected 

for the carrier State; we have been able to provide social and behavioral science, and genetic counseling services through these centers 

to patients. I n adddition, these programs have been very much aware 

of the problem of reduplication of services within the region, and 

have begun an outreach program to minimize it.

There are some very good examples. In New York City, the Mount 

Sinai Hospital and the New York Hospital have taken over a large 

region and do not duplicate any service, using each other’s support 

system to manage almost 500 or 600 students. The same is true now 

for Chapel Hill and Bowman Gray, and the Mayo Clinic and the 

University of Minnesota.

The other thing tha t is important is tha t of the five regional centers 

tha t exist in the total Northeast, they now cover an outreach into 9 

states, making it unnecessary to provide new centers within tha t 

region, and actually educate themselves on treatment programs.

We have been able to effectively form networks in the areas of 

catchment and association, and have begun uniform data collection 

throughout the country. In addition, since the major problem in this 

disease is the cost, we have been able to work very closely with thirdparty payment programs within some of the areas.

I would just like to present, briefly, two pieces of data tha t might 

be interesting. In Kentucky, four cases were studied specificially as 

to cost effectiveness, and these patients used a total of $19,500 for 

227 hospital visits. And when they were converted into a home care 

program, the costs dropped to $10,817—a savings of $8,700 for four 

cases in a given year.

In the Seattle region, we have increased identification of patients 

from 128 to 241; and by having 50 percent of the patients converted 

in tha t region to a home care program, we have saved $55,000 in 

ambulatory visit costs by this change.

The Foundation has worked closely with the Health Services Administration, both locally, at th e State level, and at the Federal level, 

to coordinate the efforts of these funds. This month, all of the centers
216

will meet t o deal with the prob lems of da ta colle ction, pa tie nt iden tification, a nd edu cational program s.

We feel we continu e to rem ain an idea l example of comprehensiv e 

care to a chronic, life lon g illness th at can be rev erted by plasma in ­

fusions. How ever, we feel th at we still feel th at we have a lot to be 

done. At the same tim e th at we are utilizing Federal fun ds, we are 

actively worki ng on local pro gra ms to supp ort those existing programs and those th at will be developed, so th at within a period of, 

hop efully, 10 yea rs, we will see these regional centers bein g totall y 

sel f-s upporting and no longer in need of any Federal support .

The new pro gra ms have clearly increased identif ication , hav e delivered services, and have actually cut costs. An d it is fo r th at reason 

th at we are again supp ortin g whole hearted ly the 3-year extension at 

the levels th at t his committee has recom mended. Th an k you.

Senator H athaway. Th ere has no t been any fund ing fo r the blood 

sep ara tion centers fo r the las t 2 yea rs, and the Presiden t does not 

include any money for this y ear’s budg et.

Dr. Aledort. We ll, the re was a sma ll amount th at was supp ortin g 

the sep ara tion cen ter money, and we did su pp ort this pilot pro gra m 

and this inv estiga tion of t he Booz, Allen & Ha mi lto n study. We are 

not ha pp y to see th at it was not funded last yea r, and there fore all 

the money is in the trea tm en t ce nters in th is new fiscal ye ar, October 1.

I do feel, from the da ta th at we hav e collected, th at the re is need 

to pu t money into th at piece of the legislation because of the prob ­

lems in the lack of ap prop ria te com ponent therap y use, whi ch was 

the reason fo r pu tti ng th at piece of legisla tion in at the beginning. 

And I t hin k th at the fal lout for othe r diseases goes well beyond just 

hem ophilia—the leukemic plate let tra ns fusio n problems, the white 

cell tra nsfusio n prob lems, which are now being met by ind ividual 

centers doing pla smaph eresis on lar ge numbers of fam ily members, 

could be alle viated if the blood th at was collected as whole blood— 

the 9 m illion un its t hat are collected in this country —could begin to 

be used more effectively; we would not have to have these expensive 

plas maphe resis program s around . An d we hope th at money would 

continue to be pu t into th at piece of the legisla tion to con tinue the 

efforts to get th at to hap pen .

Se nator H athaway. So you supp ort the autho riz ati on th at is requested in the bill ?

Dr. A ledort. Yes.

Se nator H athaway. Th ank you very much . We appre cia te you r 

testimon y.

Dr. A ledort. You a re welcome.

Senator H athaway. At this po int I orde r printed all statem ents 

of those who could no t att end and othe r pe rti ne nt ma terial sub mitted 

fo r th e record.

[The m ate ria l refer red to fo llo ws :]
S ta te m e n t o f th e

C o u n c il o f Home H e a lt h A gen cie s an d Com mu nity H e a lt h S e rv ic e s 

N a ti o n a l Lea gu e f o r N urs in g 

S u b m it te d to th e

Subco m m itte e on H e a lt h an d S c i e n t i f i c R e searc h 

S e n a te Com m ittee on Human R e so u rc es 

on S.2 474

Marc h 10, 197 8

The C o u n c il o f Home H e a lt h A gen cie s an d Comm unity H e a lt h S e r v ic e s , in 

b e 'h a lf o f i t s 1500 M e d ic a r e - c e r tif ie d home h e a lth a g e n c ie s , a p p r e c ia te s 

th e o p p o rtu n it y to p r e s e n t ou r vie w s on S .2 4 7 4 , th e H e a lt h S e rv ic e s 

E x te n sio n A ct o f 19 78 . Our co mments r e l a t e to S ec. 320, Home H e a lt h 

S e r v ic e s .

CHHA/CHS commends th e sp o n s o rs o f S .2 474 f o r t h e i r r e c o g n itio n o f th a 

v i a b i l i t y o f home h e a lth s e r v i c e s . In e x te n d in g th e a u th o r iz a tio n f o r 

th e g r a n t pro gra m th ro u g h f i s c a l y e a r 19 81 , yo u ha ve on ce a g a in demo ns t r a t e d y o u r s u p p o rt f o r a v i t a l , b u t o f te n n e g le c te d , co m po ne nt of 

th e h e a lth c a re d e liv e r y sy st em

The p re v io u s g r a n t aw ar ds p ro v id e d $ 6 ,0 0 0 ,0 0 0 in d e v e lo p m e n ta l and 

ex p a n sio n g r a n ts , e n a b li n g HEW to fu nd 112 p r o je c ts - 30 d e v e lo p m e n ta l 

and 82 e x p a n sio n p r o j e c t s . A lt h o u g h an e v a lu a tio n o f t h i s pr og ram i s 

n o t y e t c o m p le te d , p re lim in a ry i n d ic a tio n s a re th a t th e pr og ra m was 

s u c c e s s fu l in m eeti n g i t s g o a l-to p ro v id e home h e a lth s e r v ic e s in a re a s 

w he re >su ch s e r v ic e s a re n o t o th e rw is e a v a i l a b l e .

In d e e d ,a r e c e n tly p u b li s h e d r e p o r t #OPEL 7 7 -1 1 , Home H e a lt h G ra n t pr ogra m 

E v a lu a tio n M eth odolo gy, s t a t e s t h a t :

"D e s p it e th e d if f e r e n c e s t h a t e x i s t among th e s e (hom e h e a lth ) 

a g e n c ie s in te rm s o f t r a d i t i o n , p h il o s o p h y , an d s t a f f i n g , 

i t i s a p p a re n t th a t each h a s bee n s u c c e s s fu l in u s in g g r a n t 

m oni es to in c r e a s e s e r v ic e s an d th e numb er o f p a t i e n t s se rv e d 

an d to become f i s c a l l y v i a b l e . I t i s a ls o a p p a re n t t h a t 

th e g r a n t money p ro v id e d an o p p o rtu n it y f o r th e s e a g e n c ie s 

to m ee t co mmun ity nee ds t h a t o th e rw is e wo uld n o t ha ve bee n 

m et , by in c r e a s in g th e nu mber o f em plo yee s a lre a d y on s t a f f , 

by a d d in g s e r v ic e s , by ex p an d in g th e s e r v ic e a r e a , o r , in th e 

c a s e o f on e ag en cy , by u n d e rw ritin g th e c o s ts o f c a r e o f p a t i e n t s 

who a r e u n ab le to pay .

" in a d d i t i o n , on e c h a r a c t e r i s t i c o f th e c u r r e n t g r a n t pro gr am 

wa s i d e n t i f i e d w hic h, i f m o d if ie d , m ig ht enhan ce th e e f f e c t s 

o f th e g r a n t pro gr am on th e c a p a c ity develo pm ent and f in a n c ia l 

s e l f - s u f f i c i e n c y of home h e a lth a g e n c ie s . In c o n t r a s t to a g e n c ie s 

lo c a te d in m aj or p o p u la tio n c e n t e r s , r u r a l home h e a lth a g e n c ie s 

f r e q u e n tly e x p e rie n c e d i f f i c u l t y in id e n t i f y i n g an d h i r in g p e rso n n el q u a l i f ie d to p ro v id e th e nu mber and ty p e s o f s e r v ic e s
218

a p p r o p r ia te . B ecause , s a y , a p h y s ic a l t h e r a p i s t docs 

n o t l i v e in th e s e r v ic e a r e a , an ag en cy may n o t be a b le 

to s t a t e h o n e s tl y in a g ra n t a p p lic a tio n th a t i t e x p e c ts 

to add a p h y s ic a l t h e r a p i s t i f i t r e c e iv e s a g r a n t. On 

th e o th e r hand, i f a p h y s ic a l t h e r a p i s t i s lo c a te d d u rin g 

th e fu n d in g c y c le , no g r a n t money i s a v a i la b le fo r ad d in g 

t h i s p e rs o n to th e s t a f f . In mos t su ch c a s e s , p ro s p e c ti v e 

em plo yees a re u n w il li n g to w a it fo r th e home h e a lth ag en cy 

to fin d n e c e s s a ry fu n d in g b e fo re d e c id in g on em ploy men t 

o p p o r tu n i tie s p ro v id e d by o th e r h e a lth c a re o r g a n iz a tio n s 

w it h th e same s e r v ic e a r e a .

I t has th e r e f o r e been su g g e s te d to th e a d m in is tr a to r o f 

th e home h e a lth g ra n t pro gra m th a t me ans be e x p lo re d f o r 

mak ing a v a i la b le to home h e a lth a g e n c ie s , th ro u g h th e 

re g io n a l o f f i c e s an d on a n o n c o m p e ti ti v e b a s i s , lim ite d 

am ou nt s o f money f o r s p e c i f i c p u rp o s e s, su ch a s h ir i n g an 

a d d itio n a l em plo yee, c o n d u c ti n g tr a i n i n g pro g ra m s, e t c . ”

Ou r c o n ce rn f o r th e c o n ti n u e d devel opm en t o f home h e a lth c a r e i s couple d 

w it h a d i s t i n c t aw are n e ss o f an in c re a s e d ne ed f o r c o n ti n u e d e d u c a ti o n 

o f ag en cy p e rs o n n e l. In o u r Septe m ber 1976 te sti m o n y p re s e n te d d u ri n g 

th e HEW re g io n a l h e a r in g s on Home H e alt h C are , we sp oke o f th e d i r e ne ed 

f o r tr a i n i n g m onie s to upg ra d e an d in c re a s e agency p e rs o n n e l to ad min ­

i s t e r , im pl em en t an d e v a lu a te q u a lity s e r v ic e s .

We wou ld l i k e to ha ve some w ord in g in th e com m it te e r e p o r t w hi ch in d ic a te s 

t h a t th e t r a i n i n g m on ie s can be use d f o r e i t h e r lo n g -te rm o r s h o rt-te rm 

g r a n ts . T her e i s a p r e s s in g nee d to upgra de th e s k ilI s o f home h e a lth ag en cy 

p e rs o n n e l in su ch a re a s a s a d m in is tr a tio n , f i s c a l an d p e rs o n n e l man ag em en t, 

man agem ent in fo r m a ti o n sy st em s an d s u p e r v is io n . W hile som e o f th e s e need s 

c o u ld be me t th ro u g h s h o r t- te r m tr a i n i n g p ro g ra m s, we wou ld li k e to see 

r e g u la tio n s w r itt e n w hic h wou ld a ll o w tr a i n i n g m oni es to en co m pa ss contin u in g e d u c a ti o n o f f e r in g s in a v a r ie ty o f s e t t i n g s up to an ac adem ic 

y e a r o f s tu d y .

As a f i n a l p o in t, CHHA/CHS b e lie v e s t h a t m on ie s m us t be mad e a v a i la b le to 

fu nd a p r o je c t to e s t a b l i s h n a tio n a l c r i t e r i a f o r d e te rm in in g th e ne ed fo r 

home h e a lth s e r v ic e s . We u rg e yo u to in c lu d e an a u th o r iz a tio n o f $500,0 00 

i n S .2 474 fo r su ch a p r o j e c t .

We wou ld l i k e a ls o to comm ent on th e h e a lth p la n n in g b i l l c u r r e n tly under 

c o n s id e r a tio n in th e S e n a te . The ne ed fo r a f e d e r a lly m an dat ed c e r t i f i c a t e 

o f ne ed h a s be en d e m o n str a te d ti m e and tim e a g a in . W ith e ac h p a s s in g d a y , 

in c r e a s in g nu m be rs o f home h e a lth a g e n c ie s a re b e in g c e r t i f i e d to s e rv e 

a r e a s w he re ne ed i s n o t i n d ic a te d , th u s in c r e a s in g th e c o s ts to th e M ed ic a re / 

M ed ic aid pro gr am made n e c e s sa ry by th e fu n d in g o f m u ltip le a d m in is tr a tiv e 

s t r u c t u r e s .

-2 -
219

States' attempts to enact certificate of need legi slati on have foiled 

or have been enacted only after certain urban areas are ini... tied with 

agencies. Oftentimes, the state cer tify ing agency reco gnize s that need 

for a new agency cannot be rationalized but it cannot deny cer tif icat ion 

without statuatory or regulatory justifica tion. Such cert ific ate ol 

need must be applicable to all types of home health agencies.

CHHA/CHS is pleased to present its views and wi ll be happy to provid e 

further information, and/or documenta tio n of these. We hope the 

committee will consider our comments carefull y and favorably.

*

LB: ns 

3/9/78

-3-

«

28-386 0 - 78 - 15
220

NATIONA.. leag ue for nursin g

H ri tt e n Testimony 

to the

*

SU3C OMM IT TEE CH HEA LT H 

C:T HUMAN

U .S .

S C IE N TIF IC RESEARCH 

RESOURCES 

SENATE

14 March 1978
221

We are the National League fo r Nursing, a coalit io n of nurses, oth er health 

pro fessiona ls, consumers and health agencies—17,000 individu al memuers and 1,900 

agencies, dedicated to developing and improving the standards of qualit y nursing 

education, nursing service s, and health care de liv ery in the United State s—a ll of 

whom work together to help meet community nursing needs and to assure high qualit y 

nursing education. Among it s func tio ns , the League is o ffic ia ll y recognized as the 

national ac cred itin g agency fo r a ll nursing education programs by the Council on 

Postsecondary Ac cred itation (COPA) and the U.S. Office of Education.

• Since the 1960's, the role of the Federal government in health care has been, 

in ad dition to expanding financing fo r the aged and poor, to expand the resources 

devoted to health. The e ff o rt can only.be regarded as a success. The growth in

♦

the number of reg istered nurses, aided by Federal expansion of nursing schools as 

well as nurses' ro le s, has been dramatic.

Cut new, the Ad minist ratio n's perceptions and p rio rit ie s are sh if ti n g . There 

is a concern th at the hea lth sector is growing too fast and th at includes the supply 

of nurses.

Ten years ago, an increaseo supply of nurses and doctors, health planning, 

prospective reimbursements, PSRO's, were a ll regarded as solutions to the problem.

Cut the re is s t ill the very sta rk re a lity that there is unequal access to the health 

care system, both to financin g and to care it s e lf .

The irony of the situ ation lies in the fa ct that ju st as nursing seems to be 

showing signs of success in terms of pro viding solution s to unequal access and risin g 

costs , a new skepticism has surfaced on the pa rt of the Ad ministration. I t would be 

mistake to allow th is skepticism to obscure the need fo r continued fin ancial as sis ­

tance to those portio ns of the hea lth care system that are most promising with regard 

to cu tting costs and increasing access. I t w il l be to the be ne fit of us a ll i f the 

Congress decides to make th is short-term extension of Federal Funds in the in te re st of 

long-run reruns.
222

A discontinuation of funds at the time would be very disr up tiv e to a great 

many schools who re ly on these funds fo r major budget items.

The National League fo r Nursing has rec ently analyzed the resu lts of a 

Special Study of Capitation Provisions of the Nurse Train ing Act of 1975, conducted 

by the American Nurses' Association, American Association of Colleges of Nursing 

and the National League fo r Nursing. The study surveyed pu blic and private schools 

of nursing to determine prim arily how the funds were used and what ef fe cts cessation 

of funding would have.

Among the schools surveyed the greatest percentage of funds was used fo r fa cu lty *

sa larie s. In a ll three types of programs, fa cu lty sa larie s was reporte d to be the 

highest item of expenditure with use o f ca pitatio n funds. For example, out of $67,000 

(average dolla r amount received per Baccalaureate program), $45,900 (in eve. age colla r 

amount per Baccalaureate program) was expended on fa cu lty sa laries . In many cases, 

discontinuing these funds would mean losin g at least two or three fa cu lty members. Now • 

that schools have increased th e ir enrollments so that they could be e lig ib le fo r these 

funds, i t would the refore be most unfa ir to students en rolled in these programs to 

abrup tly discontinue the funds.

More than half of the schools stated that a reduction or dis continuation of these 

funds would have a severe impact on th e ir programs. 71? of the Baccalaureate programs 

stated that they fe lt i t would be cruc ial to continue these funds. Schools plan curricu la years in advance, and often times these funds are an essential part of these 

plans.

Monies were also heavily depended upon, according to the survey, fo r continuing 

education and curriculum expansion. New programs are being supported by these funds, 

and in many cases, are not capable of sustaining the loss of federal support. In 

add ition , many nurse pra ctitioner programs, offered through continuing education departments, as well as through cu rricula in it ia te d with federal dolla rs , would be affected .

'• cessation of funds at th is time without a thorough evaluation of the need to continue
223

these programs would have dauiagir.g ef fe cts to the entire health care system, and to 

the students in these programs as well.

At the very le ast , perhaps a gradual phasing out of these monies could be 

accomplished once the ov erall requirements fo r nurse manpower have been accurately 

assessed. Select funding according to regions might also present a via ble altern ative .

The role of nurses in health encompasses not only professional prac tice and 

technical s k il ls , but is in ext ric ably related to the complexities of the entire health 

care system. In recent years our role has changed dra matica lly to meet the needs of 

a hea lth care system undergoing widespread transform ation . We wish to continue to 

address the problems in hea lth care.

As a pro fession, we are committed to attainin g a ratio na l use of expensive resources as we ll as equitable qualit y of care. We have, in fa ct, made many inroads 

to the problems in m al di stributio n, primary care, and hea lth education, to name a few.

In order to fu rther direct our e ff o rt s toward pro viding remedies fo r the curren t 

health care c ris is , we w il l need continued Federal support, and ther efor e, we strongly 

support the proposed two-year extension of the Nurse Tra ining Act.

Representing the larges t segment of pro vid ers, nurses are becoming involved in 

many new modes of hea lth care de livery such as ou t-pa tie nt c lin ic s , in dust ries, schools, 

and primary care settin gs , as well as in the tr aditio nal ho spital and community health 

se ttings . We are pro viding a wide range of new services inclu din g psychotherapy, 

counciling to familie s on death and dying, home he alth, physical assessment and hea lth 

education.

To date, NLN's 1976 survey on newly-licensed reg istered nurses reports that 86.2% 

are s t ill employed by hospitals with 3.9% by nursing homes and 9.9% fa ll in g in to an 

"other" category. I t seems reasonable to expect, however, th at th is trend may charge.

The growing tren d toward non-inst itutional care w il l require nurses th at are prepared 

in expanded ro les. I t w il l require nurses with a knowledge of economics, reimbursement procedures and above a ll sound decision-making a b il it ie s . As the data in th is 

testimony w il l show, many nurses pre sently hold po sition s fo r which they are un qu alified .
Thus, despite recent e ff ort s and improvements, many gaps and omissions are 

apparent with regard to the nursing profession as we ll as to the entir e health care 

system.

STUDIES UNDERWAY

We are cu rren tly engaged in e ffort s to id entify these gaps and omissions fo r 

that is the fir s t step coward so lutio ns .

Section 951 of the Nurse Tra ining Act of 1975, sp ecific ally requests informatio n to oe collected on a continuing basis regarding the current and future supply 

and dis tr ib ution of nursing personnel, nationwide. In ad ditio n, i t requests sp ecific 

data inc luding the supply and dis tr ib ution of sp ecia ltie s, educational preparations, 

sala ries, and a c ti v it y statuses.

To meet these requirements a va rie ty of studies funded by HEW are underway 

that w il l provide the data needed fo r sounu decisions in a ll of these stipulated 

areas. However, these studies w il l necessitate ad ditional time fo r completion due to 

the enormity of the task of in te gr at ing ex istin g data as well as developing measures 

that w il l accurately re fl e ct future trends in changing economic and socia l contexts.

The info rmation th at 1s pre sently availaole is fragmented, out-dated, and undiff ere ntiate d as to lev els or types o f prac tic e. Another d if fic u lt y lie s in the 

fa ct tha t as consensus has never been reached about how hea lth sta tus should be defined 

or how changes in health status should be measured. One means of determining nurse 

manpower requirements is to look at the need to improve, ma intain, or res tore the 

health status o f the population. However, a lack of consensus as to a definitio n of 

wealth status has mitig ate d th is approach. Steps to determine a measure of th is concept are cu rre ntly underway.

Models have been developed and are now being u tiliz e d in studies funded by HEW 

th at w il l furnish the required data. (See attachment)*
225

* Among these is a national model th at has been developed with the activ e 

involvement of a task force inclu ding representatives of nursing se rvice, 

nursing education , comprehensive health pla nning, the Divis ion of Nursing 

in DHEV.', and Western In te rs ta te Commission on Higher Education's nursing 

program s ta ff .

The model is based on a set of techniques referre d to as System Dynamics.

A System Dynamics model describes a set of casual relatio ns hips respon sible 

fo r changes in variable s of in te re st to po lic y makers such as those variable s 

ch aracteriz ing the supply of, demand fo r and dis tr ib u tion of nursing personnel and services at the national le vel.

*
The data that are presented in th is testimony are based or. data collecte d 

up until and includ ing 1972, from a va rie ty of sources (American horses' Association, 

National League fo r Nursing, the American Hospital Association and HEW), to fu lf i l l the requirements of the Nurse Trainin g Act of 1975. Proje ctions from 1975 to 

1990 have been made as to supply, dis trib ution and requirements by means of a 

special s ta ti s ti c a l formula ca lled the "net a ttrit io n ra te ," whereby ex istin g data 

on the to ta l numbers of nurses and the number of graduates each year are interpreted 

on the basis of assumptions about the behavior of the derived net a tt rit io n rate.

The graduation projections represent the net inputs into the nurse supply while the 

net a ttrit io n rate accounts fo r a cti vit y status (p art-tim e, fu ll-t im e , e tc .} , and 

foreign nurses inp uts .

PROJECTIONS OF SUPPLY

HEH proje cts th at by 1990 the number of those RN's av ailable fo r employment 

would range between 1 ,467,000 and 1 ,541 ,000. About 62. of these would have as th e ir 

highest educational preparation associate degrees or diplomas; 33‘. baccalaureate; 

and 5% masters or doctoral degrees.

In 1976, i t was estimated that there were 961 ,050 RN's in the supply; 162 

baccalaureate nurses and 3.4% masters or doctoral degrees.

A comparison of the estimates from 1975 and 1990 re sp ec tiv ely, forecasts an 

increase of baccalaureate nurses from 16% to 33% of the nurse supply. A decline of 

61/j to 62/ was projected fo r AD and diploma graduates, (tasters and doctoral components 

would increase from 3.4% to 5.1% and 2% respectively.

When a sta te by state pr ojec tio n of supply in 1980 was considered, the overall 

picture revealed ad ditional im plications . The pro portio n of st ate 's supply having 

only nurses whose highest education would be an associate degree cr diploma predicted 

a decline by 1980 in a ll but five sta tes. Nevertheless, th is group w il l s t ill represent 

a very sizable proportio n of the to ta l nurse supply. At least t.iree -quarte rs of the
227

to ta l nurse supply in half of the states w il l be composed of AD and diploma nurses 

by 1980. The refore, given the increasing supply of nurses in each sta te , despite 

the decrease in the numbers of AD and diploma nurses, the nuber of nurses wish these 

educational lev els w il l s t ill increase.

The proportio nate supply of baccalaureate nurses w il l increase in a ll the states 

but four--F 1o rid a, Arkansas and the Dakotas. However, only in o n e -f ifth of the states 

w il l the baccalaureate component equal at least 252 o f the st ate 's to ta l supply in 

1980.

While the master's and doctoral lev els generally showed higher pro portions by 

1980, in most states they v/ere s t ill a very small pro portio n of the to ta l supply.

PROJECTIONS OF DISTRIBUTION

State to state dis tr ib utions, analyzed according to nurse per pop ulation ra tio , 

have shown con sistent increases over the years and future projec tio ns indica te a 

continuation of the trend.

The va riat io n among states is very grea t, however; the diffe renc e between lowest 

and hignest states being about three times as many RN's/10C,000. The lowest ra tio s 

of RN‘s/100,000 population were projected in Alabama and Louisiana; the highest in 

Vermont and Washington, DC, ranging in the v ic in it y of 1 ,000 fli's /p opula tion.

While data of th is nature is useful in determining trends, i t is v ir tu a ll y 

meaningless unless related to the sp ecific area requirements of each state inc luding 

diffe re nt sp ec ialties and lev els of educational preparation, (low tne area's popula tion receives it s services also needs to be taken in to consideration. These additio nal factors arc cu rren tly being studied.

ASSESSMENT OF REQUIREMENTS

Preliminary assessments of requirements according to leve ls of educational

preparation shed in te rp re tive lig h t on the ov erall pictur e.
228

The Western In te rs ta te Commission fo r Higher Ed ucation , as part o f its work 

on the p ro je ct, “An aly sis and Planning fo r Improved D is tr ib u ti o n ," has pr ed icted 

what the ap prop ria te mix o f ed ucation al require ments sho uld be, giv en cu rren t 

u til iz a tio n pattern s. Pro ject ions were made according to c r ite r ia es ta olishe d by 

the Surgeon Ge ne ral's Co nsultan t Group on Nursin g fo r ap pr op ria te ed ucation al a tt a in ­

ment le vel fo r nurses se rving in various capacitie s. One sho uld keep in mind, however, 

th a t since the establishm en t o f the c rit e ria in 1962, nurses ro les have become much 

more d if fe re n ti a te d , and re s p o n s ib ilit ie s have changed ac cord in gly . Thus, these 

c r it e r ia are pr ese ntly con sidere d minimal ed ucation al c rit e ria .

The number of employed re gis te re d nurses ho lding mas ter's or do ctoral degrees 

has been s trik in g ly low. In 1972, 24,200 or 32 o f employed re gis te re d nurses actu ally 

he ld masters or do ctoral degrees and 107,200 or 13.72 had earned baccala ureate degrses.

I f employed RN's had the ed uc ationa l prep ar ation th a t th e ir positio ns warranted , 172 

would have been employed at the masters or do ctoral le vels and 312 at the baccala ureate 

le ve ls . Th erefore, there sho uld have been fi v e times as many nurses with masters or 

do ctor al degrees as th er e a ctu a lly were in 1972; and tw ice the number o f re giste re d 

nurses with bacca lau reate s as th e ir a ctu a lly were.

In ad ditio n, when the ed uc ationa l prep ar ation o f employed nurses was conside red 

on a statew ide basis, (1972) none o f the stat es had the number o f ba ccalau reate, 

masters or d o cto ra lly prepared nurses th a t the y sho uld have (a gain , acc ordin g to the 

Surgeons General Group c r ite r ia .) In fa c t, nine stat es needed ter, time s the number of 

nurses at th a t ed ucation al le ve l then were in supp ly.

RECENT EVIDENCE

The need fo r advanced lead ersh ip prep ar ation fo r nurses has been addressed by 

many ex pe rts as 'well as being documented in the li te ra tu re .

A fe a s ib il it y study conducted by Western In te rs ta te Commission on Higher Eciuca- *

tio n in 1976 to determine the need fo r the development o f -egio na l centers to give
229

advanced leadership prep aration to nurses provides fu rther evidence of th is situ ation.

The study surveyed schools and conducted on -site v is it s .

A ll of the schools surveyed ind ica ted th at they had u nfille d fa cu lty or 

ad ministrative po sit ions . The reason most fre qu en tly cite d fo r th is was a lack of 

app ropriate educational cred en tia ls. D eficits included a lack of doctc rates, clin ic a l 

expertise and research s k il ls .

Cu rre ntly, there are many deanships in nursing programs and dire ctor s of nursing 

service positions that are vacant. Shortages exis t in both functional areas: teaching 

and ad ministration.

Faculty shortages have long teen a problem in t nursing pro fession.

The National League fo r Nursing's 1976 Nurse-Faculty Census reports 776 budgeted 

vacancies. Regional va ria tio ns were also evident in the League study. The vacancy 

rate is twice as high in the Midwest (295) as in either the North A tlantic (150) or 

West (62).

In the area of Ad ministration, fewer than 15* of nurse adminis trators hold a 

masters degree or a doctorate. Members of search committees reported facing months 

of frustr ation as they struggled to f i l l Adminis trative as well as fa cu lty spots.

The shortage of nurses with appropriate Ad ministrative education is part ic ula rly apparent in small rural hospitals and nursing homes.

According to Some S ta tistics on Baccalaureate and Higher Degree Programs, rec ently 

published by NLN, th is trend seems destined to continue unless incentives are provided. 

While the number of students enrolled in graduate study is inc rea sin g, the percentage 

of graduate students enrolled in Nursing Administration is co ns istently decreasing.

In 1968 there were 303 fu ll-t im e masters students enrolled in Ad minis tration programs; 

and in 1976, there were 258 students en rolle d. The percentage dropped to 3.82 in that 

year.

The number of graduate students en rolled in teaching programs has also declined.

In 1968 there were 1,290 fu ll-t im e students en rolled in teaching programs and in 1976

there were 1 ,323 enrolled.
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The fe a s ib il it y study also showed that some states had no masters or doctoral 

programs at a ll . This is qu ite in dica tiv e considering th at NLN's Data Service on 

Newly-Licensed Nurses shows that they are most li k e ly to be employed in the states 

where they attended school. One could ea sily hypothesize, then, th at those states 

without masters programs might have the greatest shortages of specialize d nurse sjp ply.

To be sure, some progress has been made with Federal assistance through 

advanced nurse train in g funds. The ov erall number of doctoral programs as well as 

that of students has increased fo r the th ir d academic year in a row. In ad ditio n, the 

proportion of fu ll-t im e doctoral students increased fo r the fir s t time since 1971-1972.

Yet, despite addition al programs, hig her enrollments and gre ate r proportions studying >

fu ll tim e, doctoral graduations declined from 74 to 62.

A thorough assessment of the overall picture merits a note o f caution: Planning 

cannot be done adequately and effectively on the basis of sheer numbers. The 

ad ministra tio n's appraisal that the nurse supply is adequate seems sho rt sighted in 

lig h t of these data projec tio ns . Leadership is imperative i f nurses are to make a 

diffe renc e in the health of the people of th is nation. I t is imperative as pra ctitioners , 

as educators and as decision-makers with the opportu nity to particip ate in p o liti c a l 

processes, that we have more qualif ie d nurses leaders.

NURSE PRACTITIONER

The nurse pra ctitioner has been instrumental in addressing some of the d e fi ­

ciencies of health care in the United States. The u ti li z a ti o n and acceptance of th is 

new form of health manpower, in addition to enhancing the co ntrib ution of nursing in 

the planning and provisio n of health care, is expected to re su lt in the improved 

qualit y of health care services.

Since nurse pra ct itioners are such a new phenomena to the hea lth care system, *

more time is needed to assess th e ir to ta l impact.

»
231

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However, A Lon gitudinal Study of Nurse P ra ctitioners , conducted and funded by 

HEW, has shewn some pe rtine nt fin ding s.

The study id entified 131 ce rtifica te -a war ding programs and another 84 programs 

gra nting masters degrees. The major areas of sp ec ializ at ion included Family Nurse 

Pra ctitioners , Pe diatric Nurse Pra ctition er s and Adu lt Nurse Pra ct itioner s. Other 

major areas were women's he alth, community and mental hea lth sp ecialties. 

a The study demonstrated that many nurse pra ct itioners prac tice in rjr a l areas

and that most are fam ily pra ctitioners , with more than 90S being c e rt if ic a te nurse 

pra ctitioner graduates. These new pro fessionals could very conceivably provide

* solutions to our problems with m aldistrib ut ion and primary care. Thus fa r there is 

no national data of value to describe the impact of these pra ctitioners on maldis tr ib ution of health care services. However, selected studies have demonstrated 

th e ir cost effectiveness. For example, a study cited in the February '78 New England 

Journal of Medicine reported that average costs - inc luding nurse pra ctitioner time, 

charges fo r lab oratory tests and medications, were 20 percent les s.

These programs s t ill require Federal support; many d if fic u lt ie s s t ill need to 

be resolved before these programs can fun ction without Federal dolla rs .

Hany times the nurse pra ctitioner encounters a situ ation th at was not included 

in the Nurse Pra ct itioner Curriculum, or she/he may be expected to pra ctice seven 

days a week, with li t t l e re li e f. These situ at ions must be re c ti fi e d by pro vid ing more 

Federal incentives to practice in shortage areas. The ad ditio na l monies proposed fo r 

Special Projects w il l be very he lpful in th is regard.

Up until r.ow the market fo r these pra ct itioners has been rather slow in terms 

of acceptance and demand fo r them. Now that nurse pra ct itioners are e lig ib le fo r 

reimbursement fo r service under the Social Security amendments, tne volume ane types

• of services provided w il l undoubtedly be gr ea tly expanded.

I f the nurse pra ctitioner's fun ction is to become more than a periph eral ad ditive 

of fring e fo r the present system, and rather is to become pa rt of an ov erall strate gy 

fo r improving the qualit y and qu an tity o f primary care services av ailable, an extension
232

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o f Federal monies is essential. Three fo urtns o f nurse p ra c ti ti o n e r programs in 

the Lo ng itu dina l Study o ff e r some fina ncia l assis tance through stipends or train eeships ( 775b); and, in many cases, a v a il a b il it y o f these monies is dependent upon 

fede ral d o lla rs .

RESEARCH

A ll p ra ctitio n e rs have ways o f ev alua tin g unknowns and vario us aspects o f *

change.

Research in nu rsing approacr.es these areas in a manner w.iich is very d if fe re n t

»

from the medical disease model. Nursin g research is concerned w ith a "h o li s tic " 

model o f man; th a t is , a model th a t does not tr e a t mind and bocy as two separate 

e n ti ti e s . Nursin g research is concerned w ith he altn promoting pa tte rn s in re la tio n 

to the to ta l behavio r o f the in d iv id u a l.

In th is age o f in creas ing co mplex ity , many nurse res earch ers be lie ve a .at a 

cause and e ff e c t, di se ase -o rie nt ed model is no long er adequate. ''ar.y disease processes such as cancer, fo r example, are beginning to be stud ied w ith ••egard to str e ssfu l events in the li f e o f the in d iv id u a l.

Despite it s sh ort h is to ry , nu rsing research has aireac y made valua ble c o n tr ibu tio ns to he alth care. However, Federal fun din g p rio rit ie s , have bean oriente d toward 

the cure o f dis ea se, ra th er than pr ev en tio n, improvement ir. q u a li ty catie nt ca re , or 

ba sic research with oth er models.

In nurs ing, ou r concern is ex pe rim en tal; end there is no separateness o f mind 

and body, psych oso cial and bio physic al. The nurse regards signs end symptoms o f 

diseas e as m anife statio n o f man's wholeness, fo r the patient is ex pe rie nc ing one even t.

Nurse res earchers have made major breadthrough s in ba s'c as well as ap plied 

researc h. The nu rsing pr ofes sion has a s ig n if ic a n t con tr ib utio n to be made; however, *

ther e arc very few nurses adequately prepared to do researc h. Out o f ap pro xim ate ly

1,500 nurses in the Un ited Sta tes who have earned do ct or ate s, on ly 3GZ are engaged in

<*

res earch .
233

• i.: -

A ra tio of graduate and undergraduate students per biomedical and behavioral 

Ph.C. scie ntists employed in academic se tting s ranged from approximately 2G:1 to 

40:1 between 1960 and 1972. On the other hand, a 1974 ra tio of fu ll-t im e graduate 

students fo r each fu ll-t im e nurse fa cu lty member holding a doctorate was 153:1.

In view of the current national concerns in hea lth care , i t is necessary that 

federal support of hea lth relate d research include nursing stu dies. The problem 

of qualit y assurance, hea lth maintenance and prevention of disease need to be addressed 

through the support of research in nursin g. The lack of clin ic a l research, the area 

which inv estigates pa tie nt phenomena encountered by nurses and fo r which nurses are 

expected to in it ia te appropriate inte rventio n, is a very real deter rent to po sitiv e 

change and progress. To achieve progress, nursing must be given the opportu nity tc 

explore a changing concept of hea lth through basic, as well as ap plied, research. More 

of the same is cle arly not the answer. He need the fin ancial assistance to explore 

new solutions r.o old problems.

THE FUTURE

We are indeed witnessing the lim its of modern medicine. While tremendous strid es 

have been made, there have been very serious negative repercussions. The to ll that 

medical technology and sp ec ializ ation have taken on costs is profound. The dr ast ic 

ris e in costs have also occurred as a re su lt of the high ly tra ined sp ecialis ts re ­

quired to use th is equipment fo r dia gnostic and curative purposes.

Medical care decisions have increa sin gly been made without the slig hte st regard 

fo r costs vs be ne fits. Key examples can be seen in the areas of kidney dia ly sis and 

increased use of intensive care un its .

The consumer movement, the se lf- ca re movement, and the increa sing involvement

of the Federal government in health care a ll herald new trends.
234

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In ths midst o f these changes, the concept o f the expanded ro le o f the nurse 

has been intro du ce d in response to the grow ing needs o f the he alth care system.

With changes in the p r io rit ie s o f th e ir du tie s and a w illin gne ss to accept new 

re s p o n s ib il it ie s , nurse manpower has presented some very via ble alte rn a tive s to many 

problems th a t the he alth care de live ry system fac es. Nurses prov ide care at the 

low est le vel o f tech no logy , meet the emotional require ments o f patients fo r counseling and supp ort in an age o f ennui and deper so na liz at ion, prov ide he alth education 

(as they have always don e), in whatever ro le she/he fu nctions. *

The enactment o f many new le g is la ti v e proposals is on the ho riz on fo r he alth 

care. He alth pla nn ing le g is la ti o n , the HMO amendments, na tional he alth insura nce and

►

the coming o f age o f home he altn care w il l evoke new needs and require ments fo r

nurse manpower. Nurses must be prepared fo r these plans now. Needs fo r nurse manpower supply must be viewed in the co nt ex t o f the pr ojec te d p o li tic a l and fi na ncia l

se tt in g s. As oiffe re .n t trends take shape, obje ct ives and assumptions must change to

meet d if fe re n t needs.

Whatever fu tu re tre nds may be pro je cte d, re gis te re d nurses pre se ntly form by 

fa r the la rg est group o f he alth pro fe ssio nals . Their in cre asin gly d if fe re n ti a te d 

ro les has led to gre ate r re s p o n s ib ilit ie s and independence in pra ctice. These new 

roles warra nt more lead ersh ip pre para tion, an element which is cu rr e n tly a scarce 

commodity in the nu rsing pr ofe ssio n, as we tr u s t was communicated by the data in th is 

testim on y.

Mr. Chairman, thank you fo r the opportunity to te s tif y and we hope th a t you 

w ill co ntin ue , as you have done in the past, to assis t nu rsing to maximize it s contr ib u ti o n to he alth care.

Sources o f in fo rm ation: a ll s ta tis tic s in th is tes tim on y were documented by 

the HEW D iv is io n o f Nu rsing, the NLN D iv is io n o f Research and the W este rn 'In te rs ta te 

Commission on Higher Education.
235

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ATTACHMEHT I

To f u l f i l l the need fo r requirement projec tions pri o r to the enactment 

of Public Law 95-63, the Divis ion of Nursing launched four studies concerned 

with the projec tio n of nursing resources and requirements. Since requirements 

can be approached from several points of view ( i. e ., demancs, needs, or wants) 

i t was important to examine a va riet y of approaches.

The diffe re nt models and a b rie f summary of the methods and purposes 

u ti liz e d in each of the studies follo ws:

1• A Model of National Supply and Requirements fo r Nursing Personnel.

(Pugh-Roberts Associates, In c.)

This e ff o rt is directed from a national perspective toward the 

analysis of factors affectin g nursing requirements and resources 

from the present through the year 1990. The technique used fo r 

the development of th is model, known as .System Dynamics, describes 

a set of causal relatio ns hips resp onsible fo r changes in pe rtine nt 

va ria bles . As part of th is approach, a series of issues or parti c u la r relevance to the questions surrounding supply and re qu ire ­

ments is being developed. These w il l be used in the ov erall analysis 

of impacts on supply and requirements, part ic ula rly from a longrange viewpoint.

2. An Analysis of the Impact of Nurse Manpower Requirements of Changes

in the National Health Care System. (Vector Research, In c.)

This work was directe d toward the assessment of the impact o f three 

an tic ipated changes in the health care system on the requirements 

fo r nurses: (1) the intro du ction of National Health Insurance;

(2) the increased enrollment in Health Maintenance Organizations;

28-386 0 - 78 - 16
236

and (3) the reform ula tion of nursing roles. The model predicts 

requirements fo r nurses under various altern ative assumptions 

surrounding these subjects with one developed as "most pro bably."

Projections are based on a 10-year time frame. The f ir s t analysis 

level is on a national basis with subsequent ap plication of the 

approach to the State le vel.

*

3. Analysis and Planning fo r Improved D is trib utio n of Hursing Personnel 

and Services: State Model. (Western In te rs ta te Commission fo r Higiier

»■ Education)

This e ff o rt is being directed toward the systematic use of data 

available on a national basis , but capable of being disaggregated 

to State and county le vels , to determine nursing resources and requirements. The approach being designed is one th at would allow 

fo r pr ac tic al applic ation at the State le v e l. Proje ctions w il l 

be made fo r a 5-year period since that time frame is best suited 

to a trend approach. Since th is a c ti v it y is most spe cific a lly directed 

to the State le vel, i t w il l form the basis of the fir s t- le v e l analysis 

on the numbers of nurses av ailable and the numbers require d in each 

State. The impact of these individu al State data nationally w il l be 

examined through the ap plication of uniform c rit e ria in each State.

Since the areas th at are being addressed in th is a c ti v it y are p a rt ic ­

ula rly releva nt to ov erall health planning as well as to nurse 

requirements, th is w il l be incorporated in to the ov erall analysis to 

provide ad ditiona l in sig ht in to the ef fe ct s o f the de livery system *

on nurse requirements.
237

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4. Micro-Model fo r Nursing Manpower Heeds. (CSF, Ltd.)

The model is intended to incorporate demand anc supply factors 

into a framework fo r determining nursing manpower requirements 

on a sub-State le ve l. I t w il l have a ca pabi lity fo r annual requirement proje ctions over a 10-year period. The model incorporates 

three submodels: health services u ti li z a ti o n , nursing manpower 

demand, and nursing manpower supply. I t w il l take in to account 

reg istered nurses, licensed pr ac tic al nurses, and nursing aides/

« attend an ts/order lie s. The supply model w il l be on a county lev el

and requirements w il l be developed on an in stitu tio na l and county 

le ve l.

These modeling effort s w il l not only serve the important purpose of furth er ing 

the an alytical ca pability fo r th is series of repo rts , but w il l have wider ap plication.

In the development of approaches and in the consideration of outcomes, partic ula r 

attention has been paid to the need fo r effect iv e tools at oth er leve ls. Thus, i t is 

an ticipated th at, in addition to the actual generation of requirements estimates from 

a Federal viewpoint, the processes w il l be developed in a way that could provide 

material appropriate fo r con sideration by States ar.d the newly developing Health Systeras 

Agencies in th e ir planning.
238

NATIO NAL ASSO CIA TIO N OF FA RMWORKER O RGANIZ ATIO NS

1329 E Street, N.W ., Suite 1146

Weehinflton, D.C . 20004

202-347 2407

February 22, 1978

Dr. Karl Shapiro 

Subcommittee on Hea lth & 

Scientific Research 

Committee on Hum an Resources 

Roo m 4230

Dir ksen Senate Office Build ing 

Washington, D.C. 20510

Dear Dr. Shapiro:

Enclosed please find written testimony 

mit for considerati on in the develo pment of 

Exte nsio n Act of 1978.

that NAFO wishes to subS. 2474, the Health Services

Should you have any questi ons with the testi mony or require any 

additional information, please feel free to contact either myself or 

Sandy Breedlove at the above number.

Sincerely

P. Vecchio 

Directo r of Health & Educ atio n
I WISH TO THANK T HIS SUBCOMMITTEE FOR THE O PPOR TUNI TY 

TO ADDRES S TH E HEALTH NEEDS OF FARMWORKERS AND THE EXTENSION OF 

THE MIGRANT HEALTH PROGRAM.

Farmworker families, particularly thos e who follow

SEASONAL EMPLOYMENT, HAVE BEEN TRAD ITIO NALL Y EXCL UDED FROM THE 

TYPICAL SYSTEMS OF BOTH PRIVATE AND PUBLIC HEAL TH CARE. AMONG 

THE BARRIERS THAT IMPEDE THE FARMWORKER FAMILY'S ACCE SS TO EVEN 

THE M OST FUNDAMENT AL FORMS OF HEALTH CARE ARE:

• Lack of purchasing pow er;

° Migratory employment within isola ted, rural areas

(lack of health personne l, inconvenient health

FACILITY HOURS, LIMITED TRANSPOR TATI ON, INCONTINUITY OF CARE, ETC.);

• Limited Educat ion, resulting in lack of consumer

KNOWLEDGE AND VULNERABILIT Y;

© Discrimin ation, resulting from bein g poo r, a member

OF A MINORITY GROUP, AND/ OR INABILITY OR LIMITED 

ABILITY TO S PEAK ENGLISH; AND

• Special health characte ristics, part icul ar to the

FARMWORKER POPULATION (ENV IRON MENT ALLY -INDUCED C ONDITIONS SUCH AS PESTICIDE POISONING, NUTR ITIO NAL 

DEFICIENCI ES, HYPERT ENSION, TUBE RCUL OSIS , ETC.),
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The Migrant Health Act, initiated by Congres s in 1262 in

AN ATTEM PT TO ADDRE SS THE UNMET HEALTH NEEDS OF FARM WORK ERS AND 

THEIR FAMILIES, FOCUSED ATTENTION ON THE UNIQUE HEALTH NEEDS OF 

THE MIGR ANT POPULATION, NECESS ITATING A SPECI AL SYST EM O F HEALTH 

CARE DELIVERY. THE ACT WAS REFINED AND IMPROVED IN 1965, 1970, AND 

1973 BY AMEN DMEN TS DESI GNED TO EXPAND SERVIC ES TO PROV IDE HOSPITAL 

CARE, EXPAND COVE RAGE TO SEASONAL FARMWORKERS, AND REQU IRE POLICY 

LEVEL INPUT BY THE CONSUMER.

Migrant health centers and projects have beco me the

PREDOMINANT HEALTH CARE PROVID ERS FOR THE FARM WORK ER POPULATIO N —

IN MANY CASES THE ONLY PROVIDERS. HOWEVER, IT IS ”

«> Because the initial barriers to healt h care still

exis t;

• Because health care needs still remain un met; and

o Because problems within the Migrant Health Program

CONT INUE TO BE IDENTIFIED.

THAT THE NATIONAL ASSO CIAT ION OF FARMWORKER ORG ANI ZAT ION S (NAFO) 

URGES THIS SUBCO MMIT TEE TO CONSIDER THE FOLL OWIN G IN LIGH T OF 

S. 2474, The Health Services Extension Act of 1978.

Lack of purchasing powe r, the farmw ork er's primar y obstacle

IN OBTAINING HEAL TH CARE, IS A LSO THE MIGR ANT HEALTH PROGRAM'S MAJO R 

DEFI CIEN CY IN PROVIDING HEALTH CARE SERVI CES TO THE ELIGIBLE FARMWORKER POPULATION. HO PROGRAM, REGARD LESS OF INTENT, DESIGN, OR 

COMP ETEN CY OF STAFF, CAN DELIVER COMP REHE NSIV E SER VICES WITH AN INSUFF ICIE NT FUNDING BASE.
241

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OF STAFF, CAN DELIVER COMPREHENSIVE SERVICES W ITH AN INSUFFICIENT 

FUNDING BASE.

Migrant health centers have indeed dem onstrat ed a positive

RECORD OF ACHIEVEMENT IN REDUCING THE OVERALL COST PER PATIENT VISIT, 

INCREASING THIRD-PARTY REVENUES, AND EXPANDING SERVICES TO THE 

FARMWORKER POPULATION. AND YET, 80% OF THE ELIGIBLE FARMWORKER POPULATION IS NOT SERVED THROUGH THE MIGRANT HEALTH PROGRAM — AND, IS 

UNLIKELY TO BE SERVED OUTSIDE OF IT. To RENDER ADEQUATE HEALTH SERVICES TO THE 2,7 MILLION FARMWORKERS PLUS DEPENDENTS, USING EXISTING 

FUNDS, MIGRANT HEALTH CENTERS AND PROJECTS WOULD HAVE TO SUB STANTIALLY.

REDUCE COSTS PER PATIENT VISITS — AS WELL AS HIRE "MILAGROSOS", 

MIRACLE WORKERS.

IT HAS BEEN ESTIMATED IN PREVIOUS CONGR ESSIONA L HEARINGS 

THAT THE MIGRANT HEALTH PROGRAM REQUIRES ANYWHERE FROM $215 - $600 

MILLION TO RENDER ADEQUATE HEALTH CARE TO ALL QUALIFYING INDIVIDUALS.

1. We urge this subco mmit tee to autho rize the following funding

LEVELS THROUGH FY1983 FOR MIGRANT HEALTH:

Planning Operat ion Hqsp.u a li zat.ipn

FY 1979 $ 10 MIL. $ 100 MIL $150 MIL.

FY 1980 11 MIL. 110 MIL. 165 MIL.

FY 1981 12.1 Mil. 121 .1 MIL. 181 .5 MIL.

FY 1982 13.3 MIL. 133 .2 MIL. 199.7 MIL.

FY 1982 1A.6 MIL. 1A6.5 m i l. 219.7 MIL.
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2 . We also urge this Subcommittee to consider administrative

ALTERNATIVES WITHIN THE MIGRANT HEALTH PROGRAM TO UTILIZE 

EXISTING MONIES MORE EFFICIEN TLY AND HOLD THE PROGRAM MORE

ACCOUNT ABLE TO THE PEOPLE IT SERVES,

A . Rural Health Initiative

NAFO CANNOT SANCTION THE USE OF LIMITED M IGRANT HEALTH MONIES

TO FUND RHI PROGRAMS' AND ASKS THAT HEW BE HELD MORE ACCOUNTABLE FOR 

THOSE FUNDS M ANDATED TO MIG RANT HEALTH CARE. In FY 19 77 ALONE' $4.5 

MILLION' OR R OUGHLY 13% OF THE TOTAL MIGRANT HEALTH FUNDS' WERE CONSCRIPTE D FOR USE IN THE R H I,

Consider the relationship between source of funding and

POPULATION USE IN THE FOLLOWING THRE E RHI PROGRAMS DURING FY 19 76 

ACCORDING TO HEW FIGURES:

• At AN RHI CENTER IN FLORIDA' 22 .5 % OF THE TOTAL HEALTH 

SERVICES PROVIDED WERE USED BY MIGRANT AND SEASONA L FARMWORKERS. HOWEVER' 84% OF THE PROGRAM'S T OTAL FUNDS WERE 

DERIVED FROM MIGRANT HEALTH MONIES.

• An RHI CENTER IN TEXAS' PROVIDED 46 .6 % OF ITS TOT AL SERVICES 

TO FARMWORKERS' WHILE 8 1 .4 % OF THE PROGRAM'S TOTAL FUNDS 

WERE ACQUIRED THROUG H MIGRANT HEALTH FUNDS.

• IN CALIFORNIA' 4 3 .3 % OF AN RHI program's TOTAL SERVICES 

PROVIDED WERE UTILIZED BY MIGRANT AND SEASONAL FARMWORKERS;

87% OF THE TOTAL FUNDING WAS RECEIVED FROM MIGRANT HEALTH.

(SEE APP END IX A FOR MORE DE TAILE D A N ALYSIS ).

Migrants lose more than money to the Rural Health Initiative -

THEY ALSO LOSE THE CONTROL OF THE PROGRAM IN RELATING SERVICES TO NEED 

THROUGH A VERY LIMITED LEVEL OF POLICY INPUT. FARMWORKER-GOVERNED 

BOARDS' A MANDATE D COMPONENT OF THE MIGRANT HEALTH CENTER' ARE REPLACED 

BY BROAD CONSUMER BOARDS IN THE RHI PROGRAM. In 1976 ONLY 1 (ONE)
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OUT OF 138 (one hundred thirty-eight) RHI grants went to a farmworker-governed HEALTH PROVIDER. LIMITED BILINGU AL OUTRE ACH AND 

SERVICES, MINIMAL COMMUNITY EDUCATION PROVIDED TO FARMWORKERS, AND

UNDER-UTILIZATION OF S ERVICES BY THE FARMWOR KER ARE THE END RESULTS. 

Stated v e r y simpl y, the focus on farmworker health needs as unique

FROM THOSE OF THE LARGER POPULATION, IS SUBSUMED UNDER A SYSTEM D ESIGNED TO DELIVER SERVICES TO A BROADER GROUP OF INDIVIDUALS “ THE 

VERY REASON FOR THE ESTABLISHMENT OF THE MIGRANT HEALTH PROGRAM IN

* 1962.

Until there is a concrete formula for funding RHI programs

OUT OF MIGRANT MONIES, BASED UPON ACTUAL USE OF SERVICE S BY SEASONAL 

AND MIGRANT FARMWORKERS, AND UNTIL THERE IS AN APPROPRIATE MECHANISM 

TO ENSURE ADEQUATE POLICY INPUT BY THE FARMWORKER, THE FLOW OF MIGRANT 

MONIES INTO THE FHI MUST BE STOPPED.

B. Cons olid atio n qf Pub l ic Hea lt h Serv ic e CP.HS) Authorization s.

We understand that the House Subcommittee on Health and the

Environment is considering a consolidation of Public Health Service

monies. Based upon the funding realities of the RHI and other

"integrated" systems of health care financing, we forsee no benefit

OF SUCH A CONSOLIDATION OF FUNDS FOR MIGRANT HEALTH. In FACT, WE VIEW 

SUCH A CONSOLIDATION AS ENCOURA GING A POLITICIZED DISTRIBUTION OF

FUNDS AMONG THE PUBLIC HEALTH PROGRAM S AND A GRAVE THREA T TO THE CONTINU ING EXISTENCE OF MIGRANT HEALTH PROGRAMS.

We strongly urge this subcommittee to maintain separate

• AUTHORIZA TION LEVELS FOR THE PHS PROGRAMS AND ESTABL ISH A MEC HANISM 

TO ENSURE THAT MIGRANT HEALTH PROGRAMS RECEIVE COMPA RABLE FUNDING INCREASES as other Public Health Service progr ams, particular ly community

HEALTH CENTERS
244

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C. Coordination of Federal Initiatives in Farmworker Health

P .L . 93-6 44, Section 5(b) gives CSA authority to

COORDINATE, REVIEW, AND MONITOR FEDERAL MIGRANT PROGRAMS. We URGE 

the Subcommittee to find out why this coordinating mechanis m is not

FUNCTIONAL, AND CONSIDER FUNDING CSA TO PERFORM TH IS RESPONSIBILITY,

IF IN FACT, LACK OF FUNDING IS THE PROBLEM SOURCE.

A LINKAGE MUST BE DEVELOPED AM ONG THE DEPA RTME NT OF A GRICULTURE (W IC, Summer Feeding), the Department of Labor (C E T A ), HEW 

(TITLE I OF THE MIGRANT EDUCAT ION PROGARM, MATE RNAL AND CHILD HEALTH), 

and the Department of Transporation (rural transportation funds) for

MORE EFFECTIV E AND EFFICI ENT USE OF RESOURCES.

• AS THE COORDINATOR, CSA MUST CONSIDER THE FOLLOWING:

• All programs adminis tered through the state local agencies,

SHOULD A DDRES S AND INCLUDE FARMWORKERS IN THEIR PLANS;

• A COMMUNITY EDUCAT ION PLAN MUST BE DE VELO PED TO INFORM FARMWORKERS AND FARMWO RKER AGENCIES OF AVAILA BLE RESOUR CES AND

ENROLLMENT PROCEDURE; AND

• All farmworker health grantees (Sec. 31 9) should be encouraged to

UTILIZE OTHER EXISTING PROGRAMS AS WELL.

NAFO ALSO RECOMMENDS THAT THE FEDERAL GOVE RNME NT ASSUME A 

STRONG LEADERS HIP ROLE IN PLACING PRESSURE ON STATES, LOCALITITES, AND 

MOST IMPORTANTLY, THE EMPLOYER, TO ACCE PT MORE RESPONSIB ILIT Y IN P ROVIDING HEALTH CARE TO FARMWORKERS.

D. Fiscal Management of Special Migrant Health Projects

Given the limited resources available for migrant health, we

WOU LD LIKE TO SEE THE OFFICE OF MI GRANT HEALTH, BC HS , EXPLORE MORE COST 

EFFECTIVE APPROA CHES IN THE DELIVERY OF H EALTH CA RE TO MIGRANTS, PART-
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ICULARLY IN THE HOSPITAL IZATION AND ENTITLEMENT PROGRAMS. We SUGGEST 

THAT THE OFFICE FIND ADMINISTRATIVE ALTERNATIVES TO THE USE OF 

Blue Cross/Blue Shield as the fiscal intermediaries in the interstate

Entitlement Progra ms, and explore contractual arrangements with

HOSPITALS, USING REIMBU RSEMENT RATES MORE COST-EFFECTI VE THAN THE 

hosp ital's own UCR (usual and costomary charge).

I WILL NOW DI RECT MY REMARKS TO THOSE CONCERN S THAT MORE 

DIRECT LY AFFECT THE INDIVIDUAL OPERA TION OF AND SERVICES PROVIDED BY 

THE MIGRANT HEALTH CEN TERS AND PROJECT S THEMSELVES.

EL IGIBILIT Y

To QUALIFY FOR SER VICES PROVID ED UNDER SECTION 319, RECIPIENTS

MUST MEET RESIDE NCE AND WORK CRITERIA. BECAUSE THERE IS NO FUNCTIONAL 

DEFINI TION OF FARMWORKER, THE FOLLOWING ARE EXCLUDED FROM RECEIVING 

HEALTH CARE BENEFITS:

• Older and/or disabled farmworkers who can no longer work

in the field s;

• FARM WORKING CHILDREN WHOSE PARENTS ARE POOR SMALL FARMOWNERSJ

AND,’

• LOCAL CHILDR EN ENGAGED IN SEASONAL FARM LABOR W HOSE PARENTS

ARE UNEMPLOYED.

A NATIONAL DEFINI TION OF FARMWO RKER MUST BE DEVELOPED, FLEXIBLE 

ENOUGH, SO AS NOT TO EXCLUDE THOSE INDIVIDUALS FROM RECEIV ING MIGRANT 

Health Services that are legitimately employed as farmw orkers, have

SPENT THE GREATER PORTION OF THEI R WORKING LIVES AS AGRI CULTURE LABORERS, 

OR H AVE BECOME DISABLED AS A FARMWORKER.

v
246

- 8 -

PCHS Fund in g Formul a .

The cost of providing medical care varies significantly

FROM REGION TO REGION. THOSE REGIONS WHERE FEWER FARMWORKERS RESIDE 

AND NETWORKS OF MIGRANT HEALTH CENTERS ARE NOT APPARENT W ILL HAVE 

HIGHER COSTS FOR NECESSARY TRA NSPORATION AND OU TREACH SERVICES. In

ADDITION, THE COST OF LIVING VARIES FROM ONE REGION TO ANOTHER. AND 

YET, THE BCHS FUNDING FORMULA IS BASED TOTALLY ON THE NUMBER OF FARM- *

WORKERS WITHIN THE AREA AND THE NUMBER OF CL IENTS SERVED.

We suggest THAT BCHS TAKES into account the varying health w

NEEDS OF FARMWORKERS IN DIFFER ENT GEOGRA PHIC AREAS - VARIAN CES IN 

CLIMATE, CROPS, COST OF LIVING, AND POPULATION DISTRIBUTION - AND 

DEVEL OP MORE FLEXIBLE AND EQUITABL E FARMWORKER HEALTH GRANTS.

National Health Services..Cores

With the large numbers of Spanish-Speak ing, Asian, and

Arabic farmworkers, communicat ion barriers and lack of cultural understanding OFTEN RESULT IN UNDERUTILIZATION OF AV AILA BLE FARMWORKER 

HEALTH SERVICES.

WE RECOMM END THAT THE NATIONAL HEALTH SERVICES CORPS BE PARTICULARLY SENSITIVE TO CULTURE AND LANGUAGE WHEN TRAINING HEALTH 

PERSON NEL FOR PL ACEMENT IN MEDICALLY UNDERSE RVED AREAS. HEALTH PERSONNEL ASSIGNED TO MI GRANT HEALTH CENTERS AND PROJEC TS SHOULD COME 

INTO THEIR PLACEM ENT WITH AN UNDERSTANDING OF TH E POPULATION THEY WILL 

SERVE - PRIMARY LANGUAGE, CULTURA L BACKGROUND, AND LIVING AND WORKING 

CONDITIONS. All EFFORTS SHOULD BE MADE TO SOLICI T THE INVOLVEMENT 

of Spanish-speaking individuals and othe rs, conversant in needed *

LANGUAGES, IN TH E NATIONAL HEALTH SERVIC ES PROGRAM.
247

- 9 -

Na tio n a l Ad v is o ry Co u n c il for Mig ra nt Hea lx ±

In order to ensure accountability and responsiveness to

FARMWORKERS IN THIS NATION, NAFO RECOMMENDS EXPANSION OF THE 

AUTHORITY AND ROLE OF THE NATIONAL ADVISORY COUNCIL FOR MIGRANT 

Health, inclu ding:

• Recognition of NA CM H as the focal point for dialogue between

HEW AND THE FARMWORKER C OMMUNITY;

• RESOURCES TO HIRE STAFF TO PROVIDE NECESSARY PLANNING,

REVIEW AND OVERSITE RESPONSI BILITIES ; 4

• RESOURCES TO C ONDUCT FOUR REGIONAL MEETING S PER YEAR IN

ORDER TO EVALUATE H E W 'S EFFORTS IN PROVIDING HE ALTH CARE

TO FARMWORKERS; AND

• RESPONSIBILITY OF NA CM H TO SUBMIT AN INDEPENDENT EVALUATION 

of H E W 's Migrant Health Program yearly to the Secretary, DHEW .

In order to ensure representation of farmworkers throughout

the Nation NAC MH should be composed of active migrant and seasonal

FARMWORKERS FROM EACH OF THE TEN (10) FEDERAL REGIONS SELECTE D BY 

farmw orker-governed health projects within each Region, five (5) 

REPRESENT ATIV ES FROM VA RIOUS HEALTH PROFESSI ONS AND OCCUPATIONAL AREAS, 

AND A RE PRESENTATIVE FROM THE MIGRANT DIVISION OF BC HS AND A REPRESENTAT IVE from the Secre tary,

In closing, I wish to again point out that the track record

for the Migrant Health Program has been a good on e. Howev er, with

SUFFI CIEN T FUNDING AND A FIRM M ECHA NISM IN PLACE TO AS SURE THAT THE 

» PROGRAM IS B OTH RESPONS IVE AND ACCOUNTA BLE TO THE FARMWORKER, THE

PROGRAM CAN BEGIN TO REACH MO RE THAN THE CURRENT 15-20% OF THE 

MEDICALLY UNDERSERVED POPULATION,

Thank yo u.
(APPENDIX A)

MIGRANT AND SEASONAL POPULATION V. ACTUAL USE BY MIGRANTS IN CERTAIN HEALTH PROJECTS

NAME AND REGION

POPULATION IN COUNTY 

1 ACTUAL USE BY: 

2

o

H>

Ir*MIGRANT SEASONAL TOTAL MIGRANT SEASONAL OTHERS 1

1 . ♦Oak O rc h a rd Com mun ity B ro c k p o rt, N .Y . R eg . 2 1 ,1 2 6

1 299 1 ,3 2 4 32 3 o r 23 o r 1 ,4 2 0 o r 1 ,7 6 6

% o f u s e r s t o t o t a l POP ,

16 .58% 18.3% 1.3 % 8 0.4%

2. *C om mun ity H e a lt h o f S. Da de M ia m i, F l a . R eg . 4 1 1 ,0 0 0 9 ,0 0 0 2 0 ,0 0 0 1 ,5 5 7 o r 1 15 8 o r 9 ,3 3 8 o r l2 ,0 5 3 % o f u s e r s to t o t a l p o p .

15 .08% 12 .9% 9.6 % 77.5%

1 7 S t a t e Bd . Of H lt h ., C h a r le s to n Co. H lth , C h a r le s to n , S .C . 350 900 1 ,2 5 0 19 o r 38 o r 271 or- / 328

R egio n 4 % o f u s e r s t o t o t a l p o p . 82.6% 1.4 9% 5.8 % 11 .6%

4. ♦ D a rk e -M e rc e r-S h e lb y R eg . H lt h 1 ,6 7 2

S e r v ic e 2 ,1 4 1 1 ,5 7 1 3 ,7 1 2 29 1 o r 0 o r 1 ,3 8 1 o r G r e e n v i l l e , O hio R eg . 5 % o f u s e r s t o t o t a l p o p . 11 .64% 17 .4% 0.0% 82.6%

5. ‘ S o u th P l a i n s H e a lt h P r o v id e r 1 5 ,7 3 5 4 ,3 5 0 2 0 ,0 8 5 2 ,1 8 1 o r 1 004 o r 3 ,6 5 4 o r 6 ,8 3 9 P la in v ie w , T ex as Reg . 6 % o f u s e r s to t o t a l p o p . 9.8 1% 31.9% 14.7% 53.4%

6. *Ji m Ha gg C ty . M ig ra n t H e a lt h R io G ra nde C i t y , T ex . R eg . 6 73 9 85 824 61 o r 104 o r 179 o r 344 % o f u s e r s to t o t a l p o p .

26 .07% 17.7% 30.2% 52.0%

7'i P ro gra m d e S a lu d de N o rth e rn

C o l. 1 ,6 6 8 6 ,5 8 6 8 ,2 5 4 21 3 o r 81 o r 475 o r 769 % o f u s e r s to t o t a l p o p .

G i l l , C o lo ra d o R eg . 8 2.2 2% 27.7% 10.5% 61.8%

8. M aric o p a Co. H e a lt h D e p t. P h o e n ix , A r iz . 2 ,3 9 5 1 2 ,3 2 6 14,7 21 10 6 o r 35 0 o r 1 ,9 0 7 o r 2 ,3 6 3 % o f u s e r s to t o t a l p o p .

Reg . 9 0.0% 4.5 % 14.8% 80.7%

9. ♦O ra nge Cov e F a m il y H e a lt h O ra nge C ove, C a. 3 6 ,0 4 0 5 8 ,3 2 3 94,3 61 1 ,2 8 5 Or 498 o r 2 ,3 3 0 o r 4 ,1 1 3 % o f u s e r s to t o t a l p op.

R eg. 9 5.5 7% 31. 2% 12.1% 56.6%

10 ? +N. S a c ra m e n to V a ll e y H e a lt h

P r o j e c t 3, 73 1 - 3 ,7 31 126 o r 598 o r 1 ,2 3 1 1 ,9 55 ' " o f •!::« r :; f n i i ' t a l p o ;.. • 4. K 6 .4 '. 3 0 .6 R cq . 9 f. 3. 0

248
MIGRANT AND SEASONAL POPULATION V. ACTUAL USE BY MIGRANTS IN CERTAIN HEALTH PROJECTS

NAME AND REGION POPULATION IN COUNTY 

MIGRANT SEASONAL TC

ACTUAL USE BY:

]]. +Community Health Clinics, Inc

Nampa, Idaho Reg. 10 . 9 333 1,522 10,855 299 or 480 or 2,000 or 2,779 % of users to total pop.

9.74% 10.8% 17 3% 72%

*RHI Projects 

+HURA Projects

Unmarked are Migrant Health Projects

Table J , 1973 Migrant Health Target Population

2

^Table 1, 1975 Migrant Health Projects, Summary of Project Data, Migrant Health Report 4. 

Table 12, 1975 Migrant Health Projects, Summary of Project Data, Migrant Health Rbport 4.
250

- 12 -

MIGRANT/P.HI PROJECTS 

F .Y . 19 76

31 9 F unds 

MIGRANT 

HEALTH 

PROGRAM

33 0 F u n d s 

COMMUNITY 

HEALTH 

CENTERS

P.HI

R e g io n I 1

W ash in g to n Co. H e a lth P la n 8 9 ,0 7 0

R e g io n I I 3

Oak O rc h a rd Com m uni ty R e f e r r a l 2 0 0 ,0 0 0

P u e r to R ic o D e p t. o f H e a lth 

s 'e s t e r n R eg io n

Com m on wea lth o f P u e r t o R ic o

1 6 2 ,9 8 2

D e p t. o f H e a lth 2 0 0 ,0 0 0

R e g io n I I I 1

I n t e r c o u n t y H e a lth I n c . 8 1 .5 7 4 1 9 8 ,6 2 1

R e g io n IV 4

C o l l i e r Co. H e a lth D e p t.

W. O ra nge F a rm w o rk e rs H lth . C lin 

F l o r i d a R u ra l H e a lth S e r v i c e s 

F r o s t p r o o f , F l o r i d a

1 7 2 ,7 9 4 3 1 2 ,9 4 0

2 3 0 ,9 3 1

Com m un ity H e a lth o f S o . Dad e 7 2 5 ,6 5 1 1 4 3 ,5 5 0

R e g io n V 2

D a rk e -M e rc e r-S h e lb y R e g io n a l

H e a lth S e r v i c e s 5 0 ,0 0 0 2 0 0 ,0 0 0

S p a r ta H e a lth C e n te r 3 0 ,0 0 0 2 0 0 ,0 0 0

R e g io n VI 7

G o n z a le s Co. Me d. S o c i e t y 1 7 5 ,2 5 3 1 5 ,0 0 0

C a th o l i c C h a r i t i e s I n c . 9 1 2 ,5 0 9 4 5 0 ,0 0 0

H id a lg o Co. H l t h . C a re C o rp . 7 0 1 ,5 0 0 1 8 6 ,7 6 8

Com m un ity A c tio n C o u n c il 2 5 3 ,2 6 5 1 0 3 ,1 7 5

Home E d u c a tio n L iv e lih o o d P ro g . 5 0 ,0 0 0 1 8 5 ,0 0 0

S o u th P l a i n s H lth . P r o v i d e r O rg . 4 3 5 ,9 1 3 9 9 ,3 8 8

S o u th w e s t M ig r a n t A s s o c i a t i o n 2 7 5 ,0 0 0 1 9 2 ,2 8 9

R e g io n IX 4

M erc ed F a m il y H e a lth C e n te r 3 7 2 ,0 0 0 2 0 0 ,0 0 0

O ra n g e Cov e H e a l t h ' C e n te r 1 ,3 3 5 ,3 8 1 2 0 0 ,0 0 0

Yuma Co. M ig r a n t H e a lth C e n te r 1 0 0 ,0 0 0 1 9 4 ,0 0 0

C l i n i c a S i e r r a V i s t a , L am o n t, CA

*

►

22 5 ,7 7 0 ,8 4 0 9 6 4 ,7 0 8 2 ,7 9 9 ,0 0 6
251

JAMES H SAMMONS. M 0 

Eiecutiv* Vice President 

(751 6200)

A m e r ic a n M e d ic a l A s s o c i a t i o n

53 5 NORTH DEARBORN STREET • CHICAGO ILLINO IS 60 61 0 • PHONE (3 1 2) 75 1 60 00 • TWX 910 221 03 00

March 8, 1978

■ The Honorable Edward M. Kennedy

Chai rman

Subcommittee on Health and 

S c ie n ti fi c Research

Committee on Human Resources 

* United Sta tes Senate

Washington, D. C. 20510 

Dear Senator Kennedy:

The American Medical Ass oc iatio n submits the fo llo w in g 

statem ent on the extens ion o f cert ain programs under the 

Pub lic Health Se rvice Act and the Lead-Based Pa int Poisoning 

Prevention Ac t.

The AMA urges the re auth orization o f cert ain o f these 

programs at ap pr op ria te le vels . Although we be lie ve th at 

several pr ov isions o f the law pertain in g to programs should 

be amended, i t is ou r understanding th at the Committee is now 

co ns idering on ly an extension o f most o f the exp irin g pro vis io ns, 

and th at co ns ider at ion of su bs tantive re vis io ns o f programs w il l 

occur at a la te r tim e. Th erefore, we w ill res erve any spe cif ic 

sug gestio ns fo r change to these programs u n ti l th e ir la te r 

co nsider atio n by the Subcommittee.

We request th a t th is statem ent be made pa rt o f the 

Subcommittee's rec ord on S. 247*1.

Enclosure

28-3 86 0 - 78 - 17
Sta teme nt

o f the

AMERICAN MEDICAL ASSOCIATION

Re: S. 2474, H ealth Serv ices Extension Act o f 1978

Su bm itted to th e

Sub com mittee on Hea lth and S c ie n tif ic Research 

Com mittee on Human Resources

U nite d Sta te s Senate

March 8 , 1978

The Subcommittee on Hea lth and S c ie n tif ic Resea rch is p re s e n tl y consid ering 

exte nsions o f se ve ra l h ea lth programs co nt ain ed in the P ublic Hea lth Serv ice

A ct.

The P ublic Hea lth S erv ic e Act is a major v e h ic le fo r much o f th e Federal 

fu ndin g o f h ea lth programs th ro ughout the c o u n tr y. The Act a uth ori ze s a v a rie ty 

o f ge ne ral gra nt programs w it h wide la tit u d e fo r th e d ir e c tio n o f th e programs 

to be take n by th e re c ip ie n t. Programs e x p ir in g th is ye ar in clu de thos e d ir e c te d 

towa rd p ro vid in g c e rta in h e a lth serv ic es (su ch as comm unity h e a lth ce nte rs , 

m ig ra nt h ea lth and o th e rs ) and a ls o in clu de progra ms in basic and applied 

re se arc h, dat a c o ll e c tio n and o th e r h e a lth a c t iv it ie s . S, 2474 co nta in s only 

a few o f thes e e x p ir in g programs and we w ill ad dres s o th e r e x p ir in g programs 

when commenting on the b il l s p e rta in in g to them.

We have revie we d the programs to be exten de d, many o f which we have 

su pp or ted fro m th e ir in c e p ti o n . W hile we rem ain s u pp o rt iv e o f most o f these 

a c t iv it ie s and urge th a t you fa vo ra b ly co nsid er exte ndin g them, we have als o 

in d ic a te d those which we b e lie ve sh ou ld no t be co ntinued. Althoug h we b elie ve
253

-2 -

th a t s u b sta n tive changes sh ou ld be made to c e rta in o f the programs fo r which we 

recommend c o n ti n u a ti o n , i t is our unders ta ndin g th a t such changes w ill not be 

co ns id ere d by Congress a t th is tim e. How ever, we would be happy to wo rk w it h 

the Subcommittee in deve lo pin g needed amendments and w ill re se rv e our comments 

and d e ta il e d su gg est io ns u n t il th a t tim e.

Our comments on programs now be ing co ns id ere d by th e Subcommittee fo ll o w .

1) Comprehensive P ublic H ealth Serv ices and Hyp ertension Programs

Th is is a blo ck g ra n t program fo r th e s ta te s and allo w s each s ta te wide

la tit u d e in s e le c ti n g how the money w ill be d is trib u te d . F re q ue n tly, thes e gra nts 

su pp ly th e sole Fe deral su pport fo r many a c t iv it ie s o f th e s ta te p u b li c h ea lth 

se rv ic e s .

The AMA has su pp or ted th is blo ck gra nt program sin ce it s in ce p tio n in 1966. 

The p ro v is io n s o f th e law have served to a m eliora te many o f the d if f ic u lt ie s th a t 

c h ara cte ri ze d th e sys tem o f c a te g o ric a l gra nts which e xis te d p r io r to th e enactment o f th is program. These blo ck g ra n ts to s ta te s have perm itte d each s ta te 

to meet it s p a r tic u la r needs by e s ta b li s h in g it s own p r io r it ie s .

We su pp ort a on e-y ear ext ensio n o f th is program a t fu ndin g le v e ls a uth ori zed 

in p r io r years .

We not e th a t a new p ro v is io n a ls o pro vid es fu ndin g fo r e s ta b li s h in g and 

m a in ta in in g s ta te programs fo r th e scre enin g, d e te c ti o n , d ia g n o sis , p re v e n ti o n , 

and re fe rra l fo r treatm ent o f hypert ensio n (th is was fo rm e rl y p a rt o f th e blo ck 

g ra n t pr og ra m ).

We su pport co ntinued e ffo r ts to deal w it h the problem s o f h ypert ensio n.

2) M ig ra nt Hea lth

» The h ea lth problem s o f m ig ra nt wor ke rs and th e ir fa m il ie s ar e acu te and

d e li v e ry o f serv ic es o ft e n re qu ir e s Fe de ral p a r tic ip a tio n . The p ro v is io n s which
254

-3 -

ar e co ns id ere d fo r exte nsio n a u th o ri ze th e S ecr eta ry to pro vid e gra nts to p u b li c 

and n o n -p ro fi t p riv a te e n t it ie s fo r p ro je c ts to p la n, de ve lop and opera te m ig ra nt 

h ea lth c e n te rs . These cente rs are to pro vid e prim ary and su pp lemen tal h ea lth 

Serv ic es to m ig ra to ry and seasonal a g ric u lt u ra l worke rs and th e ir fa m il ie s . Also 

a uth ori zed are co ntr a cts w it h s ta te s fo r th e im plem en ta tio n and en fo rcem en t o f 

accepta ble env iron m en ta l h ea lth st an da rd s in m ig ra nt la b o r camps.

Over the years , the AMA has c o n s is te n tl y su pp or ted Fe de ral e ffo r ts to 4

expand th e a v a ila b ilit y o f h e a lth serv ic es to m ig ra nt w ork ers . We have poin te d 

o u t, howe ver, th a t th e develop ment o f a fe d e ra ll y su pp or ted pro gra m u t iliz in g

*

v o lu n ta ry h ea lth insu ra nc e would be th e most a pp ro p ri a te means o f p ro v id in g h ealth 

care to m ig ra nt w ork ers . One o f the co ncerns ove r th e pre sent program th a t has 

been expres se d is an undue re lia n c e on m ig ra nt h ea lth cente rs as th e method o f 

p ro vid in g s e rv ic e s. Such s ta ti o n a ry cente rs may in fa c t be to o in f le x ib le to 

cope w it h th e needs o f a m ig ra to ry p o p u la ti o n . A pp ro p ri ate changes sh ou ld be 

co ns id ere d a t a la te r date . The ext ensio n o f the program fo r fiv e ye ar s w ith o u t 

a d e ta il e d re view is , we b e li e v e , in a p p ro p ria te . A si m ple exte nsio n sh ou ld be 

fo r o nly one year.

How ever, we do b e lie ve th a t th e program has he lped to pro vid e h ealth 

se rv ic e s to th e m ig ra nt wor ke r and sh ou ld be co nt in ued pend ing in te n s iv e re vie w .

T h e re fo re , we urge a one ye ar c o n ti n u a ti o n .

3) He mop hilia Program

This program pro vi des fu ndin g fo r gra nts fo r e s ta b li s h in g comp rehensive 

hem ophilia tr eatm ent cente rs and bloo d se para tion ce nte rs .

The AMA believes th a t th e in c lu s io n o f thes e p ro v is io n s in the PHS Ac t 

is un ne ce ss ary. We b elie ve th a t p riv a te and o th e r p u b li c programs have ad equat ely 

ca red fo r those perso ns w it h hem ophilia and can continue to pro vid e q u a li ty care .
255

-4 -

We b e li e v e th a t increa se d su pport fo r basic re se arc h wo uld be a more pro d u ctive 

use o f Fe de ral funds and wou ld , in fa c t, b e n e fi t many pe op le in a d d it io n to 

hem ophili acs. Con se qu en tly , we urge th a t th is p ro v is io n no t be ex tend ed .

*

4

A) Im mun iza tio n and Dis ease C ontrol and Venereal Disease C ontrol

These programs pro vid e fe dera l fund s to a s s is t s ta te programs o f imm unizatio n a g a in st in fe c ti o u s dis eases, c o n tr o l o f dise ase s borne by ro dents , pre vention 

and c o n tr o l o f ve ne re al disease and o th e r disease c o n tr o l programs.

These a c t iv it ie s re pre se nt a m ajor fe d e ra l- s ta te c o ll a b o ra ti o n to pre ve nt 

th e spread o f in fe c ti o u s and o th e r dis eases. The AMA has been s u pp o rt iv e o f thes e 

e ffo r ts and urge s th e ir c o n ti n u a ti o n .

We commend to the Congress a c h il d im m un izat ion b i l l re c e n tl y d ra ft e d by 

th e AMA. We b e lie v e th is b i l l would enhance c u rre n t e ffo r ts to in cr ease the 

im m un izat ion le v e ls among c h ild re n and we urge it s ado p tio n. How ever, ado ption 

o f thes e amendments would not be in c o n s is te n t w it h pre se nt e ffo r ts , and we su pp ort 

a c o n ti n u a ti o n o f th e e x is tin g im mun ization program.

Likew ise we support the exte nsio n o f th e ve ne re al dise ase c o n tr o l p ro v is io n s . 

This program has playe d an im portant ro le in co m ba tting one o f the most wide sp read 

o f comm unicable dise as es and sh ou ld co ntin u e . We do urg e, however, th a t incr ea se d 

emphasis be plac ed on develop me nt o f an im mun ization a gain st ve ne re al diseases.

Such a develop ment would prove the most e ffe c tiv e use o f fe d e ra l fund s in th e long pun.

5) N ational Hea lth Serv ice Corps

S. 2474 ex tend s fo r one ye ar and in cr ease s the fu ndin g le ve l fo r th e N ational 

H ealth S erv ic e Corps program.

We su pp ort th is program and urg e fa vo ra b le c o n s id e ra tio n o f th is ext ensio n 

p ro v is io n .

»
6) Community H ealth Ce nters

\le not e th a t th e Community Hea lth Ce nters pro gra m wo uld be extended fo r 

fiv e ye ar s and th a t new p ro v is io n s would be added to fund "pri m a ry ca re u n it s " 

o f urb an com munity h o s p it a ls fo r purpo ses o f p ro v id in g med ical ca re to popula tions 

des ig nat ed as ha ving sh or ta ge s o f pe rson al h ea lth se rv ic e s .

The Community H ealth Cen ters program is one in which specia l e valu a tion 

sh ou ld be made o f it s e ff e c ti v e n e s s and the e xte n t i t has d u p lica te d o th e r e x is tin g 

re sourc es. The program sh ou ld be c a re fu ll y evalu ate d befo re co n s id e ra ti o n o f 

le ngth y exte nsions o r s ig n if ic a n t new p ro v is io n s . C onsid era tion sh ou ld be given 

to in c o rp o ra tin g thes e fund s as p a rt o f a blo ck g ra n t to th e s ta te s w it h wide 

la tit u d e pro vided to the s ta te s as to how th ey d is tr ib u te the fu nds. There fo re , 

we urge th a t no exte nsio n to th e program be o f more than one ye ar and th a t adoptio n 

o f new p ro vis io n s be de laye d u n til a fte r an a n a ly s is o f th e e x is tin g program can 

be co nd uc ted.

7) Lead-Based P ain t Poiso ning

Th is program pro vid es fo r id e n tific a tio n and rem oval o f lead -based p a in t 

haza rds in b u il d in g s .

We su pp ort th e exte nsio n o f th is program .

8) Gen etic Diseases

The p ro v is io n pro vid es fund s fo r prog rams to sc reen and counsel thos e 

w it h genetic disease s. I t a ls o fund s educational and in fo rm a ti o n a l programs in

th is are a.

We su pp ort a one ye ar exte nsio n o f these a c t iv it ie s as proposed in S. 2k7 k.
257

-6 -

9) Home H ea lth Serv ices

These funds ar e used to pro vid e gra nts to dev elop home h e a lt h se rv ic e s and 

to tr a in th e pe rson ne l needed to pro vid e thes e se rv ic e s .

Home h ea lth ca re can be an e ffe c tiv e mechanism fo r ca ri n g fo r many pe op le 

who need med ical assis ta nce bu t do not re q u ir e h o s p it a li z a tio n . S. would

extend thes e programs fo r th re e years ; howe ver, we b e lie v e th a t th e programs 

sh ou ld be evalu ate d befo re a le ngth y exte nsio n is ad op ted. Ue support a one ye ar 

exte nsio n o f thes e g ra n ts .

Con clus ion

In co nclu sio n , we re it e ra te our su pport fo r a one ye ar exte nsio n o f the 

fo ll o w in g h ea lth programs e x p ir in g th is year: co mprehensiv e p u b li c h e a lth s e rv ic e s , 

m ig ra nt h e a lth s e rv ic e s , N ational H ealth S erv ice Co rps, Lead-Based P ain t Poisoning 

p re ve n tio n , im mun ization and dise as e c o n tr o l prog rams, ve ne re al disease c o n tro l, 

g en e tic dise ase a c t iv it ie s , home h e a lth serv ic es and comm unity h e a lth ce nte rs .

S ubsta ntive changes to c e rta in programs are w arr ante d, and we ag ain 

would be plea se d to o ffe r our a ssis ta nce in develop me nt o f changes when the 

Com mittee co nsid ers th e programs in g re a te r d e t a il .
95t h Congress 

2nd Ses sio n

B ill No. ______

IN THE (SENATE) (HOUSE) OF THE UNITED STATES 

Date __________

___________o f _________ in tr oduced the fo ll o w in g b i l l ;

which was read tw ic e and re fe rre d

to th e _______________ Com mittee

A BILL

To pro vid e fo r the im m un izat ion erf c h il d re n again st m ajor in fe c tio u s disease s.

1 Be i t enacted, by th e Se nate and House o f R epre senta tives o f the

2 U nited S ta te s o f Am erica in Congress assemble d,

3 FINDINGS AND DECLARATION OF PURPOSE

A SECTION 1. The Congress fi n d s th a t - -

5 1) Many comm unicable disease s are pre venta ble th ro ugh an ade quate

6 in fa n t and child hood im m un izat ion program;

7 2) th ere is an in cr ease d in ci dence o f some pre venta ble dise as es

8 due to th e d e c li n in g ra te o f im m un izat ion o f in fa n ts and c h il d re n ;

9 3) th e s ta te s , in c o n ju n c tio n w it h p riv a te and p u b li c h ea lth

10 s e rv ic e s , ar e th e most a p p ro p ri a te forum fo r a d m in is te rin g a c h il d

11 im mun ization program;

12 4) any im m un izat ion program sh ou ld be , in s o fa r as p ra c tic a b le ,

13 a p a rt o f a p re v e n ti v e h e a lt h ca re pro gra m c a rrie d o ut in conju nc14 tlo n w it h o th e r h e a lt h needs o f the c h il d ; and

15 5) th ere sh ou ld be no fi n a n c ia l b a rrie r to im m un izat ion o f

16 c h il d re n .
259

2

1 Th erefore, i t is the purpose o f th is Act to assis t the st at es to

2 develop programs to immunize childre n ag ains t prev en table in fe ctious

3 d i seases.

4 SECTION 2. The Public He alth Se rvice Act is amended by adding the

5 fo llow in g new section:

6 "Sec. 316. (a) The Se cretary s h a ll , according to the schedule in

i 7 subsection (b ), pay to any sta te (which has enacted a mandatory c h ild

8 imm unization program meeting the standard s o f subsection (c )) a portio n

9

•

10

o f the costs o f plan ning , implementing and ad m in iste ring such program.

Such payments shall also includ e the co sts o f necessary va ccines ,

11 me dic ations and ot he r tre atmen ts.

,2 "( b ) The Federal share payable to any State th at q u a li fi e s under

13 subsection (a) sh all be determ ined as fo llow s:

14 "( 1 ) fo r fi s c a l years 1979, 1980, and 1981, the Federal

15 share sh all be 100? o f the co sts o f the program;

16 " ( i i ) fo r fi s c a l years 1982 and 1983, the Federal share

17 shall be 75? o f the co sts o f the program;

18 " ( i l l ) fo r fi s c a l yea rs 1984 and 1985, the Federal share

19 sha ll be 50? o f the co sts o f the program;

20 " ( iv ) fo r fi s c a l year 1986 and succeeding ye ar s, the

21 Federal share shall be 25? o f the co sts o f the program.

22 "(c ) In or de r to q u a li fy fo r Federal payment under th is p a rt ,

23 a S ta te 's mandatory c h il d imm unization program s h a ll:

24 " ( i) be so structu re d as to achieve and maint ain an immuni25

26

za tion ra te of at le ast 90? ag ains t the diseases li s te d or to be

determined by the Se cretary as amenable to re duct io n, under

27 subsection ( c ) ( i i i ) fo r a ll childre n under age 18 In the State

• 28 w it h in two yea rs o f enactment o f such State program;
260

1

-3-

"(II) provide for necessary follow-u p immunizations where

2 medically indicated;

3 "(ill) provide immunizations against measles, rubella,

4 poliomyelitis, dlphtherta, pertussis, and tetanus and such other

5 diseases as the Secretary, after consultation with national

6 medical and public health or ganizations, may determine are

7 amenable to reduction through a c ompreh ensive immunization program;

8 "(iv) coordina te with, and utilize the services of, private

9 health practitioners and facilities to the extent practicable;

10 "(v) make available immunizations for all children and assure that *

11 there shall be no financial barriers to receipt of such immunizations;

,2 "(vi) provide that no child shall be forced to receive

13 Immunizations if that would contrave ne the child’s, or the parents'

14 or g uardians’ thereof, religious or moral beliefs; and

15 "(vli) provide for an accurate system of records of all

16 immunizations administered under the program and for notification

17 of an individual's personal physician of all immunizations administered

18 by a party, agency or other entity other than the personal physician.

19 "(d) In the event that the Secretary, after consultation with

20 national medical and public health organizati ons, determines under

21 subsection (c)(iii) that another disease (or diseases) is (or are)

22 amenable to reduction through a compreh ensive immunization program, the

23 Federal share of the state's expenses of an immunization program directed

24 at such disease (or diseases) shall, for the first two fiscal years

25 following such det ermination by the Secretary, be 100 percent. For

26 fiscal years following the first two years, the Federal share shall be

27 determined according to subsection (b).
261

-4 -

1 "(e ) There are auth orized to be appro priate d each ye ar such sums

2 as are necessary to implement the pro vis io n s o f th is s e c ti o n ."

3 SECTION k. Sec tio n 317 o f the P ublic Hea lth Ser vice Act is amended

4 by:

5 (a) d ele tin g from su bse ct ion (b )( 2 ) the sentence be ginn ing "The

6 Sec re ta ry sh all give specia l c o n sid e ra tio n " and endin g "p riv a te e n tit ie s

7 and v o lu n te e rs ." ;

8 (b) by d e le tin g from su bs ect ion (c )( 3 )( A ) the phrase "(in c lu d in g

9 va ccines and oth er pre ve ntion a g e n ts )" ;

10 (c) by d e le tin g from the f i r s t sentence o f su bs ect ion ( f) the

11 phrase be ginn ing w it h "ru b e ll a , measles "t hro ugh" dis eases), an d";

12 (d) by d e le tin g from the second sentence o f su bs ect ion ( f) the

13 words "v accin atio n pro gra m s, ";

14 (e) by d e le tin g su bs ect ion (g )(1 )(A );

15 ( f) by d e le tin g from su bs ect ion (g )( 1)( C ) the words "o r (B )"; >

16 (g) by renumbering parag rap hs (B ), (C) and (D) o f su bs ec tio n

17 (g )( 1) as " (A )", " (B )", and "(C )" re s p e c tiv e ly .

«

HEALTH SERVICES EXTENSION ACT OF 1978

WE DN ESDA Y, MA RC H 1, 1978

U.S. Senate,

Subcommittee on H ealth and Scientific Research,

of the Committee on H uman Resources,

Washington, D.G.

The subcommittee met, pursuant to notice, at 9 :35 a.m., in room 

4232, Dirksen Senate Office Building, Senator Edward M. Kennedy 

(chairman of the subcommittee) presiding.

Present: Senators Kennedy, Javits, Pell, and Chafee.

Senator Kennedy. We will come to order.

I am pleased to open this hearing on health services programs and 

the way we deliver health care in the United States. Today’s hearing 

will give us an opportunity to build on the record this subcommittee 

developed on these programs in field hearings last fall, and in a 

session last month during which the administration presented an 

outline of its proposals.

The subcommittee’s earlier hearings examined in detail the Community and Migrant Health Center programs. We visited several of 

these centers last November. I believe tha t the record we have developed will enable us to send to the Senate a bill which will provide 

for the needed long-term stability and continued growth of these 

programs. They have clearly demonstrated their effectiveness in delivering, at a reasonable cost, comprehensive health services to urban 

and rural communities previously without health services and health 

care facilities.

Today we will focus on some of the other important programs 

which are part of the Federal Government’s effort to strengthen 

health services delivery systems and to control and prevent special 

diseases.

Our first panel wP l discuss the critical state of maternal and child 

health service programs. Millions of children still lack the most 

basic health services. Federal programs created in 1912 are no longer 

responsive to the needs of today’s society. Right now there are almost 20 different major Federal programs which finance or provide 

health services for children and expectant mothers—programs in 

HEW , the Agriculture Department, and Headstart—and they are 

not coordinated.

Our panel this morning will describe how the fragmentation and 

duplication of Federal health care initiatives has resulted in large 

gaps and the waste of scarce resources. It is my hope tha t their comments will help us establish the kind of bold and far-reaching changes 

necessary in Federal-State legislation concerning child health care. 

(263)
264

We will also hear testimony on the extension of hyp ertens ion pr ogra ms and gr an ts fo r Publi c He alth Services. Hy pertension , for 

example, afflicts more than 23 million people. It is a majo r cause of 

strokes, which kill over 200,000 Am eric ans each ye ar and disable 

over 250,000 people under the age of 65. Our witnesses have extensive firsth and experienc e with these pro gra ms and I look forw ard 

to th ei r comm ents on the adequacy of present fu nd ing and changes 

which m ay be required in these pro grams.

Our final panel will discuss the impac t of genetic diseases and the 

effectiveness o f H E W ’s pro gra ms to assure th at the Americ an people 

have availab le to them the latest inf orm ation abo ut genetic diseases, 

and the latest and most effective coun selin g and tre atmen t services. 

Gen etic disease is a m ajor cause of disability and death in our population. It affects ind ividuals of all ages, and its consequences are as 

tra gic as any cause of ill hea lth.

We owe it to paren ts, their children and th ei r ch ild ren’s children 

to focus attention and resou rces on the devasta tin g diseases which 

are genetic in or igin .

The testimo ny we will he ar tod ay, tog eth er with inf orm ation 

gathe red in our earlier hea rings, shou ld pro vid e us with a sound 

basis fo r a final bill which will strength en and su pp ort pro gra ms to 

imp rove the delivery of healt h care services to those most in need.

I will ask the panel on ma ternal and child healt h to begin.

[The prepare d statem ent of Se na tor Ke nne dy follo ws :]

Prepared Statement of Senator Edward M. Kennedy

I am pleased to open this second day of hearin gs on health services programs. 

Today’s hearings will give us an opportunity to build on the record this subcommittee developed on these programs in field hearings last fall and in a 

session las t month during which the adm inistration presented an outline of its 

proposals.

The subcommittee’s earlie r hearings examined in particular detail the community health and migrant health c ente r programs.

We visited several of these community health centers las t November. At 

community health centers in Miami, Houston and Los Angeles I was impressed 

with their facilities and equipment, and with the very dedicated ami hardworking people who staff the centers. We talked with many of the people who 

use the centers. Without exception, they felt that in the absence of this grant 

program, they would not have access to the kind of care which they have a 

right to expect. They felt the ir participation in the governance of the centers 

helped make the services responsive to their needs and desires. And they expressed to me their feelings th at the support for the cente rs must continue and 

be expanded.

We also visited a migrant health center and a mig rant camp in Homestead, 

Florida. The con trast between the modern facilitie s available through the 

community health center in Miami, and the old, crowded ill-equipped health 

facility used by the migrants was startlin g. The migrants told me they could 

use the modern facility in Miami, but preferred the migrant health cente r 

which was closer to their camp, and where the staff seemed more sensitive to 

the ir special needs and problems. The migrants made it very clear to me that 

they felt they needed the special mig rant health program, and would oppose 

any consolidation of that program with the broader community health center 

program. They also pleaded for increased funding of the mig rant health program and continued requirements for migrant control of the projects.

These programs were examined in furth er detail at the Subcommittee hearing 

here in Washington last month. I believe that the record we have developed 

will enable us to send to the Senate a bill which provides for long term 

stability and continued growth in these programs which have demonstrated
265

the ir effectiveness in delivering comprehensive hea lth services to urban and 

rural communities previously with out health professionals or hea lth care 

facilities.

Today we will focus on some of the other imp orta nt programs which are p art 

of the fede ral government’s effort to strengthen health services delivery systems 

available for underserved areas and populations, and for control and prevention of special disease.

Government programs for children were among the first health care efforts 

of the Federal Government. Over the last sixty-five years they have provided 

services to many children who would otherwise not have received needed care. 

Tragically, however, there remain some five to ten million children in the 

United States withou t any public or private sources of comprehensive and 

continuous health care. They seek and receive treatm ent services only in times 

of emergency, lacking access to prim ary health care th at might have prevented 

these health crises. At the same time, the mothers of 10% of all newborns 

receive litt le or no prenatal care there by increasing the risk of subsequent

* illness and disability to themselves and their infants. Not unexpectedly, the 

poor, persons in rural and inner city areas, and minorities are disproportionately represented in the maternal and inf ant mortality and morbidity data 

which reflect insufficiencies of the cur ren t health and medical care system.

* Since the original Children’s Bureau was created in 1912, the basic organizational and delivery components of maternal and child health care have not 

been significantly changed. The evolution of concepts in health care organization, financing, and delivery in this country makes it impe rative th at this basic 

health legislation and its adm inistrative structur e be examined carefully and 

modified to meet current and futur e considerations bearing on the health of 

mothers and children. Right now there are almost twenty different majo r 

fede ral programs which finance or provide health services for children and 

expectant mothers—program s in HEW, the Agriculture Depa rtment, and Hea dstar t—and they are NOT coordinated. I believe that the time is now ripe for 

bold and far-reach ing changes in the Fe de ral/S tat e legislation concerning child 

health care. A national effort orchestrated by strong, courageous, focused and 

creative leadership is desperately needed. There is no substitute for local and 

sta te participation in the planning and design of these services, BUT, unless 

fede ral encouragement, leadership, stan dard-setting and supp ort accompany 

local efforts, unacceptable variability in emphasis and quality will continue to 

exist. The Departm ent of Health, Education and Welfare, the Children’s Defense 

Fund, the American Academy of Pediatrics, the Carnegie Commission, the 

American Public Health Association, the American Paren ts Committee, and 

many others have called for an intensive review’ and change in the way services 

for mothers and infants are financed and delivered. A recent report of the 

American Academy of Pediatrics was extrem ely critical of present programs, 

citing the “frag mentation and duplication of Federal health care initiatives 

. . . resu lt in gaps and waste of scarce resources.” The repo rt pointed out 

specific an d extreme limitations in data collection, coordination of medical and 

social services, special services for teenagers, and research capacity. The Children’s Defense Fund made a sim ilar case in Doctors and Dollars Are Not

Enough.

« Today, I hope to begin this review. We have been working on alte rna tive

approaches that would make dramatic changes in the financing and delivery 

of matern al and child care, and would begin to focus the Federal effort in 

this area . I do not view this strategy as a sub stitute for a program of National 

Health Insu rance, but rather as a process to initiate change immediately

* bridging the present with the future. I hope our first panel will shed some 

additional light on this imp ortant area.

Our second witness will focus on HEW ’s hypertension program. Hypertension 

afflicts more than 23,000,000 adults, or approximately 18 percent of the American population. It is a major cause of stroke, w’hich kills over 200,000 Americans each year and which maims or disables over 250,000 below age 65. It is 

a major accelerating factor of arterioscleriosis, the process w’hich causes heart 

attacks. It contributes to some 1,250,000 heart attacks and some 650,000 heart 

attack deaths a year.
National surveys show that the condition is more prevalen t among blacks 

than whites and more prevale nt among the older people tha n younger adults. 

For those aged 65 to 75, we estimate that 55 percent of the blacks and 39 

percent of the whites have definite hypertension. Added together with those 

aged 75 and over, we estimate th at about 8 to 9 million persons aged 65 or 

over have hypertension.

Presently , the assistance program to states provides some $11 million in 

formula grants to state health authorities for establishing and maintain ing 

programs for the screening, detection, diagnosis, prevention and referr al for 

treatm ent of hypertension. These funds also supp ort public information and 

professional education, as well as evalu ation of patients ’ needs and follow-up 

Awards are made on the basis of a formula which allocates $10,000 to each 

sta te and provides for distribution of the remainder based on a sta te’s population and financial need weighed by the extent of the hypertension problem 

within the state. Although this program has only been in effect for the past 

two and a half years, it has provided a needed highlight and support to sta te 

efforts in this important prevention area. S. 2474 provides for a one-year 

extension of the autho rity for this program and provides for a fiscal 1979 

authorization of $15 million. This time will allow us to eva luate the program 

and determ ine its place within the context of a new, comprehensive federal 

prevention initia tive.

Our third panel will present testimony on Section 314(d) of the Public 

Health Service Act, which funds programs and systems for comprehensive 

public health services to state s. Over the las t ten years the program has provided flexible funding to supp ort a variety of sta te public health programs. In 

recent years the program has operated at a level of $90 million which has 

been divided among the states on the basis of the ir population. S. 2474 provides 

a one-year extension to allow us to evaluate and review the program within 

the context of new fede ral health program initiatives. S. 2474 also provides an 

increase in the funds authorized under 314(d) to provide added support to 

sta te public health programs.

Although 314(d) programs have suffered from a poor repo rting system, its 

basic flexibility allows for an imp ortant creative use of the fede ral funds in 

line with local needs. The Subcommittee hopes to solic it constructive comments 

concerning its operation and value, and will take these comments into account 

in considering effective ways to suppo rt state public hea lth efforts.

We will also be hearing today a series of witnesses discussing the Genetic 

Diseases Amendments of 1978, S. 2597. This legislation amends and reauthorizes 

the National Sickle Cell Anemia, Cooley’s Anemia, Tay Sachs and Genetic 

Diseases Act.

This important piece of legislation supports programs aimed at ensuring that 

the American people have available to them the lates t information about genetic 

disease, and the latest and most effective counselling and treatm ent services for 

those conditions. Unfortunate ly though it was passed three years ago, it has 

never been funded until this year, and then, only at the meagre level of 4 

million dollars.

This fail ure to support more adequ ately these critica l services is a tragic 

oversight on the pa rt of our federal authorities. Genetic disease is one of the 

major hidden causes of death and disability among our population. It is the 

second leading cause of death below the age of one year. Seven out of every 

thousand newborns have some chromosomal abnormality which impairs the ir 

health. And adults can be affected in the most devasta ting fashion, as some of 

our witnesses can att est from tragic personal experience.

I want to commend Senator Javits for the fine work he has done in draftin g 

S. 2597. It extends the Genetic Disease author itie s for three years at the 

modest auth orization level of 30 million dollars. The bill also adds some helpful 

perfectin g modifications to the law. It will make cle ar th at the Congress intends funds allocated under these authorities to be available for research and 

services applicable to all genetic maladies, not ju st those liste d in law by name 

for the purposes of illustration . S. 2597 also spells out Congress’ inte nt th at 

screening programs funded under the Act should also provide for referr al for 

treatm ent of any disorders detected.

Senator Kennedy. We are fortunate to have Lisbeth Bamberger 

Schorr from the Children’s Defense Fund, a personal friend and
267

long -ti me fr ie nd of th is comm itte e. Sh e ha s w ri tten ab ou t these 

issu es fo r man y ye ars an d ha s been a gr ea t sourc e of he lp to a ll of us.

Also on th e pa ne l is Dr. Don ald A. Com ely, American Ac adem y 

of Ped ia tric s, Jo hns H op ki ns U ni ve rs ity Com mun ity P ed ia tr ic Se ctio n, Baltim or e, Md . an d C. A rd en M ill er, Pro fe ss or an d Cha irm an 

of th e D ep ar tm en t of M at er na l an d Chi ld H ea lth, U ni ve rs ity of 

N or th Carol in a, Ch ap el H ill, N or th Car ol in a, wh o is also a stud en t 

of thi s par ticula r issue.

W e look f orw ar d to th ei r testim on y.

STATEMENT OF LISBETH BAMBERGER SCHORR, CONSULTANT,

CHILDREN’S DEFENSE FUND, WASHINGTON, D.C., ACCOMPANIED 

► BY DONALD A. CORNELY, M.D., AMERICAN ACADEMY OF PEDIATRICS, JOHNS HOPKINS UNIVERSITY COMMUNITY PEDIATRIC

SECTION, BALTIMORE, MD., AND C. ARDEN MILLER, PROFESSOR 

» AND CHAIRMAN OF THE DEPARTMENT OF MATERNAL AND

CHILD HEALTH, UNIVERSITY OF NORTH CAROLINA, CHAPEL

HILL, N.C., A PANEL

Ms. Schorr. On be ha lf of th e C hildre n’s De fense F und, we ve ry 

mu ch ap pr ec ia te th is op por tu nity to ta lk to you ab ou t to day ’s m aj or 

un met he al th nee ds in m at er na l an d ch ild he al th an d wrh at shou ld be d on e to m eet th em .

We are, of cou rse , fa m ilia r with yo ur lo ng st an di ng concern with 

im pr ov in g th e he al th of all American s, esp ecial ly those wh o have 

no t been well serv ed by t he hea lth syst em in t he past.

ou r exten sio n of th is concern to th e special needs of ch ild re n 

an d mothe rs, an d to th e special op po rtun itie s to im pr ov e th e he al th 

servic es av ailable to th is po pu latio n comes at a cr itic al tim e. The 

enormo us incre ase s in he alth ca re cos ts ha ve co nc en trated pu blic an d 

go ve rn men tal at te nt io n on way s of cu ttin g costs— wh ich ar e ind eed 

ex orb itan t; on el im in at in g excess ser vic es an d eq uipm en t—man y of 

wh ich inde ed do m ore ha rm th an good; an d on co nt ro llin g th e nu m ­

be r of sp ec ialis ts—w ho are inde ed res po nsible fo r or de ring man y 

unnecessa ry an d expensive proc ed ures. Co ncerned as we ar e ab ou t 

excesses in th e hi gh techno logy p art of ou r he al th syste m, we tend to 

lose si ght of i ts st ar k deficie ncies in de liv er in g sim ple pri m ar y care— 

th e m an y American s vi rt ual ly exclu de d from all bu t em erg ency

• care, th e m illions who lack access t o t he ca re th ey need.

The re is a gr ea t ga p between th e de m on strably effective in te rv en ­

tio ns in our he al th servic es ar m am en ta rium , an d th e ser vic es ou r 

he al th system ac tu al ly deliv ers. No wh ere is th e ga p more st ri kin g

• th an in th e ca re of in fa nts , ch ildr en , adole scents, an d pr eg nan t 

women—esp ecial ly tho se wh o ar e p a rt of di sa dv an ta ge d po pu latio ns . 

Th ese ar e th e gr ou ps fo r whom pri m ar y care an d espe cia lly pr ev en ­

tiv e ser vic es are mo st im po rtan t. B ut ou r fa ilur e to reach all A m er ican ch ild re n an d mothe rs w ith effective pri m ar y care is abysma l.

Tw en ty million ch ild ren, 39 pe rc en t of th e to ta l, un der age 15 

ar e no t pr op er ly im mu niz ed ag ai ns t one or mo re of th e six po te ntial ly da ng er ou s ch ild ho od dis eas es fo r wh ich vacci nes ar e avail ab le. 

The nu m be r of un im mun ize d ch ildr en goes up sh ar ply as income

28 -38 6 0 - 78 - 18
268

goes down. And we know two things about unimmunized children. 

We know they are in danger of serious illness and disability. And 

from the fact that they are not immunized, we know t hat they are 

not receiving regular health supervision, which every infant and 

child urgently needs to promote health development.

There are half a million children who suffer today from hearing 

loss—a major factor in learning problems. Half of these cases could 

have been prevented by proper diagnosis and treatment of middleear infections.

Between 65 and 85 percent of acute rheumatic fever that occurs 

each year could be prevented with proper detection and treatment 

of strep throats.

About one-half of the 3.7 million 15- to 19-year-olds at risk of 

unintended pregnancy are not receiving family planning services. 

Improved availability of family planning services to women of all 

ages w’ould prevent a high proportion of births of unwanted children, an unknown number of abortions, and large numbers of births 

of children at a time when health risks and the risks of damaging 

social and economic consequences are extremely high.

Pregnant women at the highest risk get the least medical attention; 

7 out of 10 mothers under 15 get no prenatal care in the first tr imester, one-fourth get no prenatal care at all, or delay it until the 

end of pregnancy; almost twice as many black as white women get 

no prenatal care, or care only in the last trimester. Late and inadequate prenatal care is, of course, closely linked with infant mortality, 

birth defects, mental retardation, and subsequent developmental difficulties.

What keeps us from closing the gaps between promise and performance of our health system ?

Reducing the economic barriers by expanding third-party payments through public and private financing plans is only part of the 

answer. A universal national health insurance program is essential.

Compared to complexities of the rest of the health system, what is 

needed to make major improvements in maternal and child health is 

relatively simple. Why traditional maternal and child health programs have not achieved their potential is a matter tha t particularly 

needs attention.

In the executive branch and both Houses of Congress, there is 

leadership already committed to giving high priority to effective 

action to meet the health needs of mothers and children. What is it 

tha t needs to be done ?

1. We need to be sure this full range of ap propriate health services 

are available to mothers and children.

Bureaucratic or other barriers which isolate curative from preventive services, which keep doctors from collaborating with social 

workers, which send pregnant women to one place for physical examinations and to another for help with nutritional needs are surely, 

in 1978, like the walls of Jericho, ready for action to make them come 

tumbling down.

We know by now, for sure, that for an effective response to most 

of the needs th at children and mothers bring to the health system, 

we require both modem medical interventions and quite simple
269

services—services that entail teaching, listening, counseling, the mobilization of social supports, and even social action. We know by now, 

for sure, tha t the separation of certain services traditionally delivered 

in the private sector from others relegated to the public sector, has 

not worked and will not work.

However, the sources of funds are segregated or integrated in 

legislation, the services they pay for cannot be allowed to come in 

incoherent bits and pieces at the point of delivery.

The brunt of fragmented care, of course, falls disproportionately 

on the poor. I t is the poor who typically have to negotiate the maze 

of multiple offices, confusing and conflicting eligibility requirements, 

bus trips, waits, and missing records. They are the most frequent 

t

victims of the lack of coherent policies, of the inability to reconcile

the requirements of categorical funding authorities, or governmental 

reluctance to use the leverage of its funds to encourage needed 

changes in service delivery.

• But today there is widespread recognition—and impressive evidence—that most primary health services are best provided by or 

through a single easily accessible port of entry. The availability of 

comprehensive continuing care in one place has been shown to be 

highly effective in improving health and family well-being as well 

as in controlling health costs.

Families tend to use providers who can respond to health needs the 

family considers important. Providing a full range of health services 

under integrated auspices seems to be more effective than complicated 

computerized case management systems—coordinating a host of disparate services—to make sure mothers and children get the health 

care they need when they need it. The accumulated evidence is impressive. Especially among the population groups tha t are most 

important to reach, primary care for mothers and children is most 

effectively rendered when there is access through one door to medical, educational, counseling, mental health, nutritional, and social 

services.

There are, of course, services tha t are most effectively made available in settings outside the curative care system, and individuals who 

are more easily reached in nonmedical settings. There is considerable 

evidence of the success of separate organized family planning programs, and of the use of schools and health departments for immunization campaigns. There is evidence of effective use of multipurpose 

« teen centers to provide health care to adolescents; of schools to provide preventive dental services and vision and hearing screening.

A promising program is underway under the auspices of the R. W. 

Johnson Foundation to train and employ nurse-practitioners to

• provide and coordinate certain primary health services in a school 

setting.

There is no good a priori formula to identify appropriate settings 

and contexts for the provision of needed services. For example, 

screening of developmental difficulties and immunizations are frequently seen as services tha t are most cost-effectively delivered 

through the schools. But what about the importance of these services 

for preschool children? Detection of developmental lags at school 

entry may not be soon enough; immunization rates among preschool
270

children are considerably below those of school children. Since frequent and continuing contact with the health system is probably 

most important in the early years, these examples suggest tha t it 

may be appropriate to emphasize different settings for different 

services at various stages of life.

It would be nice to think tha t these decisions could be made in 

each community. But the way the Federal Government writes its 

laws and regulations for payments under medicaid, its direct grant 

programs, its formula grant programs, and its benefits package under 

national health insurance are powerful determinants of who will be 

able to get what services where. For this reason, we need an extremely 

careful sorting out of these issues, so that resources can be allocated 

in some rational relation to their effective use, rath er than in re- .

sponse to tired rhetoric, bureaucratic rigidities, or the pressures of a 

panoply of vested interests.

2. We need more organized settings to make needed services more 

widely available, accessible and acceptable. •

It is now well recognized tha t simply making money available to 

reimburse providers through health insurance or medicaid—even for 

a broad range of services—does not assure th at the appropriate professionals will be available, or tha t they will be within reasonable 

reach, or tha t they will offer services in circumstances that are humane and make sense to the users of care. Appropriate health services 

will be more widely available and better utilized as more organized 

settings are established, where a variety of personnel can work together, and where strong ties can be forged between the providers 

and the people they aim to reach.

The kinds of organizational arrangements tha t will make appropriate and high quality primary care accessible to most people not 

now well served by the health system do not, with stellar exceptions, 

now exist. They will have to be created. There is ample experience 

to build on in the successful operation of neighborhood and community health centers, children and youth centers, maternal and infant 

care projects and some health maintenance organizations.

Individual practitioners and other providers offering limited 

services should be able to obtain help in making connections with 

other sources of needed services. I t is also important to encourage the 

development of small low-technology primary care centers, which 

could be attached to community programs, such as day care centers, 

and which emphasize easy physical and psychological access. »

A major Federal commitment is needed to assist professionals and 

consumer groups in local communities to establish and operate these 

organized settings and organizational links. Specifically this means:

A. Technical assistance and start-up funds for provider groups -

serving underserved areas.

B. Subsidies for health-related support services and for services 

designed to make health care accessible to people in underserved areas 

and to groups with special needs.

C. Encouraging the adoption of payment methods—including provisions to facilitate annual per capita payments and other alternatives to fee-for-service—which are simple to administer and which
271

provide incentives for using the most appropria te services and personnel.

D. Suitable standards and methods of certifying providers and 

organizations, administered in ways that do not discriminate against 

any class of qualified providers or provider groups—be they physician 

assistants, nurse-midwives or neighborhood health centers.

3. We need to encourage the development of and provide support 

for effective ways of linking children and mothers to sources of 

comprehensive health care.

Effective and economical utilization of health services, especially 

by mothers and children, and especially by disadvantaged populations, require good outreach programs and other ways of easing 

9 access.

Even when financial barriers are removed, the remaining barriers 

to access are more likely to keep poor people away from preventive 

services and other important primary care than from care for severe

* illness. Discrepancies in the health care received by the poor and the 

rest of the population are most striking in the use of preventive care. 

Poor people, especially poor children, use substantially less preventive services than the nonpoor, even when the poor are covered by a 

relatively comprehensive medicaid program.

This means that subsidies must be available to qualified providers— 

including primary care centers, community clinics, group practices, 

HMO’s, hospital outpatient departments, and health departments— 

serving areas with large numbers of persons who have not had good 

access to the health system in the past, to assist them in providing 

services which have been shown to be effective in getting people to 

primary health services. Not every measure labeled “outreach” will 

do. Written notices alone are virtually useless. Personal outreach 

performed by trusted community members, and other support services, like transportation, must be made available to all population 

groups that lack ready access to continuing primary health care.

We have comparatively little experience in this country with the 

practice of combining outreach with provision of services valued by 

recipients. The experience we do have makes clear th at home visiting 

by trained health workers, especially to families with newborn infants, and other kinds of services offered in the community are among 

the outreach arrangements tha t deserve to be further developed and 

evaluated.

* 4. We must develop and support ways of establishing reasonable 

standards of care and assuring they are met for all mothers and 

children.

B One of the most vivid lessons to emerge from the children’s defense

fund’s study of the early and periodic screening, diagnosis and treatment program, was th at minimum standards of quality are not met 

unless they are clearly stated, monitored and enforced. Children who 

were screened through EP SD T often received incomplete health 

assessments. Even States with good administrators, relatively prosperous economies, and reasonable amounts of resources did not necessarily assure high-quality services. Both the Institute of Medicine 

study by David Kessner—Assessment of Medical Care for Children, 

1974—and the Harvard Child Health Project Report, 1977, have
272

documented in grea t detail the poo r quali ty of muc h of the health 

care that childre n rou tinely receive.

5. We must find be tte r way s to esta blis h sta nd ards of care, especially in those areas of practic e where optim al procedures are widely 

agreed upon within the medical profession, and to make inform ation 

abo ut such s tan dards more w idely known.

The proposal th at you, Se na tor Kenne dy, hav e made fo r an expan ded F edera l c omm itment to h ealth care rese arch would, we believe, 

be extrem ely he lpf ul in attem pts to identify more systematic ally effective procedures and the organization al and manpower fac tors which 

affect the quality of services. As the H ar va rd child healt h project 

pointed out, more rese arch efforts should focus on im pro vin g capac ities to recognize, diag nose, and trea t childhood illnesses, and «

more research on delivery and financing alt ern ati ves needs to be 

directed tow ard ch ild ren’s prim ary care, if the he alt h system is to 

become more effective in res ponding to the special needs of children.

On the basis of w hat we know now, however, we can proce ed with *

a reasonable degree of certa inty th at qu ali ty will improve with the 

gr ea ter availabilit y of a bro ad ran ge of services, the fu rthe r enc ouragemen t of org anized set tin gs and the monito rin g and enforcement 

of accepted sta nd ards of care.

In addition , ways mu st be developed throug h which the health 

system can assume resp onsibility not only fo r those who come th rou gh 

the doo r seeking care, b ut also f or those who fai l to enter t he system .

Some existing pro gra ms, inc lud ing HM O’s and com munity health 

centers, have dem onstrated the fea sib ility of assum ing respon sibility 

for a defined population —defined eit he r throug h enrollment or place 

of residence. Such a defined population mak es possible mo nitoring 

and assessments of per for ma nce which can hav e an enorm ous positive impac t on qu ali ty of care. Th is concept must, however, be expan ded beyond isol ated gro ups of pers ons who are linked to a certain 

prov ide r or gro up of pro viders. It is only when mechanisms are 

developed throug h which everyone becomes pa rt of a defined popu ­

lation , fo r purposes of plan ning and acc ounta bility—if not fo r purposes of delivering services—that, we will be able to assure th at 

req uired health servic es are available and accessible fo r the entire 

pop ulation. It m ust be possible, in any given are a, to iden tify who is 

resp onsible for prov idi ng a given set of servic es and who, the ref ore , 

is responsible if the servic es are ineffective or una vailable.

W he ther one sing le mechanism can be fou nd to accomplish th is »

tas k in each com munity throu ghout the country is, in ou r view, still 

unc lear. Th ere is cu rre ntly conside rable c ontroversy over the issue of 

wh eth er health departm ents, at both the St ate and local levels, could 

mobilize the kin d of talent th at the tas k requires, and the kind of 

com mitment to the intere sts of consumers of care th at would make 

them cred ible as the agencies to which consumers could tu rn fo r 

assurance o f accounta bility. We m ay need to begin by using a v ari ety 

of ar ran gem ents.

Th e rel ationship between official healt h agencies, planning agencies, a poten tia l ma ternal and child healt h au thor ity and the pr ovid ers of ma ter nal and child care will be in tri ca te and complex and 

mu st be care fully designed.
273

What should be clear from the outset, however, is (1) tha t the 

accountability function should cover all mothers and children, regardless of their source of care or source of payment for care, and 

(2) tha t the Federal Government must be in a position to respond to 

evidence from any locality tha t the designated agency or organization may not be suited to perform the accountability of function, to 

assure that the accountability function is being exercised in the interests of the consumers of care, and to replace any agency not performing its function effectively.

6. We need to make sure consumers can effectively participate in 

the formulation of policy and resource allocation a t all levels in the 

delivery of maternal and child health services.

Such participation should occur through a variety of mechanisms, 

some of which remain to be developed, and would cover a w’ide spectrum, from improved information to equip consumers to participate 

in and monitor their own and their children’s care, to consumer participation in the operation of organized health delivery programs 

and health planning agencies.

Consumer participation is essential if health policy is to take into 

account the realities of how people actually use health care. Health 

care must be organized to respond to family needs in ways tha t make 

sense to families and that support family function. Parents must be 

given the opportunity, the information, and the support to function 

as collaborators with health professionals in maintaining and restoring health.

We need to be certain that there is a strong Federal leadership role 

in setting and enforcing standards for performance and for the allocation of resources.

Whatever methods and whatever funds are used to finance needed 

maternal and child health services, and to develop and support the 

infrastructure to deliver the services and to assure their continuing 

quality and receipt, the Federal Government must assume ultimate 

and residual responsibility. There must be a data system designed to 

generate and make available the information needed to monitor and 

evaluate all maternal and child health activities undertaken with 

public support. There must be a strong central review capability to 

provide the basis for a coherent national policy and for effective local 

monitoring.

The Federal Government, if it delegates to States the responsibility 

to assure th at required health resources are available and accessible, 

must be in a position to know how and for what purposes funds are 

being spent, must have the information to judge whether a State’s 

plans and practices conform with clearly defined standards and purposes, and must have the authority to assure th at the intent of Congress is actually carried out.

The issues I have dealt with in this testimony are made vivid in 

the story of a Mississippi child, told in last Sunday’s Washington 

Post. She died last June at the age of 5, of secondary pneumonia, 

brought about by a bacterial infection caused by Ascaris worms in 

her intestines. Afte r her death, the community health center in Jackson—65 miles away—sent people out to build a privy and install a 

55-gallon barrel of water. For the first time, the family had clean
274

drinking water. The health center helped get the surviving children 

on the WIC program and helped comfort the grieving mother. But 

the next time the center’s social worker went to visit the family, no 

one could be found. The mother was in jail for child neglect, and the 

children had been put in foster care. Dr. Aaron Shirley, director of 

the center, and a pediatrician who fights each day for Mississippi 

children against the most overwhelming kinds of odds, says that the 

neglect was not the mother’s, but ours. He explains th at the symptoms 

of Ascaris worms, which may look like a cold and runny nose, simply 

are not those that would signal the need for an emergency trip to the 

hospital. Hence, the necessity of outreach, the importance of easy 

access to a source of regular care.

I talked to Dr. Shirley earlier this week, and he said tha t little ,

girl’s death was not an isolated instance. And the nonsupportive 

punitive response of the welfare agency is also typical. Dr. Shirley 

was asked by the Post reporter if things were not getting better 

though. •

“Sure,” he says,

The ones who know enough to come to a clinic are better off now tha n they 

were before medicaid ♦ * * Sure, you’re better off if you can fight the hassle 

and pay for food stamps. Bu t Heaven help you if you don’t know what to do.

For those kinds, there is ju st no one reach ing out. The re is just no caring.

Perhaps this committee will keep this story in mind as you address 

the issues of Federal action to improve maternal and child health, 

as you look afresh at what administrative and organizational arrangements will succeed in mobilizing the resources of Government at all 

levels, professionals of all skills and consumers in every segment of 

the Nation—to the end tha t mothers and children will receive the 

health services they need. The danger is greater chaos and more and 

more money for less and less adequate and appropriate services. The 

task is to harness an increasingly complex health system to simple 

human needs—and no longer to permit these needs to be subordinated 

to the vagaries of the system.

Thank you.

Senator Kennedy. Excellent testimony. We are going to run into 

a problem all morning because of the objection to committees meeting during the Panama Canal debate. We will submit questions. I 

would like to just ask a couple of questions though. One deals with just 

your characterization of the Federal leadership role in setting and 

in enforcing standards for performance in allocation of resources. *

You mentioned obviously the importance of data collection system, which I completely agree with. We are not doing nearly enough 

in terms of that, in terms of a general health mechanism.

What can you just tell us about your assessment of that particular ■*

responsibility at the present time ?

Ms. Schorr. On the existing maternal and child health services 

tha t are funded through formula gra nts to the States, it is very, very 

hard to find out what is actually going on. We do know th at State 

plans are prepared. They are logged into a regional office. They are 

checked off, and the question of whether there is language in the plan 

covering various components is checked off. But tha t is where the
275

Federal supervision ends. There is no judgment made on the substance or adequacy of the State plan.

The fact is that no judgment can be made because there is no basis 

for making the judgment. There is no independent data base, which 

a Federal administrator can use to compare with what the State 

sends in. There are no quality standards. There is no body of knowledge to which the plan can be compared. The result is no Federal 

supervision, and a complete awareness out in the field tha t there is 

no Federal supervision and can be no Federal supervision under 

existing circumstances.

Senator Kennedy. Well, tha t is certainly our impression, too, one 

of real chaos. I t is a really classic failure. You touched on something

#

earlier and we will hear some different views on this about the State 

role today. I think you have given a pretty candid view in regard to 

the Federal role—what about States themselves, after they make 

whatever applications they do, they run through the routine of this,

• what has been their kind of performance?

Has this been primarily a slush fund used for a variety of dif ­

ferent purposes or could you identify perhaps some of the places 

where it has been worthwhile and give whatever generalization you 

would ?

Ms. Schorr. Senator, we at Children’s Defense Fund found it was 

extremely hard to find out what was actually happening with maternal and child health money tha t went to the States except for the 

money tha t went as project grants for children and youth centers 

and maternal and infant care centers, where we have quite dramatic 

evidence of the very, very effective use of the money.

Now, some of those are being continued at least to some extent 

under the formula grant program. But what is actually happening 

with the rest of the maternal and child health money, w’e cannot make 

any better judgment than the Federal Government can because we 

cannot find out to what purposes tha t money is going.

Senator Kennedy. Your point is t hat we ought to establish some 

accountability, some clear criteria, in terms of what we expect from 

the money that will be provided in the States and then some monitoring as to whether these criteria actually are going to be followed ?

Ms. Schorr. Some very explicit monitoring, and then some authority to be able to assure that the purposes of the congressional intent 

are actually being carried out at the local level.

n Senator Kennedy. How about EPSD T program? Wha t improvements would you make in that?

Ms. Schorr. The EPSDT program has done a very useful thing. 

It has made additional Federal funds available for health services,

* for primary health care for children. It has all the limitations of the 

program under which it operates, medicaid. Medicaid is basically a 

financing program which does not get at the issue of resources, and 

has not in the past gotten at the issue of the structure in which it 

operates. The present legislative proposals, however, to improve 

EPSDT would get at some of those issues, and we believe would 

result in some of those funds being more effectively spent.

Senator Kennedy. We have some other questions, but I want to 

try to hear the others on the panel.
276

Pro fessor M iller.

Dr. Miller. Se na tor K ennedy, t hank you for the p rivilege of meeting to discuss the ma ternal and child healt h population and pr ogram s. I have no t pre pared testimony in printed form in advance.

I would like to add ress my comments aro und three pri ncipa l issues.

One, wh at cha rac terizes the MCI I po pulat ion in terms of special 

attentions it deserves? I will not dwell on ex panding the excellent 

doc umentatio n Ms. Sc ho rr has alr ead y pro vid ed on the neglect to 

the he alth o f this population.

Second, I would like to emph asize some princ iples fo r considerin g 

revision of present policies and pro gra ms in supp ort of health services to the MC H pop ulation.

Fina lly , I wou ld like to suggest some specific actions th at may be 

indicated. *

The cha rac teristics of the population need to be kept param ount— 

women of child beari ng age, i nfants, childre n, and you th of this countr y rep res ent by fa r ou r most vulnerable and neglected population •

group. The y deserve and require s pecial finance and special pro gra ms 

fo r th eir needs.

The evidence is ab un da nt th at when they are fold ed into finance 

and pro gra ms t hat are intend ed to serve the en tire population , with ­

out special prior ities bein g attach ed to them , th at these vulnerable 

people get pushed to the end of the line. I th in k it is necessary th at 

special attentio n focus on them.

An oth er chara cte ris tic of the Mate rnal and Child population is 

derives from th eir special program ma tic requ irem ents. Because they 

require special emphasis if th eir needs are to be met, there is uniq ue 

public responsibility on th eir behalf.

Fo rty yea rs ago, w ith ena ctm ent o f the Social Security Act, it was 

esta blished beyond doubt th at our conven tion al system of health 

service could no t succeed in rea ching all women and children in an 

equitab le fashion. It was established th at there is a uniq ue pub lic 

responsibility to pro vide services th at will reach them . Tha t finding 

is no less tru e tod ay than it was 40 yea rs ago. Th ere is a uniq ue 

pub lic responsibility to provide services to women, infants and 

children.

Princ iples to be borne in mind as we con tem plate rev ising the 

ma ter nal and child he alt h autho riz ati on and fu nd ing inc lud e: No. 1.

The pur pose of these pro gra ms mu st be to serve a population , no t to

serve a professiona l gro up, not to serve a special reimbursement or *

pay ment device, not to serve special inter est groups.

No. 2. Expectation s of the pr ogram m ust be defined.

We need to specify wh at services are req uir ed, we need to esta blis h 

sta nd ards fo r performance and achievem ent. I t will no t do any «

longer to pump money into healt h service pro gra ms in the expec tation th at som ething good will come of it. We need to define wh at 

th at som ething good is to be. I think the country has mad e pro gress 

in recent yea rs and even rece nt months in definin g healt h goals. We 

have done t his aro und a defined infant mor tality rate th at repres ent s 

a national goal. We have done it in definin g accepta ble immunizatio n 

rates. I think it would be possible to define outcomes and goals in 

many oth er areas relatin g to ma ter nal and child hea lth.

No. 3. As these sen dee requirements and exp ectatio ns are defined,

I submit it is necessary to inc orporate as par t of the policy of ma-
277

ternal and child health an affirmative action complement on behalf 

of persistently neglected population groups.

We have seen within the past years a decline, for example, in infant 

mortality rate, but the rate of tha t decline is much better for white 

populations than it is for black. The gap between ethnic groups, not 

only as measured by infant mortality rates, but by immunizations 

and other indicators, continues to be distressingly large, not only 

between black and white populations, but between poor and more 

affluent groups. I see no way for the gap to be closed without explicit 

policy of affirmative action on behalf of neglected populations.

No. 4. It is important in maternal and child health to put in place 

service delivery systems that assure reaching all eligible people in 

the population. I support Ms. Schorr’s emphasis on involving them 

in comprehensive sendees. But, in all candor, I am less concerned at 

this moment with the idealized nature of those comprehensive services than I am that everybody be involved in receiving something. 

The evidence is very good, both in this country and in developing 

countries, that service systems tha t are put in place, th at reach everyone with some basic service, produce impressive results, and produce 

opportunity for expanding those services in future years. I think 

tha t ubiquity of care is important for maternal and child health 

populations. It requires, however, tha t more complete and comprehensive care be invoked for selected populations on a basis of affirmative action.

How do we do all of this?

There is much talk of a special emphasis on behalf of maternal and 

child health populations under national health insurance. I applaud 

tha t emphasis. There is discussion as well about revision of what is 

the very foundation of maternal and child health services in this 

country, title V of the Social Security Act. I happen to believe that 

no matter what is done under the banners of the national health program, we need to preserve something like title V. I t is the best device 

we have put in place so far for improving and expanding resources 

to serve maternal and child health populations. We could do worse 

than to maintain the wording of title V component of the Social 

Security Act as it is now.

The mandate and rhetoric of tha t act, address current problems. 

Why have those problems persisted for 40 years in the face of tha t 

reassuring legislation ?

The failing is not bad legislation, but weak guidelines, inadequate 

standards, and an inordinate amount of State discretion on how the 

act is to be implemented.

Title V formula funds, as was intimated previously, are widely 

regarded as discretionary funds attached to optional programs. I 

think Federal standards must be established for performance of the 

title V programs, and Federal funds must be used explicitly to reach 

the defined populations in achievement of those standards.

I believe further that any revision of title V must be addressed 

specifically towards revising, protecting, expanding and improving 

services delivery capacity of State and local health departments. 

Those departments now reach one out of four Americans with some 

direct personal health sendees. I t represents the only delivery system 

in this country by which we can assure that a population will be 

reached by essential sendees. Our private and voluntary delivery
278

systems, as im po rta nt as the y are and as im po rtan t as the y will continue to be, I th ink will co ntinue to resist a regu lator y emphasis which 

might assu re th eir rea ching everyone in an equ itab le fashion. We 

sim ply do not have reg ulato ry models in ou r society to apply again st 

private and volun tar y systems to achieve equ ity in services. I think 

goal requires a pub lic system of care on behalf of the ma ter nal and 

child health population.

A special word need be said in relati on to th e compreh ensive 

commun ity-based pro gra ms of care, such as mate rnal and in fant care 

and children and youth projects. They rep res ent sup erb models th at 

need be expande d on behalf of neglected population s. A lot of atte ntion focuses on wh eth er those pro gra ms are best left with the State s 

where they have been pu t in recent years, or wh eth er the y should be 

ret urne d to Fe de ral au thority . I am one who believes th at these al te rnatives may not make a gr ea t deal of difference. I would be more 

reassured abo ut re turn ing them to Fe deral au thor ity if those compreh ensive com munity-bas ed healt h service prog ram s th at hav e been 

retain ed un de r Fe deral au thor ity had received be tte r supp ort within 

recent years.

Al l comprehensiv e commun ity-based he alt h service pro gra ms, 

wh eth er adm inistered un de r St ate or Fe de ral au thor ity , hav e been 

underfu nded and neglected.

Those p rog ram s need to be expanded.

I would ten d, myself, to keep them un de r St ate au thor ity wi th the 

proviso th at those State s failing to meet obl iga tions on behalf of 

neglected population s would be subjected to Fe de ral tak eov er of the 

neglected pro gra ms, th at there would the n be Fe de ral responsibility 

to reach the unserved population s, and there wou ld be a Fe deral pr ovision to withh old gen era l revenue sh aring fund s from those State s 

in orde r to pro vid e the St at e’s ma tch ing portion fo r those services. 

I believe that this expec tation was i mp licit when m any of the Federal 

healt h care pro gra ms were placed under St ate au thor ity and when 

the revenue sharing fund s were established.

I think we know how to do a vas tly be tte r job in rea ching this 

entire population th an has yet been done. They need special fun din g, 

special services, and h igh pri ori ty ; I am delighte d you a re add ressing 

your selves to these issues.

Se na tor Kennedy. Th e problem is, th at is all well and good, but 

specifically wh at can you tell us wh at you th ink, given the existin g 

legisla tion, or w ha t changes w ould you mak e or wh at steps should be 

done in ter ms of the Fe de ral Government to get full impact of this 

type of effort ? Specifically wh at should be do ne? W ha t should be done 

given the current stat us of tit le V? W ha t wou ld you like to see done?

Dr . Miller. I would like to see establis hed Fe de ral goals fo r wh at 

tit le V should achieve—na tio nal per for ma nce sta nd ard s. I would 

like to see those sta nd ards applied and enforced with State s who 

accept for mu la grants, and I would like a firmly esta blis hed Federal 

ma ndate fo r affirm ative action to reach population gro ups who are 

not served by tho se stan dards.

Se na tor K ennedy. A re you satisfied th at un de r existing legislation 

th at the au tho rities there could do all of th at ?
279

I)r. Miller. I do not regard myself enough of an expert on legislation to respond to that. But I do feel strongly tha t the existing 

legislation enables vastly more than the Federal Government has 

taken advantage of.

Senator Kennedy. In terms of the same question I asked Ms. 

Schorr, let me ask about your characterization of the State performance today.

What would you tell us about that ?

Dr. Miller. Uneven, known to be dismal in many respects, but I 

believe far better than is sometimes given credit for. Good enough 

not to be written off. Within recent years, th is country has engaged in 

elaborate description of new models for delivery of health services

* and primary care. None of tha t attention has been addressed to excellent models tha t exist in the public sector of care in local and State 

health departments.

• Senator K ennedy. Dr. Cornely.

Dr. Cornely. I f I may have my prepared statement in the record. 

Senator Kennedy. Your statement will be inserted in the record $t 

the conclusion of your testimony.

Dr. Cornely. The American Academy of Pediatrics welcomes the 

opportunity to comment on public responsibility for health services 

for mothers and children. I would like to call to the committee’s attention a few points.

One is that Congress has, through several mandates, made it clear 

tha t it has a commitment to the health of mothers and children, and 

simply by citing four different pieces of legislative history, it might 

be illustrative at least that Congress has indeed made tha t commitment.

It would be improper to ignore the initial piece of such legislation, 

the Children’s Bureau in 1912, which was admirably broad in speaking to child health and its interrelationship with child welfare.

Next, as has been mentioned already, was the passage of the Social 

Security Act of 1935 and inclusion in it as one of its original titles 

provisions for maternal and child health. The thir d piece of legislation is the institution in 1963 of the National Institute of Child 

Health and Human Development which acknowledged a long-term 

obligation to pursue fundamental biological and social relationships, 

a necessity if we are going to be able to deliver what is promised.

#

I think the fourth piece of legislation which illustrates this is the 

passage in 1965 of the Medicaid Act with its later amendment for 

EPSDT.

One takes these four as more or less milestones and adds to them 

e many separate pieces of legislation which were addressed to categorical diseases or issues, and one at least, I think, sees within limits tha t 

the Congress has committed itself, however fragmented and timid 

tha t commitment might be.

One moves then to administration and looks at HE W ’s implementation of these programs. Some of the fragmentation and inadequacies 

tha t one worries about as programs come out of Congress become 

realities. I would ask Congress to think when was the last time it 

ever had the Director of the Maternal and Child Health program
280

appear before any of its committees? I think you would find it is 

over 5 years ago.

Also, if you would look at where the major office bearing the name 

of Maternal Child Health is sequestered in HEW , you would find it 

about four layers below the Assistant Secretary of Health.

Another reality is tha t if you look at HEW in its 25-year history, 

it has had about 12 Secretaries. There is an itinerant nature to that 

office. I think if that is reality, for the Academy of Pediatrics one 

of the strongest things Congress could consider would be to add some 

structural base in HEW at the appropriate level, competently staffed 

and addressed to the health of mothers and children. If you do not 

do th at, it seems to us that you increase the likelihood of the fragmentation which comes out of Congress and the inadequacies and 

t

misunderstandings which are associated with a parade of administrative changes about every 2 years. The present HEW occupation with 

reorganization results in less progress than one can tolerate very long.

Second, I think Congress should also consider when it passes »

legislation in which children’s or mothers’ health is a principal or 

primary focus, the possibility of administratively recommending, if 

not assigning, the responsibility for that legislation to a specific office of Maternal and Child Health. As it is now, you have maternal 

and child health programs, such as immunization, run by, for example, CDC. The primary population which is the target of immunization is children. You have an investigative agency in CDC attempting 

to administer a health program, thereby fragmenting the system.

Congress must insist in some fashion when it passes a piece of legislation that it be placed in an appropriate office.

Well, the Academy has looked at two specific pieces of maternal 

and child health legislation recently, and, continuing the discussion,

I would want you to know t hat we obviously have addressed these 

to the Senate Finance Committee which has current authority over 

these, so we will not be misunderstood.

The title V program, we find, is misunderstood—misunderstood by 

Congress and misunderstood by the administration—and it becomes 

the epitome of misunderstanding when you go down to the State 

level. Contrast for a minute the fact that in title V, Congress passes 

appropriations of about $400 million a year with the fact that in 

title XIX for children, as best as we can tell, the county spends between $3 and $4 billion a year. It should be obvious just from the d ifference in those comparative funds that it was never the intent for *

title V to be a major program that delivered health services even to 

the poor population in this country.

The purpose of title V was to identify distinct administrative units 

technically competent to address the many issues tha t are necessary "*

in bringing a level of health to the mother and child population.

From time to time, those units are given responsibilities to initiate 

more or less special projects—demonstrations to explore new relationships, for example, with crippled children. Even so, the approximately $400 million which Congress appropriates, matched by an 

equal amount from States, still only constitutes less than $1 billion 

a year to which tha t act addresses itself. We think if you read the
281

mandate, if you looked at the appropriation, you would see it was 

never the intent to do tha t under title V. But title V does bestow 

responsibility which wTe do not think has been fulfilled. It gives responsibility to develop resources. It gives responsibility to promote 

and implement standards. It gives responsibility to fact-find and to 

assemble information to stimulate programs of delivery.

It has not been doing that throughout the country in any way tha t 

could be considered satisfactory. Pa rt of th at is because of misunderstanding which starts at Congress, is aggravated as it goes through 

the administration, and becomes, as I say, almost abject confusion at 

the State level.

May I emphasize one other thing which has been said by both of

* my colleagues here.

Consider for a moment the major issue with which Congress and 

the Department of HEW have been diligently struggling in areas of 

health. You will get some idea how badly children do and mothers

* do in general health. You are talking about cost containment, control 

of fraud in medical care programs, and national health insurers.

Cost containment, control of fraud in medical care programs, and 

national health insurance are not issues prompted by a major concern 

for child health. Cost containment isolates short-term hospitalization 

and nursing homes, and these are not major components of a maternal 

and child health program, however important they may be to the 

broader health program.

Children frequent the inpatient side of hospitals very infrequently 

and have the lowest rate of hospitalization and the fewest days of 

hospitalization of any age group, and the differences are of great 

magnitude. Fraudulent use of public funds for health care can 

hardly be presented as a major problem in maternal and child health, 

since health services to these population segments are essentially of a 

preventive and ambulatory orientation. We do not experience an 

overuse of preventive health services for women surrounding maternity care or family planning sendees, and for children and youth. 

Quite the contrary, our struggle has been and remains to attempt to 

have children and mothers-to-be utilize even minimum services.

Members of this subcommittee know very well tha t if the costs involved in considering national health insurance were those projected 

for the maternal and child population needs, there would be little 

hesistancy in moving aggressively forward with a universal entitle-

* ment. But, children and their health needs tend to get lost in the 

complex of large expenditures and services required to serve the general—older age groups—population. Unless Congress takes the step 

to add a significant and appropria te structural base for maternal

F and child health in our Federal health administration, the Academy

feels we as a nation simply fail to understand and meet our responsibility to children.

So, in HEW with a parade of Secretaries and with chronic reorganization, and with the acknowledged necessity to concern themselves with large expenditures, maternal and child health over time 

has simply moved to the end of the line.

We think one structural thing tha t Congress would be wise to 

consider doing would be to develop what you did in 1912, a deliberate
282

office, assign it in HEW at sufficiently high level, give it competent 

staff, and require it to carry out its obligation to States and State 

plans.

Second, when it comes to State plans surrounding title V, are 

think you would be wise to consider requiring tha t there be an advisory committee in each State to participate in the development of 

provisions for the enforcement of the State plan which the State 

must submit in order to get its formula grants. Without that, and 

without standards coming out of the national office, you are getting 

nothing but Pablum. What you are doing is having money coming 

out and being spent in such a fashion tha t you cannot identify any 

kind of technical competence in delivering services.

Last, you should pay some attention to some of the reorganiza- *

tion which furth er fragments the system at the regional office level.

There was a deliberate attempt, successfully executed by administrations in the late 1960s, to decentralize the administration of programs 

in an acknowledged attempt to bring them closer to the people. This •

was a farce, however, since history has revealed tha t “decentralization” was simply a bureaucratic runaround.

The net effect is tha t regional offices are now stripped of any kind 

of technical competence to provide assistance to States of any kind 

of technical knowledge to implement national standards which should 

be required if you are going to be having effective State grant-in-aid 

programs.

Thank you.

Senator Kennedy. We are interested in your proposal, the study 

that was done. We will make this a part of this record. I think i t has 

a lot of material in it. It is useful. There are some common areas in 

both the approach you have outlined and outlined there, and one that 

I favor.

I just have one question. How are we going to get the private sector, the private physicians, the pediatricians really into this program, 

given the track record, given what the fact of the matter is in terms 

of the States at the present time ?

Just in terms of my own State of Massachusetts, it is a very difficult time to get that kind of service to needy people and to the poor 

people. The question is whether just adding resources and adding 

money to the system is going to do very much. I f you can comment 

upon what you have seen in recent times, what you think presently 

and where you think in the future how we are going to deal with that »

particula r issue ?

Dr. Cornely. It is comfortable to represent pediatricians because 

they are the least difficult group to get involved with public responsibilities in public health programs. I call your attention to the fact **

that when the Academy of Pediatrics was formed, it was formed 

because it objected to AMA at th at time refusing to support FederalState grant-in-aid, and it formed itself to support tha t concept.

I think the major problem for the pediatricians who are in pri ­

vate practice, and I am not in that area, is the prohibitive confusion 

in Federal regulations. You see, Senator, they do not read the Federal 

Register as daily reading matter. The next thing you know, before 

they get around to knowing there is a proposal to be put out by the
283

Department, they are already enforced. This results in complexities 

and confusion.

Then they are justified on the basis tha t the administration has 

to have accountability. Th at is a true statement, but tha t is not justification for complexities. Most of the time pediatricians whom I 

know from working on tha t particular task force on title V say that 

there is no lack of desire to participate. It is very difficult to do it. 

It is very difficult to figure why am I submitting the kind of info rmation they require since they give me no justification or no playback. They justify it on the basis tha t it represents their responsibility 

to execute accountability back to Congress.

So we would prefer to see that there be some more attention paid 

to the sanity of the regulations and to simplicity rath er than tryingto allow virtually anyone who has an ambition to add another element of information to further complicate the system.

Senator Kennedy. I think I would have trouble differing with

* anything that you mentioned there or arguing with it. I think what 

we have seen is, for whatever reason, an increasing number of pediatricians are opting out of the medicaid system. That has been 

true.

Dr. Cornely. That is very easy to understand in regard to mediaid. EPSDT in 22 States prohibits anyone from the State or local 

health department from delivering EPSDT service—your State is 

an exception, your State allows private practitioners to participate. 

In 22 States, the Governors have said the most inexpensive way in 

which I can implement this is to use my own established health program. So they have well-baby clinics. They convert them into screening clinics. The CHA P legislation said that it not enough. I t should 

move, giving not just screening, but also provide diagnosis and treatment. It also suggests that there is to be a deliberate' attempt to move 

private practitioners back into it. Confusion results because at the 

State level the Governors are in a quandry. How can they meet their 

budgets and pay their bills unless they do it in the most inexpensive 

way. It is not as expensive to do it through their own clinics as it 

is to go through private practitioners.

Senator Kennedy. Tha t is certainly an explanation in those areas 

which have those provisions. I think you would find the tra ck records 

in the remaining 28 States not dissimilar from the ones you have 

outlined here. I may be wrong.

* We will put tha t part in the record on that, but I think tha t tha t 

has been a concern. It might be for reasons you have outlined here 

before, but it is a trend, it is development and movement which is 

obviously a very substantial concern.

* Senator Chafee. I would just like to comment a little bit on Ms. 

Schorr’s testimony. I must say I was stunned to read on page 2 of 

your testimony that 20 million children, 39 percent of the total under 

age 15, are not immunized against one or more of the six potentially 

dangerous childhood diseases for which vaccines are available. This 

certainly comes as a bit of discouraging news.

When you think of everything we are doing with community health 

centers, HMO’s, medicaid and other programs which we seem to 

pour out of this Government yet we are not doing what seems to be

28 -386 0 - 78 - 19
284

minimal on preventive measures. I do not have a solution. All I can 

say is I just wonder what is happening out there in the big world 

with all the money and effort and a whole host of programs, 1 zillion 

Federal programs. I do not have an answer to my question. I am 

just discouraged.

Ms. Schorr. A very brief comment. The Secretary of H EW shares 

your concern and has undertaken new initiative to get more children 

immunized. Their goal, I think, is 90 percent of the children within 

another year or two. I think in your comments you really highlighted 

what the problem is. That is we have 1 zillion programs, and they are 

not adequately coordinated so that needed services get to the families 

in the communities in ways they can make use of them. I think tha t 

is what we are asking you to do, to look at these programs and see -

what has to be done to them so that the famly is in a better position, 

has better access to sources of immunization, and other needed care.

Immunization rates have been going down. They have not been 

going up. They have been going down over recent years. *

Senator Chafee. It seems t hat is about the easiest thing to do is 

to immunize children. Then, on page 3, you get into another area of 

great interest to me, the lack of attention to pregnant women, including teenagers; 7 out of 10 mothers under 15 get no prenatal care 

in the first trimester and one-fourth get no prenatal care at all, twice 

as many blacks—I do not know what the answer to this is. I would 

think community health centers would be doing a lot.

Ms. Schorr. We do know that the neighborhood health centers and 

maternal and infant care centers have a quite different record in 

terms of the number of women they get into care early.

Senator Chafee. Different from what?

Ms. Schorr. A far better record than these nationwide figures. We 

know it is possible to do, that if you combine outreach services with 

the services of not only obstetricians but nurse-midwives, and other 

health workers, community workers, put those together and make 

them readily available in neighborhoods where people live, get info rmation out about them, and deliver the services in circumstances 

where there is no racial discrimination, where steps have taken to 

overcome language and cultural barriers, where the client or patient 

is treated with dignity and respect, we know tha t it is possible to 

get women in early in their pregnancies and provide high quality 

prenatal care. It has not happened everywhere, it doesn’t happen 

without clearly focused efforts. »

Senator Chafee. You do not know how’ these statistics work out in 

different sections of the country? It would seem to me in the great 

area of blue western sky, say a place like Idaho, I just cannot believe 

these figures would apply there. I can see some of the areas in the «♦

great urban centers, where these statistics might be true. Give me 

some encouragement.

Ms. Schorr. The statistics are available by States. They are collected by the National Center for Health Statistics and are available 

by State. Perhaps we could make them available to you fo r the record.

Senator Chafee. I am curious, we must be doing a decent job 

somewhere in this country in preventive medicine. I would like to
285

think we are, but your statistics do not give me much for celebration.

Ms. Schorr. There is no question but tha t we are doing a decent 

job with groups of people, defined groups of people reached by organized community programs. Whether there are whole States that 

can claim that they are reaching all their pregnant women early in 

their pregnancies, perhaps Dr. Comely or Dr. Miller could clarify.

Dr. Cornely. I will mention a few States. Take the State of Nebraska. They have publicly supported services for pregnant women 

in two cities, Lincoln and Omaha. Beyond that, everything is out-of - 

State. There are no publicly sponsored services out there for pregnant 

women. The women in those areas of the S tate are expected to go to 

local practitioners, and if they do not, no one knows about it. You 

go to West Virginia, you find precisely the same picture. So this is 

not a dramatic event any more than immunization is a dramatic event.

So stimulus for people to get these services, I suppose, requires a 

♦ tremendous, aggressive approach to try and sell through outreach

preventing services.

[The prepared statement of Dr. Comely and the health statistics 

referred to earlier follows:]
286

AMERICAN ACADEMY OF PEDIATRICS 

Testimony before the

Human Resources Committee 

Subcommittee on Health and Scientific Research 

Presented by

Donald A. Come ly , M.D., FAAP 

March 1, 1978

9
287

M a te rn a l and C h ild H e a lth in tlie U.S .A .*

The A m er ic an Acade my o f P e d i a t r i c s a p p r e c i a t e s t h i s o p p o r tu n ity 

t o o f f e r co m m en ta ry t o th e S ubcom m it te e on H e a lth on th e m a tte r o f 

p u b lic r e s p o n s i b i l i t y f o r th e h e a l t h o f c h ild r e n o f t h i s c o u n tr y . 

Me mbers o f t h i s S ubcom m it te e s h o u ld u n d e rs ta n d t h a t t h i s t o p i c o f 

p u b lic r e s p o n s i b i l i t y f o r th e h e a l t h an d w e lf a r e o f m o th e rs an d 

c h ild r e n i s n o t a new fo u n d i n t e r e s t o f th e A m er ic an Acade my o f 

P e d i a t r i c s . Ou r Academ y was fo rm ed in 193 0 an d on e o f th e f a c t o r s 

p ro m in e n t in th e d e c is io n o f o u r fo rm a tio n wa s th e i n t e r e s t o f th e 

p e d i a t r i c i a n s o f t h i s c o u n try t o s u p p o r t th e c o n c e p t o f f e d e r a l - 

s t a t e g r a n t - i n - a i d t o fo c u s on th e h e a l t h an d w e lf a r e o f m o th e rs an d 

c h i l d r e n . We dee m i t im p o rta n t t o n o te t h a t th e f i r s t f e d e r a l - s t a t e 

g r a n t - i n - a i d pro gra m in h e a l t h in t h i s c o u n try was f o r m a te rn a l an d 

c h i l d h e a l t h . T h is c o n c e p t h a s been g iv e n e x p r e s s io n in th e S o c ia l 

S e c u r ity Act o f 193 5 an d T i t l e V o f t h a t o r i g i n a l A ct a d d re s s e d 

m a te rn a l an d c h i l d h e a l t h an d c o n tin u e s in f o rc e to d a y . T hus , f iv e 

y e a r s b e f o re C o n g re ss f o rm u la te d th e c u r r e n t o r g a n i z a t i o n a l l e g i s l a ­

t i o n to p ro m ote th e h e a l t h o f m o th ers an d c h ild r e n th e A m er ic an 

Academ y o f P e d i a t r i c s wa s fo rm ed an d a d o p te d o u r m o tt o , " F o r th e 

We l f a r e o f C h ild r e n . "

O ver th e p a s t 65 y e a r s C o n g re ss h a s ta k e n s e v e r a l a c tio n s to e x p r e s s 

i t s co m m itm en t t o th e p u b l i c r e s p o n s i b i l i t y f o r c h i l d h e a l t h . We 

w is h t o c a l l y o u r a t t e n t i o n t o fo u r o f th e s e a c t i o n s w hic h ca n a s s i s t 

in u n d e rs ta n d in g o u r c u r r e n t p o s tu r e an d o f f e r a p e r s p e c ti v e f o r

‘ T est im o n y p r e s e n te d b e f o re S e n a te S ubcom m it te e on H e a lth , W ed ne sd ay , 

Marc h 1, 19 78 on b e h a lf o f th e A m er ic an Acade my o f P e d i a t r i c s .

D onal d A. C o m e ly , M.D. p r e s e n t i n g .
288

- 2 - .

f u t u r e d e v e lo p m e n ts . C e r t a i n l y , th e fo rm a tio n o f th e C h ild r e n 's 

B ure au in 19 12 r e p r e s e n t s an im p o rta n t la n d m a rk . An a d m ir a b ly b ro a d 

vie w o f c h i l d h e a l t h an d i t s i n t e r r e l a t i o n s h i p s w it h c h i l d w e lf a r e 

wa s e x p r e s s e d in th e c h a rg e g iv e n by C o n g re ss t o th e C h ild r e n 's 

B u re a u . The se co n d s i g n i f i c a n t g u id e p o s t wa s th e S o c ia l S e c u r ity 

A ct o f 1935. As m e n ti o n e d e a r l i e r , on e o f th e o r i g i n a l T i t l e s o f 

t h i s A ct ( T i t l e V) i s o l a t e d th e c o n c e rn an d co m m itm en t o f C on g re ss

b

f o r c h i l d h e a l t h . T h is T i t l e b e a r s i t s o r i g i n a l na m e. M a te rn a l an d

C h ild H e a lt h an d C rip p le d C h i l d r e n 's S e r v i c e s . I t m an d ate s in e v e ry

s t a t e th e fo rm a ti o n o f a d i s t i n c t a d m i n i s t r a t i v e u n i t t o fo c u s on *

th e p ro m o ti o n o f th e h e a l t h o f m o th e rs an d c h i l d r e n and f o r c h ild r e n 

w ith c h r o n ic h a n d ic a p p in g c o n d itio n s .

I t i s w e ll a t t h i s p o in t t o em p h asiz e t h a t th e m ajo r t h r u s t o f 

T i t l e V fr om i t s in c e p tio n h as bee n t o pro m pt th e fo rm a tio n o f a 

t e c h n i c a l l y co m p e te n t bo dy in e a c h s t a t e a d d r e s s in g th e b r e a d th o f 

is s u e s in v o lv e d in a d v a n c in g th e h e a l t h o f th e m a te r n a l an d c h ild 

p o p u l a t i o n s . The a p p r o p r i a t i o n s p ro v id e d by C o n g re ss e a c h y e a r in 

th e fo rm o f g r a n t - i n - a i d t o im ple m ent t h i s Ac t ad d f u r t h e r r e c o g n itio n 

o f C o n g re s s io n a l i n t e n t t h a t th e MCH an d CC u n i t s in e a c h s t a t e a re 

t o en g ag e in a v e ry b ro a d s e t o f a c t i v i t i e s d e te rm in e d by e a c h s t a t e 

com m ensu ra te w it h i t s n e e d s an d r e s o u r c e s . Th e a p p r o p r i a t i o n s , 

c u r r e n t l y a p p ro x im a te ly $400 M illio n , s u p p o r t th e o p e r a tio n o f th e s e 

s t a t e u n i t s an d s e l e c t e d p ro g ra m m a ti c e f f o r t s a d d r e s s e d t o s p e c i a l 

p ro b le m s an d is s u e s a f f e c t i n g th e h e a lth o f m o th e rs and c h i l d r e n .

E q u a lly im p o rta n t t o u n d e r s ta n d i s t h a t th e l e v e l o f a p p r o p r ia tio n s 

n e v e r h as s u g g e s te d t h a t T i t l e V o f th e SSA wa s t o be th e f i n a n c i a l 

s y s te m t o s u p p o r t h e a l t h s e r v i c e s n ee d e d ev en by j u s t t h i s c o u n t r y 's

4
p o o r c h ild r e n an d m o th e rs . T i t l e V p ro g ra m s s t i m u l a t e th e o r g a n iz a ­

t i o n o f p ro g ra m s, a s s i s t in t h e i r d ev elo p m en t an d i n t e g r a t i o n i n t o 

th e t o t a l f a b r i c o f h e a l t h s e r v i c e s an d e x p lo r e th ro u g h d e m o n s tr a tio n s 

an d s p e c i a l p r o j e c t s th e r e s o u r c e s an d a rra n g e m e n ts n ee d e d t o a d d re s s 

s p e c i a l i z e d n e e d s o f t h i s p o p u la tio n se g m en t.

The t h i r d s i g n i f i c a n t a c tio n by C o n g re ss r e l a t i v e t o c h i l d

h e a l t h wa s th e i d e n t i f i c a t i o n an d d ev elo p m en t o f th e N a tio n a l I n s t i ­

t u t e o f C h il d H e a lt h an d Human D ev el opm en t in 1963. By t h i s a c t i o n . 

C o n g re ss gav e r e c o g n itio n to th e c r i t i c a l n eed t o i n v e s t in a lo n g 

te rm co m m itm en t t o a d v a n c in g th e h e a l t h o f th e f e t u s , c h i l d an d 

y o u th . W it h o u t t h i s b a s i c r e s e a r c h arm t o co m ple m en t th e h e a lth 

s e r v i c e a c t i v i t i e s o f to d a y i t w ould be f u t i l e t o e x p e c t to a c h ie v e 

th e l e v e l o f h e a l t h t h i s c o u n try h o ld s o u t f o r i t s c h i l d r e n . W hile 

a s m a ll p o r t io n o f T i t l e V a p p r o p r ia tio n s a re m andate d an d u t i l i z e d 

f o r r e s e a r c h fo c u s e d on th e d e liv e r y o f h e a l t h s e r v i c e s f o r t h i s 

p o p u la tio n , th e s e p a r a te co m p le m en ta ry m is s io n o f th e NICHD o f 

r e s e a r c h on fu n d a m e n ta l b i o l o g i c a l an d b e h a v io r a l r e l a t i o n s h i p s 

a f f e c t i n g h e a lth an d d ev elo p m en t h as bee n a p r u d e n t p e r c e p tio n by

C o n g re s s .

The f o u r th a c tio n o f C o n g re ss we ch o o se t o i d e n t i f y t h a t i s

r e l a t i v e -t o th e p u b lic r e s p o n s i b i l i t y f o r m a te rn a l an d c h i l d h e a l t h 

was th e p a s s a g e in 196 5 o f T i t l e XIX o f th e S o c ia l S e c u r ity A ct and 

i t s s u b s e q u e n t am en dm en t o f 19 67 a d d re s s e d t o e a r l y an d p e r i o d i c 

s c r e e n in g , d ia g n o s is an d t r e a tm e n t f o r c h ild r e n who a re c l a s s i f i e d 

a s p o o r. T h is M e d ic aid p ro g ra m i s r e p o r te d t o sp e n d betw een $3 

and 4 B i l l i o n s a n n u a lly f o r p e r s o n a l h e a l t h c a re s e r v i c e s f o r c h i l d r e n 

I t i s h e l p f u l in u n d e r s ta n d in g th e n a tu r e o f e x i s t i n g d e f i c i e n c i e s
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in o u r m a te rn a l an d c h i l d h e a l t h pr ogra m :, to n o te th e m ag n it u d e o f 

ta x s u p p o r te d e x p e n d itu r e s f o r t h i s p o p u la tio n g ro u p when d i s t i n g u i ­

s h in g T i t l e s V an d XIX o f th e SSA . C o n g re ss h a s a p p r o p r ia te d 

a p p ro x im a te ly $30 0 M illio n a n n u a lly f o r T i t l e V p ro g ra m s an d when 

m atc h ed by s t a t e an d l o c a l fu n d in g i t m ig h t i d e n t i f y a t o t a l o f $50 0- 

600 M illio n . T i t l e XIX r e p o r t s $3- 4 B i l l i o n s p e n t a n n u a lly f o r 

p e r s o n a l h e a lth s e r v i c e s to e l i g i b l e p o o r c h i l d r e n . I t i s c l e a r 

t h a t th e i n t e n t o f th e s e tw o C o n g re s s io n a l m an d ate s a re d i f f e r e n t , 

how ev er com ple m enta ry th e y m ig h t be p e r c e iv e d . T i t l e V was n e v e r 

in te n d e d t o be th e mea ns by w hic h ev en p o o r c h ild r e n w er e t o r e c e iv e 

t h e i r p e r s o n a l h e a l t h s e r v i c e s . T i t l e XIX i s in te n d e d t o p ro v id e

f o r su c h s e r v i c e s t o e l i g i b l e p o o r c h i l d r e n , how ev er r e s t r i c t e d th e 

d e f i n i t i o n o f e l i g i b i l i t y .

T hes e f o u r a c tio n s by C o n g re ss o v e r s l i g h t l y more th a n th e p a s t 

h a l f c e n tu ry a re s e l e c t e d t o h i g h l i g h t on one h an d t h a t C o n g re ss 

h as re c o g n iz e d th e n e e d f o r s p e c i a l a t t e n t i o n t o th e h e a l t h o f m o th ers 

an d c h ild r e n w h il e on th e o th e r han d t o i n d i c a t e th e d e c id e d ly tim id 

an d h a l t i n g n a tu r e o f th e co m m itm en t w hic h h as r e s u l t e d in u n n e c e s sa ry 

fra g m e n ta tio n an d i n s u f f i c i e n t h e a l t h s e r v i c e s . Add t o th e s e f o u r, 

m o ie - o r - le s s m ajo r m ile s to n e s in c h i l d h e a l t h , th e num er ous l e g i s l a ­

t i v e a c tio n s on mo re c ir c u m s c r ib e d d is e a s e s o r c o n d itio n s a f f e c t i n g 

c h ild r e n an d th e p o t e n t i a l f o r f ra g m e n ta tio n i s in c r e a s e d w ith o u t 

a s s u r a n c e o f ad equacy o f c o v e ra g e f o r a l l th e h e a l t h n e e d s o f a l l

c h i l d r e n .

When one mo ves t o th e im p le m e n ta ti o n o f th e s e l e g i s l a t i v e 

i n t e n t s by th e E x e c u ti v e b ra n c h o f o u r f e d e r a l g o v ern m en t,
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th e o r iz e d in a d e q u a c ie s be co me more r e a l i t i e s . Focu s f o r th e moment 

on th e m a jo r s i t e o f th e f e d e r a l a d m i n i s t r a t i v e im p le m e n ta ti o n o f 

m a te rn a l an d c h i l d h e a l t h p ro g ra m s, th e D ep art m en t o f H e a lth , E duca ­

t i o n , an d W e lf a re an d ex am in e i t s re s p o n s e in o r g a n iz in g i t s r e s o u r c e s 

f o r m a te rn a l an d c h i l d h e a l t h . Members o f C o n g re ss m ig h t s t a r t by 

r e f l e c t i n g on when wa s th e l a s t ti m e an y o f i t s C om m it te es had th e 

o p p o r tu n ity t o have th e d i r e c t o r o f DHEW's m a te rn a l an d c h i l d h e a lth 

p ro g ra m a d d re s s th em o r be p r e s e n t f o r an y d e s i r e d d is c u s s i o n . We 

b e lie v e yo u w i l l f in d t h i s l a s t o c c u r r e d o v e r f i v e y e a r s a g o . W it h in 

DHEW th e e f f o r t f o r m a te rn a l an d c h i l d h e a l t h i s d iv e r s e d r a t h e r 

th a n fo c u s e d an d th e o f f i c e b e a r in g th e s p e c i f i c i d e n t i f i c a t i o n o f

m a te rn a l an d c h i l d h e a l t h p ro g ra m s i s b u r ie d a t l e a s t th r e e l a y e r s 

b e n e a th t h a t o f th e A s s i s t a n t S e c r e ta r y f o r H e a lth . T hus, th e 

a d m i n i s t r a t i v e p la c e m e n t o f th e MCH pro gra m o f f i c e , th e s c a t t e r 

r a t h e r th a n c o a le s c in g o f e f f o r t s f o r t h i s fo c u s an d th e s h e e r c o n ­

f u s io n an d e f f o r t ex p en d ed in an a lm o s t c h r o n ic p re o c c u p a tio n w it h 

r e o r g a n iz a t io n h a s r e s u l t e d in l e s s p r o g r e s s th a n ca n lo n g be

t o l e r a t e d .

A v e ry c o n c e rn in g a d m i n i s t r a t i v e r e a l i t y h a s bee n t h a t in i t s 

t w e n ty - f iv e y e a r s as a D ep a rt m e n t, HEW h as had a b o u t a doze n 

d i f f e r e n t S e c r e t a r i e s . I f t h i s i s to be th e e x p e r ie n c e we m ust 

e x p e c t, th e n we s u g g e s t C o n g re ss ta k e s t e p s t o i n s u l a t e i t s co m m itm en t t o m a te rn a l an d c h i l d h e a l t h fr om th e v e ry r e a l r i s k s o f 

n e g le c t o r l im ite d u n d e r s ta n d in g an y new a d m i n i s t r a t i v e a rra n g e m e n t 

m ig h t i n s t a l l . A d i s t i n c t a d m i n i s t r a t i v e u n i t i n DHEW c h a rg e d 

w it h t h a t same r e s p o n s i b i l i t y em bra ced by C o n g re ss in i t s T i t l e V 

o f th e SSA m an dat e t o e a c h s t a t e w ould se em t o be b o th re a s o n a b le
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an d im p e r a tiv e . I t w ould le s s e n th e h a z a rd o f f ra g m e n ta tio n o f 

r e s p o n s i b i l i t y , l e a d e r s h i p an d d i r e c t i o n w hic h h as v e ry s i g n i f i c a n t l y 

h a n d ic a p p e d th e e f f o r t s o f im p le m e n ta ti o n d u r in g t h i s d e c a d e . T h is 

d i s t i n c t u n i t s h o u ld be p la c e d im m e d ia te ly u n d e r th e A s s i s t a n t 

S e c r e ta r y f o r H e a lth .

C o n g re ss c o u ld a l s o s tr e n g th e n th e im p le m e n ta ti o n c a p a b i l i t y 

f o r i t s m an dat e by i d e n t i f y i n g t h i s MCH P ro gra m O f f ic e a s th e a d m in i- *

s t r a t i v e s i t e f o r th o s e p ro g ra m s i t g e n e r a te s who se fo c u s i s p r i n ­

c i p a l l y o r p r im a r ily c h i l d an d m a te rn a l h e a l t h . Th e Academ y i s

r

m in d fu l o f th e wi sd om in th e s e p a r a tio n o f l e g i s l a t i v e an d a d m in is t r a t i v e pow ers an d p r e r o g a ti v e s in o u r s y s te m o f g o v ern m en t an d 

does n o t in te n d i t s s u g g e s tio n s t o im p a ir t h a t d i s t i n c t i o n . How ev er , 

w it h th e S e c r e t a r i e s o f DHEW b e in g so m ew ha t t r a n s i e n t in t h a t 

p o s i t i o n , w it h by f a r th e m ajo r fu n d in g in th e D ep art m en t u n d e r s ta n d ­

a b ly c o m p e ll in g th e D e p a rtm e n t's a t t e n t i o n t o th e n e e d s o f o th e r 

ag e g ro u p s an d i s s u e s o f v e ry li m i te d a p p l i c a b i l i t y t o c h i l d r e n , a 

s t r u c t u r a l a rra n g e m e n t se em s b o th r e a s o n a b le an d p r u d e n t in in s u r in g 

a d e q u a te a t t e n t i o n to th e h e a l t h p ro g ra m s f o r c h i l d r e n . C o n sid e r 

th e m ajo r i s s u e s b o th C o n g re ss an d th e D ep art m en t h av e bee n d i l i g e n t l y 

s t r u g g l i n g w it h in th e a r e a o f h e a l t h in th e s e tim e s . C o st c o n t a i n ­

m ent, c o n t r o l o f f ra u d in th e m e d ic a l c a r e p ro g ra m s an d n a t i o n a l 

h e a l t h in s u r a n c e a re n o t i s s u e s pro m p te d by a m a jo r c o n c e rn f o r 

c h i l d h e a l t h . C o st c o n ta in m e n t i s o l a t e s s h o r t te rm h o s p i t a l i z a t i o n 

an d n u r s in g homes an d th e s e a r e n o t m ajo r com ponents o f a m a te rn a l 

an d c h i l d h e a l t h p ro g ra m , how ev er im p o rta n t th e y be t o th e b ro a d e r

h e a l t h p ro g ra m . C h ild re n f r e q u e n t th e i n p a t i e n t s i d e o f h o s p i t a l s *
v e ry in i r e q u c n t ly an d have th e lo w e st r a t e o f h o s p r t a l i z a t i o n , th e 

f e w e s t day s o f h o s p i t a l i z a t i o n o f an y ag e g ro u p , an d th e d i f f e r e n c e s 

a r e o f g r e a t m a g n it u d e . F ra u d u le n t u se o f p u b lic fu n d s f o r h e a l t h 

c a r e ca n h a r d ly be p r e s e n te d a s a m a jo r p ro b le m in m a te rn a l an d 

c h i l d h e a l t h s in c e h e a l t h s e r v i c e s t o th e s e p o p u la tio n se g m en ts i s 

e s s e n t i a l l y a p r e v e n tiv e an d a m b u la to ry o r i e n t a t i o n . We do n o t

e x p e r ie n c e an o v e ru s e o f p r e v e n tiv e h e a l t h s e r v i c e s f o r women s u r ­

ro u n d in g m a te r n ity c a r e o r fa m il y p la n n in g s e r v i c e s , an d f o r c h i l d r e n 

an d y o u th . Q u it e th e c o n tr a r y , o u r s t r u g g l e h a s been an d re m a in s to

a tte m p t t o have c h ild r e n and m o th e r s - to -b e t o u t i l i z e ev en min imum

s e r v i c e s . Me mb ers o f t h i s S ubco m m it te e know v e ry w e ll t h a t i f th e 

c o s t s in v o lv e d in c o n s id e r in g n a t i o n a l h e a l t h in s u r a n c e w er e th o s e 

p r o j e c t e d f o r th e m a te rn a l an d c h i l d p o p u la tio n n e e d s , t h e r e w ou ld 

be l i t t l e h e s ita n c y in m ov in g a g g r e s s iv e ly fo rw a rd w it h a u n i v e r s a l 

e n t i t l e m e n t . T hus, c h ild r e n an d t h e i r h e a l t h n e e d s te n d t o g e t 

l o s t in th e co m ple x o f la r g e e x p e n d itu r e s and s e r v i c e s r e q u ir e d to 

s e rv e th e g e n e r a l ( o ld e r ag e g ro u p s) p o p u la tio n . U n le ss C o n g re ss 

ta k e s th e s t e p t o ad d a s i g n i f i c a n t an d a p p r o p r ia te s t r u c t u r a l b a s e 

f o r m a te rn a l an d c h i l d h e a l t h in o u r f e d e r a l h e a l t h a d m i n i s t r a t i o n , 

th e Acade my f e e l s we a s a n a tio n sim p ly t a i l to u n d e rs ta n d an d m ee t

o u r r e s p o n s i b i l i t y t o c h i l d r e n .

One c o u ld r e c i t e a l i s t o f s p e c i f i c h e a l t h p ro b le m s f a c in g th e 

m a te rn a l an d c h i l d p o p u la tio n a t t h i s tim e . O bvio us in su c h a l i s t

w ou ld be th e c o n c e rn ab o u t p re g n a n c y in th e yo un g a d o le s c e n t fe m a le ;

th e h ig h e r th a n n e c e s s a ry i n f a n t m o r t a l i t y r a t e s in a t l e a s t o n e - 

t h i r d o f th e s t a t e s ; th e p r e c a r io u s a rra n g e m e n ts o r la c k t h e r e o f f o r 

a p p r o p r ia te p e r s o n a l h e a l t h c a r e o f f a m i li e s who a re p o o r, who r e s i d e
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in u rb an an d in r u r a l s e t t i n g s ; th e n e a r a b se n c e o f a p p r o p r ia te 

m a te rn a l h e a l t h s e r v i c e s d u rin g th e p r e n a t a l p e r io d in v a s t s e c tio n s 

o f t h i s c o u n try an d so on . Mo vin g to u n iv e r s a l e n t i t l e m e n t u n d er

som e fo rm o f n a t i o n a l h e a l t h in s u r a n c e w i l l i t s e l f n o t a d d r e s s e a c h

o f th e s e is s u e s a d e q u a te ly . H ow ev er , u n t i l th e f i n a n c i a l im pedim ent 

t o a c h ie v in g a p p r o p r ia te p e r s o n a l h e a l t h c a r e i s re m oved , m illio n s 

o f c h ild r e n sim p ly lo s e v a lu a b le and n eed ed s k i l l s an d t a l e n t s to 

be p r o d u c tiv e a d u l t s .

The Academ y h as ex am in ed so m ew ha t e x t e n s i v e l y tw o p ro g ra m s 

g e n e r a te d by C o n g re ss w hic h fo c u s on m a te rn a l an d c h i l d h e a l t h . The 

r

T i t l e V and EPSDT Pro gra m s w er e re v ie w e d an d c o n tin u e u n d e r d is c u s s io n .

We a re aw ar e t h a t l e g i s l a t i v e l y e a c h o f th e s e p ro g ra m s a re u n d er th e 

a u t h o r i ty o f th e S e n a te F in a n c e C om m it te e. Ou r co mmen ts h av e bee n 

s h a re d w it h t h a t C om m itte e in a p r e lim in a r y fa s h io n an d we e x p e c t

a more th o ro u g h d is c u s s io n in th e n e a r f u t u r e .

The T i t l e V pro g ra m s u f f e r s b a d ly fr om th e l im ite d u n d e rs ta n d in g 

a t many l e v e l s o f f e d e r a l , s t a t e an d lo c a l g o v ern m en t o f i t s p rim a ry 

p u r p o s e . E a r l i e r in t h i s te s ti m o n y th e c o n t r a s t in l e v e l s o f 

e x p e n d itu r e s b etw een T i t l e V an d T i t l e XIX p ro g ra m s wa s made e x p l i c i t .

B ot h th e w o rd in g o f th e r e s p e c ti v e m andate s as w e ll a s th e le v e ls 

o l fu n d in g s h o u ld e n a b le one t o u n d e rs ta n d t h a t T i t l e V h a s as i t s 

p r i n c i p a l m is s io n th e d e v e lo p m e n t o f a s u f f i c i e n t c a p a b i l i t y in 

e a c h s t a t e t o a d d re s s th e g e n e r a l is s u e o f th e h e a l t h s t a t u s , h e a l t h

n e e d s an d h e a l t h s e r v i c e s f o r m o th e rs, c h ild r e n an d c h i l d r e n w it h 

h a n d ic a p p in g c o n d i t i o n s . S p e c ia l g ro u p s an d s p e c i a l e f f o r t s in th e 

fo rm o f s p e c i f i e d p r o j e c t s an d d e m o n s tr a tio n s a re t o be p u rs u e d in 

th e s t a t e s . Eac h s t a t e , how ev er, m ust d e v e lo p an a p p r o p r i a t e p la n 

o f i t s n e e d s an d in te n d e d p u r s u i t s to m in im iz e o r re m ov e h e a l t h n eed s
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an d p ro b le m s . In a d d i t i o n , th e a s s e s s m e n t o f th e h e a l t h o f t h i s 

p o p u la tio n , th e d ev elo p m en t o f r e s o u r c e s , th e d ep lo y m en t o f s p e c i a l 

r e s o u r c e s , th e p ro m u lg a ti o n o f s ta n d a r d s o f c a r e , th e s t i m u l a t i o n 

o f a t t e n t i o n t o th e h e a l t h o f m o th ers an d c h i l d r e n , c a s e f in d in g ,

c o o r d in a tio n o f p u b lic an d p r i v a t e i n i t i a t i v e s in h e a l t h f o r t h i s 

p o p u la tio n gro u p a re th e sc o p e o f r e s p o n s i b i l i t i e s o f th e T i t l e V

# p ro g ra m s in e ach s t a t e . Th e Academ y f in d s th e s e s t a t e p la n s to be 

in a d e q u a te i n m ost j u r i s d i c t i o n s an d i t a p p e a rs t o be th e r e s u l t o f 

a la c k o f u n d e r s ta n d in g o f t h i s m is s io n and in a d e q u a te f i n a n c i a l

*

s u p p o rt to d e v e lo p th e n e e d e d c a p a b i l i t y t o re s p o n d t o t h i s c h a rg e .

We te n d t o f e e l t h a t r e d r a f t i n g t h i s fu n d a m e n ta l p ie c e o f l e g i s l a t i o n 

w ould be th e b e t t e r a p p ro a c h t o ad d th e c l a r i t y , p r o v id e th e t e c h n i c a l 

c a p a b i l i t y , an d t o d e v e lo p th e n ee d e d n a t i o n a l , s t a t e an d lo c a l

r e s o u r c e s .

The EPSDT P ro gra m h as been d e s c r ib e d by many a s a d e b a c le an d 

i t i s n o t d i f f i c u l t t o s u p p o r t su ch a c o n te n tio n . D ata i s s p a rs e 

b u t w hat i s a v a i l a b l e c e r t a i n l y s u g g e s ts t h a t th e EPSDT Pro gra m 

s u f f e r s v e ry b a d ly fr om la c k o f d i r e c t i o n , la c k o f t e c h n i c a l co mpe ­

te n c e in th e c e n t r a l an d r e g io n a l f e d e r a l o f f i c e s , o p p r e s s iv e 

r e g u l a t i o n s an d p o l i c i e s a l l o f w hic h r e s u l t in b u t a f r a c t i o n o f 

th e e l i g i b l e c h ild r e n b e in g s e rv e d a t a l l , muc h l e s s a d e q u a te ly .

Th e A d m i n i s t r a t i o n 's p r o p o s a l t o c o n v e r t t h i s i n t o a C om pre hen si ve 

H e a lt h A sse ssm en t P ro gra m g e n e r a l l y mo ves in th e c o r r e c t d i r e c t i o n 

b u t u n t i l th e C o n g re ss h a s g iv e n i t a more th o ro u g h re v ie w i t w ou ld 

se em re a s o n a b ly f u t i l e t o e n u m e ra te s p e c i f i c q u e s tio n s and p ro b le m s 

in th e p r o p o s a l a t t h i s tim e .
296

- 10 - ’ • .

The A m er ic an Academ y o f P e d i a t r i c s i s p r e p a r e d to p ro v id e 

a p p r o p r ia te b o d ie s o f th e C o n g re ss i t s i n s i g h t s an d re co m m en d ati o n s 

in more c o m p le te d e t a i l whe n th e y a re p re p a re d t o a d d r e s s th e s e

i s s u e s .
THE NATIONAL FOUNDATION-MARCH OF DIMES

P e r c e n t o f L iv e b o rn Whose M o th e rs B eg an P r e n a t a l C are E ach T r im e s te r 

an d P e r c e n t W e ig h in g 5 ^ 1 b s . o r L e s s , by R a c e , 42 S t a t e s an d D .C ., 19 74

R eg io n an d S t a t e

T r im e s te r In W hi ch P r e n a t a l C are Beg an

T o ta l F i r s t S ec ond T h ir d

No

P r e n a t a l

C are

N o t

R e p o r te d

T o t a l , 42 S t a t e s 6. D .C .

A ll B i r t h s

7. o f t o t a l 1 0 0 .0 6 9 .2 2 0 .8 4 .6 1 .3 4 .1

% lo w w e ig h t 7.4 6 .6 8 .6 8 .6 2 0 .1 9 .7

W h it e B ir t h s

7. o f t o t a l 1 0 0 .0 7 3 .0 1 8 .3 3 .9 1 .0 3 .8

X lo w w e ig h t 6 :3 5 .8 7 .0 - 7 .1 1 6 .3 7 .7

N o n w h it e B i r t h s

X o f t o t a l 1 0 0 .0 5 2 .3 3 1 .6 7 .9 2 .7 5 . 5 ’

X lo w w e ig h t 1 2 .4 1 1 .3 1 2 .6 1 1 .5 2 6 .3 1 5 .6
□ Impaired letal growth re LlA in a "sm all for dale " 

baby, who is born a t fu ll te rr l f.tno nths ), but with low 

birthweight. Poor maternal nyulton during pregnancy 

may be associated with slow fetal growth These infants 

suffer in utero from poor nutritio n, poor oxygenation 

and other adverse conditions.

□ Prenatal care an d low birthweight. Wh ile prenatal 

care is not the only influence on birthweigh t. its importance is obvious wherever data on the outcome of 

pregnancy have been examined.

In a recent study in New York City, this was true even 

among women whose social and medical histories gave 

every indication of a favorable outcome They were 

married, had finished high school, had no history of 

previous feta l deaths and had no complications during 

labor or delivery.

This study was based upon live births to women 

whose ages ranged from less than 15 to as high as 39. In

all age groups, low birthweight and infant mo rtality 

rates were markedly higher among the mothers who 

had no prenatal care, whether or not they were at these 

social or medical risks.

The results were especially revealing for teen-age 

mothers Among teen-agers whose pregnancies were 

not at these social and medical risks, low-weight ratios 

varied from 5.5 per cent for those who began care in the 

firs t trimester, to 8 5 per cent when care started in the 

second and th ird trimesters, to 9.9 per cent for mothers 

wh o had no prenatal care at all.

Among teen-age mothers with high-risk pregnancies, 

the low-weight ratios also reflected the influence of pref Percen

(•ret frai

Percent of mothers who began prenatal care in the

first trimester, 42 reporting states and D.C., U.S.A., 1975

State______________ Percent

Rhode Island 06 3

Utah 05.7

Connecticut 05.2

Iowa 020

Wbcontm 01 0

New Hampihire 70.5

Maryland 779

Oh«> 77 0

Monlan.O 77.0

Virginia 77 2

Delaware 770

Kama* 76.5

Indiana 75.7

Maine 755

Michigan 75.3

Oregon 75.3

Nebraska 75.3

Missouri 740

Colorado 74 5

Wyoming 73.9

California 730

Louisiana 72.9

State______________Percent

Minnesota 72 0

North Dakota 72.5

New Jersey 719

Nevada 71.2

North Carolina 71.2

Illinois 70.5

Kentucky 69 0

Tennessee 69.7

Vermont 69.3

Te«as 609

Hawaii 609

Mississippi 60 6

New York 66 5

Ceorgia 67 7

South Carolina 66 0

Oklahoma 66 6

Florida 65 5

South Dakota 64 3

West Virginia f

 60 9

Arizona ' 601

District of Columbia 56 6

Source CerHet for Health Suinlict

natal care, varying fro m 15 4 per cent of births to highrisk mothers whose medical care began during the first 

trimester, t o 231 per cent among such women who had 

no care at all.

f

Percent of newborns weighing 5 lbs. 8 o i. or less by

trimester in which mother began prenatal care

42 reporting states & D.C., 1975

Infant deaths. Americans take o ur role as world leaders 

almost for granted. We are first in space technology, 

agricultural production and industrial developme nt 

Our men and wom en of me dicine have made lasting 

contributions to the health o f all mankind.

But in p rotecting human life at birth, those firs t fragile days of life, we have fallen behind other advanced 

nations for many years. We have a higher in fan t death 

rate than 16 o ther countries.

This poor showing canno t be explained away by 

internationa l differences in definitions and reporting 

standards. The MOD believes that our disprop ortionately high rate of infan t dea th could be reduced significantly if all pregnant women received early, continuous prenatal care, including adequate nutrition.

Hence our expanded eff orts — as reflected in the 

recently adopted resolution by the NF Board of 

Trustees — to make prenatal care widely available and 

accessible, better understood and utilized.

The outc om e o f pregnancy is strongly influenced by 

a variety of social, c ultural and demographic risk factors such as income, education and accessibility of 

medical care. The disadvantaged, the undereducated, 

the ethnic minorities, in general, experience poorer outcomes than others.
299

Senator Chafee. Thank you, Mr. Chairman.

Senator K ennedy. Thank you.

Ms. Schorr. Thank you.

Senator Kennedy. With the understanding of our good friend, 

Mike Gorman, I am going to ask th at we take the Panel on Comprehensive Public Health Programs.

We have Robert Whalen, Commissioner of Health, New York 

State, Albany, N.Y.; accompanied by Joseph E. Cannon, M.D., Director of the Department of Health, Providence, R.I., and James E. 

Word, Deputy Commissioner, State Department of Health, Nasville, 

Tenn.; and Dr. Donald Wallace, Health Officer, Prince Georges 

County Health Department, Cheverly, Md.

Senator Chafee. Mr. Chairman.

I am pleased to see we are examining one of the few Federal programs which addresses a sorely neglected subject—tha t of health 

protection and disease prevention. I think that if we put ju st a fraction of the money into prevention tha t we do into costly medical care, 

we could do a great deal to improve the health of the people of this 

country. Prevention is so much more desirable than cure, and I am 

concerned tha t we are taking for granted the importance of organized public health protection programs—as evidenced by the lack of 

adequate funding in recent years for Comprehensive Public Health 

Services under section 314(d).

Because we no longer worry about many of the killing and disabling diseases of yesterday—and this is due in large measure to the 

fine job our public health departments around the country have done— 

we must remember tha t the need for organized community health 

programs has not diminished—on the contrary, the increasing environmental hazards will put a great burden of responsibility on 

our hard-pressed public health officials in the future.

As you know, I have recently introduced a bill, S. 2567, which 

amends 314(d) of the Public Health Service Act to increase Federal support for public health programs and to encourage State and 

local governments to increase their spending for these programs. My 

bill would provide a floor of guaranteed Federal support, but would 

grant not more than 10 percent of state and local expenditures for 

these activities up to a ceiling of $1.50 per capita. I have included a 

floor of $1 per capita for each State’s allocation, and while this is a 

modest figure compared to the amount the Federal Government 

spends on treatment for illness, this might bear some further investigation. However, the concept of this bill—tha t of a shared Federal - 

State-local commitment to organized community health protection 

programs represents an essential new national emphasis on sickness 

prevention. My bill would preserve the flexibility which the 314(d) 

block grant program gives to States to deal with unique regional 

needs. I t also continues to allow for a comprehensive array of public 

health programs which would not be possible with a patchwork of 

narrow categorical disease prevention grants.

I welcome the comments of the witnesses here today on this concept, as well as the views and recommendations of all other interested parties.

Senator K ennedy. Dr. Whalen.

2 8 -3 86 0 - 78 - 20
30 0

STATEMENTS OF ROBERT P. WHALEN, M.D., COMMISSIONER OF

HEALTH, NEW YORK STATE, ALBANY, N.Y., ACCOMPANIED BY

JOSEPH E. CANNON, M.D., DIRECTOR, DEPARTMENT OF HEALTH,

PROVIDENCE, R.I.; JAMES E. WORD, DEPUTY COMMISSIONER,

STATE DEPARTMENT OF HEALTH, NASHVILLE, TENN.; AND

DONALD WALLACE, M.D., HEALTH OFFICER, PRINCE GEORGES

COUNTY HEALTH DEPARTMENT, CHEVERLY, MD., A PANEL

Dr. W hal en. Se nator Ke nnedy , Se nator Chafe e, I am Dr. Rober t 

P. Whalen , comm ission er of the New Yo rk St at e Dep artm en t of 

He alth. I am befo re you tod ay rep res entin g the Ass ocia tion of State 

and Ter rito rial He alth Officials, also know n as AST HO . #

May I begin by th an ki ng you and your colle ague s fo r the wisdom 

and su pp or t which br ou gh t the pa rtn er sh ip in he alt h prog ram into 

being 11 yea rs ago. Th ro ug h yo ur for esi ght, you helped to esta blis h 

the commo n res ponsi bility of Gov ern ment on all levels—Fe de ral , *

St ate an d local —to wor k toge ther to pur sue initiatives to imp rove 

an d prote ct the healt h of the Am eric an people . We believ e the hea lth 

advances of the pa st decade bear eloquent witness to the value of 

Fe de ral block gr an ts fo r com mu nity and St ate public an d preven tive 

he alt h pro gra ms .

P art ly as a res ult of thes e adva nces , an in fa nt born tod ay in the 

Un ite d State s has an ave rage life exp ecta ncy of 73 yea rs ; our in fa nt 

m or talit y rate is the lowe st in the Na tio n’s his tor y; an d in the pa st 

14 yea rs, we h ave seen a 25-pe rce nt declin e in rate of de ath fro m our 

No. 1 kille r, cor ona ry ar te ry disease. Since 190 0, there has been an 

age-a dju ste d 61- per cen t red uctio n in our Na tio n’s ove ral l de ath rate .

Much of the cre dit fo r thes e adva nces belongs to ou r public he alt h 

de pa rtm en ts who have ca rri ed ou t rele ntle ss—and oft en un du pl icated—cam paigns to prote ct the peo ple’s healt h and pr ev en t sickness 

and dea th.

I t is on the basis of th is rec ord th at we St ate he alth officials believe the tim e has come to enl arg e our efforts in the fields of disease 

pre ven tion and healt h pro tection. In short , we believ e it is tim e th at 

we m atc hed our healt h rheto ric with dol lars, an d tim e th at the Sta tes 

were more equa l pa rtn ers in the Fe de ral-S tate he alt h pa rtn ersh ip .

F if ty or 100 yea rs fro m now, if an histo ria n were to look back at 

ou r cu rre nt he alt h spendin g polic y, I susp ect he or she would come 

to the conclu sion th at we were unable to tel l the diffe rence between ,

sickn ess and hea lth . Fo r, in ou r zeal to tr ea t sickne ss, and to pa y for 

the cost of this tre atm en t, there exis ts the cle ar and im mi nen t danger 

of igno rin g our esse ntia l objec tive— the ach ieve men t of optimu m 

he alt h and well -being thro ug h the pre ven tion of illness. *

La st year, the Fe de ral Gov ern ment spe nt over $45 bill ion on 

he alt h, by fa r the gr eates t sha re of it on sickne ss tre atm en t. Ye t the 

Fe de ral investment in basic he alt h pre ven tive and pro tec tive services 

is at low ebb, sta nd in g at less th an 50 cents pe r person ye arl y, out of 

a to tal Government h ea lth o utl ay of some $ 270 pe r person per yea r.

In the lig ht of these sob erin g economic da ta, the Associa tion of 

St ate and Te rrito rial Hea lth Officials reco mmends the ena ctm ent of 

leg islation to pro vid e fo r a na tio na l he alt h pro tec tio n syste m, one
301

tha t will generate a new health incentive plan for the all of our 

States and all of the American people.

Senator Kennedy. Doctor, we are supposed to recess at 11 o’clock 

because of the Panama Canal debate. We are going to extend the 

time a little bit after that. We have another panel so we would include 

your statement in its entirety in the record, and if you could high ­

light it.

Dr. Whalen. I will make a few remarks, Senator.

Senator Kennedy. We apologize for the inconvenience.

Dr. Whalen. I believe you asked th e question were 31 4(d) funds 

merely a slush fund. I think we as responsible public officials fully 

understand that the same th ing we demand of providers in the health 

care field, we must demand of ourselves. We stand fully ready to 

account f or whatever funds are given to us and have been active in 

partne rs with the Federal Government in developing the reporting 

system which outlines the disposition of 3 14 (d) funds.

I would like to leave a copy of tha t latest report for the record.

We also recognize we must be kept to standard also and have been 

actively partic ipatin g with the Center for Disease Control in the 

implementation of the legislation of last year requiring the development of standards for public health programs throughout the country.

We do not come before you to say tha t every health departm ent is 

as good as it could be or as good as it can be. We would like to point 

out tha t we have been faced with 31 4(d) funding, which has not 

increased over a decade and has been eroded to 50 percent of the 

level of the real dollars tha t were available to us in 1966.

In addition to that, in a good many of States, particularly those 

in the Northeast, we have been faced with severe-----

Senator Chafee. What is tha t figure again? Give us tha t dollar 

figure based on what you are getting.

Dr. Whalen. It has been a level appropriation . It is $90 million 

nationwide.

Senator Chafee. It is a level in dollar, not a level in inflated 

dollars?

Dr. Whalen. That is correct.

Senator Chafee. In effect, you are getting less?

Dr. Whalen. Tha t is correct.

Now, we also have been faced, partic ularly in the Northeast, and 

partic ularly my own State of New York, with fiscal constraints on 

the State scene which came about because of absolute necessity. I 

think it is very difficult for a health officer today to sit in his State 

and see the things tha t ought to be done tha t are quite cost beneficial 

and be unable to do them.

Let me give you a few quick examples. Tomorrow, if I were given 

the funding, I would immediately star t newborn screening for hypothyroidism. We can expect 1 child in 8,000 births to have hypoth yroidism. This would be a preventive program which would save 

many dollars in the long run by preventin g a lifelong episode of 

mental retarda tion for a child and the severe anguish it causes for 

the family. I think we could mount a program tomorrow costing less 

than 50 cents per school child to move to chloride mouth rinses in
302

thos e school distr icts where fluoridation is eit he r not possible or has 

no t been adopted .

I think we shou ld be doing m ore in the field of toxic substances in 

our environment. There are few State s which hav e not been faced 

with this problem in one way or ano the r. We face the lim ita tio n of 

lab orato ry c apa city to adequa tely m onitor it. We face t he inad equacy 

of a corp s of toxicologists who can spell out fo r us wh at those human 

healt h hazar ds are, pa rti cu larly those th at affect a pr eg na nt woman 

and a newborn child.

I th in k in most areas of the country our school he alt h pro gra ms 

require complete reexam ina tion, a complete cha nge of app roach. I f 

we a re going to adminis ter E PSD T, we s hou ld look at t he 25 percen t 

of the population in our State s which is in our school system each 9

day. We should look at the typ e of school he alth edu cation we are 

giv ing to them . Our schools could become pr im ary healt h care pr ovide rs.

Senator C hafee. I n y ou r State do you pro vid e th at service in yo ur »

schools for yo ur youngsters i n p aro chi al schools?

Dr. Whalen . Yes; in paroc hia l schools also, Senator.

Senator K ennedy. Let me ask, Doctor, it is inter estin g in how you 

might spend the money, addition al money, why do we n ot tak e wh at 

you have go tten this pa st year o r las t year? You g et abo ut $5 million.

Dr. W iialen. $5 million.

Senator Kennedy. W hy do you no t tell us how much of th at has 

been in terms of servic es, wh at per cen tag e of th at is in terms of 

services ?

Dr. Whal en. Th ere is a ma ndate in the prese nt gr an t th at 70 

percen t be devo ted to local healt h services. These are utilized largely 

to staff our distric t offices in the pa rk are as of the State , Ad iro ndack 

Par k and Catskill St ate Pa rk . They lar gely supp ort sanitary engineeri ng services and sup erv ising pub lic healt h nu rsing services to 

those counties whi ch are lar gely ru ra l and low in population and 

hav e no local healt h services of th eir own. That is where the bulk of 

ou r funds is going.

Senator K ennedy. W ell, how m uch o f th at is in salarie s-----

Dr. Whal en. I would have to guess, Senator. I would guess th at 

pro bably 75 percen t is in salaries.

Senator K ennedy. 75 percent?

Dr. W hal en. Yes.

Senator Kennedy. Wo uld you pro vid e th at fo r us? I would be 

v

intere sted in all of you prov idi ng wh at is happ en ing in terms of the 

States.

Dr. W halen . Fine .

We can, Senator , leave with you fo r the record tab ula tio ns which *

ind ica te wh at is bei ng done with the fund s in each Sta te.

I think those are the major points I wou ld make. There are many 

things cost beneficial, and the y are no t going to be done unless we 

ma tch our r hetor ic w ith ou r dolla rs.

[In form ation subsequently sup plie d fo r the record follow s:]
NEW YORK STATE DEPARTMENT OF HEALTH 

COMPREHENSIVE STATE HE ALTH PLAN - (BLOCK GRANT) 

314d FY77

Stat istics

Personal Service includ ing Frin ge Benefits

Other than Personal Servic e

72%

28%

100%

Program Expenditures % $

Personal Health Progra m 22.69 1,017,739

Laborato ry P rogra m .81 36,049

Envi ronmental Health Progra ms 29.82 1,337,567

Heal th Resources Program 5.98 268,104

General Administr ativ e Services 40.70 1,825,476

Totals 100.00 4,484,935
Page 1 of 6

I - uAK Lea*ti. b o .r a n Rep orting Sya tea

ktaahlurcoa, DC (20 2) 265 -4350 . _ - -

Part II I - Inv entory of Health Prog reae __________________ ...__

CLASS

COPC ___

(10 )

SET

NUMBER___ (20 )

New Tor t n 77 TOTAL FT 77 EXPENDITURES F.0CMH ES

PROCRAM TITLE EXPENDITURES CARE. IF AMT

PUBLIC

HEALTH HEALTH TE/1SION "

(30 ) (40 ) (50 ) (60) (70) (80)

al th Prograao

01 L.A. Pub lic Health Program 34 .96 4.97 8 1

W ____

30b

n o _____

02 Epidemiology 12 ,55 5.28 7

03_________

04

43 4.0 85 22.848

Child Health D ir ec tion 27 2.7 72 18 .X U

f o r m a l 4 Chl\d Hea lth «4;,22P

06_________ 2. 71 8.99 1 1

16 .90 8.97 6 18.485

WB_______

H *_____ Bft

______

)2«_______

>3Q--------

i n _____ IM______

747 .64 3

Ot 

_______

10.

_______

u

______

13.

14 __ __

15 - .

14

1.4 08 .614 66 U 05

1. 414.QOS

74.617

358 .728 2 13Q

926 .761

42. 222 0----------

801 ,83 2 744.392 2, 39 4.

34______

40_____

•V)

m ______

413.324

1.7 66 .734

18

1 1

_______

Denta l He alth .

133 171 9AU12-------------

___ 50. 91 0_____

To ta l Pereo nal Hea lth 99 ,077 ,998 1.0 17 ,739

304

* « • »
♦ a • •

Aae oo la tlo e o f Sla t* aM I « ( ( l u r U l he al th U lt ic la la

la d o n a l Pub lic Health Prograe Report Inf Sy etee

Washington. DC-— (20 2)---- 243-4330 ■ -------------------------------

Pa*e 2 of 4

-Fan II I - i nvento ry o t Health PrograM

New York

FT 77 EXPENDITURES

FT 77 (3144) psnr-aaM r-rerunTTrer<

CLASS SET PROCRAM FOR INPATIENT

CASK, ip ANT

PUBLIC

HEALTH

MENTAL

HEALTH

HYPERTENSION

(10 ) (20 ) (30) (40 ) (30 ) (40 ) (70 ) (80)

440 22 Helen Hayes R eh abi lita tion Ho spita l 8, 25 9.5 81 8,11 4,85 9*

440 23 Roswell Park Manorial In st it u te 49 ,44 1,99 4 34,874 ,22 4*

440 24 NTS Hom for Vet erans 4 Th eir Dependents at Oxford 2,1 19 ,002 2,1 19 .002

43 .1 10 .083 ------------
I

*TSa A ss oci at io n of . St at e and T errit o ria l Health O ff ic ia l!

Nationa l Pub lic Health Program Rep orting System

Wa shintton. X (202 ) 265-4350 ____________ - -Page A.of * -- --

----------------------P a x i l l L - Inventnry_nf_flaalxh _Pt

New York

----- ET 77 TUTSI.

PY 77 314 (d)

CLASS

_ CODE -

SETNUMBER - PROGRAM TITLE . _

PROGRAM FOR INPATIENT PUBLIC MENTAL HYPER-

(10) (20) (30 ) (40) (50 ) (60 ) (70) (40)

Laboratory rogram Area

-5 00 . _ La bo ratories 6 .Research. AdalnlattaTi.T< _Se cxlcee 3.4 34 .101 2.7 07

501

1

a a ■a inj32 C lin ic a l Laboratory Ev aluatio n Center 314 .239

520 33 Environmental Health Center 1.6 08 ,723

521 34 Saf e Dri nkin g Water Lab C er ti fi ca ti o n 16,051

521 35 Environmental Health Center -Q ua lity Control 1,6 19 ,237 97

TOTAL LABORATORY PROCRAM 23 ,20 4.20 9 36,049

5

05

/

a « v a
♦ a < »

Nati on al Pub lic Hea lth Prograa Rep orting Sy ete a

___ Wash ington. DC - (202J-26 5-A350__________________________________________________________________ . ----------- _

Part Ill- In ven to ry of Health Prograaa

-----------------------------------------------------------------------------------------------------------------------

T c S f

------------------------------------------------------------

Pege 4 ol 6

-

n 77 TOTAL FT 77 EXPENDITVR1S

----- FOR INPATIENT

CARE. IP ANT

FT 77 314 (0)

rucM M o t d e UMMS-------------------

CLASS

COOT NUMBER PROGRAM TITLE

” " PROCRAM

EXPENDITURES

PUBLICHEALTH HEALTH

HTPERt

TENSION

(1 0) ' (WJ n o ) (40) (50) (SO) (70) (40 )

a i Haalch-P rofz

t? 25 4, 17 1 140 ,241

J

- 420- 17 1,74 0— 160 ,24 0

4 -

89

‘ 201,0*16 89

- i.n i'A M - 37 4,3 33

142 ,70 4

I AA 13.037

aso AS 4 60.3 27 34 7.39 8.

471 44 Pu hllo Uarar 528 ,51 6 13 0.3 41

_ 671 . A7 rirtnU nj U.H T "r ng fl* 2J1.9O9

TOTAL ENVIROMMENTAL HEALTH PROCRAM 5. 34 4.94 4 1,3 37 ,547
•The A ss oc ia tion of St at e and T errit o ria l Health O ffic ia ls .

—n tlo c a l Pub lic Wealth Program Repor tlag System

Washington, DC (20 2) 265-4350

Page 5 of 6-----------

------------ —

____ P a rt. Il l- In ven to ry of . H «-llth_f rogiame_______

------------------------------------------------------------- Ns* Tork FT 77 314 (4 )

CLASS SIT PROGRAM FOR IMPATIENT PUBLIC s s TM - HYTIR---------

(10 ) (20) (30 ) “ '( 4 0 ) “ ’"“ (50) (60) (70 ) (SO)

24 .403 .755

____ Z06______ 49__________

5 0 . ________

51__________

510 .14 5

143 -092

1 *0 0,4 4*

4* 4.0 74

1____720 1. 70 4,19 4

3,1 13 ,'M

444 .04 *

7*, 7« *

1 3,700,17*1

3.3 20 .169 26 .72 5

____731--------- 4,1 64 040

6 0 -------------- 1, 03 1,*3 4

97 4,0 44

1,47 4,1* 7

• 1,4 43 ,13 1

7, 17 3,14 0 -56 . *62--------

G ---------------

2J4 47, 44 4

—- -74ft---------

51.54 1-------------------------- 21 .604 --------

paexa

*7,^97

ft 4 9 ------------ 220,1 02----------------------------

261--------

1 742 71 Rad io lo gi ca l Technology 145 ,032

»

I

« H l 72 V it al Records 716,339

753 73 B lo e t s t ls t lc s l Se rv ices *4 9.3 10

| 760 74 Emergency Medical Se rv ices 1.9 12 ,392 115 ,319 ___________ ---------------

308
* • • »

| Nati on al Fob 11c Hea lth Progran Reporting System u u k iu t M dc n a n ?as- 4i so ___

Page b of 8

Nee York

FT 77 TOTAL FT 77 EXPENDITURES

FT 77

PROCRAM

314 (D) .

XFENDITURES

-1 c ^ 5 5 coot SET NUMBER PROCRAM TITLE PROCRAM EXPENDITURES FOR INPATIENT CARE, IF ANT PUBLIC HEALTH MENTAL HEALTH HTrEN­ TER SI ON

(10 ) (20 ) ( » ) (W) (50 ) (80 ) (70 ) (80 )

Ce oeral Ada nle tr etl o n anc Se rv ices

8000 75 b.C U tl V . 399.859

8000 78 Fi nan ci al end Ad minist ra tiv e Se rv ices 4, 00 8.40 1 5.8 788000 77 Employee Re1s tloos 51.592 49,393

8000 78 Date Proceeeln g 1.5 00 .294 44, 18 4

8000 79 Legal Se rv ices . 1.3 91 .445 18

'• 8 000 80 Health C i n 1qe* 1nu 1 Education 257 ,39 2 41.803

8000 u 1 Regional and Local Health Management 2,3 84 .925 1,8 82 ,402

TOTAL GENERAL ADMINISTRATION AND SERVICES 9.97 3.90 8 1. 82 5.4 78

1

II

. ------TOTAL NEW TCNK----------------- -----------854, 73 7,07 0— 4.4 84 .935 2,3 94 ---------

%

309

E this mm is p<
310

Se na tor Kennedy. Dr . Canno n, you are surro unded by two good 

Rhode Island Senators here. Wo uld you like to say a wor d?

Dr . Cannon. Yes. I am delighte d to see both Senator s here, one 

a Repu blican an d one a Democ rat.

Se na tor Kennedy. No p artis an sh ip on this committee.

Dr . Cann on. I have had the pleasure of servi ng un de r Gov ernor 

Cha fee—S enato r Cha fee -while he was Governor, and while he was 

Governor, and I hate to say this befo re any Demo crats, bu t he was 

one of the finest G overnors th at I have seen because he ha d a concern 

fo r people.

Se na tor C hafee. Do n ot be relu ctan t to say th at a t all. [L au gh ter .]

Dr. Cann on. I think, Senator , I have a sta tem ent th at I would 

rea d, an d it is brief. I would like to say a coup le of thin gs. That as a 

res ult of the block gr an t money, and I wor ked in 1964, 1965, and 

1966 -with a small gro up of healt h officers w ith the Sur geo n Ge neral’s 

office. I t di d not come out t he w’ay we expected.

Th e block gr an t money in the State of Rhode Island , and I must 

confess th at all State s are different, inc lud ing Rhode Isl and. There 

is a plac e, by the way, fo r some people who do not know , it is a 

plac e called Rhode Island ------

Se na tor C haf ee. Pull the microphone over closer.

Dr . Cann on. Th ere is a plac e called the St ate of Rhode Isl an d 

Pr iv at e Plan tatio n. We are able to do thing s there in a simple way. 

We are very simple people. Pe rh ap s I am the most simple of most. 

We do use block gr an t money to develop new things. Fo r exam ple, 

the HM O pro gra m in Rho de Island rea lly started as a res ult of 

block gr an t money.

We had some 27 nur se associations th at gave sca ttered and fr ag ­

mentary home healt h services. We were able to cut the nurse agencies 

to nine and develop un ifo rm accounting systems and refe rral system s 

and repo rting systems th at the y all use now. We developed with 

block gr an t money the first home healt h agen cy concept in Rhode 

Island , and th at has been a continuing effo rt now on the par t of 

most. These are t hin gs th at would never have happened witho ut th at 

block gr an t money.

I t gives us the flexibility at the local level to do things th at we 

see are nee ded to be done in ou r S tate s.

I would like to lay to res t one th ing I have heard . I saw it in the 

Blue She et the oth er day. Th is may no t be po pu lar with HEW , bu t 

I am no t concerned abo ut th at. I am n ot po pu lar with a l ot of people.

I wou ld like to lay to rest the alleg atio n th at State s do not p rop erly 

account fo r block gr an t money. The real pro blem lies, not with the 

State s, bu t with HEW . We account for every dime. It is much easier 

fo r a Fe deral person to develop sta nd ards fo r acc ounta bility in a 

cat ego rical pro gra m. Tha t is relatively simple. Bu t you require a 

fa irly bro ad percep tion and know ledg e of pro gra ms in a wide spectru m of activities fo r acc ounta bility on a block gr an t pro gra m. I t is 

a most flexible and dyn amic type of pro gra m. We still need cat egor ical pro gra ms bu t we certainl y need the block gr an t which has 

gone back wards as fa r as a stable level of su pp ort is concerned.

I have n othing fu rthe r to say.

If you have any questio ns, fine.
311

Senator Kennedy. Do you support performance standards?

Dr. Cannon. Yes, sir. We use them all the time.

Senator Kennedy. We are able to at least do an evaluation of what 

is happening in various States and what kind of performance?

Dr. Cannon. As was mentioned earlier, there is a quite detailed 

report on this tha t was done through the National Public Health 

Program Reporting System. We are able to account for what we get 

from the Federal Government and how it is expended.

Senator Kennedy. And how effective i t is, at least an evaluation 

of how effective it is ?

Dr. Cannon. Yes, sir. We think we can in our block grant program. There are those who think we cannot. I do not necessarily 

agree with them. All wisdom does not lie in HEW .

Senator Kennedy. W hat is your view about inclusion ? I think Dr. 

Whalen mentioned the inclusion of preventive health care programs 

within this section.

Dr. Cannon. Jus t to highlight a couple of things. Home health 

care, we think we can do, and we have some good things going in 

Rhode Island. We think with the use of a little block grant money, 

and there are salaries involved in this, but all those salaries provide 

services—well, handgun education.

We had a doctor killed by a patient. We have been trying to get 

things going and we think tha t we can. Some of this money could 

fund a sensible, intelligent handgun control program in Rhode Island. 

That is the type of thing we want to use block grant money for. 

There are other things, life styles.

Senator Kennedy. Dr. Word.

Dr. Word. Mr. Chairman, I was not prepared to make a statement. 

But in light of some of the discussions, there are a couple of statements I would like to make for the record.

Fir st of all, I would like to direct your attention in the material 

tha t you will receive that we have documented tha t $1.5 billion is 

spent by State and local governments in the provision of basic public 

health services. We can give you a list of those services. We have 

found there are some 60 public health services that are common to all 

50 States; $1.5 billion was spent by State and local governments for 

provision of basic public health services. The Federal Government 

shares in tha t to the tune of $90 million.

When you define the $90 million you get under 314(d ), $15 million 

of tha t goes to mental health. There is about $75 million tha t goes 

into the kinds of services we are talking about. And roughly calculating, that is about 5 to 6 percent.

Now, the proposal that we are discussing has been introduced by 

Senator Chafee and it is the proposal where the Federal Government 

would cost share with States and localities. For example, the first 

year the program would cost, with a floor of $1, tha t is minimum 

of $1 per capita. It would cost the Federal Government about $225 

million, going up to about $300 million the th ird year.

So what we are asking you to do is not to block grant dollars to 

State and local health departments, we are asking you to cost share 

with us. We spend $1.5 billion at the local and State government 

level. The Federal Government has spent $75 million. We would like

l
312

you to enha nce th at pa rtn ersh ip by sharing at the level of 10 pe rcent 

the first ye ar; 15 percen t the second year, and 20 per cent the th ird 

ye ar; going from a level of $225 million to a maxim um of abo ut $300 

million , which is roughly $1.50 pe r ca pita.

Tha nk you.

Se nator K ennedy. Dr. Wallace .

Dr . W allace. It is a p leasure to be here, sir. I v ery warmly endorse 

the rem ark s o f Drs. W halen a nd C annon, a nd M r. Word .

We have a real bin d on fund ing in our county. We feel fund ing 

pro posals would especially help us. My goal is more com munity suppo rt services. I would love to provide more occ upa tion al thera pis ts, 

more physical therap ists, aud iologists, nu tri tio nists, social workers.

The se pers onnel would go int o pro gra ms such as home health, com- <

mun ity outreach and even small medical clinics ser vin g und erserved 

are as of P rin ce George’s Cou nty. We need more money.

Senator Chafee. I can not hear you very well. Spe ak into the 

mic rophone please.

Dr . Wallace. We do have a bind. We are dev eloping a healt h 

care system in the cou nty th at gobbles up Fe de ral, State , and local 

dollar s. The Hea lth De partm ent does need more help and more 

funding .

Senator Chafee. I agree w holehe arte dly w ith w ha t these gentle men 

are saying. I would like to e xpre ss our appreciat ion for them coming 

down. I know per son ally the work Dr . Canno n has done. He testified 

before Pa ul Roger s’ committee when I was in the State Hou se in an 

attempt to get a whole block gr an t concept. I t is one of these thi ng s 

th at has wo rked out well.

As they testified, it has not kept pace in fu nd ing due to erosion of 

inflatio n. I think the y mak e a very good point. It is preven tive 

medicine concept.

Th an k you for coming.

Senator J avits. Mr. Ch air ma n, I, too, would like to than k Dr .

Whalen of my own Sta te. I have been unb elie vably engaged this 

mo rning, inc lud ing the Pa na ma Can al trea ty and the SA LT trea ty 

and every thing else and I have had Dr . W ha len’s testimony mo nitored. I appre cia te the testimony very much and will stu dy it very 

car efu lly.

Senator Kennedy. Senato r Pell.

Senator P ell. I am very gla d to see Dr. Can non here. I enjoyed 

worki ng so much w ith him fo r over 18 years now. *

Dr. Cann on. I do not know who came first, you or me—ab out the 

same time.

Senator P ell. O ur h air is about the same colo r anyway .

My rul e of thu mb fo r Rho de Isl an d is th at in any Federal pro- *

gram that gives us abou t h alf o f 1 percen t o f t he total ap prop ria tio ns, 

we do p retty well, and if we get less, we do no t ge t our prop ortio nate 

share. I f we get more, we do better. I am a lit tle worrie d abo ut the 

whole concept of block gr an ts and wh at makes you think the other 

991/2 percen t of the money th at we do not get will be spe nt as well as 

it is in Rho de Island ? I have comp lete fa ith in your spending. I f we 

enl arg e this from 100 million r oughly to 500 million -----
313

Dr. Cannon. Well, I have a very quick answer to that, Senator. 

I think tha t we feel that the State Health Officers, and there are some 

good ones, are not all stupid. We do a reasonably good job. I think 

there are some which I would not want to mention tha t do not do 

as good a job.

Senator P ell. Pull the microphone a little closer.

Dr. Cannon. 1 have been impressed with what most State health 

directors I have known over the years have done. I think they use 

this money wisely. I would not say that all of them have used it as 

well as it should be used. I think tha t this is true of almost every 

program.

Senator Pell. Is it not correct to say there are only two States that 

have statewide health systems, or are there more ?

Dr. Cannon. Yes, sir. But even Delaware is not quite as complete 

as we are.

Senator P ell. There are no others ?

• Dr. Cannon. No. They mention Hawaii as similar but they really 

function on a litttle different basis.

Senator P ell. Thank you very much.

Senator Kennedy. I just want to say tha t my concerns about 

whether it is in this program or in the child and maternal health 

program we discussed earlier, I think one of the real failures of the 

Congress is the failure to get accountability in many of these programs, and to do the kind of evaluation. And I think if we are going 

to talk about an important increase in expansion, I think we have 

to be very, very sure how these resources are being expended and 

whether they are really meeting what I think Senator Chafee rightfully pointed out, the whole important area of preventive health 

care, whether this is really the best instrument to do it. I think as 

far as I am concerned t hat is why I want to have an answer and a 

chance to see what the record has Deen, and what is happening today.

Very frankly, I think in terms of my own State it has been a 

very mixed bag.

Senator Chafee. You mean the block gra nt concept?

Senator Kennedy. Block grant concept. In terms of how those 

funds have come into the state, whether they have been identified 

as special funds tha t should be used in terms of developing new 

alternative ways, of both delivery and preventive health care and 

special kind of health care needs. And it has been a very mixed bag. 

w

I think tha t is probably being somewhat charitable to it.

I just want to make sure myself as we consider the kind of expansion on this, that we are at least going to be sure th at we are not just 

augmenting or supplementing, you know, general funds in States,

♦ but they are being targeted in what I think all of us very well agree 

is an important purpose, preventive health care, and new and innovative ways.

Senator Chafee. I would like to say this, tha t I agree with you 

tha t these programs should be appraised. However, I think it is important to bear in mind this program has been level funded in actual 

dollars for 11 years. In effect, it is cut in half. Therefore, the chance 

for innovative programs in this particular area has been extremely 

limited, and you are lucky if you can continue to maintain what you
314

hav e done. Once you get int o these home care pro gra ms , somebody 

has to carry them on. Maybe the State s sho uld step up and ca rry it 

on, and the block gr an t money should move on to som ething else.

Even in c ategorical g rant s you have steady main ten anc e of pr og ram s; 

you do no t nece ssarily get innova tion , wh eth er it is he art care or 

tuberculosis or wh atever it mi gh t be.

Se nator P ell. M r. Ch air ma n, I would hop e the two different ap ­

proa ches could be molded together. W ha t it rea lly boils down to is 

a question of policy and cost. One is more costly th an the oth er and 

has fewer re gulatory c onstrain ts.

As Senator C hafe e points out, if you look at it fro m t he v iew point 

of inflation i t has been level fun ded and the o ther question is whether 

there should be fa r few er reg ula tions or guideline s th at the re are «

now, and perha ps one could compromise there because the re could be 

too many guid elines now, and I think the y sho uld be used in general 

ways—I see some of these thoughts as to how money would be spent, 

which Dr. Can non advance d. Maybe we could hav e somew here in *

between.

Se nator Kennedy. B ut we wa nt to th an k you very much. We will 

work closely with you and appre cia te very much yo ur presence here.

Dr . Whal en. We a pprec iat e the o pp ortunity to come.

[The p rep ared sta tem ent of Dr. Whal en fo llo ws:]
315

STATEMENT OF

ROBERT P. WHALEN, M.D. 

COMMISSIONER

NEW YORK STATE DEPARTMENT OF HEALTH

REPRESENTING

ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS

BEFORE THE

SENATE SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH

RE: S.2474

MARCH 1, 1978

28-386 0 - 7 8 - 2 1
316

Mister Chairman, memb ers of the Subcommi ttee, I am Docto r Robert 

P. Whalen, Commi ssi one r of the New York State Departme nt of Health. In my 

pre sence before you today, I represent the Associ ati on of State and Ter ritorial 

Healt h Offi cials, also known as ASTHO.

Sen ato r Kennedy, let me begi n by t hankin g you and you r col lea gue s 

for the wis dom and support whic h brought the Partne rsh ip in H eal th Pro gra m 

into being elev en years ago. Thr ough your foresight, you hel ped to est abl ish 

the common res pon sib ili ty of government on all levels -- federal, stat e and 

local — to work togeth er to pursue initiatives to impro ve and pro tec t the 

healt h of the Ameri can people. We b elieve the health adva nces of the past 

decad e bear e loquent wit ness to the value of federal block grants for com munity 

and state pub lic and preventive health programs.

Par tly as a result of these advances, an infant born tod ay in the 

Unite d States has an average life expect anc y of 73 years; our infa nt mor tality 

rate is t he lowest in the n at io n’s history; and in the past 14 years, we h ave 

seen a 25 perc ent decline in rate of d eat h from our number one kill er, corona ry 

arter y disease. Since 1900, there has been an age -adjusted 61 p ercen t reduct ion 

in our n ati on' s overall deat h rate.

Much of the cred it for these adva nces belongs to our publi c health 

departmen ts, who h ave c arr ied out relent les s — and ofte n unduplica ted -- cam paigns 

to pro tect the people 's health and pre vent sick ness and death.

It is on the basis of this reco rd that we State Health O ffi cia ls 

bel ieve the time has come to enlarge our e fforts in the fields of disease 

pre vention and hea lth protection. In short, we believe it is time that we 

matche d our health rhet oric with d ollars, and time that the states wer e mor e equal 

par tners in th e federal-state health p artnership.

Fifty or one hundre d years from now, if an h ist ori an wer e to look back 

at our current healt h spen ding polic y, I suspect he or she would come to th e 

conclus ion that we were unable to t ell the dif fer enc e bet ween sickne ss and health. 

For, in o ur zeal to treat sickness, and to pay for the cost of thi s trea tment, 

there exists the clear and imminent dange r of igno ring our essential obj ective — 

the ach ievement of opt imum hea lth and well- bei ng through the pre vention of 

illness.

Last year, the federal gov ernment spent over $45 billion on health, by 

far the greate st share of it on sic kness treatmen t. Yet, the Fede ral investment 

in basi c health p rev ent ive and prote cti ve ser vices is at low ebb, standi ng at less 

than 50 cents per per son yearly, out of a total gove rnment hea lth outla y of some 

$270 per person, per year.

In the light of these sob ering economic data, the Associa tio n of S tate 

and Terr ito ria l Hea lth Offi cials rec omm end s the enac tment of legisl ati on to provide 

for a nat ional health p rot ect ion system, one that will genera te a new he alt h 

inc entive plan for the all of o ur states and all of the Ame ric an people.

Senator Chafee has introd uce d S.25 67 to d o p recisely this, and 

we warmly e ndo rse his bill. Its p rincipal econom ic impact wou ld be to incr ease 

federal spend ing for hea lth pr ote cti on from the current level of less than 50 cent s 

per p ers on to a m aximum pe r capita o utl ay of $1.50 yearly.
317

-2-

I come before you t oda y to say, unl ess we are prepar ed to make such 

an inve stment in our publ ic hea lth de par tme nts , the ir valu able potential may 

be lost.

Federal Par tne rsh ip for Healt h spe ndi ng und er Section 314d now stands 

at $90 million annually, which repr ese nts less tha n five percent of t he total 

local, state and federal funds exp ended on health p rograms covered unde r 314d.

Thus, the federal gove rnment is not act ing as a p artne r with th e stat es in the 

field of health pr ote cti on, it is a cti ng as a mi nority stockholder. What we 

have is a sit uat ion in w hic h ther e are no incent ive s to state or local governments 

to inc rease healt h spe nding bec aus e ther e is no federal matchi ng arrange ment to 

enc our age them to do so.

Wit hou t such incentives, dis tinguished Sena tors, I can assu re you 

> that the stat es will not be in a pos iti on to add ress their most serious public

hea lth pr oblems and needs.

Let me cite sever al exampl es of what I mean.

“ I daresay every state in t he nation is c onf ron ted w ith the pro blem of

env iro nme nta l contami nat ion by i ndustrial che mic als and wastes. Yet, for want 

of funds, the whole field of environme nta l toxic olo gy is in its infancy. We simply 

do not have, wit hout add itional federal help, the res ources and p ers onnel to 

monitor these chemicals, take steps to pre ven t their discharge, and assay their 

haz ard to man.

In my h ome state of N ew York, these env ironmental health per ils take 

the form o f PCBs that foul the sediment of the Hud son Rive r from 200 miles inland 

to the sea, trichlore thy len e and other poten tia l car cin oge ns in the dri nki ng water 

wells of a numb er of Long Island comm unities, mire x and othe r toxic pestic ide s in 

fish in Lake Ontario, and God knows how man y other industrial con taminants we 

haven't as yet discovered.

We Sta tes m ust have more federal help if we are to seek out these 

insidi ous inv aders of man and his env ironment, dis cover their lon g-t erm effects 

in h umans, and p urge them or prevent their di scharge. Doin g this will requi re 

ski lle d sci ent ifi c per sonnel, sophistic ate d equipm ent and — most of all — money.

For indeed, the uns een h eal th ene mie s we face today are not the 

communi cab le disea ses and natural par asi tes of ye ars gone by, but the environmental 

par asi tes that conta min ate our drinki ng waters, our fis heries and farmlands, and, 

for t oo many Americans, our pla ces of work.

There are ma ny ot her heal th init iatives, bes ides toxicology, that we will 

be una ble to pur sue with out a balanc ed and exp and ed fed eral-state health pa rtne rship.

For example, a numb er of stat es are car ryi ng out pilot progra ms which 

are p rov ing rem arkably effec tiv e in d ete cting and treati ng the most ubi qui tou s of 

American d ise ases: high blood pressure. These programs, which find and control 

high blood press ure before it c an lead to a mo re disab lin g illne ss and costly 

hospit ali zat ion , hav e a tre men dou s healt h potent ial , since hyp ert ens ion strikes an 

e estim ate d one in ten American s. We need to mak e these pre ven tiv e advanc es available

to all of our citizens.
What motiv ate s an individual to stop smoking, cur tail drinking, adopt 

a better diet and a saner lifestyle? We must learn more about human motivat ion, 

but one thing is clear: healt h education, partic ula rly the kind that is aimed 

at schoolchi ldr en during their formative years, is one o f the bes t investments 

govern men t can make, bec ause it prom ises a who le lifetime of he althy practices.

We need more pers onnel, partic ula rly publ ic health nu rse s, to increase 

our h ome health care cap abi lit y and thereby cut down on u nne cessary utiliz ati on of 

expens ive hos pitals and nursin g homes.

And the o fte n crushing and crus hingly expensive tragedy of birt h de fects 

can m an y times be pre vented or ame liorated with the kind o f aggressiv e scre ening 

progr ams some states have adopted, and other states woul d adopt, were there federal 

encourage men t to do so.

We States, with your help, can increase our com mitment to these and 

other programs, which are vita l to the heal th of the Ame ric an people. But we 

cann ot do so unle ss the Congress appr oves a hig her level of aid to the States for 

their c omm uni ty- bas ed progr ams of disease prev ention and control.

We certainly cannot address our most pressi ng hea lth cha llenges if ea ch 

yea r we must sweat thr oug h a one-ye ar exte nsion of the 314d program. This is 

no par tnership, nor does it permit forwa rd planning for health. Indeed, there can 

be no p art nership when one of the pri ncipals is be ing slowly starved, in the sense 

that feder al parti cip ati on in this progr am has stood still since 1967, a per iod 

of time in w hic h inflation alone has vir tually doubled costs.

So, Mr. ‘Chairman, and members of the Subc ommittee, the time has come 

to ask our selves whe the r we rea lly be lieve that, in te rms of the people 's health, 

an ounce o f p reven tio n is wort h a po und o f cure. If we do believe in the wis dom 

of that ancient saying, then we m ust move forward to n ew hor izo ns in the 

federal-s tat e hea lth partnership. And we must do so now, so that organized 

com munity di sease prevent ion p rog ram s can be a par t of the fou ndation on w hic h 

we build a pr ogr am of National Hea lth Insurance.

I thank you for giv ing A STH O t his opp ort uni ty to be h ear d on this 

important matter. I will gladl y entert ain yo ur questions.
319

Senator Kennedy. Next we will have a panel on Genetic Diseases, 

Dr. Leon Rosenberg, chairman, Department of Genetics, Yale University; Dr. Robert Murray, chief. Division of Medical Genetics, 

Howard University; Mrs. Joan Marks, director, Genetic Associates 

Program, Sarah Lawrence College; and Mrs. Marjorie Guthrie, 

president-emeritus, Committee to Combat Huntington’s Disease.

Senator Javits ?

Senator J avits. On Monday, February 27 ,1 introduced along with 

18 of my colleagues, the National Genetic Diseases Act Amendments 

of 1978. I was the author of the original legislation, enacted as title 

IV of Public Law 94-278 in 1976, the National Sickle Cell Anemia, 

Tay-Sachs, and Genetic Diseases Act. This legislation provides for

* the national program of basic and applied research, health services, 

such as testimony and counseling for the diagnosis, control and trea tment of genetic diseases; and information and education programs 

with respect to such diseases. The program was funded for the first 

time in fiscal year 1978 at $4 million.

The bill we have introduced would reauthorize the Genetic Diseases 

Act for 3 more years at the same authorization level of $30 million. 

In addition, the bill expands, strengthens and improves the existing 

legislating, insuring th at it carries out the original legislative intent. 

It provides for planning based on local need for specific genetic 

services as well as program evaluation through appropriate peer review. It requires new, noncategorical initiatives in genetics research 

and services for all genetic diseases, and reemphasizes the generic 

intent of the legislation to include all genetic disorders. Much of the 

activity specified in the act will involve the State and local health 

departments, but allocation of Federal funds to these organizations 

should be only one mechanism by which programs are implemented. 

The bill provides flexibility of funding to allow mechanisms for 

funding local programs as well as demonstration and pilot programs 

of merit.

The bill requires the Secretary to develop a procedure whereby 

consumers and professional genetic disease experts are authorized to 

make program recommendations, and to advise on a wide range of 

interdisciplinary issues involving research, detection, prevention and 

treatment of genetic diseases. A study is authorized to be conducted 

by the National Commission for the Protection of Human Subjects 

on the ethical and legal implications of genetic screening, counseling

* and education services.

More th an 2,300 genetic diseases have been described to date—and 

the list is growing rapidly. About 30 percent of hospitalized children 

have diseases of genetic origin, 40 percent of all infant mortality

* results from genetic factors, and 80 percent of all mental retardation 

in this country is genetically related. Many forms of blindness, deafness, and crippling disorders are passed from generation to generation. Furthermore, genetic components are strongly implicated in 

some of man’s most common afflictions, such as diabetes, nigh blood 

pressure, schizophrenia, heart disease, and some forms of cancer.

I want to stress one signal fact, inherited diseases are, above all, 

family diseases which impact overwhelmingly on the well-being and 

integrity of the family. Diseases which are passed from parent to child
320

may strike m ultiple members of a fam ily sim ulta neo usly, inflicting a 

uniq ue and ter rib le bur den . Evidence shows th at the divorce rate in 

fam ilies where a genetic defect has been discovered is four times 

hig her than amo ng the gen eral public. Access to psychological and 

psy chiatric counseling and supp ort is inv alu able in helpi ng to cope 

with the psychological stre ss of acute physical illness—a stress which 

in its elf could be lif e thre ate nin g.

An oth er im po rta nt f act th at cannot be stres sed too str ongly is th at 

genetic diseases are chronic diseases. Many of these conditions man ifes t themselves at bi rth , and most las t th roug h life, often pla cin g 

pa tie nts and fam ilies under severe finan cial strains which can grind 

them to pove rty.

But he reditary disord ers have a uniq ue feature in th at often the y 

are susceptible to early detection and tre atm en t. Today , 60 genetic 

disord ers can be detecte d before b ir th ; more th an 60 metabolic diseases 

are amenable to tr ea tm en t; ca rri er tests are ava ilab le for 60 diseases 

which can iden tif y the healt hy ind ivi dual who may be ca rry ing a 

defective gene th at would produce disease in fu tu re offspring.

Co ntras t the economics when pre ventive genetic medicine is in ­

volved. A more common genetic disease, which occurs about once in 

every 14,000 birth s is called PK U. Th is is dis ord er, if und etec ted, 

produces severe mental retardation caused by an er ro r in metabolism. 

It costs $1.25 to screen a newborn baby for PK U. I f the dis ord er 

is diagnose throug h screening tests at bi rth and tre ated imm edia tely 

with a special dietary regime n, these children will grow up to lead 

normal lives. I f undetected and u ntreate d, a PK U v ictim would most 

like ly spend a lifetime in an insti tutio n at a cost of more than a 

qu arter of a millio n dollars . Ye t even such cogent economic ar gu ­

ments pale when we conside r the lifetime of sorrow and bur den 

these families are spared.

I t is not possible to measure the emotional tra um a and tra gic un ­

certa inty fac ing fam ilies with he reditar y disease. Wh en we possess 

the tools and the medical knowledge to prevent and trea t diseases 

which are so devasta tin g, how can we continu e to tol era te such pain 

and cost an d hum an suffering?

I t is there fore imperative th at all peop le in need have access to 

genetic services, which should be i nteg rated into pr im ary healt h care.

Fi na lly , I would like to make an im po rta nt comment. Th is bill 

establishes a vo lunta ry program for scre ening, tes ting, coun selin g 

and inf orm ation. I believe th at each of us has the righ t to as much 

inform ati on as medicine can provide—in form ation concerning disease, 

the pa tte rn of transm ission of he reditary disease, of the risk s of 

recurre nce, and the consequences of the disease in pract ica l terms for 

eve ryd ay living , inc lud ing financial burdens. Th ere is some my stery 

sti ll associated with medicine , but th ere is also a grea t deal of kno wledge. W ith this infor ma tio n, “in forme d choice” is possible; th at is, 

each person may mak e a valu e decision confident of the fac t th at he 

or she has all the inf orma tio n possible. To withh old medical knowledge which could pre vent crippling and death is un fa ir and un jus t. 

To wi thd raw fro m seeking th at inform ati on is to proceed in a vac ­

uum , witho ut the benefit and the righ t to ou r own valu e decisions.

As infe ctio us diseases are brought inc rea sin gly under con trol, genetic disorders are be coming a leadi ng co ntrib uto r to the N ati on ’s mor-
321

bi di ty rates . The prov isi on s of th is bill will st re ng th en an d im prov e 

th e na tion al pr og ra m of ge ne tic dis eas e servic es pr ov id ed in th e N atio na l Ge netic D isease s Ac t.

I w an t t o th an k t he p an el v ery muc h fo r ap pe ar in g.

Co uld we ask th e me mb ers of th e pa ne l to sum up th ei r re mar ks 

in ab ou t 5 m inutes each ?

Dr. Ros en bu rg, if you feel th at you nee d it, we wi ll le t yo u ta ke 

10 minu tes, an d eac h of th e o th er s 5.

STATEMENTS OF DR. LEON E. ROSENBERG, CHAIRMAN, DEPARTMENT OF HUMAN GENETICS, YALE UNIVERSITY ; DR. ROBERT F.

MURRAY, CHIEF, DIVISION OF MEDICAL GENETICS, HOWARD 

• UNIVERSITY ; MRS. JOAN H. MARKS, DIRECTOR, GENETIC ASSOCIATES PROGRAM, SARAH LAWRENCE COLLEGE; AND MRS. MARJOR IE GUTHRIE, PRESIDENT-EMERITUS, COMMITTEE TO COMBAT

HUNTINGTON’S DISEASE, A PANEL

Dr. R osenberg. My name is Dr. Le on E. Ro sen berg. I am a p ro ­

fessor of H um an Genet ics, Medici ne an d Ped ia tric s, an d ch ai rm an 

of t he D ep ar tm en t of H um an Ge netic s at th e Ya le U ni ve rs ity Schoo l 

of Me dic ine . I am also th e di re ct or of Y al e’s N IH -s po ns or ed Cen ter 

fo r H um an Ge netics an d In her ited Diseas es. F o r ne ar ly 20 ye ars, I 

have stud ie d gene tic diseases at th e bedside an d at th e la bo ra to ry 

bench, an d ha ve witne sse d th e enormo us gr ow th in ou r un der st an din g of bo th no rm al gene tic me chanism s an d tho se ab no rm al ones 

wh ich cause disease. D ur in g th is sam e in te rv al , I ha ve ca red fo r 

scores of pa tien ts an d famili es each afflic ted with , or at risk fo r a 

gene tic diso rd er. Thi s ex pe rie nce ha s convinc ed me th at, as a Natio n, 

we ha ve been fa r mo re reso urce fu l in ac qu irin g kn ow led ge ab ou t 

gene tic diseas es th an in ap pl yi ng th at kn ow led ge to th e care of sick 

peo ple. F o r th is rea son I believ e Pub lic Law 94-278 is an hi stor ic 

piec e o f l eg islatio n an d I u rg e its exten sio n an d its fu ll ap pr op ri at io n.

I feel ce rtain th at I nee d no t re mind th is co mmittee th at genetic 

di so rd er s ar e th e mo st wi de sp read an d am on g th e mos t bu rden some 

of kn ow n afflictions, th at th ey affect ap pr ox im at el y 6 pe rc en t of ou r 

citize ns, or th at they are respon sib le fo r 30 pe rcen t of ch ild ho od 

ho sp ita liz ations , fo r 40 pe rcen t of in fa n t m or ta lity , an d fo r ne ar ly 

80 pe rcen t of m en tal re ta rd at io n. In as m uc h as re ci ta tion of th is 

lita nty un de rsco res t he glob al im pa ct of g eneti c diseas e, I men tio n it. 

Ho we ve r, ne ithe r co mpilatio n of such he al th stat is tics no r en um er atio n of th e hu nd re ds of kn ow n ge ne tic di so rd er s pr ov id es a sufficient 

ra tion al e fo r th e ex pe nd itu re of Fed er al fu nd s fo r th e su pport of 

« gene tic he al th services. I pre fe r to j ust if y such ex pe nd itu re s in te rm s

of specific stra tegi es for specific disorde rs.

To me, ge ne tic he al th ser vic es me ans screen ing of ne wb orns fo r 

ph en yl ke to nu ria because ea rly diag no sis an d ap pro pri at e di et ar y 

man ag em en t can pr ev en t th e sev ere m en tal re ta rd at io n wh ich occ urs 

re gu la rly in th e un trea te d pa tien t. Ge ne tic he al th ser vic es me ans 

te st in g of bla ck in fa nts fo r sic kle cell anem ia becaus e such de tection, 

fol low ed by ap pro pri at e im mun izat io n or an tib io tic pr og ra m s, can 

fo re stall th e of ten leth al ba ct er ia l infections to wh ich these ch ild re n 

ar e pred isp osed . Ge netic he al th ser vic es me ans th e re gu la r, pr op hy -
322

lactic admi nis tra tio n of antihemophilic factor to children and adult s 

with hem oph ilia because such costly bu t effective tre atmen t will pr even t the c rip pling consequences of this disease. Gene tic healt h servic es 

means tes tin g of Jewi sh teenagers fo r the Tay-S ach s gene because 

ind ividuals and couples who carry this tr ait have a righ t to make 

inform ed marita l and pro cre ational decisions based on this info rm ation. Genetic health services means counseling the relatives of p atients 

with Hun tin gton ’s disease because some of these ind ivi duals are at 

risk for the disease and must bea r th at burde n, whereas oth ers are 

not a t ri sk and are e nti tle d to th at relief .

In the ory , genetic healt h services sho uld be fa r less expensive and 

easier to org anize th an man y oth ers for, af te r all, they are based on 

sound pre dic tive princi ple s and are aimed at pre ven tion of disease. 

In pra ctic e, however, they are cu rre ntl y very difficult to delive r because n eit her the pub lic nor the medical profession underst ands ade ­

qua tely the princ iples upon which genetic medicine is base d, and 

because our healt h car e system is much more orient ed to crisis in te rven tion th an disease p revention.

Pr ev entin g coronary artery disease in genetic ally susceptible in di ­

vid ual s by lon g-term res triction of dietary fats, and cholesterol has 

none of the gla mo r of by-pass gra ft he art sur gery. Pr ev en tin g pu lmo nary emp hyse ma by adv isin g gen etic ally predisp osed ind ivi duals 

to avoid cig are tte smo king and other noxious inhalants has none of 

the dram a of emergency venti lat ory assistance. I t is at cruel parad ox 

th at we are willin g to pay infi nite ly more fo r trea tin g disease than 

we are fo r maintaining hea lth. Th is postu re has a pa rti cu larly deleteriou s effect on the provisions of genetic healt h services. Des pite 

their obvious human benefits and demo nstrated cost effectiveness, most 

th ird pa rty payers refu se to conside r gen etic screenin g, diagno stic 

amniocentesis, a nd genetic counseling reim bursable expenses.

Th is un fortu na te state of affairs mu st be reme died. Unt il it is, 

oth er fund ing app roaches mu st bear an even greater burden. In 

fac t, the need for Fe de ral funds to su pp ort the team s of phy sicians, 

param edical associates, nurses and social worke rs req uired to deliver 

hig h quality genetic services is gr ea ter now than ever. In the past, 

gr an ts from the Na tional Foundatio n-Marc h of Dimes were a ma jor 

source of su pp ort fo r pers onnel eng aged in prov idi ng diag nos tic, 

the rap eutic and coun selin g services fo r genetic disease. Th e very recent decision of the fou ndation to dir ect its clin ical su pp ort fun ds 

elsewhere ha s c rea ted a h uge and critical ga p which only the Fe deral 

and State gov ernments can fill.

In conclusion , I believe the time h as come for the trut hs of genetic 

research to be tra ns lat ed more effectively into well org anized , hu ­

man e, clin ical pro gra ms. Those of us at unive rsity med ical centers, 

research institut es, and State h ealth departm ents must begin to make 

wh at we do co mm ensurate w ith wh at we know.

Th e 1978 ame ndm ents to the Na tio nal Genetic Diseases Ac t cla rif y 

the intent of this bill to pro vid e com preh ensive genetic services as 

par t of pr im ary he alth care fo r all persons nee ding such services. 

Th e funds autho riz ed in this bill will, if ap prop ria ted, speed us toward th at goal.

Th an k you.

[The p repa red sta tem ent of Dr. Rosenberg follo ws :]
323

March 1, 1978 

L. E. Rosenberg

TESTIMONY AT PUBLIC HEARING REGARDING EXTENSION OF AND

AMENDMENTS TO PL94-278

My name is Dr. Leon E. Rosenberg. I am a pr ofe ss or o f Human Ge netics, 

Medicine and P edia tric s and Chairman o f the Department o f Human Genetics 

a t the Yale U niv ers ity School o f Me dic ine . I am also the d ir e c to r of 

Yal e's NIH-sponsored Center fo r Human Genetics and In herite d Diseases.

For ne ar ly 20 ye ar s, I have stud ied ge ne tic diseases at the bedside and 

at the la bora to ry bench, and have witne ssed' the enormous growth in our 

understandin g of both normal ge ne tic mechanisms and those abnormal ones 

which cause dis ea se. During th is same in te rv a l, I have cared fo r scores 

o f patients and fa m ilie s each a ffli c te d w it h , or at ris k fo r a ge ne tic 

dis ord er. This experience has convinced me th a t, as a nation, we have 

been fa r more re so urce ful in acquirin g knowledge about ge ne tic diseases 

than in ap plying th at knowledge to the care o f sic k people. For th is 

reason I be lie ve PL94-278 is an h is to n e piece of le g is la ti o n and I urge 

its ex te ns ion, and it s f u ll appro priation.

I fe el cert ain th at I ne ed n't remind th is committee th at ge ne tic 

di so rd er s are the most widespread and among the most burdensome o f known 

a ffli c tio n s , th at they a ff e c t ap prox im ately 6 perce nt o f our c it iz e n s , 

or th at the y are re sp on sible fo r 30 pe rcen t o f child ho od h o s p ita liz a tio n s , 

fo r 40 pe rcen t o f in fa n t m o rta li ty and fo r ne ar ly 80 pe rcen t o f mental 

re ta rd atio n. Inasmuch as re c it a ti o n o f th is li ta n y underscores the 

glob al impact o f ge ne tic dise as e, I mention i t . However, neither co mpilatio n 

o f such he alth s ta tis tic s nor enumeration o f the hundreds o f known 

ge ne tic diso rd er s prov ides a s u ffic ie n t ra tio n a le fo r the expe nd iture of
324

- 2 -

federal funds fo r the support of genetic health services. I prefer to 

ju s ti fy such expenditures in terms of specific stra tegies fo r sp ecific 

dis ord ers.

To me, genetic health services means screening of newborns fo r 

phenylketonuria because ea rly diagnosis and appro priate dietar y management can prevent the severe mental retard ation which occurs re gu larly in 

the untreated pat ient . Genetic health services means testing of black 

infants fo r si ck le cell anemia because such de tection, followed by 

appropriate immunization or a n tib io tic programs, can fo re sta ll the often 

lethal ba cterial infe ctions to which these ch ild ren are predisposed. 

Genetic health service s means the re gu lar, prop hy lactic administratio n 

of an ti-h em ophilic fa ct or to ch ildren and ad ults with hemophilia because 

such co stly but effective treatment w il l prevent the cripplin g consequences of th is disease. Genetic health services means test ing of 

Jewish teenagers fo r the Tay-Sachs gene because in divid uals and couples ' 

who carry th is tr a it have a ri g h t to make informed ma rital and procreatio na l decisions based on th is infor mation. Genetic health services 

means counselling the re la tives of pa tie nts with Huntin gton's Disease 

because some of these individu als are at risk fo r the disease and must

bear that burden, whereas others are not at risk and are e tit le d f j

that re li e f.

In the ory, genetic health service s should be fa r less expensive and 

easier to organize than many others fo r, a ft e r a ll, they are based on 

sound pr ed ictiv e prin ciples and are aimed at preven tion of disease. In 

pr ac tic e, however, they are cu rrently very d iffic u lt to deliv er because 

ne ith er the pu blic nor the medical profession understands adequately the 

prin ciple s upon which genetic medicine is based, and because our health 

care system is much more oriented to c ris is inte rv en tio n than disease
325

- 3 -

preven tion . Preventing coronary artery disease in ge netic ally susceptible 

in dividu als by long-term re str ic tio n of die ta ry fats and chole ste rol has 

none of the glamor of "by-pass" gra ft hea rt surgery. Preventing pulmonary 

emphysema by advising genetic ally predisposed individu als to avoid 

cig are tte smoking and oth er noxious inh ala nts has none of the drama of 

emergency ventila to ry assistance . I t is a cruel paradox that we are 

w illin g to pay in fin it e ly more fo r treating disease than we are fo r 

mainta ining health. This posture has a pa rt ic u la rl y deleterio us effect 

on the pro vis ion of genetic health services. Despite th e ir obvious 

human bene fits and demonstrated cost effectiven es s, most th ird party 

payers refuse to consider genetic screening, diagnostic amniocentesis, 

and genetic counselling reimbursable expenses. This unfortunate sta te 

of a ff a ir s must be remedied. Until i t is , other funding approaches must 

bear an even gre ate r burden. In fa ct, the need fo r federal funds to 

support the teams of physicians, paramedical associates, nurses and 

social workers required to deliv er high qualit y genetic service s is 

greater now than ever. In the past, grants from the National FoundationMarch of Dimes were a major source of support fo r personnel engaged in 

providing diag no stic, therapeutic and counsellin g service s fo r genetic 

disease. The very recent decision of the Foundation to direct it s 

c lin ic a l support funds elsewhere has created a huge and c rit ic a l gap 

which only the federa l and state governments can f i l l .

In con clusion, I believe the time has come fo r the truth s of genetic 

research to be tra ns lated more e ff e ctive ly in to well organized, humane, 

c lin ic a l programs. Those of. us at univ ers ity medical cente rs, research 

in s ti tu te s , and sta te health departments must begin to make what we do 

commensurate with what we know^/The funds authorized in th is b ill w il l , 

i f appro priate d, speed us toward th at goal.
326

Sena tor J avits. T ha nk you very much , Dr. Rose nberg.

Dr. M urr ay, would you follow ?

Dr . Murray. Mr. Ch air ma n, Sen ato rs, ladies and gentlemen, my 

nam e is Robert F. Murray, Jr. I am a pro fessor of pedia trics and 

medicine in the College of Medicine, grad ua te pro fessor of genetics 

and hum an genetics in the Gr aduate School of Arts and Sciences, 

chief, Division of Medical Genetics, De pa rtm en t of Pe diatr ics and 

Child Hea lth o f Ho wa rd Unive rsity. I also dir ect the Gene tic Cou nseling Division of the Center for Sickle Cell Disease, Ho wa rd Univer sity. In addition , I am a Fellow and mem ber of the Board of 

Direc tors of the In stitu te of Society, Ethics and the Life Sciences, 

the Ha sting s Center. I have rece ntly been appoint ed a member of the 

Bioethics Advisory Board to the Secre tary of Hea lth , Ed ucation, and 

Welfare .

I am spe aking in su pp ort of the rene wal of Pu blic Law 94-278, 

tit le IV , The Na tio nal Sickle Cell Ane mia , Cooley’s Ane mia, TaySachs and Genetic Diseases Act. There are three points th at I want 

to speak to.

1. Th is bill should be passed because it is im po rta nt to provide 

continu ous su pp ort fo r the pro gra ms of edu cation , screening and 

counseling fo r genetic diseases where the y are alr eady well establish ed and are beg inn ing to have a significant effect on people who 

are at increased risk to inhe rit a genetically determined disease. Th is 

is pa rti cu larly im po rta nt whe re these pro gra ms hav e not been yet 

integ rated int o the gen era l healt h care delive ry system of the commu nity. In thi s con text, it is especially vital th at the effective, comprehensive sickle cell centers and sickle cell screen ing and education 

clinics should be c onti nued. In sim ilar fas hio n, other well established 

or newly emerg ing pro gra ms th at are deliv eri ng effective genetic 

servic es should be give n pr iorit y in aw arding gr an ts and con tracts 

at leas t un til they can be mad e sel f-s up po rting or else become a pa rt 

of th e h ealth care system . If th e alread y existing p rogra ms have been 

effective, it sh ould be possible to add the ca pability fo r screenin g for 

other diseases which should be less expensive th an star ting new program s from scratch .

2. I t is im po rta nt to pay attention to the eth ica l and mo ral conflicts th at can arise when pro gra ms of genetic service are established 

on a large scale, especially in communities th at are no t prepared for 

them.

I t might be cost effective to do genetic screen ing in a population 

th at is easy to get at, for exam ple children en terin g nurse ry school, 

bu t a properl y performed screening program is certa in to uncover 

instances of no np ate rnity . He re the child ’s need fo r a stab le fam ily 

is threate ne d by the righ t of the fath er to the inf orma tio n from the 

genetic tests. Should the coun selor vio late the eth ica l pri ncipl e of 

tr uth tel lin g in order to pres erve the fam ily and the mo the r’s integrity ? Wh ich takes precedence, the obl iga tion of the screener to the 

person being screened or to the State which may be financin g the 

screen ing program ? Should the genetic counselor's prime obliga tion 

be to the pa rents or the unb orn fetus or to the St at e’s intere st in 

red ucing tne burde n of genetic disease? Where screen ing tests ide ntify couples a t high ris k to hav e chi ldr en with gen etic ally determ ined 

disease, how should th ei r obligations be ran ked? Does th eir righ t to
327

procreate and be parents of children who may be genetically handicapped supersede thei r obligation to society and the human gene 

pool not to give birth to genetically abnormal children ? Is the righ t 

to be born free of genetic defect valid in an ethical sense? Is the 

information obtained in genetic testing subject to the same rules of 

confidentiality as other medical information or is genetic inform ation more properly the property of genetic or blood relatives?

This means tha t results of genetic testing can be shared with them 

without the permission of the person tested. The provision in this 

bill recommending t hat the National Commission for the Protection 

of Human Subjects be continued and tha t it review7

 the ethical im­ plications of programs of education, screening and counseling for

* genetic disease clearly recognizes the need for a detailed study of 

these a nd other profound ethical and legal questions that are raised 

by the programs that would be promulgated by this bill.

3. I served as a member of the Committee for the study of Inborn 

w Errors of Metabolism, a working group of the National Research

Council of the National Academy of Sciences. In 1975, afte r 2 years 

of intensive study, this committee issued a report, “Genetic Screening, 

Programs, Principles and Research.” One of the m ajor recommendations of this report sets forth a series of conditions which should 

guide the development of new genetic screening programs. A key 

step recommended by this group in the development of new programs 

is a pilot study or neld trial. This will serve not only to help identify technical and procedural difficulties but should help surface previously unsuspected legal, psychosocial, and ethical conflicts that

might cause harm to individuals or to entire communities.

An example of this harm is the unexpected stigmatization, not 

only of patients with the disease, but also persons who are otherwise 

healthy carriers of the sickle-cell gene. If one or more pilot programs 

in education, screening, and counseling for sickle-cell disease had 

been carried out before launching the large-scale program, it is probable th at some of the negative effects of the early sickle-cell screening programs might have been avoided or, at the very least, have 

been minimized. Some of the danger tha t was done by poorly conceived and ill-advised educational programs and screening without 

counseling is still being repaired by the ongoing sickle-cell centers and 

screening and counseling clinics.

Provi ding funds for plannin g will make it possible for qualified

* professionals to set up new screening programs for genetic diseases 

or thei r carrier states as the technology for genetic testing is improved and refined. Pa rt of the planning strategy should involve 

setting up pilot programs to make certain tha t flaws in program de-

* sign are found early and tha members of the community are ready 

to p articipate in the program to maximize the likelihood tha t its net 

impact will be positive.

Even though there are certain principles tha t are common to all 

genetic disorders, each of them has its own peculiarity. Furthermore, 

the same genetic disease can be responsible for different ethical and 

psychosocial problems in different ethnic or religious groups.

There is a definite and growing need and desire for the genetic 

services tha t will be provided by this bill. More than 70 percent of

28-386 0 - 78 - 22
328

a sam ple of 5,000 small-colle ge students who were surv eye d abou t 

ethics and genetic disease, fel t th at it was im po rtan t to know what 

abn orm al genes they car ried. A sim ilar prop ortio n felt th at genetic 

screen ing and counseling services were needed. To pro vid e continu ity in existing genetic services, to provide fo r the most hum ane, 

beneficial, and also pract ica l int rod uction of new gen etic services and 

the expansion of existing ones to meet the grow ing desire and need 

fo r these services, I recom mend th at the committee appro ve this bill. 

Se na tor J avits. Than k you so much.

[The prepa red statem ent of D r. Murr ay f ollows:]
329

T esti m o n y b e fo re th e S e n a te S ubcom m itte e on H e a lt h o f R o b ert F . M urr ay, 

J r . , M.D . on re n e w al o f P .L . 9 4 -2 7 8 , T i t l e IV

M ar ch 1 , 1978

Mr. C hai rm an, S e n a to rs , L a d ie s and G en tl em en , my name i s R o b ert F . 

M urr ay, J r . , M .D ., M .S ., F .A .C .P . I am P r o f e s s o r o f P e d i a t r i c s an d M edic in e 

in th e C o ll e g e o f M e d ic in e , G ra d u a te P r o f e s s o r o f G e n e ti c s and Human G e n e ti c s 

in th e G ra d u a te School o f A rts an d S c ie n c e s , C h ie f, D iv is io n o f M edic al

G e n e ti c s , D epar tm ent o f P e d i a t r i c s and C h il d H e a lt h o f Howar d U n iv e r s ity .

I a ls o d i r e c t th e G e n e ti c C o u n se li n g D iv is io n o f th e C e n te r f o r S ic k le C e ll 

D is e a s e , Howard U n iv e r s ity . In a d d itio n , I am a F e ll o w an d member o f th e

Boa rd o f D ir e c to r s o f th e I n s t i t u t e o f S o c ie ty , E th ic s an d th e L if e S c ie n c e s , 

th e H a s ti n g s C e n te r. I have r e c e n t ly b een a p p o in te d a me mber o f th e B io ­

e t h i c s A d v is o ry Boa rd to th e S e c r e ta r y o f H e a lth , E d u c a ti o n an d W e lf a re .

I am sp e a k in g in s u p p o rt o f th e re n e w a l o f P .L . 9 4 -2 7 8 , T i t l e IV ,

Th e N a ti o n a l S ic k le C e ll Ane mia, C o o le y ’s Ane m ia , Ta y Sachs an d G e n e ti c 

D is e a s e s A c t. T h ere a re th r e e p o in ts t h a t I w an t to sp ea k t o .

1 . T h is b i l l s h o u ld be p a ss e d b e c a u se i t i s im p o rta n t to p ro v id e 

c o n ti n u o u s s u p p o rt f o r th e pro gra m s o f e d u c a tio n , s c r e e n in g

an d c o u n s e li n g f o r g e n e tic d is e a s e s w he re th e y a r e a lr e a d y 

w e ll e s ta b lis h e d and a r e b e g in n in g to have a s i g n i f i c a n t

e f f e c t on p e o p le who a r e a t in c r e a s e d r i s k to i n h e r i t a

g e n e t i c a l l y d e te rm in e d d i s e a s e . T h is i s p a r t i c u l a r l y im p o rta n t w her e th e s e p ro gra m s h a v e n 't y e t been in te g r a t e d in t o th e 

g e n e r a l h e a l th c a r e d e liv e r y sy st e m o f th e co m m uni ty . In 

t h i s c o n te x t, i t i s e s p e c i a l l y v i t a l t h a t th e e f f e c t i v e , 

c o m p re h en si v e s i c k l e c e l l c e n t e r s an d s i c k l e c e l l s c r e e n in g

an d e d u c a ti o n c l i n i c s sh o u ld be c o n tin u e d . In s im ila r fa s h io n

o th e r w e ll e s ta b lis h e d o r new ly em erg in g pro gra m s t h a t a re
330

T est im ony o f R .E . M urr ay, j- r . , u .v .

P .L . 9 4 -2 7 8 , T i t l e IV

Pa ge 2

d e liv e r in g e f f e c t i v e g e n e tic s e r v ic e s sh o u ld be g iv e n 

p r i o r i t y in aw ar din g g r a n ts an d c o n tr a c ts a t l e a s t u n t i l 

th e y ca n be made s e l f s u p p o rti n g o r e l s e be co me a p a r t of 

th e h e a lth c a r e sy ste m . I f th e a lr e a d y e x i s t i n g pr ogra m s 

ha ve bee n e f f e c t i v e , i t sh o u ld be p o s s ib le to ad d th e cap ab i l i t y f o r s c r e e n in g fo r o th e r d is e a s e s w hi ch sh o u ld be le s s 

e x p e n siv e th a n s t a r t i n g new pro gra m s from s c r a tc h .

2. I t i s im p o rta n t to pay a t t e n t i o n to th e e t h i c a l an d m ora l 

c o n f l i c t s th a t ca n a r i s e when pro gra m s o f g e n e tic s e r v ic e 

a re e s ta b lis h e d on a la rg e s c a l e , e s p e c i a l l y in com m unitie s 

th a t a r e n 't p re p a re d f o r th em .

I t m ig ht be c o s t e f f e c t i v e to do g e n e tic s c r e e n in g in a 

p o p u la ti o n th a t i s e a sy to g e t a t , f o r ex am ple c h ild r e n 

e n te r in g p ri m ary s c h o o l, b u t a p ro p e rly p erf orm ed s c re e n in g 

pr ogra m i s c e r t a i n to u ncover in s ta n c e s o f n o n - p a te r n ity . Here 

th e c h i l d 's nee d fo r a s ta b l e fa m il y i s th r e a te n e d by th e 

r i g h t o f th e f a t h e r to th e in fo rm a ti o n fr om th e g e n e tic t e s t s . 

Sh ould th e c o u n s e lo r v i o l a t e th e e t h i c a l p r i n c i p l e o f t r u t h 

t e l l i n g in o rd e r to p re s e r v e th e fa m il y an d th e m oth er s in ­

t e g r i t y ? Wh ich ta k e s p re c e d e n c e , th e o b lig a tio n o f th e 

s c r e e n e r to th e p e rs o n b e in g s c re e n e d o r to th e s t a t e whi ch 

may be fin a n c in g th e s c re e n in g pro gra m ? Shou ld th e g e n e tic 

c o u n s e lo r 's prim e o b lig a tio n be to th e p a r e n ts o r th e un bo rn 

f e tu s o r to th e s t a t e ' s i n t e r e s t in re d u c in g th e burd en of 

g e n e tic d is e a s e . Wh ere s c re e n in g t e s t s i d e n t i f y c o u p le s a t 

h ig h r i s k to hav e c h ild r e n w it h g e n e t i c a l l y d e te rm in e d d is e a s e
331

T est im ony of R .F . M urr ay, J r . , M.D. 

P .L . 9 4 -2 7 8 , T i t l e IV

Pa ge 3

how sh o u ld t h e i r o b l ig a tio n s be ra nked? Doe s t h e i r r i g h t 

to p ro c r e a te an d be p a r e n ts o f c h ild r e n who may be g e n e t ic a l l y h a n d ic ap p ed su p e rc e d e t h e i r o b lig a tio n to s o c ie ty 

an d th e human gen e p o o l n o t to g iv e b i r t h to g e n e t i c a l l y 

abnorm al c h ild r e n ? I s th e r i g h t to be b orn f r e e o f g e n e tic 

d e f e c t v a lid in an e t h i c a l se n se ? I s th e in fo r m a ti o n o b ta in ­

ed in g e n e tic t e s t i n g s u b je c t to th e sam e r u l e s o f c o n fid e n ­

t i a l i t y a s o th e r m e d ic al in fo rm a ti o n o r i s g e n e tic in fo rm a ­

tio n mo re p ro p e rly th e p ro p e rty o f g e n e tic o r b lo o d r e l a ­

tiv e s ? T h is me an s t h a t r e s u l t s o f g e n e tic t e s t i n g can be 

sh a re d w it h them w it h o u t th e p e rm is sio n o f th e p e rs o n t e s t ­

ed . The p r o v is io n in t h i s b i l l reco mmen di ng th a t th e N a ti o n a l 

Com miss ion fo r th e P r o te c tio n o f Human S u b je c ts be c o n ti n u e d 

an d th a t i t re v ie w th e e t h i c a l im p lic a tio n s o f pro gra m s of 

e d u c a ti o n , s c r e e n in g an d c o u n s e li n g fo r g e n e tic d is e a s e c l e a r ­

ly re c o g n iz e s th e nee d f o r a d e ta ile d s tu d y o f th e s e an d o th e r 

p ro fo und e t h i c a l an d le g a l q u e s tio n s th a t a re r a is e d by th e 

pro gra m s th a t w ou ld be p ro m u lg ate d by t h i s b i l l .

3. I serv ed a s a mem ber o f th e Com m itte e f o r th e Stu dy o f In ­

born E rro rs o f M eta b o li sm , a w ork in g gro up o f th e N a ti o n a l 

R esearc h C o u n cil o f th e N a ti o n a l Acad emy o f S c ie n c e s . In 

1975 , a f t e r two y e a r s o f in te n s iv e s tu d y , t h i s com m itte e 

is s u e d a r e p o r t , G e n e ti c S c re e n in g , P ro g ra m s, P r i n c i p l e s an d 

R e se a rc h . One o f th e m a jo r re com m endati ons o f t h i s r e p o r t 

s e t s f o r th a s e r i e s o f c o n d itio n s w hic h sh o u ld g u id e th e 

devel opm en t o f new g e n e tic s c r e e n in g p ro g ra m s. A ke y
332

Test im ony o f R .F . M urr ay, J r . , M.D.

P .L . 9 4 -2 7 8 , T i t l e IV

Pa ge 4

s te p rec om me nded by t h i s gro up in th e devel opm en t o f new 

pro gra m s i s a p i l o t stu d y o r f i e l d t r i a l . T h is w i l l s e rv e 

n o t o n ly to h e lp id e n t i f y te c h n ic a l an d p ro c e d u ra l d i f f i c u l ­

t i e s b u t sh o u ld h e lp s u rfa c e p re v io u s ly u n s u sp e c te d l e g a l ,

p s y c h o s o c ia l an d e t h i c a l c o n f l i c t s t h a t m ig ht c a u se harm to •

in d iv id u a ls o r to e n t i r e co m m u n it ie s. An ex am pl e o f t h i s 

harm i s th e u n ex p ec te d s tig m a tiz a ti o n , n o t o n ly o f p a t i e n t s 

w it h th e d is e a s e , b u t a ls o p e rs o n s who a re o th e rw is e h e a lth y 

c a r r i e r s o f th e s ic k l e c e l l g en e. I f on e o r mo re p i l o t p ro ­

gram s in e d u c a tio n , s c r e e n in g an d c o u n s e li n g f o r s i c k l e c e l l 

d is e a s e ha d been c a r r ie d o u t b e fo re la u n c h in g th e la r g e s c a le 

pro g ra m s, i t i s p ro b a b le th a t some o f th e n e g a tiv e e f f e c t s of 

th e e a r ly s i c k l e c e l l s c re e n in g pro gra m s m ig ht ha ve be en a - 

v o id e d o r a t th e v e ry l e a s t , ha ve be en m in im iz e d . Some o f th e 

dam age t h a t was do ne by p o o rly c o n ce iv e d an d i l l - a d v i s e d 

e d u c a tio n a l pro gra m s an d s c re e n in g w it h o u t c o u n s e li n g i s 

s t i l l b e in g r e p a ir e d by th e ongoin g s i c k l e c e l l c e n t e r s an d 

s c re e n in g an d c o u n s e li n g c l i n i c s .

P ro v id in g fu nds fo r p la n n in g w i l l make i t p o s s ib le f o r q u a l i f i e d p ro ­

f e s s i o n a l s to s e t up new s c r e e n in g pro gra m s fo r g e n e tic d is e a s e s o r t h e i r 

c a r r i e r s t a t e s a s th e te c h n o lo g y f o r g e n e tic t e s t i n g i s im pr ov ed an d r e ­

f in e d . P a rt o f th e p la n n in g s tr a te g y sh ould in v o lv e s e t t i n g up p i l o t p ro -

*

gram s to mak e c e r t a i n th a t fl a w s in pro gra m d e sig n a re fo un d e a r ly an d th a t
Test im ony o f R .F . M urr ay, J r . , M.D.

P .L . 9 4 -2 7 8 , T i t l e IV

Pa ge 5

mem bers o f th e co mmun ity a re re a d y to p a r t i c i p a t e in th e pro gra m to m ax im iz e th e lik e lih o o d t h a t i t s n e t im p act w i l l be p o s i t i v e .

Ev en th o u g h th e r e a r e c e r t a i n p r i n c i p l e s t h a t a r e common to a l l g e n e tic 

d is o r d e r s , each o f them h as i t s own p e c u l i a r i t y . F u rth e rm o re , th e sam e g e n e tic 

d is e a s e can be r e s p o n s ib le f o r d i f f e r e n t e t h i c a l an d p s y c h o s o c ia l pro b le m s 

in d i f f e r e n t e th n ic o r r e l i g i o u s g ro u p s .

T h ere i s a d e f i n i t e an d gro w in g need an d d e s ir e f o r th e g e n e tic s e r ­

v ic e s t h a t w i l l be p ro v id e d by t h i s b i l l . More th a n 70Z o f a sa m ple o f 5 ,0 00 

s m a ll c o lle g e s tu d e n ts who w er e su rv e y ed a b o u t e t h i c s and g e n e tic d is e a s e 

f e l t t h a t I t wa s im p o rta n t to know w hat abnorm al g en es th e y c a r r i e d . A 

s i m i l a r p r o p o r tio n f e l t th a t g e n e tic s c r e e n in g an d c o u n s e li n g s e r v ic e s wer e 

n e ed e d . To p ro v id e c o n tin u ity in e x i s t i n g g e n e tic s e r v i c e s , to p ro v id e f o r 

th e m ost hu man e, b e n e f i c i a l an d a ls o p r a c t i c a l in tr o d u c tio n o f new g e n e tic 

s e r v ic e s an d th e e x p a n sio n o f e x i s t i n g o n es to m ee t th e gro w in g d e s ir e an d 

need f o r th e s e s e r v i c e s , I rec om me nd t h a t th e com m it te e p a ss t h i s b i l l .

THANK YOU!!
334

Senator J avits. Mrs. Marks, would you proceed?

Mrs. Marks. I am Joan Marks, director of the human genetic program at Sarah Lawrence College in Bronxville, N.Y. I am grateful 

to the committee for this opportunity to speak to the need for a 

national commitment to train all levels of health professionals to 

recognize the role th at genetics plays in human disease. The 20 million Americans who suffer the results of genetic disease and the countless Americans who may be at risk for genetic disease themselves or 

in their offspring, have a well-established need for a more intensive 

effort from the biomedical community to understand and, through 

understanding, improve techniques for accurate diagnosis, treatment, 

and possibly prevention.

But far less recognized is the devastating effect tha t the presence 

of genetic disease can have on an entire family. Not only does society 

at large fail to recognize the impact of this major public health 

problem, but most health professionals, including physicians, are 

severely limited in their capacity adequately to care for the millions 

of people with genetic disease. If one recognizes that as a discipline 

genetics was not part of the curriculum of the vast majority of 

today’s health practitioners owing to the fact tha t it has emerged 

as a substantial discipline only in the last two decades, then it is 

easier to understand the unfamiliarity of many health professionals 

with the needs of families and individuals who face the crisis of 

genetic disease.

In my work as an educator of genetic counselors who are trained 

to serve as nonphysician members of a genetic counseling team directed by a physician, I have come to a deep appreciation of the 

widespread lack of knowledge about our current understanding of 

human genetic disease by health professionals—nurses; doctors, including psychiatrists; lab technicians; psychologists; and social workers. This lack of knowledge among such health professionals, on whom 

the family in crisis is utterly dependent, greatly increases the burden 

tha t genetic disease places on families. Such lack of knowledge is not 

inevitable by any means and could be markedly altered by an aggressive attempt to educate health-care workers in the fundamentals of 

human genetics and in the techniques of emotional support which 

are crucial to maintaining such families a t a functional level.

I do not believe that training physicians and other health-care 

workers in genetics is a matter of quality care versus minimal care. 

I maintain tha t the failure to train health professionals in clinical 

genetics and genetic counseling results in an absence of care for the 

estimated 20 million Americans subject to the effects of inherited 

disease. To quote the fathe r of a Down Syndrome, or mongoloid, 

in fa nt :

If only our doctor had come and sat down with us to answer our questions 

and our fears. Instead, we were made to feel this was a situation which 

couldn’t be handled by anyone. One feels that if the professionals can’t handle 

it, then you can’t either. I couldn’t find anyone to get help from.

Coupled with, perhaps even due to, the need to train professionals 

to deal with the effects of genetic disease, an organized national 

effort must be made to educate physicians and other health professionals in the basic principles of clinical genetics and the technology
335

now available to diagnose, treat, and even prevent genetic disease 

for those individuals who wish tha t option. Although most genetic 

diseases are relatively rare, taken together as a group genetic diseases 

account for nearly 40 percent of all admissions to children’s hospitals. 

It is estimated that $400 million is spent annually in the United 

States for the care of patients with Down Syndrome alone. However, 

a 1974 survey by the National Academy of Sciences of 1,000 Board 

certified physicians indicated tha t nearly three-fourths of the doctors 

reported tha t they had not had any course work in genetics in medical schools because it was not available. In fact, only half the physicians polled had a reasonable knowledge of genetics. Clearly, other 

health professionals with less advanced degrees are even less knowledgeable about genetic diseases and, thus, unable to provide appropriate help to those in need.

A physician who does not understand genetic principles and their 

cardinal feature, predictability, will not only misdiagnose certain disorders in individuals, but will fail to perceive his or her responsibility to the families of such patients who should also be the focus 

of their care. Approximately 4,000 continuing education courses for 

physicians were offered durin g the year 1974-76. Only 16 were given 

in genetics.

Despite the growing emphasis on preventive medicine, physicians 

have failed to focus on the potential of genetic medicine. While no 

survey has been made of continuing education courses in other health 

disciplines, it seems likely tha t very few schools in nursing, social 

work, or public health have a genetic curriculum. More than 90 percent of the physicians polled in the National Academy of Sciences 

study said they wanted such courses.

At this juncture, as p art of an overall strategy for the use of the 

limited amount of Federal funds available for support of health 

professional education and health services, a program targeted to 

provide for effective programs of continuing education in human 

genetics for physicians and other health professional practitioners 

deserves a very high priority. I base this recommendation on the 

service needs as cited by others testifying today, as well as on the 

data indicating the the widespread lack of knowledge of most health 

professionals. Such a targeted use of Federal funds could be very 

effective and should be time limited so as to provide incentives for 

the development of alternative methods which would, over a 5-year 

period, phase out the need for a longer period of funding.

In addition to training health professionals, there is a great need 

to develop new public education materials tha t are both accurate and 

sensitive to the implications tha t genetic disease has for individuals 

who carry them. An informed public can do much to diminish the 

impact of this major health care problem.

In summary, I believe Federal funding should be provided to:

One. Develop training programs for health professionals, including continuing education programs for those now in practice, and to 

strengthen existing programs training physicians and other health 

professionals, including genetic associates, with the ultimate objective 

of providing better genetic services commensurate with our present 

understanding of the tranmission of genetic disease.
336

Two. Develop an imp roved national p ublic ed uca tion pro gra m with 

resp ect to genetic diseases and their na ture and to the possibilities 

fo r diagnosis and tre atm en t, as well as fo r preven tion, of genetic 

diseases f or those who wish this choice.

[The pr epare d sta tem ent of Mrs. Ma rks fo llo ws :]

o
337

Testim ony pre sented to

The Subcommit tee on Healt h and Scientific Research 

Mar ch 1,1978

R

Joa n H. Mark s 

Dire ctor

Human Genetics Program 

Sarah Lawre nce College 

Bronxville, New Yor k

*
338

I am Joan Marks, Director of the Human G enetics Pro gra m at Sarah 

Lawrence C ollege in Bronxville, New York. I am g rate ful to the Committe e for 

this opport uni ty to speak to the n eed for a nati ona l com mit men t to train 

all levels of he alt h p rof essionals to recognize the role that genetics 

plays in human disease. The 20 mil lio n A meri cans who suffer the resul ts of 

geneti c disease and the countless America ns who ma y be at r isk for genet ic 

dis eas e themselves or in their o ffs pring have a well est abl ish ed nee d for 

a mor e intensive effort from the bi omed ical commun ity to u nde rst and and, 

through understanding, improve techniques for accu rat e diagnosis , treatment 

and possib ly prevention. But far less rec ogni zed is the devast ati ng effect 

that the p res enc e of geneti c disease can ha ve on an entir e family. Not 

only does society at large fail to recogniz e the impac t of this maj or public 

healt h problem, but most health p rofe ssion als, inc luding phy sici ans, are 

severely limited in their capacity adeq uate ly to care for the million s of 

peopl e with genetic disease. If one reco gnize s that as a dis cip lin e genetics 

was not part of the cur ricu lum o f the vast maj ori ty of today's health 

practitioners owing to the fact that it has emerged as a substantia l 

dis cipline only in the last two decades, then it is easier to u ndersta nd 

the unf ami lia rit y of many healt h pro fession als wit h the needs of families 

and individuals who face the crisis of genetic disease.

In my work as an educa tor of genetic couns elor s who are trained to 

serve as non-p hys ici an members of a genetic cou nsel ing team dire cte d b y a 

phys ician, I hav e come to a deep appr ecia tion o f the wid esp rea d lack of 

kno wledge about our current underst and ing of hu man gene tic d ise ase by health 

pro fes sionals - nurses, doctors, including psy chiatr ist s, lab techn icians,
339

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psychologists, and social workers. This lack of kno wledge among such health 

professionals, on w hom the fmaily in crisi s is utt erl y depen dent , greatly 

increases the burden that gen eti c disea se places on families. Such lack 

of knowle dge is not inevitable by any means and could be m ark edl y altered 

by an aggressive attempt to educate h eal th care workers in the funda ment als 

of h uma n genetics and in the techniques of emotional suppo rt whi ch are crucia l 

to ma int ain ing such families at a functiona l level.

I do n ot believ e that training phy sici ans and other heal th care workers

in g enetics is a mat ter of q ual ity care versus minimal care. I main tai n

that the failure to train he alt h professio nal s in clinical gene tics and

geneti c counseling results in an absence of care for the est imated 20 mi lli on

Americ ans subject to the effects of inherite d disease. To quote the fathe r

of a Down Syndrome, or mongoloid, infant:

" If only our doctor had come and sat down with us to answer 

our questions and our fears. Instead, we wer e made to feel 

this was a situation whic h coul dn't be ha ndl ed by anyone.

. One feels that if the prof ess ion als can't ha ndl e it, then 

you can't, either. I couldn't find anyon e to get h elp from."

Coupled with, perhaps even due to, the need to train pr ofe ssi ona ls to 

deal wit h the effects of g enetic d iseas e, an o rganize d national effort must 

be mad e to educate phy sicians and other h eal th prof ess ion als in the b asi c 

pri nci ple s of c linical genetics and the tec hnology no w avai labl e to diagnose, 

treat, and even prevent gen eti c disease for those indi vidu als who wis h that 

option'. Alt hou gh most genetic diseases are rel ati vel y rare, taken together 

as a group genetic d iseases account for n ear ly 40% of all admi ssio ns to 

chil dren's hospitals. It is es tim ate d that $400 mill ion is spent annually 

in the U nit ed States for the care of pa tie nts with Down Syndrome. Howeve r, 

a 1974 survey by the National Aca dem y o f S cien ces of 1,000 Boar d-ce rti fie d
340

-3 -

physi ci an s in dic ate d th a t near ly 3/4 th s of th e do ct or s re port ed th ey had 

no t had any coursew ork in genet ic s in medic al scho ol be cause i t was no t 

a v ail ab le . In fa c t, on ly h a lf th e ph ysi ci an s poll ed had a re as onab le 

knowledge of g en eti cs. C le arl y, oth er heal th p ro fe ssi o n als with le ss advanced 

de gr ee s ar e even le ss kno wle dge able about genet ic dis ease s and, th u s, un able 

to pr ov id e appro pri ate he lp to th os e in nee d.

A physi ci an who does no t un de rstand genet ic p rin c ip le s and th e ir *

card in al fe atu re , p re d ic ta b ili ty , w il l no t on ly misd iag no se c e rta in dis ord er s 

in in d iv id u als , bu t w il l f a i l to per ce iv e h is or her re sp o n sib il it y to the 

fa m il ie s of such p a ti e n ts who shou ld als o be th e focu s o f th e ir ca re .

Ap pro xim ately 4,0 00 co nt in ui ng ed uc at io n co ur se s fo r physi ci an s were off er ed 

du ring th e ye ar s 1974-1976. Only 16 were given in geneti cs! Des pite the 

grow ing emp hasis on pre ven tive m ed icine, physi ci an s hav e fa il e d to focus on 

th e p o te n ti a l of genet ic m ed icine. While no survey has bee n made of co ntin ui ng 

ed uc at io n co ur se s in oth er h ealt h d is c ip li n e s , i t seems li k e ly th a t ve ry few 

sc ho ol s of nurs in g, so cia l work, or public h ealt h have a genet ic s cu rriculum .

More th an 90% of the physi ci an s po ll ed in th e N at io na l Academy of Sc ienc es 

stud y sa id th ey wanted such co ur se s.

At th is ju n ctu re , as p a rt o f an overa ll str a te g y fo r th e use of th e lim ited 

amount of fe d era l fun ds av ail ab le fo r su pp or t of h ealt h pro fe ssi o n al ed uc atio n 

and healt h se rv ic e s, a prog ram ta rg ete d to pr ov id e fo r e ffe c ti v e prog rams of 

co nt in ui ng ed uc atio n in human genet ic s fo r physi ci an s and o th er heal th 

p ro fe ssi o n al p ra c ti ti o n e rs de se rv es a very hig h p r io r ity . I ba se th is 

recom mendatio n on the se rv ic e needs as cit ed by oth er s te s ti fy in g to da y, as 

wel l as on th e data in d ic ati n g th e widesprea d lack o f knowledge of most 

h ealt h p ro fe ssio n als . Such a ta rg ete d use of fe d era l fun ds co uld be very
341

-4-

effective and should be tim e-l imi ted so as to provide incen tive s for the 

developme nt of alternat ive m ethods whi ch would, over a five year pe riod, 

pha se out the n eed for a longer p eri od of funding.

In addit ion to training healt h p rof essiona ls, there is a grea t need 

to d evelop new public e duc ation materi als that are b oth accurat e and 

sensitive to the implications that gene tic d isease has for indiv idua ls 

who carry them. An informed publ ic can do m uch to d imin ish the impact 

of this maj or healt h care problem.

In summary, I believe federal funding should b e pro vid ed to:

1. develop training progra ms for health pro fess ion als , inclu ding 

con tinuing education programs for those now in prac tice , and to str engt hen 

existing programs training phy sici ans and other he alt h prof essiona ls, 

including genetic associates, with the ulti mat e obj ecti ve of provid ing b ett er 

geneti c services commensu rate wit h our presen t und ers tan din g of the tran smissi on 

of geneti c disease

2. develop an improved na tional public educ atio n p rog ram with respect 

to gen etic diseas es and their n ature and to the poss ibi lit ies for diagn osis 

and treatment, as well as for prev enti on, of genetic disease s for those

who wi sh this choice.
34 2

Se na tor J avits. Th an k you very much.

Mrs. Gu thr ie, you ha ve 5 m inute s.

Mrs. Guthr ie. I do no t rea lly need a lot of tim e, Sen ato r. I came 

un pr ep ared with notes, because I felt I wa nte d to speak fro m my 

heart .

I wante d to tell you I am here as foun de r and pre sid ent -em eri tus 

of the Com mitt ee to Com bat Hun tin gt on ’s Dise ase, bu t I would pr efe r to feel I am her e rep res entin g any family wi th any genetic 

disord er.

Si tti ng in our audi ence tod ay I wante d to recogniz e a colleague,

Meg Cau lfield , who rep res ent s osteo genis is im perfe cto and the Am erican Brittl e Bone Society. Th is room could be fu ll, filled wi th peop le 

who have genetic disord ers. My fee ling is th at while pro fessional s «

hav e give n you th ei r test imo ny, while the y hav e told you wh at the y 

th in k you ought to do, and ap pr ec iat ing yo ur inter est in th is act, 

ri gh t now there are mil lion s who are suf fering with many problem s 

an d we need help . We hav e to hav e a plac e to go to and ask wh at can 

you do fo r us whi le you are wo rki ng on resear ch, wh at are you goi ng 

to d o fo r use who do no t know wh at to tel l ou r ch ild ren? W here can 

we get inf orma tio n fo r the younger generat ion who could do be tte r 

th an ou r gen era tio n if inf orma tio n and cou nseling w’ere av ai la bl e!

I am very gr at ef ul th at you have br ou gh t the prob lem to the fore.

We sup po rt th is act.

We hope th at you can convince the othe r Mem bers of Congress 

th at the y mu st ap pr op riat e the $90 millio n fo r the fu ll 3 years as 

or igi na lly inte nded. To give us $4 millio n fo r 1 ye ar and the n hope 

th at so methin g c an be do ne, make s n o sense. We w ant hel p th at mean s 

dollars to pro vid e the servic es needed—the resear ch needed.

Th an k you and pl ease su pp ort us.

Se na tor J avits. H ow very war m and kind of you. How very eloquen t. Th an k you very much. I wish all my colleagues could he ar 

you. I will do my utm ost to tra ns m it yo ur sp ir it to them . Th an k you 

fo r br ingi ng so ma ny of yo ur own fri en ds who wor k ha rd and are 

influe ntia l int o H un tin gt on ’s Dise ase effort .

Th ere is one th in g I woul d like to ask all of you. We hav e no time 

fo r questions. I f I sub mit ques tion s in writ in g, will all the members 

of the pan el be good eno ugh to ans wer them in w rit in g?

W ith ou t obje ction, the y will be incl ude d as par t of the reco rd. I 

will ask fo r yo ur a nsw ers 1 week af te r we sub mi t the questions.

Dr. Murr ay , I have to ask you one que stion because an amend ment s

has been in tro duced on t hi s question.

W ha t is y ou r at tit ud e on ma nd ato ry screen ing as opposed to volun ­

ta ry sc reen ing fo r whic h you testified ?

Dr. Murray. Th is man da tor y scre ening was one of the pro vision s *

th at caused so muc h tro uble du rin g the ea rly day s of sickle cell disease. M any peop le fe lt th at t he ir rig ht s were vio late d and also becaus e 

cer tain gro ups were selected out fo r such man da tor y scre enin g, othe r 

gro ups were excl uded . One has a numb er o f prob lems, n ot on ly eth ica l, 

bu t economic, in tr yi ng to set up gen etic servic es, when one has a 

ma nd ato ry provision a ttached t o i t.

I would say th at i t would cause m ore pro blems t ha n it wou ld solve.
343

Senator J avits. You are opposed to it ?

Dr. Murray. I am definitely opposed to it.

Senator J avits. Dr. Rosenberg, would you care to offer professional opinion on that?

Dr. Rosenberg. I agree entirely with Dr. Murray.

Senator J avits. One last thing.

Dr. Rosenberg, you mentioned in your testimony the fact tha t the 

March of Dimes, the National Foundation which has been a supporter 

of genetic centers has announced plans to redirect their funding. I 

understand a representative is here in the audience, Mr. Clyde Shorey 

of the March of Dimes.

Mr. Shorey, I do not want to ask you to be a witness when you 

» have not been called. But would you be kind enough to get for me at

my request a letter from the Foundation which will state their policy, 

their reason for their policy, and what they see will be their policy 

in the next few years. This will have a material effect on what we 

do here.

Mr. Shorey. Yes; Senator, we will certainly do that. We very much 

support this legislation, and we support continuation of genetic 

counseling centers. We want to make this very clear to you and to the 

committee. I will see tha t you get this letter. I will send, together 

with a policy statement, will send tha t to all the members of the 

committee.

Senator J avits. Thank you. That will be fine.

Could we have that, say, within 1 week ?

Mr. Shorey. You will have it righ t away.

[The following was received for the record:]

28 -38 6 0 - 7 8 - 2 3
344

FRAN KL IN D ROOSEVELT, FOUN DER

MAR RY E GR EE N. CHAIRM AN OF TH E BOARD

T H E N A T IO N A L

F O U N D A T IO N

MAR CH OF D IMES ,2 7 5 MAM AR ON EC K AVE NUE. W HIT E PL AINS . NE W YORK 1 0 6 0 5 9 1 4 4 2 8 -7 1 0 0

CH AR LES L MASSEY

PRESIDE NT

March 7 , 1978

RECB MAR 1519 78

*

The Hon. Ja co b J a v its 

U ni te d S ta te s Se na te 

W as hing ton, D.C . 20510

De ar S enato r J a v it s :

In re sp onse to yo ur re q u e s t, d ir e c te d to Mr. Clyde 

E. Sh orey duri ng th e re c e n t h eari n g s of th e Su bcom mi tte e on 

H ea lth and S c ie n tif ic R es ea rc h of th e Sen at e Comm ittee on 

Human R es ourc es, I am ple ase d to send you th e encl ose d 

st ate m ent s e ttin g fo rth th e p o s it io n of The N a ti o n a l Fo un da tion 

March of Dimes on th e support of g e n e ti c s e rv ic e pr og ra m s.

We a re c o n fi d en t th a t you w il l conti nue yo ur ro le of 

le a d e rsh ip in c re a tin g new fe d e ra l i n i t i a t i v e s to ^ i n t a i n and 

ex te nd s e rv ic e s fo r p a ti e n ts and fa m il ie s w ith g e n e ti c d 

o rd e rs .

CLM:oz

Encl osu re

s

BIRTH DEF ECT S • TH E SALK INST ITUT E
S ta te m e n t o f C h a rle s L . M ass ey , P r e s id e n t 

Th e N a tio n a l F o u n d a ti o n -M a rc h o f Dime s 

To th e S u b co m m it te e on H e a lth an d S c i e n t i f i c R e s e a rc h

o f th e S e n a te C o n m it te e on Hu nan R e so u rc e s

THE NATIONAL FOUNDATION-MARCH OF DIMES AND GENETIC SERVICES

I n r e s p o n s e to th e r e q u e s t o f S e n a to r J a v i t s , I w ould l i k e to s e t f o r t h th e 

p o s i t i o n o f The N a tio n a l F o u n d a ti o n -M a rc h o f Dime s on th e s u p p o r t o f g e n e tic 

s e r v i c e p ro g ra m s. T h ese p ro g ra m s a r e o f m a jo r c o n c e rn t o th e F o u n d a ti o n an d a r e 

r e c e iv in g v e r y s u b s t a n t i a l f i n a n c i a l s u p p o r t fr om u s a s p a r t o f o u r o v e r a l l 

o b j e c t i v e o f p r e v e n tin g b i r t h d e f e c ts an d im p ro v in g th e outc om e o f p re g n a n c y .

R e a liz in g th e tr e m en d o u s Im p o rta n c e o f g e n e tic s r e s e a r c h an d s e r v ic e s to 

th e ac co m p li sh m e n t o f o u r g o a l s , we b eg an a nu m be r o f y e a rs ag o to mak e g r a n t s 

t o i n s t i t u t i o n s to fu n d r e s e a r c h i n g e n e tic d is e a s e s an d s e p a r a t e l y t o p r o v id e 

th e se e d mo ney t o i n i t i a t e c l i n i c s w h ic h w ould p r o v id e g e n e tic s e r v i c e s .

We a r e c o n tin u in g to mak e a s u b s t a n t i a l nu m be r o f g r a n t s f o r r e s e a r c h i n t o 

th e p ro b le m o f g e n e tic s an d t h e i r c a u s a l r e l a t i o n s h i p t o som e b i r t h d e f e c t s .

T h ro u g h th e s e p a r a t e p ro g ra m o f fu n d in g g e n e tic s e r v i c e s , w h ic h in c lu d e s 

s c r e e n in g h ig h r i s k g ro u p s f o r c a r r i e r s o f c e r t a i n d i s o r d e r s , d ia g n o s is an d 

tr e a tm e n t o f g e n e tic d i s e a s e s , p r e n a t a l d ia g n o s is o f some b i r t h d e f e c t s an d 

c o u n s e lin g f o r p a t i e n t s an d f a m i l i e s , th e F o u n d a ti o n h a s h e lp e d e s t a b l i s h many 

g e n e tic c o u n s e lin g c e n te r s th ro u g h o u t th e U n it e d S t a t e s . C u r r e n t ly , "83 o f th em 

r e c e iv e fu n d s fr om u s . Th e fu n d in g o f th e g e n e tic s e r v i c e p ro g ra m s i s o n ly a 

p a r t o f o u r t o t a l m e d ic a l s e r v i c e p ro g ra m . G ra n ts a r e a l s o mad e f o r n e o n a ta l 

i n t e n s i v e c a r e c e n t e r s , p r e n a t a l an d p e r i n a t a l c l i n i c s an d s i m i l a r s e r v ic e s in a 

b ro a d a t t a c k to im p ro v e th e ou tc om e o f p re g n a n c y . In 19 77 g r a n t s f o r g e n e tic 

s e r v ic e s am ounte d to a p p ro x im a te ly $ 2 .5 m i l l i o n o u t o f a t o t a l o f a b o u t $6 m i l ­

l i o n s p e n t f o r m e d ic a l s e r v ic e p ro g ra m s.

Th e p h il o s o p h y o f th e F o u n d a ti o n f o r ma ny y e a r s i n fu n d in g m e d ic a l s e r v i c e 

p ro g ra m s h a s b een t h a t th e f u n c tio n o f a v o lu n t a r y h e a l t h ag e n cy i s to p r o v id e 

i n i t i a l s e e d mo ney n e c e s s a r y t o d e m o n s tr a te th e n ee d f o r an d v a lu e o f new s e r ­

v i c e s , n o t t o fu n d e s t a b l i s h e d p ro g ra m s i n p e r p e t u i t y . We b e l ie v e t h a t v o lu n ta r y 

a g e n c ie s can b e s t s e r v e th e p u b li c by c r e a t i n g in n o v a tiv e d e m o n s tr a ti o n s o f n e e d ­

ed an d e f f e c t i v e s e r v ic e s an d th e n m ovi ng on to new a r e a s o f c h a lle n g e a s o th e r 

p ro b le m s a r e le s s e n e d o r s o lv e d . Our p o l i c y , e s t a b l i s h e d i n 1 9 7 1 , i s t o l i m i t 

th e d u r a t io n o f fu n d in g o f m e d ic a l s e r v i c e p ro g ra m s t o a maximum o f f i v e y e a r s .

Man y o f o u r c u r r e n t l y fu n d ed g r a n t s f o r g e n e tic s e r v i c e s h av e m et o r a r e 

a p p ro a c h in g th e f iv e y e a r l i m i t . T h e r e f o r e , u n d e r o u r p o l i c i e s an d th e te rm s o f 

th e g r a n t s th e g r a n te e i n s t i t u t i o n i s e x p e c te d to as su m e f i n a n c i a l r e s p o n s i b i l i t y 

o r s e c u r e o th e r s u p p o r t f o r a c t i v i t i e s s u p p o r te d u n d e r a g r a n t .
346

-2 -

We r e a liz e th a t in some in s ta n c e s th e se re q u ir e m e n ts p re s e n t h a rd sh ip to 

some g ra n te e s when o th e r so urc es o f fu ndin g a re d i f f i c u l t to o b ta in . We a re 

th e re fo re p re p a re d , as o u r g ra n ts re ach th e fiv e y e a r maximum te rm , to c o n sid e r 

fu ndin g fo r an a d d itio n a l y e a r or two i f th e g ra n te e ca n dem onst ra te th a t su ch 

an e x te n sio n i s ne ed ed as a te m pora ry ex p ed ie n t in a n tic ip a t io n o f a lte r n a tiv e 

so u rc es o f su p p o rt .

Ha ving dem onst ra te d th e g re a t im port an ce o f g e n e ti c s e r v ic e s , we b e li e v e 

th a t t h e i r fu ndin g sh ould now be pic ked up by o th e r mec ha nism s o f pa ym en t.

Sin ce th ir d p a rty p a y e rs, in c lu d in g both m edic al in su ra n c e an d M ed ic aid , f r e ­

q u e n tl y do not co ver th e se s e rv ic e s th ey mus t be p a id f o r e ith e r by th e p a tie n ts 

th em se lv es or by su p p o rt in g g ra n ts from th e fe d e ra l o r s t a t e go ve rn m en ts .

We s tr o n g ly endors e en ac tm en t an d fu ndin g o f a n a ti o n a l g e n e ti c d is e a s e s 

a c t which w ill enable th e s t a t e ag en cy a d m in is te rin g m a te rn a l an d c h il d h e a lth 

prog rams to m a in ta in an d dev el op g e n e ti c s e r v ic e s . The s e rv ic e s o p e ra te d by th e 

g ra n te e s o f th e F oundati on sh ould form th e b ase o f e x p e r tis e f o r th e p la n n in g

an d d e li v e ry o f g e n e ti c s e rv ic e s un der s ta t e p la n s subm it te d i n im ple m enta tion

o f su ch an a c t . I t i s e s s e n tia l th a t th e fu ndin g under su ch a n a c t be s u f f ic ie n t

to m a in ta in an d ex pa nd th e se g e n e ti c s e r v ic e c e n te r s as p a r t o f th e s t a t e p la n so

th a t co m pr eh en sive s e rv ic e s o f hig h q u a lity w ill become a v a ila b le to a l l .

March 7, 1978
347

March 13, 1978

Dear Dr. Murray:

I want to thank you for your excellent testimony before 

the health Subcommittee of the Senate Human Resources Committee 

on March 1 concerning the National Genetic Diseases Act Amend ­

ments which I have introduced.

As I mentioned at the hearing, because time was so short 

I would like to submittto you sone additional questions to be 

included in the hearing record:

1. At the hearing I asked your opinion regarding mandatory testing. Do you feel that any circumstances 

would warrant mandatorv screening?

2. Do you feel that genetic services are reaching the 

economically disadvantaged, the rural populations, 

and minority groups? If not, how can we correct 

this problem?

3. What role do you feel states should play in planning 

for g,enetic services?

A. How can we assure that a good pilot program will be 

adopted on a wide-scale basis?

5. As the nubile becomes increasingly aware of genetic 

services, will we be prepared to meet the demand?

6. How can we assure quality of services in screening 

and testing? Where should liability lie in terms of 

testing, or when a mistake in test results occurs?

Again, thank you for vour testimony and your continued 

Interest and cooperation.

Sin cerely,

Jacob K. Javits

Robert Murray, M.D.

College of Medicine 

Howard University 

Box 75

520 W Street, N.W.

Washington, D.C. 20059
J |

k

HO WAR D UNIV ERSIT Y

<111 COLLEGE OF MEDICINE

DEPARTMENT OF PEDIATRICS AND CHILD HEALTH

DIVISIO N OF MEOICAL GENETICS

March 29, 1978.

REC’O MAR 3 11978

The Honorable Jacob K. Ja vi ts

United St at es Senate

Committee on Human Resources

Room 4230

Dirkson Senate Of fic e Building

Washington, D.C. 20510

Dear Senator Ja vi ts :

This is in response to your le tt e r dated March 13, 1978 in which

you asked me to respond to si x ad ditio na l qu estio ns to be includ ed in

the record o f the hearings before the Health Subcommittee o f the Senate Human Resources Committee, March 1, 1978, on renewing and amending the National Genetic Diseases Act.

My resp onse s to the questions posed in your le tt e r are as fo llows:

1. I do not fe e l th at the re are any circumstances which

would warrant mandatory screening fo r any ge ne tic disease s. Only i f one cou ld demonstrate a clea r and pre ­

sent danger to th e population , at large would I consider

the p o ss ib il it y o f having mandatory screening fo r ge netic

diseases. I cannot th in k o f such a danger th at can be

unquestionably demonstrated to exis t fo r the proximate

ge ne tic fu tu re o f the pop ula tion at large. This questio n was examined in great depth by the Maryland Commis sion on Hereditar y Diseases. The re su lt s o f th ei r

de lib er at ions and st ud ie s re su lted in the repeal o f

mandatory PKU screening in th at st ate .

2. In my opinion, ge netic se rv ices are no t reaching the

economically disadvan taged, ru ra l population s and especia ll y mi nority groups. This opinion is not based on

large sca le sur vey s, which have been conducted but on

impressions gathered from tr ave l about the cou ntry, conve rsations with colleagues , healt h prof es sion al s and laymen. Lim ited surveys in some locales have shown, with

respec t to Si ck le Cell scr een ing , th at the ma jor ity o f

people who seek te st in g are mi dd le-class individu als

with a bet te r than average edu cat ion al background.

I think th is problem can be corre cte d f ir s t, by educating physi cia ns to the need fo r such se rv ices and seco ndly ,

by educating the pu bli c about the advantages o f such

se rv ices and how they can be loc ate d. This cannot be

520 W STR EET, N.W. • BOX 75 • WASHING TON, D. C. 20059 • 636-6340 • 636-6341 • 636-6342
349

le tte r to Sen. Ja vi ta (continued.)

March 29, 1978

page 2

acc om plis hed overn igh t bu t w il l re qu ire carefu l plan ­

ning and in te nsi ve e ffo r t and sp eci a l funding over the

ne xt se ve ra l yea rs to rea ch th os e c it iz e n s who need the

in fo m ation and who need to tak e advantage o f th es e se rv ic es. The s ic k le c e l l programs, in th e ir sh or t his to ry ,

I b eli ev e , have demo nstra ted one way that th is may be

done. Of co ur se, th e methods o f educati on and outre ach

sho uld be ta il o red to f i t the p e c u li a r it ie s o f s p e c if ic

gen et ic diso rd er s and/or po pu latio ns at r is k .

3. I f e e l th at the st a te s sh ou ld beg in to inco rp or ate gen et ic

se rvic es to an ev er -inc re as in g deg ree in th e ir p u bli c he al th

and he al th car e programs. As you know, each st a te has

i t s own p e c u li a r it ie s with re sp ec t to po pu latio n d is tr ib u ­

ti on and th e a v a il a b il it y o f pro fe ss io nal serv ic es. Each

st a te would, th er ef or e, have to s e t up re gi on al p il o t

programs to dete rmine what th e ir need s ar e, what sp eci a l

problems e x is t and how th es e can be et be served . These

co uld be fo llo wed by dem onstration p roje cts to show that

such se rv ic es can be adequa tely d el iv er ed be fo re bein g

laun ched on a sta tew ide b asi s. Th is means th at i t might

tak e the ne xt thre e to fiv e yea rs with fe der al support

as w el l as seme st a te fi n a n cia l sup por t to car ry out

th es e pre lim ina ry programs be fo re we might be ab le to

say that gen et ic se rv ic es co ul d be sa fe ly , r eli a b ly and

b e n e fi cia ll y de liv ey ed to th e en ti re po pu lat ion o f a

giv en st a te .

4. One way o f assurin g th at good p ilo t programs would be

adopted on a broad sc ale ba si s would be to t ie fe der al

fun ding to the development o f such p ilo t programs during

th e f i r s t two to fo ur yea rs in which sta te s might be ab le

to apply fo r funds to esta b li sh programs to provide genet i c se rv ic es where none had pr ev io us ly ex is te d . The

st ru ct ure and orga niz ati on o f th e p ilo t programs would

be reviewed by a committee o f pe er s or ex per ts who would

be ce rt ain th at the p ilo t programs were hig h qu al ity and

were prop erly de sig ne d to re ve al p o te n ti a l problems that

might a ris e in gen et ic scre en in g and to id e n ti fy problems

yet unf ore see n that migh t be de trim en ta l to more comprehensive sta tew ide programs.

5. We w il l not be prep ared to meet th e demands fo r gen et ic

se rvic es un le ss we beg in now to expand the tr ai ni ng o f

he alth pro fe ss io nals alr ead y prov idi ng se rv ic es and to

expand the po ol o f competent p ro fe ss io nals with sp eci a l

tr ai ni ng in del iv er y o f gen eti c se rv ic es and in part ic ula r - gen et ic co un se lin g. This might mean th at we shou ld

support the temporary in cr ea se in the number o f per sons

trai ne d to do geneti c co un se lin g and make long range

pla ns to be sure th at th er e i s an adeq uate sup ply o f
350

le tt e r to Sen. Ja vi ts (con tinued)

March 29, 1978

page S

persons with sp ec ial tra ining in th is fie ld and re la te d

sup portiv e fi e ld s, e. g. ch ild development programs and

d is a b il it y counseling and training programs. I f pu blic

education is pro perly phased with trai ni ng o f ge netic

counselors and other persons sp ec ia lly or iented in

ge netic technology we wi'll be less li kely to sti mulate

pu blic demand beyond the avail abil it y o f se rv ic es . This

means th at some so rt o f broad-based plan is es se ntial to

the development o f the kin d o f ge ne tic se rv ices program

that w il l cl ea rl y have a posi tive impact on American

cit iz ens.

6. Perhaps the most re liable way o f ass uring th at qua lity *

o f se rv ices in screening and te st in g w il l be adequate

would be to have the se se rv ices monitored by eit her st a te ­

wide or preferab ly a nation-w ide qu al ity co ntro l program.

The Center fo r Disease Control serves as such a capac ity

in si ck le c ell te st in g and could expand i ts program o f

qu al ity co ntro l to include oth er ge ne tic dise as es . Each

te st in g ce nt er , or laboratory should be able to demonst ra te th at i ts di re ctor and tec hn ical personnel have

met some minimum stand ard fo r trai ning and experience before th at laboratory would be recogn ized as an o ff ic ia l

ge netic te st in g laboratory. Since the number o f people

involve d in such se rv ices w il l probably no t ge t to be

extr emely lar ge, i t is probably not be st at th is time to

begin a program o f st ate or na tio na l lic en sure. Most

people who have considered th is problem sug gest that

there be ac cr ed ita tio n o f te st in g and cou nseling programs and the re would be routi ne monitoring o f them to

assu re th at only the be st qu al ity o f se rv ices would be

de liv ered .

I am not ce rtai n where the li a b il it y should li e when err ors

are made in ge ne tic te st in g. One cou ld fo llo w the general medical model in which the ph ysician who orders the

te st is fi n a ll y res ponsibl e fo r the damage th at comes from

err ors in the te s t. However, the tech niques used in ge netic

te st in g, such a chromosome an al ys is, sp ec ial bioch emical

methods; inc lud ing radio active labelin g tec hniqu es, and/or

■immunologic assays sugg est to me th at the brunt o f err or

shou ld be placed on the shoulders o f the labo rato ry performing the te st. I t is , o f course, up to the ge netic

cou nselor or ph ysician to ve ri fy th at the te st is corre ct

and that i t is co ns istent with th ei r cli n ic a l impress ion.

Because the im plica tio ns o f ge ne tic te st in g are so broad

and fa r reaching, i.e . they extend in to fu tu re gener atio ns

o f the fa mily , I would sugg est th at perhaps a ll ge netic

te sts shou ld be repeated to ver ify th ei r accuracy before

being accepted as d efi n it iv e. This would inc rea se the

expense o f te st in g somewhat, but I be lie ve th at a person \
351

le tte r to Sen. Ja vit s (co ntinued)

March 29, 1978

page 4

sho uld be co ns idered inn ocen t o f car rying a gen et ic tr a it

u n til proven g u il ty . Th is i s one o f the is su es in gen et ic

te st in g which, I f e e l , de se rv es in te ns e sc ru tiny and stu dy .

The National Corrmission fo r the Pr ot ec tio n o f Human Subje ct s

or any ot he r such d eli b era ti v e body concer ned with the

e th ic a l is su es in vo lved in te sti n g , as w el l as the le gal

is su es, sho uld in vest ig ate th is and ot he r qu es tion s very

in te n sely . I t i s one o f those items which was not st udie d

or at le a st not st udie d in dep th by the group th at promogated gu id el in es fo r development o f programs fo r gen et ic

screen ing and te sti n g .

Thank you very much fo r the op po rtu nit y to respond to th es e qu esti ons. I would welcome the op po rtu nit y to a s s is t in any way I can to

promote the passage o f th is v it a l le g is la ti o n . I f e e l th at i t i s v it a l

th at we devel op th es e se rv ic es and th at the sup port o f such a b i l l with

i t s f u l l ap propria tion would help assure th at American c it iz e n s would

have the b es t program o f gen et ic te sti n g and se rv ic e in th e world. You

are to be corrmended f o r your wisdom in promoting th is program.

Robert F. Murray, Jr .,[ M .D . Il

Pro fe ss or , P ed ia tr ic s 8 Medicine

C h ie f, D iv isio n o f Medica l Gen et ics

RFM/med
352

» ' *-j‘ ~ c* •„

Dear Mrs. Marks:

March 15, 1978

I want to thank you for your excellent testimony before

the Health Suhconmlttee of the Senate Human Resources Committee

on Marc h 1 concerning the National Genetic Diseases Act Ame ndmen t a which I have introduced.

As I mentioned at the hearing, becau se tine was so short

I would like to submit to you some additional questions to he

included in the hearing recordi

1. In your testimony you stress the problem of lack of

knowledge within the medical community. Are the

instances frequent when lack of knowledge interferes with good caret .'

2. Do yo u think that, federal funding for education

programs will be effective in tackling the proble m

of lack of knowledge?

3. We are witnessing teenage pregnancy in epidemic

proportions. Given the problem of providing even

basic aex education and contraception information,

how would you assure provision of genetic counseling

to these teenagers?

A. Eow well Informed do you feel the general public is

in terms of genetic services and their availability?

♦

Again, thank you for your testimony and your continued

interest and cooperation.

Sincerely,

Jacob K. Javits

Mrs. Joan E. Marks

Director

Huma n Genetics Program

Sarah Lewrence College

Bronxville, New York 10708
353

S A R A H L A W R E N C E C O L L E G E

B R O N X V IL L E . N E W Y O R K 1 O 7 O B

TKLKRHONK

•1 4 > > 7 -0 7 0 0

March 2 0 ,1 9 7 8

S e n a to r Ja co b J a v i t s MAR 2 '

S en at e O ff ic e B uil din g 

W as hi ng to n, D.C. 20 51 0

De ar S e n a to r J a v it s :

Thank you f o r th e o p p o rt u n it y to re sp ond to some q u e sti o n s 

wh ich tim e d id n o t allow a t th e H eal th Su bc om mi tte e o f th e S en at e 

Human R es ou rc es Comm itte e h e a ri n g on March 1. My an sw ers are :

1. A b so lu te ly . F a m il ie s who e v e n tu a ll y re a ch g e n e ti c c e n te r s 

ha ve tr a g ic h i s t o r i e s o f sp en din g y e a rs and c o u n tl e s s sums

o f money tr y in g to g e t a d ia g n o sis f o r t h e i r g e n e ti c pr ob le m . 

O ft en th e y ha ve p a re n te d more th an one c h il d w it h th e same 

c o n d it io n w it h o u t any u n d e rs ta n d in g th a t th e c o n d it io n was 

h e r i t a b l e . Ev ery g e n e ti c s u n it in th e c o u n tr y can doc ume nt 

m is d ia g n o se s, ba se d more on la ck o f kn ow led ge th an on 

in co m pe te nc e.

2 . I b e li e v e fe d e ra l fu ndin g w ill g iv e th e im pe tu s to a v i t a l 

e d u c a ti o n a l pr og ra m . Once su ch a pr og ram i s e s ta b li s h e d , and 

i t s p o s it iv e e f f e c ts r e a liz e d , fu nd in g w il l be fo rt hc om in g 

as i t al m os t alwa ys i s when in n o v a ti v e prog rams pr ove t h e i r 

w ort h. Then g e n e ti c s wou ld be in c o rp o ra te d in on -g oin g 

prog rams o f p u b li c an d p ro f e s s io n a l e d u c a ti o n .

3. The q u e st io n o f p ro v id in g g e n e ti c c o u n se li n g to te e n a g e rs 

w it h in pr og ram s o f te en ag e se x ed u ca ti o n i s a c h a ll e n g in g 

one wh ich ha s n o t, to my kn ow le dg e, be en a tt e m p te d . How eve r, 

p i l o t s tu d ie s to id e n tif y th o se te e n a g e rs w it h a fa m il y 

h is to r y o f g e n e ti c d is e a s e could be devel oped . Once i d e n t i f i e d , 

th e s e te e n a g e rs co uld be in fo rm ed as to t h e i r fu tu r e ne ed fo r 

co mpr eh en siv e g e n e ti c c o u n se li n g as w el l as giv en some b a s ic 

in fo rm a ti o n ab ou t in h e rit a n c e a p p ro p ri a te to t h e i r ag e and 

le v e l o f i n t e r e s t .

4 . I s tr o n g ly b e li e v e th e g e n e ra l p u b li c is al m os t t o t a l l y 

un in fo rm ed as to th e r o le g e n e ti c s p la y s in human d is e a s e , 

do es not beg in to u n d e rs ta n d how h e re d it y a f f e c ts t h e i r 

re p ro d u c ti v e li v e s , an d c e r ta in ly i s un aw are o f th e a v a i l a b i l i t y

»
354

-2 -

g e n e ti c s e rv ic e s . D esp ite th re e m il li o n b ir t h s a year in 

th e U ni te d S ta te s and a wel l-do cu m en te d r is k o f b eari n g 

a Down syndrom e c h il d a t age 35 and o ld e r, no s in g le 

in s titu tio n - p u b li c or p riv a te - has e f f e c tiv e ly tr a n s m it te d 

th is me ssa ge to th e p u b li c . Not only is t h is an im po rt an t 

me ssa ge to g e t to th e p u b li c bec au se o f th e a v a i la b il ity 

of p re n a ta l d ia g n o si s to det er m in e th e pre sence o f an 

a ffe c te d c h il d , but th e s t a t i s t i c s show th e age a t pa re nt ho od 

to be in c re a sin g ra th e r th an d ecre asin g !

The g e n e ti c s comm unity is in debte d to you fo r yo ur continu ed 

su pport and d e te rm in ati o n to i n s t i t u t e a fe d e ra l prog ram to bri ng 

g e n e ti c s e rv ic e s to our c itiz e n s .

S in c e re ly y o u rs ,

Jo an H. Marks 

D ir e c to r

Human G enet ic s Program

*

JHM:mlz

I
355

7 J' A*. ” ? ’ > ? . . Mar ch 13, 1978 >, .

* ' .* * . * ' ** •-* * "* "? ' * '

Dear Mrs. Buthria: , *. ' * ,

- I want to thank y ou for your excellent and heartfelt,

testimony before the Healt h Subcommittee of the Senate Human

Resources Committee on Marc h 1 concerning the National Genetic

Diseases Act Amendments whi ch I have introduced. - ' -

" • \ - •* - : ■

As I mentio ned at the hearing, because time was so short ‘

I would like to submit to you some additional questions to be

Included in the hearing record:

1. What discrimination do patients and families with

genetic disease suffer in terms of Job security,

life insurance, and other problems?

2. Are there other services we could ba providing in

addition to those we have Included in the legislation?

3. Should we be doing more in terms of long-term counseling

for the chron ically ill, particularly for those suffering from diseases for wsrhich there is no treatment?

Is there sufficient psychological and psychiatric

counseling?

Again, thank you for ynur testimony and yo ur continued

interest and cooperation.

With best wishes,

•Sincerely,

Jacob K. Javits

Mrs. Marjorie Guthrie

Committee to Combat Hun tin gto n’s Disease

25P W. 57th Street

New York, Hew York
356

A Voluntary Nationa l Hea lth Agency founded in 1967

Committee to Combat Huntingt ons Dise as e Inc.

c c h d d e d ic a t e d to d i t i c t i o n

ANO CARE OF THOSE WHO SUFFER

HUNTING TON’S OISEASE AND TO ITS ERADICATION THROUGH RESEARCH

The Honorable Jacob K J a v it s 

321 RSOB 

Washington, D C

Dear Sen ato r Ja vit s:

250 Ve st 57th Street N oe York. Nae York 100191212) 757-0443

March 20, 1978 

IK li Mbit 6 . i3i

Thank you ag ain fo r the op po rtu nity to respond to the th re e s p e c if ic

qu es tio ns which you asked con cer nin g the need fo r the NATIONAL

GENETIC DISEASES ACT.

For ten ye ar s si nce the for ma tion of the Committee to Combat Huntin gton’ s 

Disea se , we have been c o ll e c tin g dat a from the many fa m il ie s who come to 

us fo r hel p, fo r infor mation and , most impor tan t, fo r ass is ta n ce re la ti n g 

to the problems con cer nin g th e ir jo b s, l i f e in su ra nc e, cop ing with fi n a n cia l needs, dis cr im in at io n wi th in the Ve ter ans Ad min istration, e t c ., 

to name on ly a few . Let me c it e examples:

1) A young man (D. C.) had th re e more ye ar s be fore he was e n ti tl e d to f u l l 

ret ire men t b en efi ts from the Navy. Because he was "a t ris k " fo r H D, an 

e ff o rt was made to r e t ir e him pri or to the ap pr op ria te tim e, and th is 

would have reduc ed h is b en efi ts d r a stic a ll y . We arr anged fo r a neu ro lo gi st 

to examine him. The do ctor repo rte d th a t, at th is tim e, the "p ote n ti al" 

pa tien t was NOT an H D p ati en t. With a gr ea t deal of e ff o r t on our par t, 

and with the help o f our pro fe ss io nal fr ie n d s, we est ablish ed h is ri gh t to 

remain in the Navy, and when h is f u l l to ur of duty is comp leted he w ill 

re ce iv e the b en efi ts due him.

The e ffo r t to fi g h t th is kind o f b a tt le has in crea se d h is fe a rs and, who knows, 

perhap s has brough t the ons et of H D ju st th at much sooner, i f indeed he eve r 

r e a ll y becomes a p ati en t. Th is kind of str e ss is go ing on in many fa m il ie s.

The th re at of lo si ng a jo b, of bein g held back ra th er than promoted, of being cu t o ff from ins ura nce IF the knowledge o f H D su rf a ces, is w ell documented. 

Young peop le who know of the p o s s ib il it y of H D in th e ir fu tu re s, because of 

these an x ie ti es and fe a rs, ha ve, in some ca ses, tak en on the m an ife stations 

of H D. To our su rp ri se, a ft e r a period of tim e, the symptoms disa pp ea r.

The in div id ual is s t i l l "a t r is k ," however, and may become a pat ie nt at 

some fu tu re tim e.

*

Another example: a young man ( A. W.) was diagnosed as hav ing H D by a competent, knowledgeable n euro lo gis t, and TEN ye ar s la te r , wi th the symptoms 

see mingly remaining the same, has now been to ld th at he does NOT have H D. This man, now fo rty ye ar s old , is hoping to pursue h is ed ucation in co ll e g e , 

planning to make up the te n lo st ye ar s.

2) There have been su gg es tion s th at th is le g is la tio n should in clud e some 

pla ns fo r sc re en in g, as a form of e arly d ete cti on , where, through 

am nioc en tecis , some gen eti c dis or der s might be dia gn osed . I f e lt th at 

th is was inheren t in the meaning of the word "d ete cti o n ." Th is 

might be c la r ifie d .
357

2 -

3) Long term co unse llin g, in my op inion, means th at a l l alo ng the way, 

from the time th at a fa m ily le ar ns o f the p art ic u la r in her ited dis ord er , 

ev er y member of the fam ily shou ld have the op po rtu nity to dis cu ss HOW the y 

ar e going to COPE wi th th is inform ation. What is h elp fu l to a paren t or 

to a ch il d d if fe r s from yea r to ye ar , depending on many fa cto rs : whether 

or not a pare nt with the di so rd er li v e s in the home; the number of pat ie nts 

in a home; the age of the ch il d who is a wi tn es s to the onset and d ete ri ora ­

ti on of h is pa re nt , e tc . D if fe ri n g circumsta nces bring d if fe re n t res ponses 

from each member of a fa m ily, the community, the phys ic ia ns, e tc . As the 

fa m ily becomes aware of a disor de r li k e H D th er e is a gr eat need fo r 

someone to tur n to and i t is importa nt to no te th at where the fa m ily does 

have fi n a n c ia l re so ur ce s fo r b ett er ca re , in the home, wi th psy ch ol ogi ca l 

co unse llin g, e t c ., the pat ie nts do NOT DETERIORATE AS RAPIDLY OR AS 

SEVERELY as tho se who don’ t have such su pp ort.

Our ex pe rie nc e po in ts out th at i f and when su pp or tiv e serv ic es ar e av a il ab le 

p ati en ts do not need ye ars of h o sp it a li za ti o n , and ar e capable of ma intaining the ms elv es in th e ir homes fo r long er pe rio ds o f tim e, even though there 

may be ongoing bra in c e l l lo ss and phys ic al d ete ri ora ti on . Pati en ts may 

become me ntall y and p hysic all y handica pped, ne ve rt hel es s the y ar e capable 

of deve lop ing methods fo r cop ing with in th e ir li m it a ti o n s. While th er e is 

no recogn ize d treatm ent fo r H D we bel ie ve th at ju st CARING is a form of 

treatm ent and should be ava il ab le to a l l . Handicapped peo ple can and must 

have the rig h t to make th eir co ntr ib uti on to so cie ty . Being a pa rt of the 

worl d is ano the r v i t a l form of tre atmen t.

There is undoubtedly going to be an ex plos io n of infor ma tio n about in her ited 

dis or der s in the next few ye ars . We must make ev er y e ffo r t to assu re 

pat ie nts and fa m il ie s wi th in her ited dis or der s th at as knowledge becomes 

av a il ab le they w ill have the infor ma tio n fo r te stin g , tre atmen t, w h ate ver. .. 

as soon as p ossib le , on a vo lu nt ar y b a sis . But the peopl e must know WHERE 

to go, and to WHOM the y can speak. The HOPE from ju st loo kin g ahead is 

ano the r v it a l form of trea tm en t.

I do hope th at th es e comments w ill be hel p fu l in co nsi de ra tion of th is a c t. 

Our Hu nti ngton 's Disea se Comnission has documentation from a l l ove r the 

coun try which is av a il ab le to thos e who wish fo r more in-d ep th inform ation.

I look forward to fu rt her di sc uss io n o f th is b i l l wi th you.

LOVE

Marjorie Guthr/e 

Founder/ Pr e/ . Emeritus

MG / ic
358

Senator J avits. Thank you all very much.

Senator Kennedy. Could I add my warm word of welcome to all 

of you. I have had a chance to be aware of the positions that all of 

you were speaking to, and I just want to let you know tha t you have 

all my help and support in terms of legislation as well. Thank you.

Senator J avits. Thank you for the very generous statement you 

made in opening this hearing. I deeply appreciate it. It will encourage me and the supporters of this legislation to carry it on to consummation.

Thank you very much for your indulgence.

Senator Kennedy. We will now have our final witness, Mike 

Gorman, an old friend.

STATEMENT OF MIKE GORMAN, EXECUTIVE DIRECTOR, CITIZENS 

FOR THE TREATMENT OF H IGH BLOOD PRESSURE, INC.

Mr. Gorman. My statement will be brief. If I may submit the full 

statement-----

Senator Kennedy. We will include it in the record.

Mr. Gorman. Just a couple of comments, Senator, directed to the 

difference between this bill, the House bill, and the administration 

bill. I think that the key issue involved here is block grants—well, 

one thing I will say, since we went to Secretary Richardson in 1972,

Dr. DeBakey, Mrs. Lasker and your humble servant, the death rates 

in the United States have been reduced over the past 3 years, over 

the past 5 years. We have had 300,000 less deaths. A major reason 

for this is the hypertension program. This is the National Center for 

Health Statistics data I refer to in the text.

Now we have a very small formula gran t, and it is at $11 million.

It goes to 50 States. All 50 States participate in this.

I sent a questionnaire to them. This is attached to my statement. 

Thirty-six of the States agreed th at they wanted separate categorical 

hypertension grants continued, even if block grants were developed 

eventually, whether title III of the Rogers bill was passed, which 

requires further incentives and so forth, tha t they still wanted the 

hypertension gran t preserved as a separate entity.

Now, the position of our committee, very simply, Mr. Chairman, 

summarizing a lot of discussions we have had, is tha t we are very 

glad that you are renewing it for 1 year at least, and I quote you,

“so that we may consider this entire problem in relation to a comprehensive review of public health and disease control programs.”

In other words, that later in the year you are promising us a review of all prevention and detention programs with the hope hyp ertension will come out with a lot more than the $11 million we have >

now; we feel like paupers at the present time.

One final comment. I think this is germane to the legislation before 

you, and incidentally I might say this parenthetically about the 

administration position. The administration also agrees with us; they 

have not yet set up their block grant proposal, as you probably know.

They have agreed tha t hypertension should be excluded from it. It 

should be a separate grant program.
359

Dr. Richmond testified before this committee on February 9, and 

before Mr. Rogers last week, to tha t effect.

We are happy we can agree with the administration and we can 

even agree with the Office of Management and Budget, which is a 

very difficult thing to do some of the time.

One final comment about the Rogers bill, which has a lot of good 

features in it and will be the subject of conferences between your 

two bodies. It is H.R. 10553.

Now, in tha t bill we are lumped in with rat control, lead base 

paint poisoning, and so on. We do not think t hat is very good billing. 

We do not think tha t is good billing at all for a program basic to 

the health of so many people and which has demonstrated the first 

successful preventive program against a chronic disease. It really 

works. There has been no program before.

As I say, we do not know how it is going to come out. We have 

testified before Mr. Rogers. We did last week. We said then tha t of 

course he could include all he wants in the block grant, b ut the hy pertension formula program is an entirely separate program, and it is 

now in its fourth year historically. It has the suppo rt of the State 

health officers. It should be at a level of $30 million or $35 million a 

year. We can prevent deaths; we can prevent morbidity. It is not 

a small problem. I do not denigrate the wiping out of rats. I do 

not denigrate taking lead off walls of buildings. But I think our 

program deserves to get major billing. We have to come out of the 

minor leagues somehow, and that, in essence, is the thrust of my 

plea, sir.

Senator Kennedy. Thank you very much. We might have some 

other kinds of questions. Let me just ask you in a broader context, 

we are concerned about the general kind of issue of preventive 

health, and I think tha t point has been emphasized by a variety of 

different members of this committee and the importance of it, under 

what conditions would you see th e stress on hypertension a part of a 

preventive health care program ?

Wh at would be the criteria which would have to be met before you 

could support it ?

Mr. Gorman. You are asking the fundamental question, what is 

going to be in the bill? Wha t is going to be in this prevention and 

detention effort that will be the components of a major bill?

I would say tha t two of the lead items in the bill would be anti ­

smoking and hypertension. I would think they would be two obvious 

emphases. If you can prevent people from smoking, you can stop 

80 percent of lung cancers, which is now the second leading cause of 

cancer resulting in 94,000 needless deaths a year. Not academic.

And in the field of hypertension, where, if we could get at 10 million people who have uncontrolled hypertension, 10 million people 

who do not know they have it, it has not been detected, we could 

save many lives.

Now, what else is included, I sometimes worry about that . I noticed a reference this morning in the Blue Sheet and it did refer, 

whether correctly or not, Senator, I guess this can be on the record, 

I do not see why not, it said the new Kennedy prevention bill still 

being draf ted will cover comprehensive public health services, hyper -

28-386 0 - 78 - 24
360

tension , disease control, venereal disease, genetic diseases, and leadbased p aint program s.

I think if y ou get too big, you get ineffective. I am in no position 

to lecture this comm ittee. Bu t I came to this city to work fo r Mr.

Tr um an , and I have had some experience. I th in k when you get a 

bro ad spectru m bill in which you include every thi ng, th at it is not 

going to do the job. Y ou have to pick two or thre e program s and show 

th at prevention can work, th at you can rea lly prevent disease.

If 1 c an mak e one final statem ent. I am a su pp orter ind ividually, 

as is Dr . DeB akey, of th e Hea lth Security Act. We know th at the 

majo r inh ibition to its passage is th at each ye ar th at we do not pass 

it, th e costs keep going up 15 percen t a y ear, alm ost inev itab ly. Unless 

you can keep peaple out of hospitals and , in ma ny cases, ou t of doc- *

to rs ’ offices, wh at we are trea ting is the end res ult of neglect. We 

hav e g ot to educ ate our people to tak e care of themselves. Th e person 

who smokes, boozes it up with a qu art and a ha lf a day, and also is 

25 pou nds overweight, all these thi ngs, and then he goes to a doctor 

and says fix me up, mak e me like new. I w’ant to look like Rober t 

Re dford . The doctor trea ts him , bu t does no t mak e him look like 

Ro bert Redfo rd.

Tha t is medical care in the Un ite d State s today .

[T he prepare d statem ent of Mr. Gor man and ad ditio na l ma terial 

sup plied for the record f ollows :]
361

TEST IM O N Y ON H E A L T H SE R V IC E S EX T EN SIO N A C T O F 19 78 (S .2 4 7 4 )

B E F O R E SE N A T E SU B C O M M IT T E E ON H E A L T H & S C IE N T IF IC R E SE A R C H

by

M IK E GORM AN, E x e c u ti v e D ir e c to r , C it iz e n s fo r th e 

T r e a tm e n t of H ig h B lo od P r e s s u r e (D R. M IC H A E L E. D eB A K EY , C h a ir m a n )

9:3 0 A .M . W ed n e sd ay , M a rc h 1, 19 78

R o o m 42 32 D ir k s e n S e n a te O ff ic e B u il d in g

M r. C h a ir m a n a n d M e m b e rs of th e C o m m it te e :

W e a p p r e c ia te th is o p p o rtu n it y to s u b m it o u r v ie w s on S. 24 74 .

We a r e n a tu r a lly d is a p p o in te d a t th e s u m of m o n ey a u th o riz e d in th e le g i s ­

la ti o n fo r o n ly one y e a r - - $1 5 m il li o n . H o w e v e r, w e do a p p r e c ia te th e f a c t th a t 

th is a u th o riz a ti o n fig u re a t le a s t o ffe rs us th e p o s s ib ility of s o m e in c r e a s e o v e r 

th e a tr o c io u s ly in a d e q u a te s u m of $11 m il li o n re c o m m e n d e d by th e A d m in is tr a ti o n 

fo r h y p e rte n s io n fo rm u la g ra n ts in b o th F i s c a l 19 79 a n d F is c a l 1980. T h is a p p r o p ­

r ia tio n re c o m m e n d a ti o n is th e s a m e a s th e s u m v o te d by th e C o n g re s s in F is c a l 

1978. T he C a r te r A d m in is tr a ti o n d o e s n o t s e e m to re c o g n iz e th e p ro b le m of in ­

fla ti o n in th e h e a lth s e c to r , a lt h o u g h i t is v e r y a w a r e of i t in its re c o m m e n d a ti o n s 

fo r th e D e p a rtm e n t of D e fe n se . A n a p p r o p r ia tio n of $11 m il li o n f o r F is c a l 19 79 

w ould a c tu a lly r e s u lt in a c u t of a p p ro x im a te ly te n p e r c e n t in p r o g r a m a c tiv itie s 

b e c a u s e of th e im p a c t of in fla ti o n , a n d L o rd know s how in fla ti o n w ould f u r th e r 

im p a c t th e s a m e penny a n te a p p r o p r ia tio n of $11 m il li o n fo r F i s c a l 1980. We 

w ould li k e to re m in d th e S u b c o m m it te e th a t th e $1 5 m il li o n a u th o r iz e d fo r F is c a l 

19 79 is th e s a m e a m o u n t w h ic h w as a u th o riz e d in F is c a l 1976 .

W hile w e a r e n o t e x a c tl y h a p p y w it h th e A d m in is tr a ti o n f ig u r e s fo r th e
362

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h y p e rte n s io n fo rm u la g r a n t p r o g r a m , w e a r e in r a t h e r fu ll a g r e e m e n t w it h th e 

p ro p o s a l of D o c to r J u li u s R ic h m o n d , A s s is ta n t S e c r e ta r y fo r H e a lt h , b e fo re th e 

S e n a te S u b c o m m it te e on H e a lt h a n d S c ie n ti fi c R e s e a r c h on F e b r u a r y 9. N oting 

th a t a ll 50 S ta te s now h a v e o p e ra ti v e p r o g r a m s in th e fie ld o f h y p e rte n s io n , D o c to r

R ic h m o n d to ld th e C o m m it te e :

"W e w il l p ro p o s e th e e x te n sio n of th is p r o g r a m f o r th r e e y e a r s to

*

s tre n g th e n th e e ffo r ts o f the S ta te s in fo ll o w -u p fo r tr e a tm e n t. "

We r e g a r d th is s ta te m e n t a s p a r tic u la r ly s ig n ific a n t b e c a u s e , a lt h o u g h th e

h y p e rte n s io n p ro g ra p a h a s d one a n o u ts ta n d in g jo b in th e d e te c ti o n a n d r e f e r r a l fo r 

tr e a tm e n t of m il li o n s of h y p e rte n s iv e s w h o se d is e a s e w a s p re v io u s ly unkno w n to 

th e m , a s h ig h a s 40 a n d 50 p e r c e n t of th e s e d ia g n o s e d h y p e r te n s iv e s d ro p o u t of 

tr e a tm e n t a f te r a fe w m o n th s . T h e re is a n e n o rm o u s n e e d fo r e d u c a ti o n o f th e h e a lth 

p ro f e s s io n s a n d th e la y p u b li c a lo n g th e v e r y s im p le lin e s th a t fo r m o s t h y p e rte n s iv e s 

m e d ic a ti o n m u s t b e ta k e n fo r th e r e s t of th e ir liv e s if th e y a r e to p r e v e n t b e in g a t 

h ig h r i s k fo r h e a r t a tta c k s , s tr o k e s a n d k id n e y d i s e a s e s . J u s t a s a d ia b e ti c ta k e s 

in s u li n o v e r a lif e tim e s p a n , th e h y p e rte n s iv e m u s t ta k e m e d ic a ti o n . H o w e v e r, it 

is n o t e a s y to ch an g e p u b li c a ttitu d e s ; th e d if fic u lt y in g e tt in g m il li o n s of A m e ric a n s 

to giv e up sm o k in g d e s p ite a 1 4 - y e a r e d u c a ti o n a l c a m p a ig n is a c a s e in p o in t.

A t th a t s a m e h e a r in g on F e b r u a r y 9, D o c to r R ic h m o n d te s tif ie d th a t th e 

A d m in is tra tio n w ould so o n b e s u b m it ti n g le g is la tio n p ro p o s in g a c o n s o li d a ti o n of 

e x is tin g d is e a s e p re v e n ti o n a n d c o n tr o l p r o g r a m s in to a s in g le a n n u a l g r a n t to th e 

S ta te s . T h is g ra n t w il l in c lu d e e x is ti n g a u th o r itie s f o r d is e a s e c o n tr o l, le a d - b a s e d 

p a in t p o is o n in g , v e n e r e a l d is e a s e , r a t c o n tr o l a n d th e 314(d ) p r o g r a m s , b u t it w il l

n o t in c lu d e h y p e rte n s io n .
363

- 3 -

M r. C h a ir m a n , I su b m it th a t th is p o s it io n on th e h y p e rte n s io n fo rm u la g ra n t

is n o t a n a c c id e n t. T he A d m in is tr a ti o n h a s e x a m in e d th e n e e d s a n d th e e ffe c tiv e ­

n e s s o f th e h y p e rte n s io n c o n tr o l p r o g r a m v e r y c a r e f u ll y , a n d i t h a s c o m e to th e 

c o n c lu sio n th a t i t is to o la r g e a p r o g r a m to s q u e e z e in to a r e la tiv e ly lim it e d 

b lo c k g ra n t. In a d o p ti n g th is p o s it io n , th e A d m in is tr a ti o n h ad to c o n v in c e th e 

O ff ic e of M a n a g e m e n t an d B u d g et, w h ic h w a s o rig in a ll y o p p o sed to th e e x c lu sio n 

> of h y p e rte n s io n fr o m th e b lo c k g ra n t.

I s u b m it , M r. C h a ir m a n , th a t i t is an a c h ie v e m e n t of e x tr a o r d in a r y 

m a g n it u d e to in d u c e th e O ff ic e of M a n a g e m e n t a n d B u d g et to c h an g e its m in d on

a n y th in g .

M r . C h a irm a n , w e do a p p r e c ia te y o u r s ta te m e n t in th e C o n g re s s io n a l 

R e c o rd of F e b r u a r y 1, th a t you a r e p ro p o s in g j u s t a o n e - y e a r e x te n s io n "so th a t 

w e m a y c o n s id e r th is e n tir e p ro b le m in r e la tio n to a c o m p re h e n s iv e re v ie w of 

p u b li c h e a lth a n d d is e a s e c o n tr o l p r o g r a m s . . . a n d th a t a f te r o u r h e a r in g s a n d 

f u r th e r a n a ly s is , we w il l h a v e a c l e a r e r p ic tu r e of th e s e re la tio n s h ip s a n d w il l

b e a b le to e x te n d th is le g is la ti o n fo r th r e e m o re y e a r s , o r a m e n d it c o n s is te n t

w it h o th e r p r o g r a m s . "

We a r e a ls o d e li g h te d w it h y o u r s ta te m e n t th a t " D is e a s e p re v e n ti o n is

one of m y p a ra m o u n t c o n c e rn s in th e h e a lth fie ld , a n d l a t e r in th e y e a r I in te n d

to in tr o d u c e c o m p re h e n s iv e p ro p o s a ls a im e d a t ex p an d in g th e F e d e r a l G o v e rn ­

m e n t's c o m m it m e n t to p re v e n ti n g i lln e s s . In o r d e r to h a v e th e fle x ib ility to 

in te g r a te f e d e r a l a u th o r itie s in th e im p o r ta n t a r e a of p re v e n ti o n , w e a r e r e ­

s e r v in g th e op ti o n of re v ie w in g th e s e e x p ir in g a u th o r itie s l a t e r th is y e a r in th e 

c o n te x t of a b ro a d p re v e n ti o n e ffo r t. W e a r e n o t a t th is ti m e p re ju d g in g w h ic h 

o f th e s e p r o g r a m s w ould , in fa c t, b e in te g r a te d o r w h ic h r e m a in s e p a r a te . "
364

- 4 -

C it iz e n s fo r th e T r e a tm e n t of H ig h B lo od P r e s s u r e w e lc o m e s w it h th e 

g r e a te s t e n th u s ia s m th e o p p o rt u n it y to te s tif y l a t e r in th e y e a r on a c o m p r e ­

h e n siv e b ill in th e im p o r ta n t a r e a of p re v e n ti o n of d is e a s e th ro u g h a n a ti o n a l

p re v e n ti o n e ffo rt. A s w e h a v e n o te d b e fo re , w e th in k w e h a v e th e b e s t c a s e to

o ffe r fo r in v e sti n g a r e la tiv e ly fe w d o lla r s in p re v e n ti o n a n d , by so do in g , p re v e n t 

b il li o n s o f d o lla r s in c o s ts re s u ltin g fr o m h e a r t d is e a s e , s tr o k e , k id n e y f a ilu r e

a n d d ia b e te s . .<

T he only tr u e c o s t r e s t r a i n t to th e in e v it a b le s p ir a lin g of m e d ic a l c a r e

c o s ts in th is c o u n tr y is a p r o g r a m of p re v e n ti o n . A s D o c to r Jo hn K n o w le s, P r e s i ­

d e n t of th e R o c k e fe ll e r F o u n d a ti o n , s ta te d in a D e c e m b e r, 19 77 is s u e of S c ie n c e :

"T h e in d iv id u a l m u s t r e a liz e th a t p e rp e tu a ti n g th e p r e s e n t s y s te m of 

h ig h -c o s t, a f t e r - t h e - f a c t m e d ic in e w il l only r e s u l t in h ig h e r c o s ts a n d g r e a te r

f r u s t r a t i o n . 11

T h is is th e a im of th e C it iz e n s fo r th e T r e a tm e n t of H ig h B lo od P r e s s u r e .

We w ant to a l e r t m il li o n s of o u r c iti z e n s to th e f a c t th a t th e y h a v e h ig h b lo od 

p r e s s u r e a n d sh ow th e m th a t i t c an be e a s il y a n d r e a s o n a b ly c o n tr o ll e d . If we

f a il, w e h a d b e tte r b e p r e p a r e d to b u il d a n o th e r 10 0, 00 0 h o s p it a l b e d s in th is

c o u n tr y .

M r. C h a irm a n , w e h a v e h ad a c h a n c e to e x a m in e H .R . 10553, th e H e alt h

S e rv ic e s A m e n d m e n ts A c t o f 1978. B eyond s o m e s u r p r i s e th a t th is b il l a u th o riz e s 

only $12, 7 0 0 ,0 0 0 fo r h y p e rte n s io n fo rm u la g ra n ts in F i s c a l 19 79 - - w hen th e s a m e 

c o m m it te e a u th o riz e d $15 m il li o n fo r h y p e rte n s io n fo r m u la g ra n ts in b o th F is c a l 

19 76 an d F i s c a l 19 77 - - w e fin d T it le II o f th e b ill s in g u la rly p r e m a tu r e . In a s e c ­

ti o n e n ti tl e d " P r e v e n tiv e H e a lt h S e r v ic e s , " i t o p ts fo r a b lo c k g ra n t a p p ro a c h to a •

w h o le s e r i e s of su p p o se d ly p re v e n ti v e p r o g r a m s fo r th e y e a r s F is c a l 19 80 th ro u g h

I
365

- 5 -

F i s c a l 1 9 82. In d e fi n in g w h a t i t m e a n s b y " p re v e n ti o n , " H .K . 10 55 3 m e r e ly 

r e p e a ts a la u n d ry l i s t o f e x is tin g p r o g r a m s in th e d is e a s e c o n tro l a r e a . It 

s e e m s to us th a t i t d o e s th is w it h o u t a n y r e a l s e n s e of th e p r i o r i t i e s in p r e v e n ti v e 

p r o g r a m s a n d w it h o u t a n y d o c u m e n ta ti o n r e s u ltin g f r o m h e a r in g s on th e v a lu e of 

e a c h p r o g r a m lis te d .

We a r e n o t c o m fo rta b le in b e in g s q u e e z e d in to th is la u n d ry l i s t on a c o ­

e q u a l b a s is w it h r a t c o n tr o l, le a d - b a s e d p a in t p o is o n in g , a n d s o o n . W e d o n 't 

d e n y th e im p o r ta n c e of th e s e p r o g r a m s , b u t w e f e e l th a t th e y h a v e a r a t h e r lo w 

p r i o r i t y c o m p a re d to a h y p e rte n s io n p r o g r a m w h ic h h a s b e e n r e s p o n s ib le fo r th e 

m o s t s u s ta in e d r e d u c tio n - in - d e a th r a t e s in A m e r ic a n h is to r y . W h il e w e c a n n o t 

s p e a k f o r th e S ta te h e a lth o ff ic e rs in th is a r e a , w e c an c e r ta in ly p o in t’to o u r r e c e n t 

s u r v e y in d ic a ti n g th a t th e y p la c e a n u m b e r one v a lu e upon a n in d e p e n d e n t, h ig h ly 

v is ib le h y p e rte n s io n fo r m u la g r a n t p r o g r a m . A ll 50 S ta te s now h a v e o n -g o in g 

h y p e rte n s io n p r o g r a m s ; m a n y of th e m a r e in v o lv e d in m a s s iv e h y p e rte n s io n 

s c r e e n in g a n d fo ll o w -u p p r o g r a m s in c lo s e c o o p e r a tio n w it h 13 0 n a ti o n a l an d 

S ta te m e d ic a l, v o lu n ta ry a n d f r a t e r n a l o r g a n iz a tio n s . In o th e r w o r d s , th is p r o ­

g r a m h a s c r e a t e d a p o w e rf u l id e n ti ty of its ow n a n d h a s g e n e r a te d e n o rm o u s p u b ­

lic s u p p o rt.

T he N a ti o n a l H y p e rte n sio n P r o g r a m is c o n s id e re d to d a y by m e d ic a l 

a u th o r itie s a n d by th e N a ti o n a l C e n te r fo r H e a lt h S ta tis tic s a s th e m o s t s u c c e s s ­

fu l p re v e n ti v e e ffo r t in th e h is to r y o f A m e ric a n m e d ic in e . A t a p r e s s c o n fe re n c e 

in S e p te m b e r, 1977, D o c to r M ic h a e l E . D e B a k e y , P r e s id e n t of B a y lo r C o ll e g e of . 

M e d ic in e a n d one of th e w o r ld 's m o s t d is ti n g u is h e d c a r d io lo g is ts , p o in te d o ut th a t
366

K - 6 -

h ig h b lo o d p r e s s u r e is a m a jo r fa c to r in 68 p e r c e n t of a ll f i r s t h e a r t a tta c k s , 75 

p e r c e n t of a l l f i r s t s tr o k e s , a n d 30 to 40 p e r c e n t of a l l c a s e s of to ta l k id n e y f a ilu r e .

T he n a ti o n a l h y p e rte n s io n e ffo r t is c u tt in g d e e p ly in to th e s e d e p r e s s in g 

f ig u r e s . A t th a t s a m e p r e s s c o n fe re n c e . D o c to r D e B a k e y p o in te d o u t th a t in 1976, 

f o r th e s e c o n d y e a r in a ro w , th e n a ti o n a c h ie v e d its lo w e s t o v e r - a ll d e a th r a te

f r o m a l l c a u s e s . H e s ta te d th a t h is c o n v ic ti o n w a s b a s e d upon fig u r e s r e le a s e d

b y th e N a ti o n a l C e n te r fo r H e a lt h S ta tis tic s , th a t th e d e c lin e s in h e a r t a tta c k s an d

s tr o k e s w e re p r im a r ily th e r e s u l t of p u b li c e d u c a ti o n c a m p a ig n s a le r tin g b o th

la y m e n a n d p h y s ic ia n s to th e d a n g e r of h ig h b lo o d p r e s s u r e .

" T h e sa v in g of th e s e li v e s is o n e o f th e g r e a t fe a ts in th e h is to r y o f p r e ­

v e n ti v e m e d ic in e in th is c o u n tr y in th e l a s t 30 y e a r s , " D o c to r D e B a k e y s ta te d .

He m e n ti o n e d th a t th is u n p re c e d e n te d s a v in g o f li v e s th a t w ould h a v e b e e n lo s t to 

h e a r t d is e a s e a n d s tr o k e s w as a f e a t u n im a g in e d 6 in c e th e in tr o d u c ti o n o f p e n ic il li n

in th e 1 9 4 0 's .

S in c e th e in c e p ti o n o f th e h ig h b lo o d p r e s s u r e p re v e n ti o n a n d c o n tr o l e ffo r t 

in 1972, 290, 00 0 p e r s o n s a r e a liv e to d a y b e c a u s e th e y le a r n e d to c o n tr o l th e ir h ig h 

b lo o d p r e s s u r e , a c c o rd in g to b o th D o c to r D e B a k e y a n d th e N a ti o n a l C e n te r fo r

H e a lt h S ta tis tic s .

On J u ly 21, 1977, D o c to r R o b e r t L e v y , D ir e c to r o f th e N a ti o n a l H e a r t, 

L ung a n d B lo o d In s titu te , te s tif ie d b e fo re a H o u se S e le c t S u b c o m m it te e on A gin g 

e x a m in in g th e p ro b le m of w hy 40 p e r c e n t of A m e ric a n s o v e r th e a g e o f 65 s u ffe r 

f r o m h ig h b lo o d p r e s s u r e , w it h only a s m a ll p e r c e n ta g e of th e s e re c e iv in g t r e a t ­

m e n t. M ovin g on to th e l a r g e r p ic tu r e of th e e x te n t of h ig h b lo o d p r e s s u r e in th e 

U n it ed S ta te s - - 24 m il li o n h a v e a lr e a d y b e e n d ia g n o s e d a s h y p e rte n s iv e a n d th is

r
367

- 7 -

is a c o n s e rv a tiv e f ig u r e - - D o c to r L e v y re v e a le d s o m e s o b e r in g fa c ts on th e i m ­

p a c t of h ig h b lo o d p r e s s u r e upon th e n a tio n 's h e a lth a n d upon its e c o n o m y . D e ­

s c r ib in g th e s e e f f o r ts . D o c to r L e v y to ld th e S u b c o m m it te e :

" T h e P r o g r a m h a s b e e n h ig h ly s u c c e s s f u l. W e h a v e s e e n a m a jo r c h a n g e

in th e d e te c ti o n , e v a lu a ti o n a n d tr e a tm e n t o f p a ti e n ts w it h h ig h b lo o d p r e s s u r e . 

O v e r 6 m il li o n p re v io u s ly u n d ia g n o se d p a tie n ts h a v e b e e n d e te c te d . T he n u m b e r 

o f p a ti e n t v is its to p h y s ic ia n s fo r h ig h b lo o d p r e s s u r e h a s in c r e a s e d o v e r 50% 

d u rin g th e p a s t fi v e y e a r s . T he n u m b e r o f h y p e r te n s iv e s w h o se b lo o d p r e s s u r e 

is now n o r m a l on tr e a tm e n t h a s in c r e a s e d b y a lm o s t 100% to a lm o s t 8 m il li o n 

a n d b o th th e g e n e r a l p u b li c a n d th e h e a lth c a r e p r o f e s s io n a ls a r e m u c h m o r e 

a w a r e o f th e p e r ils of h ig h b lo o d p r e s s u r e a n d th e p r o m is e s o f f e r e d b y tr e a tm e n t. 

O f g r e a t e s t im p o r ta n c e , th is n ew a w a r e n e s s of a n d b e h a v io r to w a rd h ig h b lo o d 

p r e s s u r e a p p e a r s to b e p a y in g b ig d iv id e n d s . S in c e 1972, h e a r t a tta c k s in th is 

c o u n tr y a r e dow n o v e r 10% a n d d e a th s f r o m s tr o k e h a v e d e c lin e d by a b o u t 20% 

in th e s a m e ti m e p e rio d . T h e s e u n p re c e d e n te d g a in s h a v e r e s u lte d in th e r e d u c ­

ti o n in th e n u m b e r of c a r d io v a s c u la r d e a th s in th is c o u n tr y to b e lo w one m il li o n in

b o th 197 5 a n d 19 76 a f te r o v e r a d e c a d e of m o re th a n a m il li o n d e a th s e ac h y e a r . It

sh o u ld a ls o b e n o te d th a t th is d e c lin e h a s o c c u r r e d d e s p ite a n in c r e a s in g a n d 

a g in g p o p u la ti o n . W ith th e s e g a in s th e a v e r a g e li fe e x p e c ta n c y of A m e ric a n s

h a s in c r e a s e d by tw o y e a r s in th e p a s t fi v e y e a r s a n d w e now h a v e th e lo w e st

d e a th r a t e in o u r n a tio n 's h is to ry .

"H o w e v e r, d e s p it e th e s e m o s t f a v o ra b le h e a lth s t a t i s t i c s , i t is ob v io u s

th a t w e s t ill h a v e a lo ng w ay to go. O f th e a p p ro x im a te ly 23 m il li o n A m e ric a n s
368

- 8 -

w ith h y p ert en si o n , a lm o st 10 m il li on a r e aw are of th e ir hi gh bl oo d p re s s u re bu t 

a re e it h e r not on tr e a tm e n t o r th ey a r e on in ad eq uat e th e ra p y an d th e re a re sti ll 

so m e se ven m il lion who a re unaw ar e of t h e ir co nd itio n. "

W ha t does th e C o n g re ss th in k of th e hi gh bl oo d p r e s s u re p ro g ra m ? Th e 

fo llo w in g ex c e rp t fro m th e Sen at e A p p ro p ri ati o n s C om m it te e R e p o rt on L ab or- H E W

fo r F is c a l 1978 ca n s e rv e a s an il lu s tr a ti o n :

*

"C o n si d era b le p ro g re s s has bee n m ad e in th e u n d ers ta n d in g of h e a rt 

d is e a s e over th e p a s t two d ecad e s, an d th is re s e a rc h is no w pa yi ng of f in s e v e ra l

w ays. F ro m 197 0 to 1976 d eath s du e to co ro n ary a r te r y d is e a s e hav e decli n ed by 

m o re th an 15 p e rc e n t, m o re th an tw ic e th e d ecli ne fro m n o n -c a rd io v a sc u la r d is e a se .

In th is sa m e p eri o d , death s du e to str o k e decli ned 22 p e rc e n t an d th o se du e to h y p e rte nsio n by 39 p e rc e n t. In 197 5 th e num b er of death s fro m m a jo r c a rd io v a sc u la r 

d is e a s e s dro pped bel ow on e m il li o n fo r th e f ir s t ti m e sin c e 196 7 d e sp it e an e v e rin c re a sin g an d ag in g popula ti on. A m o st gra ti fy in g tr e n d is th at th e re d u cti o n in 

th e d eath r a te in th e p a st s e v e ra l y e a rs ha 6 st eep en ed . Y et ex p en d it u re s on r e ­

s e a rc h aim e d a t re ducin g m o rta li ty and th e c o s t of th e se d is e a s e s is le s s th an 

on e p e rc e n t of th e ir c u rre n t an n u al co st.

"T he sh a rp n e ss of th e d ecli n e coin cid es w ith th e d ev elo pm ent of the 

n ati o n al hig h bl oo d p r e s s u re ed uca tion p ro g ra m . Sin ce 1972 th is fe d e ra ll y - 

co o rd in ate d eff o rt - in it ia te d by th is C om m it te e - in vo lv in g o v er 20 0 co opera ti ng 

publ ic an d p riv a te o rg a n iz a ti o n s, has aim ed a t im pro vin g p h y si cia n an d pu bl ic 

a w a re n e s s of th e in c re a s e d r is k of h e a rt a tt a c k , s tr o k e , kid ney fa il u re , h e a rt 

fa il u re , an d o th er kil li ng an d ex pensi ve d is e a se s a s so c ia te d w ith hig h bl oo d 

p r e s s u re . In 1971 le s s th an 4 m il li o n of th e 27 , 0 00 , 0 00 A m e ric a n s w ith hi gh

>
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bl oo d p r e s s u re w ere under ad equate c o n tr o l. T his fi g u re has no w m o re th an

do ub le d; th e re h as bee n an in c re a s e of m o re th an 50 p e rc e n t in th e num b er of 

p ati en t v is its to ph y si cia n s fo r h y p ert en sio n an d h y p ert en siv e h e a rt d is e a s e . A

c u rre n t o bje cti ve is lo ng te r m m ain te n an ce th era p y . A port io n of th e in c re a s e d

fu nd s pro v id ed in th is b il l sh ou ld be u se d fo r th is im p o rt a n t an d eff ecti v e p ro g ra m . "

How do th e S ta te s fe e l ab out th e h y p ert en si o n fo rm u la g ra n t p ro g ra m ? 

t On N ovem ber 30 , 19 77 , C it iz ens fo r th e T re a tm e n t of High Blo od P re s s u re , in

co o p era ti o n w ith th e A sso cia ti o n of S ta te an d T e rr ito ria l H ea lth O ff ic ia ls , se n t a 

d e ta il e d q u esti o n n a ir e to a ll 50 S ta te s so li cit in g th e ir fr an k op in io ns on th e h y p e rte nsio n fo rm u la g ra n t an d it s e ffe c ti v e n e ss. S um m ari zin g th e re s u lts of th e Sta te 

h ealt h o ff ic ers a s b rie fl y as p o ssib le , 36 of th e 42 S ta te s w hi ch re tu rn e d th e 

q u e sti o n n a ir e sta te d em p h ati call y th a t th e F is c a l 1978 fu nd in g le v e l of $11 m il li on 

fo r th e se g ra n ts fe ll fa r sh o rt of ev en th e m in im um n eeds fo r an eff ecti ve sc re e n in g ,

d ete cti o n an d fo llow -u p p ro g ra m .

Of th e 36 S ta te s re sp ondin g in th e p o sit iv e, th e v a s t m a jo rit y of th em 

e x p re ss e d a w il li n g n ess to advoca te a t le a s t $30 to $35 m il li o n a y e a r o v er th e next 

th re e y e a rs fo r th ese h y p ert en si o n fo rm u la g ra n ts - - an ap p ro x im ate tr ip li n g of 

th e p re s e n t le v e l of fu nd in g.

We hav e ap pen ded to th is sta te m e n t a su m m ary of th e re p li e s fro m th e 

Sta te h ealt h o ffi c e rs an d a se le c ti o n of e x c e rp ts fro m th e ir re p li e s w hi ch in d ic ate 

th e p ro b le m s th ey a r e fa ci ng du e to in ad eq u ate fu nd in g.

In H ou se te sti m o n y in 19 77 , D oct or Jo sep h W il ber , D ir e c to r of A dul t

H ea lt h S e rv ic e s of th e Sta te of G eo rg ia an d P re s id e n t of t he G eorg ia H e a rt A 66 oc ia

I
370

. io -

ti o n , ga ve his v e rd ic t on th e h y p ert en sio n fo rm u la g ra n t p ro g ra m on beh alf of his

fe ll ow Sta te h ealt h o ffi c ia ls . H ere is w ha t D oct or W il ber to ld a Hou se co m m it te e:

"I t w as th e im p etu s of th e p assag e by th e C o n g re ss of th e 197 5 H ea lth

S erv ic es A ct w hi ch ga ve th e n e c e s s a ry push to th e S ta te s. T od ay , a ll 50 Sta te s

i

have be gu n hig h bl oo d p r e s s u re p ro g ra m s , an d fo r th e f i r s t ti m e we a r e se ei ng 

an in c re a sin g nati onal re co g n it io n th at th is is a co m m on publi c h ealt h p ro b le m 

w h ere re s u lts ca n be se en in te rm s of re d u ced d is a b il it y , d eath s and h ealt h co sts

im m ed ia te ly if t he m a jo rit y of th e pe op le w ith hi gh bl oo d p r e s s u re ca n be d ete cte d ,

ed ucate d an d tr e a te d . It wou ld be a tr em en d o u s ste p b ack w ard no t to in c re a s e

th e fu nd s av ail ab le to th e S ta te s a t th is ti m e whe n th e ir p ro g ra m s a r e ju s t get ti ng

under way .

"W e h e a r a lo t th ese day s ab out ke ep in g h ealt h co sts do wn , an d p ro p e rl y

so , " D oct or W ilber co ntinued . "T he g re a te s t c o st c o n s tr a in t yo u ca n in it ia te is 

pre ven ti o n of d is e a s e . The hig h b lo od p r e s s u re p ro g ra m I a m ta lk in g ab out on 

beh alf of m y fe llow Sta te h e a lt h off ic ia ls is th e f i r s t p re v en ti v e p ro g ra m b ei ng 

la unched a g a in st a m a jo r ch ro n ic d is e a s e . It kee ps peo ple out of h o sp it a ls , 

b e c a u s e 99 p e rc e n t of its v ic ti m s ca n be tr e a te d on an a m b u la to ry b a s is . F o r 

ex am p le , chro n ic kid ney fa il u re re q u ir in g ki dney d ia ly sis c o s ts $20,0 00 a y e a r 

fo r ea ch p ati en t h o sp it ali zed . In our ex p eri en ce in G eo rg ia , we hav e fo un d th at 

any w h ere fro m 25-5 0 p e rc e n t of th o se su ff eri n g e n d -sta g e kid ney fa il u re co uld 

hav e bee n tr e a te d su c c e ssfu ll y if th e ir hi gh bl oo d p r e s s u re h ad b een d ete cte d 

and tr e a te d e a r lie r. I co ul d u se th e sa m e a rg u m e n ts in th e c ase of 6tr o k e. High 

blo od p re s s u re is th e m a jo r qau se of s tr o k e s , an d we a ll kn ow th at th e to ta l 

c o s t of h o sp it ali zin g a str o k e v ic ti m is sta g g e ri n g . "

>
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In v e r y s im p le te r m s , M r. C h a irm a n , w e h a v e tw o p r im a r y o b je c ti v e s

a t th e p r e s e n t ti m e :

(1 ) A o n e - y e a r re n e w a l of th e h y p e rte n s io n fo r m u la g r a n t p r o g r a m a t

a le v e l of a t le a s t $3 0 m il li o n - - th e m in im u m a m o u n t s u g g e s te d in th e N o v e m b er

19 77 s u rv e y of th e S ta te h e a lt h o f f ic e r s .

(2) A n o p p o rt u n it y to d e m o n s tr a te a t h e a r in g s la t e r th is y e a r th a t w e 

a r e th e b e s t p o s s ib le e x a m p le of a p re v e n ti v e p r o g r a m a g a in s t th e le a d in g k ille r s 

of o u r d a y , a n d th a t w e sh o u ld be v ie w e d a s s u c h in th e d ra fti n g o f a n y r e a l i s t i c 

d is e a s e p re v e n ti o n p ro g r a m . If w e can h e lp it, w e do n o t in te n d to lo s e o u r 

v is ib ility by b e c o m in g s u b m e rg e d in a n a m o rp h o u s b lo c k g ra n t p r o g r a m w h ic h 

m e r e ly th ro w s a bun ch o f e x is ti n g p r o g r a m s in to one lu m p c a lle d " p re v e n ti o n . "

- 30 -

T
M

372

CITIZENS FOB THE TREATMENT OF HIGH BLOOD FBES8UBE, INC.

1101 Ss va nt ssnth S tr u t. N.W.. SulM a n 608

HONORARY CHAIRMAN (202) 2M -44 U

ME MO RANDUM

SU BJ EC T: RE PL IE S TO QU ESTIO NN AIR E ON ST ATE

HY PE RT EN SION PROG RA MS

FROM : Mike Cor m an , E xecu ti ve D ir ecto r, C it iz en s

fo r th e T re at m en t of High B lo od P r e ssu re

(BRTRAM R. IROWN, M. D.

•AUL ■. CORNBLV. M.O.

IMOMAa J. OBBOAN. JR..

,arribt a. dubtan. m.d.

HONORABLE JOHN W.

HOLUB a. IMBRAMAM. M.D.

HAROLD D. tTBKOVITX. MJI

jobbrh M. acMN. d.m4>.

Maa. milbb rbnnvbackbr

COWARD BBNNBTT WILLIAM8. IBS.

LEONARD WOODCOCK

IRVINO a. WRIOHT. M.D.

LBBTBR WUNDERMAN

JBRRT WORK

On N ovem ber 30, 19 77 , th ro ug h th e go od o ffi c es of Doc to r Ly ma n

O ls en , P resid en t of th e A sso cia ti o n of St at e an d T errit o ria l Health

O ff ic ia ls an d with th e cooper ation of it s W as hi ng ton o ff ic e, we se nt

ou t a d eta il ed quest io n n air e so li c it in g op in io ns on the curren t State

hyperte n si on fo rm ula gr an t.

We w ere m o st en co ur ag ed by bo th th e qu an tit y an d the qu al ity of the

r e p li e s . F orty -t w o Sta te s res p onded , m ost of th em at c o n sid er ­

a b le le ngth . Th es e a r e ju st a fe w of th e hig hlights of the su rv ey :

(1 ) ATTIT UDE TOWARD PR ES ENT HYP ER TE NS IO N FORM UL A GR AN T

Th e vast m ajo rit y of th e St ate he alth o ffi c er s e x p r e sse d th ei r st ro ng

su pp or t fo r re te nti on of the p rese n t fo rm ul a gra nt a s an in de pe nd en t

an d v is ib le program . Th ey w ere a lm o st un if orm all y oppos ed to

an y att em pt to lu mp th e p rese n t gr an t in to an o v e r -a ll p rim ary

p roje ct gra nt. Th ey ar gued , qu ite p e r su a siv e ly , th at hyper te n si on

m on ie s sh ould no t be d is tr ib ute d to gran te es at th e co m m unit y le v e l.

Th e d is e a s e of hyper te nsion is en dem ic in a ll 50 S ta te s, an d it sh ou ld

be ha nd led by St at e he al th d ep artm en ts .

(2) AD EQ UA CY OF EXISTING FO RM UL A GR AN TS

This ques ti on eli c it e d the sh a rp est re sp o n se. T h ir ty -s ix o f the

42 Sta te s st ate d v ery em p hati ca lly that th e F is c a l 19 78 fun din g

le v e l of $11 m il li on fo r th ese gra nts fe ll fa r sh o rt of m ee ti n g ev en

th e m in im um n eeds fo r an e ff e c ti v e scre e n in g , d ete cti on and fo ll o w ­

up p rogram . F iv e Sta te s w ere a g a in st an y in c r e a se in fu nd ing,

w h il e on e oth er St ate took no c le a r c u t p osi ti on .

Of th e 34 Sta te s re sp on di ng in th e p o sit iv e , m o st of th em ex p ress ed

a cle a r w il li n g n ess to advoc at e at le a s t $3 0 - 35 m il li o n a year ov er

th e nex t th ree yea rs - - an appro xim ate tr ip li n g of the p resen t le v e l.

7
373

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The S ta te h e a lt h o ff ic ia ls s p e ll e d out in c o n s id e ra b le and fa s c in a ti n g d e ta il 

d e s c rip tio n s of th e ir e x is ti n g h y p e rte n s io n p ro g r a m s fo ll ow ed by a n o u tl in e 

of ho w m any m o re people could be re a c h e d w it h a d d it io n a l fu ndin g.

In th e a tt a c h m e n t to th is s u m m a ry , we in c lu d e e x c e rp ts fro m s o m e of th e 

S ta te r e p o r ts so a s to giv e e v e ry o n e in te r e s te d in h y p e rte n sio n c o n tr o l so m e 

in d ic a ti o n of th e w id e v a rie ty of te c h n iq u e s b ein g u sed a t th e p r e s e n t ti m e , 

both to d e te c t h y p e rte n s iv e s an d to k e ep th e m on tr e a tm e n t.

(3) C O V ER A G E OF A M BULATORY C A R E FO R H Y PE R T E N SIV E S

B e c a u se th e r e w as d is a g r e e m e n t la s t y e a r b etw een th e tw o b o d ie s of th e C o n g re ss 

w it h th e H ouse voti ng fo r c o v e ra g e of a m b u la to ry c a r e "w h e re a p p r o p r ia te " and 

th e S en ate h o ld in g to " r e f e r r a l fo r tr e a tm e n t, " we in clu ded a q u e sti o n d e sig n e d 

to o b ta in th e a tt it u d e of th e S ta te h e a lt h o ff ic e rs on th is is s u e .

D e sp it e th e c o n tr o v e r s ia l n a tu re of th is is s u e , th e re s p o n s e of th e S ta te h e a lt h 

o ff ic e rs w as o v e rw h e lm in g ly on th e s id e of th e H ouse p o s it io n . T h ir ty 

S ta te s v o te d fo r a m b u la to ry c o v e ra g e ; s ix S ta te s v o te d a g a in s t it, an d in th e 

c a s e of th e o th e r six S ta te s it w as d if fic u lt to d is c e r n a c le a r - c u t p o sit io n on 

th e is s u e . A s to w hat p e rc e n ta g e of th e fo rm u la g ra n t sh o u ld b e a ll o c a te d to 

a m b u la to ry c a r e , th e fi g u re of te n p e rc e n t w as m o s t fr e q u e n tl y u se d ; h o w e v e r, 

so m e w an te d so m ew h a t le s s th an th is , w h il e a n u m b e r w an te d a n y w h e re fro m 

15 to 30 p e rc e n t u se d to d e fra y m e d ic a l a n d d ru g e x p e n se s fo r in d ig e n t p a ti e n ts .

Of c o u r s e , p r a c tic a lly a ll of th e s e re s p o n s e s w e re p re d ic a te d up on a c o n s id e r ­

a b le e n la rg e m e n t of th e p r e s e n t fo rm u la g ra n t.

In s o m e of th e c o m m u n ic a ti o n s, th e re w e re s u g g e s ti o n s th a t m o re e x p e rie n c e 

had to be g a in e d by th is r e la tiv e ly new p ro g r a m b e fo re one co u ld ta lk fa c tu a ll y 

on th e p ro s an d cons of th e is s u e . In fa c t, s e v e r a l S ta te s th is y e a r a r e c o n d u cti n g 

ju s t su c h an in q u ir y to fi nd ou t ho w m an y of th e s c re e n e d p a ti e n ts c a n n o t p ay fo r 

m e d ic a l c a r e and m e d ic a ti o n s .

It is o u r fe e li n g th a t w he n h e a rin g s a r e held th is y e a r on th e re n e w a l of th e 

le g is la ti o n , th is is s u e m ay be r e s o lv e d . H o w ev er, sin c e th e r e is a li k e li h o o d 

th a t th e r e w il l be ju s t a o n e -y e a r re n e w a l of 3 1 4 'd ) p r o g r a m s , th e b e tte r s tr a te g y 

m ig h t be to c o n c e n tr a te on o b ta in in g a m o re a d e q u a te su m u n d e r e x is ti n g la w 

an d p o stp o n in g u n ti l n e x t y e a r th e re s o lu ti o n of th is m a tte r .

If any of yo u w ould li k e a fu ll s e t of th e r e p lie s , we can a c c o m m o d a te yo u.

In r e tu r n , w oul d yo u be go od enough to le t us have your v e ry fra n k r e a c tio n 

to th e r e s u lts o f th is su rv e y ?

r
A TT A C H M EN T

E X C E R P T S FR O M Q U ESTIO N N A IR E ON H Y PER T EN SIO N FO RM U LA GRANTS

ALA BAM A

A s a n a ti o n we a r e now on o u r way to sp endin g tw o b il li o n d o lla rs a y e a r to 

tr e a t e n d -s ta g e re n a l d is e a s e . Goo d s e n s e d ic ta te s th a t w e can w e ll a ffo rd 

to sp en d m o re th an 11 m il li o n to h e lp p re v e n t it. H e re in A la b a m a , D r. T h o m as 

A n d re o li , d ir e c to r of n e p h ro lo g y a t th e U n iv e rs it y of A la b a m a , in d ic a te s th a t 

30 p e rc e n t of th e 20 0 to 30 0 new kid ney fa ilu r e c a s e s in A la b a m a e ac h y e a r r e s u lt 

fro m u n c o n tr o ll e d h y p e rte n s io n .

M o rta li ty and m o rb id it y fr o m u n c o n tr o ll e d h y p e rte n s io n is th e m o s t e n d em ic 

p ro b le m we fa c e to d a y . F u n d s to d e a l w it h th is p ro b le m can no lo n g e r c o n ti n u e 

to be so d is p ro p o rti o n a te to th e n e ed . T he fo rm u la g ra n t p ro g r a m is w o rk in g in 

A la b am a an d w e n e e d m o re of it.

ARIZ ONA

In s u m m a ry , we s tr o n g ly s u p p o rt in c re a s e d fu ndin g to a t le a s t th e s u g g e ste d 

le v e l of $30-3 5 m il li o n p e r y e a r o v e r th e n e x t th r e e y e a r s . ..O n ly r e c e n tly h a s 

h y p e rte n sio n begun to b e a d d r e s s e d w ith any r e g u la r ity . To re d u c e o r w it h d ra w 

fu ndin g a t th is p oin t w ould s e r io u s ly je o p a rd iz e th e p r o g r e s s bein g m ad e in 

c o n tr o ll in g a m a jo r c h ro n ic d is e a s e p ro b le m a s e v id e n c e d by th e re d u c ti o n in 

h y p e rte n s iv e d is e a s e - r e la te d d e a th s in re c e n t y e a r s .

FL O RID A

F lo r id a 's a ll o tm e n t is in a d e q u a te to m e e t th e n e e d s of th e H y p e rte n siv e s 

in F lo r id a . A d d it io n a l fu ndin g is n e ed e d to p ro v id e a c o m p re h e n s iv e s ta te w id e 

e d u c a ti o n , d e te c ti o n , and tr e a tm e n t p ro g r a m th ro u g h o u t th e s ta te . S p e c ia l 

e m p h a sis is n e ed e d on th e d ia g n o sis an d tr e a tm e n t a s p e c ts of o u r p ro g ra m s 

w h ic h w e c o n s id e r a p r io r ity . F un d in g sh ould be in c r e a s e d by a m in im u m 

of 1 00%.

GEO RGIA

O ur g ra n t of $270, 00 0 has b een in v a lu a b le in s u p p le m e n ti n g th e $5 50 , 00 0 in 

s ta te fu nds fo r ongoin g h y p e rte n sio n c o n tr o l p r o g r a m s in G e o rg ia . In e le v en 

h e a lt h d is tr ic ts in o u r s ta te , th e s e fu nds plu s s ta te fu nds h av e a ll o w e d us to 

tr a in p ubli c h e a lt h n u r s e s , d ie ti ti a n s an d h e a lt h w o rk e rs in h y p e rte n sio n c o n tr o l. 

T his has re s u lte d in o v e r 1 0 0 ,0 0 0 a d u lt s bein g s c r e e n e d , 1 6 ,0 0 0 h y p e rte n s iv e s 

id e n ti fi e d a n d r e f e r r e d fo r d ia g n o s is , and 6, 00 0 e n te re d in a p ubli c h e a lt h p ro g r a m 

fo r lo ng te r m m a in te n a n c e a s s is tin g p riv a te p h y s ic ia n s in li f e ti m e blo od p r e s s u r e 

c o n tr o l.
375

A TT A C H M E N T - (2)

IL LIN O IS

O ur d e p a r tm e n t is e m p h a siz in g th e e v a lu a ti o n of e ffe c ti v e n e s s a n d c o s t of 

e ac h of th e 17 p ro g r a m s in h y p e rte n s io n c o n tr o l fu nded by o u r d e p a r tm e n t 

a n d c a r r ie d out by lo c a l a g e n c ie s . We b e li e v e th a t s u p p o rt of a v a r ie ty of 

a p p ro a c h e s , e ac h w it h c a r e f u l e v a lu a ti o n of e ffe c ti v e n e s s and of c o s t, is 

o u r f i r s t r e s p o n s ib il it y . We d e fi n e e ffe c ti v e n e s s a s th e n u m b e rs of new 

c a s e s of h y p e rte n sio n re m a in in g u n d e r d o c u m e n te d c o n tr o l 6 m o n th s a f te r 

o n s e t of tr e a tm e n t.

IOW A

We a r e in th e p r o c e s s of s u rv e y in g so m e 6, 500 p e rs o n s w ho p a r tic ip a te d in 

s c r e e n in g p ro g r a m s in 19 75 to e v a lu a te th e e ffe c ti v e n e s s of th e s c r e e n in g a n d 

r e f e r r a l . O ne q u e sti o n a sk e d r e la te s to th e re a s o n s th e p a ti e n t sto p p ed ta kin g 

m e d ic a ti o n . R e s u lt s of th is s u rv e y sh o u ld be a v a ila b le in a p p ro x im a te ly th r e e 

m o n th s .

KEN TUCKY

A lt h o u g h th e h y p e rte n sio n fo rm u la g ra n t to K entu cky e x c e e d s $100, 00 0 p e r 

y e a r , th a t a m o u n t is in a d e q u a te to s e r v e th e to ta l n eed of h y p e rte n s iv e s in 

th e S ta te . We a r e d e fi n it e ly in fa v o r of in c re a s in g th e a p p ro p ria ti o n s of S ta te s 

fo r th e ir h y p e rte n s io n p ro g r a m s b u t fa v o r th e p r e s e n t fo rm u la b a se d up on p e r 

c a p it a in c o m e w it h in a S ta te and th e e s ti m a te d h y p e rte n s iv e p o p u la ti o n .

M ARYLA ND

P r e s e n tly o u r 31 4D fu nds a r e b ein g u ti li z e d to c o o rd in a te and im p ro v e e x is ti n g 

r e s o u r c e s . We have a Hig h B lo od P r e s s u r e C o m m is sio n w h ic h is b ro a d ly 

r e p r e s e n ta tiv e of p ro v id e r g ro u p s th a t re v ie w s and a d v is e s on e x p e n d it u re s 

of th e s e fu n d s. B ase d on c u r r e n t re q u e s ts fro m lo c a l c o m m u n it ie s a n d o u r 

S ta te 's 5 -y e a r p la n , a p p ro x im a te ly $ 5 5 0 ,0 0 0 a y e a r is n e ed e d on a p e rm a n e n t 

b a s is to s u p p o rt a s ta te w id e p ro g r a m fo r c o n tr o ll in g hig h b lo od p r e s s u r e . W ith 

th is a m o u n t of fu n d in g , w hic h is m in im a l - a b o u t $1 p e r h y p e rte n s iv e in M a ry la n d - 

a s s is ta n c e can b e p ro v id e d to e x is ti n g h e a lt h c a r e r e s o u r c e s to e n a b le th e m to 

b rin g m o s t h y p e rte n s iv e s u n d e r c o n tr o l. O u r p r e s e n t a ll o tm e n t is n o t a d e q u a te 

an d w e a r e n o t a b le to m e e t th e n e e d s of lo c a l c o m m u n it ie s .

T h e re fo r e , we w ould be s tr o n g ly in fa v o r o f tr ip li n g th e a m o u n t of 31 4D fu nds 

c u r r e n tly a v a ila b le fo r hig h b lo od p r e s s u r e .

M IC HIG AN

T h e re is no q u e sti o n th a t th e p r e s e n t a m o u n t of r e s o u r c e s a v a ila b le to M ic h ig an 

fr o m th e c u r r e n t fo rm u la g ra n t is in s u ffic ie n t to c o v e r th e e x is ti n g n e e d s in th e

T

28* 386 0 - 78 - 25
A TT A C H M E N T - (3)

st a te . O u r c u r r e n t a ll o tm e n t s u p p o rt s e ig h t li m it e d d e m o n s tra ti o n p ro je c ts 

s e r v in g only a s m a ll fr a c ti o n of th e p opula ti on in n e e d . To m o u n t a s ta te w id e 

p ro g r a m , we e s ti m a te w ould re q u ire ab o u t th re e to fo u r ti m e s th e am o u n t 

c u r r e n tly a v a ila b le . We w ould th e re fo re s tr o n g ly s u p p o rt a p ro p o s a l to in c r e a s e 

th e o v e ra ll n a ti o n a l a ll o tm e n t and th e m in im u m of $100, 00 0 p e r s ta te p e r y e a r.

M IS SIS SIP PI

M is s is s ip p i's h y p e rte n sio n p ro b le m ex te n d s to a p p ro x im a te ly 20% of th e to ta l 

p o p u la ti o n o v e r 18 y e a r s of a g e . T his p e rc e n t r e p r e s e n ts a b o u t 2 8 0 ,0 0 0 people 

w it h a d ia s to li c p r e s s u r e of 90 o r g r e a te r .

T he M is s is s ip p i S ta te B o a rd of H e a lt h 's h y p e rte n sio n p ro g r a m is p re d ic a te d on 

a m b u la to ry c a r e . T he n u m b e r of p a rti c ip a n ts in th e p ro g r a m a s of N o v em b er 

19 77 is 1 0 ,6 2 2 . Up on e n te rin g th e p ro g ra m , h y p e rte n s iv e s re c e iv e th e fo ll ow in g 

s e r v ic e s : EK G, c li n ic a l c h e m is tr y , c o u lt e r s e r i e s , b lo od s u g a r , c h e m ic a l 

u r in a ly s is and c h e s t x - r a y . A ll p a ti e n ts in th e p ro g r a m r e g u la r ly o bta in m e d ic a ti o n s and b lo od p r e s s u r e c h e c k s th ro u g h th e county h e a lt h d e p a r tm e n ts .

T he B o a rd of H e a lt h 's a ll o tm e n t fo r h y p e rt e n sio n is in a d e q u a te to m e e t th e n e ed s 

of h y p e rte n s iv e s in th e s ta te . A s m en ti o n e d a b o v e, a ll d ru g m o n ie s a r e no w 

e x h a u s te d . The ag en c y a d v o c a te s a t le a s t $3 0 m il li o n a y e a r o v e r th e n e x t th re e 

y e a r s fo r h y p e rte n sio n p r o g r a m s . A fl o o r d o ll a r a m o u n t is a go od id ea p ro v id e d 

th a t it is e s ta b li s h e d a t an e q u it a b le le v e l.

MON TA NA

We b e li e v e th a t th e m o s t u se fu l m e a s u re of th e e ffe c ti v e n e s s of a h y p e rte n sio n 

c o n tr o l p ro g r a m is th e p ro p o rti o n of d ia g n o se d h y p e rte n s iv e s r e f e r r e d who r e ­

m a in on d ru g s an d u n d e r m e d ic a l m a n a g e m e n t o v e r a giv en p e rio d of ti m e , e .g .

1 o r 2 y e a r s a f te r r e f e r r a l o r lo n g e r. S c re e n in g is only th e b eg in n in g of p re v e n ­

ti o n : lo n g -te r m m e d ic a l m a n a g e m e n t (i n clu d in g d ru g s ) is th e tr u e p re v e n ti o n .

NEW JE R SE Y

T he n eed fo r a s ta te w id e c o o rd in a te d h y p e rte n sio n c o n tr o l e ffo rt is ev id e n t, 

b a s e d up on th e p re v io u s y e a r s ' e x p e rie n c e . . . A s ta te w id e s u rv e y to d o c u m e n t 

r e s o u r c e s , gaps and d u p li c a ti o n s of s e r v ic e w il l be c o m p le te d in F e b r u a r y of 

1978. D e m o n str a ti o n s e r v ic e p ro je c ts have been fu nded o v e r th e p a s t 15 m onth s 

to d e v elo p w o rk a b le , p r a c tic a l m o d e ls fo r c o m m u n it y -b a s e d p r o g r a m s .

NEW YO RK

T he fis c a l 19 78 a ll o tm e n t is d e e p ly a p p re c ia te d by New Y o rk . T h e re is no 

q u e s ti o n , h o w e v e r, th a t i t is h o p e le s s ly in a d e q u a te to th e ta s k . We w ou ld 

h e a r tily e n d o rs e an in c r e a s e to $3 0 - $3 5 m il li o n .
377

A TT A C H M E N T - (4)

NORTH CARO LIN A

A c itiz e n 's s u rv e y in d ic a te s th a t th e r e a r e 7 5 4 ,6 0 0 p e rs o n s w ho have h ig h blo od 

p r e s s u r e , a n d it is e s ti m a te d th a t a p p ro x im a te ly 60% a r e n o t u n d e r a d e q u a te 

• c o n tr o l. An a d d it io n a l 3 3 9 ,0 0 0 a d u lt s o v e r th e a g e of 1 8 h av e h y p e rte n s io n but 

a r e n o t a w a re of it. The p r e s e n t a ll o c a ti o n does n o t p e r m it us to fu ll y a d d r e s s 

th is p ro b le m . N o rt h C a ro li n a s u p p o rts th e in c r e a s e of th e H y p e rte n sio n F o r m u la 

G ra n t to $3 0 m il li o n e ac h y e a r fo r th e n e x t th r e e y e a r s . We a ls o s u p p o rt th e 

p rin c ip le th a t no s ta te r e c e iv e le s s th an $ 1 0 0 ,0 0 0 p e r y e a r .

SO UTH CA RO LI NA

In South C a ro li n a w e e s ti m a te th a t th e r e a r e 450, 00 0 p e rs o n s w it h blo od p r e s s u r e s 

o v e r 1 5 0 /9 5 . O ur a ll o c a ti o n of $ 1 7 7 ,0 0 0 d o es n d t a p p ro a c h a r e a s o n a b le su m to 

a d d r e s s th is p ro b le m . We a r e fo rtu n a te to h av e li m it e d S ta te fu n d s fo r th is 

p u rp o s e a s w e ll but s till can only b eg in to m e e t th e n e e d s id e n ti fie d . We w ould 

s tr o n g ly s u p p o rt a ll o c a ti o n of $30 to $3 5 m il li o n fo r hig h b lo od p r e s s u r e c o n tr o l.

TE XAS

O u r c u r r e n t a ll o tm e n t is in a d e q u a te . We w il l n e e d a p p ro x im a te ly th r e e to fo u r 

ti m e s o u r c u r r e n t a ll o tm e n t to e s ta b lis h an d m a in ta in th e d e s ir e d s e r v ic e s on a 

s ta te w id e b a s is .

UTA H

S ta te s sh o u ld h av e le g is la ti v e a u th o rit y to a ll o c a te fu n d s, a t th e ir d is c r e tio n , 

fo r p u rc h a s e an d d is tr ib u ti o n of a n ti h y p e rte n s iv e m e d ic a ti o n s , w hen in d iv id u a l 

n e ed is c le a r ly in d ic a te d . A p re c e d e n t h a s b een s e t by im m u n iz a ti o n an d tu b e r ­

c u lo s is p ro g r a m s w h e re b y b o th u s e fe d e ra l fu nds to p u rc h a s e " d ru g s " u se d in 

d is e a s e p re v e n ti o n a n d h e a lt h m a in te n a n c e .

VIR GI NI A

The c u r r e n t a ll o tm e n t is n o t a d e q u a te to h an d le th e n u m b e r o f h y p e rte n s iv e s 

in th e s ta te . A n a p p ro p ria ti o n of $3 0 to $3 5 m il li o n p e r y e a r w ould be a 

r e a lis tic fig u re to m e e t c u r r e n t o b je c ti v e s , b ut w ould n e e d to be h ig h e r to 

p ro v id e m e d ic a ti o n to a ll h y p e rte n s iv e s in th e s ta te who co u ld n o t a ffo rd to pay.
378

HAVE A HEART

The S to ry o f an A ttem pt to E n ro ll Three C h il d re n in a H eart C li n ic 

Spo ns or ed by th e M is s. S ta te Board o f H ealt h

Cn March l , K

th e Macon Day Care s o c ia l w or ke r c a lle d th e Noxubee 

Co un ty H ea lt h Dep ar tm en t to si g n up th re e c h ild re n fo r a h e a r t c l i n i c . 

P h y sic a l ex am in ati ons by v o lu n te e r p h y sic ia n s ha d show n h e a r t i r r e g u l a r i t i e s 

th a t we re re fe rre d fo r more th oro ugh d ia g n o s is . The s o c ia l wor ke r 

ha d le a rn e d from a Head S ta r t wor ke r th a t th e r e was a h e a r t c l i n i c 

to be h e ld in Macon d u ri n g March and th a t bl ood work an d x -ra y s ne ed ed 

to be do ne . On th e ph on e, sh e was to ld to b ri n g th e c h il d re n over to 

th e h e a lt h dep art m en t. The re th e nurs e to ld h e r th a t i t r e a l l y h u rts 

l i t t l e c h ild re n to ha ve so much bl oo d dra wn an d th a t sh e would ha ve to 

ta k e them to th e h o s p ita l fo r bl ood work an d x -ra y s .

On March 2 sh e came to our Com bined com munity C hil d De velopm ent 

s o c ia l work s t a f f m ee ti ng in f r u s t r a t i o n . We c a lle d th e R eg io nal 

H ealt h Dep ar tm en t o f f ic e fo r an u n d ers ta n d in g o f t h e i r p ro ced u re . Noone 

was th e re but th e s e c r e ta r y . From h e r, we le a rn e d th e pho ne num ber o f 

th e C a rd io v ascu la r D ep ar tm en t a t th e S ta te Bo ard o f H e a lt h . The 

d ir e c to r th e re im m ed ia te ly re tu rn e d ou r c a l l an d in fo rm ed us th a t a 

h e a r t c lin ic was to be h eld in Macon on Ma rch 20 an d th a t form s 

re q u e s ti n g an appoin tm en t mu st be on h e r de sk by March 13. To ha ve 

th o se form s f i l l e d o u t by H ealt h Dep ar tm en t s t a f f wo uld re q u ir e th e 

co m ple ti on o f bl oo d work an d x -ra y s . She sa id i t was not uncommon 

p ra c tic e to us e h o s p ita l f a c i l i t i e s i f th e lo c a l h e a lth dep ar tm en t 

did not have them . Ne xt we te le phoned D r. Tom W all er, R eg io nal H ea lt h 

O f fic e r, wor king in a co unty o f f ic e . He s a id he wo uld in v e s tig a te 

th e re aso n fo r Koxubee Co unty not do in g bl oo d wor k. I t shou ld be done 

th e re as th e re we re no fu nds to pay fo r work done a t th e h o s p ita l fo r 

no n- M ed ic ai d p a t i e n t s . A l i t t l e w hil e l a t e r , Ms. S ta f fo r d , su p e rv is in g

)
379

-2 -

n u rs e c a lle d to sa y th a t blo od t e s t s co uld be don e a t th e Noxubee 

H ealt h Dep ar tm en t on March 7 when c h ild re n co uld be se en by a d o c to r 

(w hi ch sh e th en 6 aid was n’ t n e c e ssa ry i f we ha d sig n ed d o c to r s ’ 

r e f e r r a l s ) . X -r ays co ul d not be done u n t i l May 15 , to o l a t e to 

me et th e H eart C lin ic ap poin tm en t d e a d li n e , sh e chu ck le d . V.'hen I 

demande d th a t x -ra y s don e on th e 15th be note d on March 13 fo rm s, 

sh e g ra n te d th a t sh e co uld c a l l th e S ta te Bo ard an d arra n g e fo r th a t 

p e rm is sio n . A ltho ug h i t see med c le a r in our d is c u s s io n s th a t th e 

p re li m in a ry wo rkup s co uld be don e w it h o u t p a re n ts ta k in g o f f from 

t h e i r jo b s , i f th e s o c ia l wor ke r o b ta in e d t h e i r p erm is sio n , we 

decid ed to c a ll th e S ta te Bo ard a g a in to v e r ify th a t th e re w o u ld n 't 

be any s lip - u p 6 . T his tim e we ta lk e d w it h an a s s i s t a n t in th e 

C a rd io v ascu la r U n it . She to ok th e nam es and a d d re ss e s o f th e c h ild re n 

and th e s o c ia l wor ke r and sa id sh e wo uld wa tch fo r th e x -ra y s when 

th ey a r riv e d a t th e S ta te Board fo r p ro c e s s in g . The n sh e ask ed th e 

ag es o f th e c h i l d r e n . . . . 3, U, and 5 . She ask ed , "Why a r e n 't you 

s ig n in g them up to se e a P e d ia tr ic C a rd io lo g is t? " She as ke d how 

fa r we we re fro m S ta r k v ille (w he re we were a t th e moment) o r 'Ve st 

P o in t o r Co lumbu s. She sa id th a t th e in te r n s in th e r e g u la r h e a r t 

c l i n i c s d i d n 't lik e to fo o l w it h c h ild re n an d would j u s t r e f e r them 

to th e P e d ia tr ic H eart C lin ic s on A p ril 3 In West P o in t o r on May 5 

in S ta r k v ille o r May 6 in Co lum bus. We to ld h e r we d id n 't know su ch 

c l i n i c s e x is te d . She sa id not to f e e l ba d, mo st o f th e h e a lth , 

d epart m ent s t a f f d id n 't know ab out them e i t h e r . She would be 

gla d to sc hedule ap poin tm ents fo r our c h ild re n fo r West P o in t but 

we wo uld ne ed to g et th e p re li m in a ry wo rkups in 'Ve st P o in t. Then 

sh e ag re ed th a t w ith a phone caU.1 fro m h e r an d a fo ll o w -u p c a l l from 

us to both Nox ubee and We st P o in t H ealt h D ep ar tm en ts we sh ould be ab le 

to arra n g e fo r a tr a n s f e r o f wo rkup s don e i n one p la c e to th e o th e r fo r 

th e sc h e d u li n g re q u e s t to be made to be se n t to Ja ck so n .
380

Ther e a re s t i l l many p la c e s wh ere t h i s a tt e m p t a t h e a rt sc re e n in g 

ca n go wrong . The H ealt h D ep ar tm en t may y e t demand p a re n t p a r tic ip a tio n 

on da ys when p a re n ts c a n 't le a v e wo rk, th e c h ild re n may g e t c o ld s , th e 

tr a n s f e r o f re c o rd s may not go sm ooth ly . Bu t we w ill t r y . When I 

st opped in to se e th e Head S ta r t nurs e to sh a re ou r in fo rm a ti o n on 

H eart C lin ic s fo r c h ild re n , sh e was o u t, but h e r s e c re ta ry s a id th a t 

sh e knew a l l ab out them . In f a c t sh e had ab out q u it tr y in g to g e t 

appoin tm ents sc hedule d fo r P e d ia tr ic H eart C lin ic s bec au se th ey a re 

u s u a ll y c a n c e ll e d a t th e l a s t m in ute .

f (."4 KtX-'V. 1+ ‘J • v d U S

VJ^i'No do ub t ab out i t , th e h e a lt h

d epart m ents r e a lly know how to r e l a t e to peo ple bec au se th e y 'v e been 

doin g i t fo r d e c a d e s."

Ju dy B ar ber

S o c ia l S e rv ic e s D ir e c to r 

Com bined Community C hil d De velopm ent 

S e rv ic e s, In c .

Drawer NP

M is s. S ta te , M is s. 39762

1
381

AMERICAN HOSPITAL ASSOCIATION

444 NORTH CAPITOL STR EET N W . SUITE 500 WASHINGTON. D C 70001 TELEPHONE 702 638 1100

WASHINGTON OFE ICE

STATEMENT OF THE AMERICAN HOSPITAL ASSOCIATION 

BEFORE THE SUBCOMMITTEE ON HEALTH AND SC IENT IFIC RESEARCH 

OF THE SENATE HUMAN RESOURCES COMMITTEE 

ON S .2 4 7 4

THE HEALTH SERVICES EXTENSION ACT OF 19 78

Marc h 8 , 19 78

Th e A m er ic an H o s p ita l A s s o c ia tio n r e p r e s e n ts som e 6 ,4 0 0 member h o s p i t a l s , lo n g ­

te rm c a r e i n s t i t u t i o n s , m en ta l h e a lt h f a c i l i t i e s , an d h o s p it a l s c h o o ls o f 

n u r s in g , as w e ll as more th a n 2 7 ,0 0 0 p e rs o n a l m em be rs. We a p p r e c ia te t h i s 

o p p o r tu n ity to p r e s e n t th e vie w s o f th e A s s o c ia tio n on S .2 4 7 4 , th e H e a lth S e r v ic e s 

E x te n sio n Act o f 1978, w hi ch r e v i s e s an d e x te n d s th e a u th o r i ty f o r a nu m be r o f 

h e a lt h pro gra m s c o n ta in e d in th e P u b lic H e a lth S e rv ic e A ct. We s u p p o rt in g e n e ra l 

th e e x te n s io n o f th e s e pro gra m s an d w ou ld l i k e to e x p re s s s e v e r a l a r e a s o f 

c o n c ern to th e h o s p it a l f i e l d w it h an ai m o f im p ro v in g an d s tr e n g th e n in g th e

b a s ic s t a t u t e .

D is e a se C o n tr o l Pro gra m s

We a r e en c o u ra g e d by th e in c r e a s e d e m p h asis S .2 474 p la c e s on p r e v e n tiv e h e a lth 

m e a su re s. H e a lt h e d u c a tio n , p r e v e n tio n , an d p ro m o ti o n a re o f h ig h p r i o r i t y to th e 

AHA, an d in t h a t c o n n e c tio n , we r e c e n tly e s ta b l is h e d a C e n te r f o r H e a lth P ro m o ti o n 

to p ro v id e I n c re a s e d v i s i b i l i t y an d s t a f f s u p p o rt to a c t i v i t i e s in s u p p o rt o f 

p r e v e n tiv e h e a lth m ea su res. T h is c e n te r w i l l a ls o s e rv e a s a v e h ic le to g u id e 

AHA h e a lth p ro m o ti o n a c t i v i t i e s in su ch c a s e s a s im m u n iz ati o n pro gra m s 3n d pro gra m s 

to d e te c t h y p e rte n s io n .

1

CABLE ADDRESS AMERWOSP

f
382

We b e li e v e th a t fe d e ra l i n i t i a t i v e s in th e are a of h e a lt h pr om ot io n ca n b e s t be 

ac hie ved w it h th e support o f th e v o lu n ta ry s e c to r. Fo r ex am pl e, la s t year we 

pl ed ge d to su pport HEW's Im mun ization I n i t i a t i v e — th e s ta te d goal o f wh ich was to 

in c rease th e p erc en ta g e of c h il d re n who are fu lly imm unized from 40 to 90 p erc en t 

by O ct ober, 197 9. As a r e s u lt of th is com mit ment, th e AHA des ig ne d a pack ag e of 

m a te ria ls on th e ne ed fo r im mun izatio n of c h il d re n and d is tr ib u te d th e se m a te ria ls 

to a l l member h o s p it a ls so th a t th ey co ul d be p re sen te d to m ate rn it y p a tie n ts . 

In c re a sin g th e c h il d im mun izatio n a u th o riz a ti o n pro vid ed un de r S ecti o n 317(g )( 1) (A ) 

from $23 to $35 m il li o n fo r FY 1979 wou ld add th e n ecess ary support to th e p riv a te 

and p u b li c s e c to r to en su re th a t th e go al o f th e Im m un izat io n I n i t i a t i v e wo uld be

me t.

M igrant H ea lt h S erv ic es

Mr. Ch air ma n, th e number of m ig ra nt and se aso n al farm w or ke rs and th e ir fa m il ie s 

in our co untr y is esti m ate d to be ap pro xim at el y 2 .7 m ill io n . Acc or ding to HEW's 

H ea lth S erv ic es A d m in is tr ati o n , th e in fa n t m o rta li ty r a te of th is group is 25 p erc e n t 

h ig h er th an th e n a tio n a l avera ge. Fur th er m ore , th e m o rta li ty ra te of m ig ra nt 

w or ke rs fo r tu b e rc u lo s is and o th e r in fe c ti o u s d is e a se s i s two and o n e -h a lf tim es 

th e n a ti o n a l r a t e , and th e ra te of h o s p ita liz a tio n is 50 p erc en t h ig h e r th an th a t 

o f th e n a ti o n as a who le. .

N ea rly h a lf a m il li o n pe op le receiv ed am bu la to ry h e a lt h care s e rv ic e s un de r th e 

m ig ra nt h e a lt h s e rv ic e s prog ram la s t y e a r, b u t th e re a re s t i l l many are a s w he re , 

bec au se o f la ck o f fu nds, no h e a lt h c e n te rs ha ve be en e s ta b li s h e d . L ast year 

fu nd s we re so scarce th a t s e rv ic e s we re li m it e d to h ig h - r is k mot he rs and I n fa n ts . 

M oreover, m ig ra nt fa m il ie s , o fte n in d iv id u a ls w it h m arg in al inco mes , tr a v e l from 

s ta t e to s ta t e in searc h of employmen t and a re u s u a ll y in e lig ib le fo r Med icaid 

and o th e r lo c a l community s e rv ic e s . U n fo rtu n ate ly , th e f a ilu r e to o b ta in p rev en ti v e 

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o r pr im ar y care se rv ic e s o fte n r e s u lts in a nee d fo r more c o s tl y acu te c a re In an

I n s tit u tio n .

The AHA s tr o n g ly su p p o rt s th e ex te n sio n of th is pr og ram and recommends In cre ase d

a u th o riz a tio n le v e ls . S.2474 wou ld in c re a s e a u th o riz a tio n s fo r th e o p era ti o n of

m ig ra nt h e a lt h c e n te rs to $4 0, $4 4, $ 48.4 , $ 53.2 , and $5 8. 6 m ill io n , r e s p e c tiv e ly , 

in F is c a l Y ea rs 1979 th ro ug h 198 3. While th i s a d d iti o n a l su p p o rt would per m it 

some ex pa ns io n of s e rv ic e s pro vid ed th ro ugh th e se C en te rs , th e AHA recom mends 

a u th o riz a ti o n le v e ls of $4 2, $4 7, and $5 4. 4 m ill io n , r e s p e c tiv e ly , fo r F is c a l Yea rs 1979 

th ro ug h 193 1. The AHA en dors es th e amoun ts a u th o riz ed fo r ea ch f is c a l y ea r by S ecti o n 

319 (h)(3) which are ea rm arke d fo r In p a tie n t and o u tp a ti e n t h o s p it a l s e rv ic e s fo r th e m ig ra nt 

p o p u la ti o n . A ls o, we su p p o rt th e a u th o riz a tio n o f $4 m il li o n a y ear fo r p r o je c t g ra n ts 

to a s s i s t in th e pla nnin g and deve lopm en t o f m ig ra nt h e a lt h c e n te rs .

Community H ealt h C en te rs

The Community H ea lth C en te rs (CHC) prog ram su p p o rt s am bu la to ry care p r o je c ts to

pro vid e s e rv ic e s to m edic all y un der se rv ed p o p u la ti o n s in bo th urb an and r u r a l a re a s.

The s e rv ic e s pro vi ded th ro ug h CHCs ad d re ss a br oa d ra ng e o f p re v e n ti v e and prim ar y 

h e a lt h care n eed s, and in clu d e fa m il y -ce n te re d , m u lti d is c ip li n a ry ap pro ac he s to 

th e d e li v e ry of h e a lt h care s e r v ic e s , in c lu d in g o u tr each and tr a n s p o r ta ti o n . The 

prog ram is now serv in g ab ou t 9 .5 p erc en t of th e 45 m il li o n peo ple re s id in g in 

th e ca tchm en t a re a s id e n tif ie d by HEW as m ed ic all y u n d ers erv ed . U n fo rtu n ate ly , 

fu nd in g ha s be en so li m it e d in th e p ast th a t many c e n te rs ha ve be en unab le to 

pro vid e th e co m pr eh en sive s e rv ic e s a u th o riz ed un der e x is tin g law. Because th is 

prog ram is an e f f o r t to ad dre ss a d i f f i c u l t , com ple x pr ob lem o f s e rv ic e d e liv e ry , 

and bec au se i t em ph as izes p rev en ti v e and pr im ar y h e a lt h ca re s e r v ic e s , we str o n g ly 

support i t s c o n ti n u a ti o n a t th e pr op os ed new a u th o riz a tio n le v e ls .

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We would like co endorse at th is poin t a pr ovisi on Included In S.2474, In se ct io n

106, which would es ta blish a new grant program for h o sp it a l- a ff il ia te d primary

care ce nt ers. These grants would support demo nstra tion pr oj ec ts to provide funds

to public general hosp it als or pr iva te no n-pr ofit hosp it als In urban area s which

prima rily ser ve a pop ulation designated by Che Secre tar y of HEW as havin g a

shortag e of personal health se rv ic es . In rec ent yea rs hosp it al s ser ving such areas

have become the pr incipa l sour ce of medical care for many disadva ntag ed per son s.

This phenomenon has placed an Inc rea sing burden on hos pital emergency rooms and

ou tpatient c li n ic s , pa rt ic ul ar ly In the pr ovisi on of routi ne or primary healt h

care. Further, the expansion of th is demand for se rv ic es has exacerb ated the

already seriou s problem of ho sp ital d e fi c it s sinc e many of these pa tien ts are

ne ith er sponsored by pu blic programs nor able to pay for the se rv ic es they need.

This urban In it ia ti v e sponsored by Senators Jacob Javit s and Edward Kennedy and

oth ers Is welcomed by hos pi ta ls as a pos itiv e reco gn iti on of the unique ro le these

urban hos pi ta ls play In ser ving the medical needs of the poor and near-poor In

th eir communities. We do not be liev e tha t grant s fo r primary care ce nt ers w il l

com pletely so lve the problem of assuring ac cess to qu al ity he alth care se rv ic es

in urban, underserved ar eas, nor do we bel ie ve that It w il l end the finan ci al

problems of urban hosp it als . Nev erth ele ss, these grants would provide much needed

support to a ssis t urban hos pital s In redesig nin g th ei r system for rendering

ambulatory care and thus permit them to ser ve th ei r pat ie nts In a more e ff ic ie n t

and e ff ecti v e manner. We would be w il lin g to work with you and your sta ff In

furth er development of th is innovative Idea.

National Health Service Corps

Se ction 107 of the b il l req uir es the Secre tar y of HEW to submit to Congress a

sp ec ia l report on the prese nt and future di re ct io ns of the Ns tlo nal Health

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Service Corps. He support the Consittee's call for such a report and hope that

the AHA and other interested organizations will be consulted in its development.

Home Health Services

Section 110 of S.2474 vould redesignate the program of federal granta for development

and expansion of home health services (now section 602 of Public Law 94-63) as

section 320 of the Public Health Service Act and would extend the program for

three years at an authorized level of $12 million a year. In addition, $2 million

a year would be authorized under this section for training home health aides and

related personnel for work in these agencies.

Mr. Chairman, the American Hospital Association supports the extension of the

home health grant program under section 602 of P.L.94-63 and strongly endorses

the increased funding levels provided in your bill. Home health programs can be

an appropriate and cost effective alternative to Inpatient care, and the American

Hospital Association has given the establishment of hospital-based home care

programs a high priority. In this connection we want to advise you of our

recently established Center for Ambulatory and Home Health Care Services. This

center, located in our Chicago headquarters, will serve as a focal point for

conaideratlon of the special characteristics and needs of hospital-based home

health services programs, as well as those of outpatient departments and emergency

rooms.

Since its enactment in 1975, the home health services grant program authorized

by section 602 of P.L.94-63 has provided needed assistance in the development of

services to provide medical care to the elderly or handicapped at home rather

than in an lnatltutlon. Among the applicants receiving assistance under section 602

have been a number of hospital-based home health programs, and we are hopeful that

the Increased funding provided in your bill will enable more hospitals to receive

these grants.
The AHA a ls o su p p o rt s th e a u th o riz a tio n o f $2 m ill io n a y ear fo r tr a in in g pro vid ed 

by S.2 47 4. I f home care s e rv ic e s are to become a v ia b le a l te r n a tiv e to 

I n s tit u tio n a liz a ti o n fo r some p a tie n ts , th e re mus t be an ad equat e su pply of tr a in e d 

p ers o n n el. In a d d iti o n , ho wev er , th e AHA b e li e v e s th e re Is a need fo r more 

te c h n ic a l a s s is ta n c e to I n s tit u tio n s o r o rg a n iz a ti o n s wh ich a re In te re s te d in 

e s ta b li s h in g a home c a re prog ram. Tho se who wo uld see k to becom e p ro v id e rs of 

home h e a lt h s e rv ic e s need to acq u ir e a b a sic u n d ers ta n d in g o f th e fe d e ra l law s 

and re g u la ti o n s gover nin g home c a re . The Departm ent o f H ealt h , E ducat io n, and 

W el fa re does pro vid e a c e rta in amount o f te c h n ic a l a s s is ta n c e th ro ug h I t s reg io n al 

o f f ic e s In th e form o f te le phone c a lls , o n - s lte v i s i t s , and w or ks ho ps , b u t th is 

a s s is ta n c e mus t be g re a tly In cre ase d I f home h e a lt h prog rams a re to become more 

w id el y e s ta b li s h e d . To th i s en d, we wo uld recommend c h a t, in a d d it io n to th e 

fu nd s fo r expansi on, de ve lo pm en t, and tr a in in g , fu ndin g be pro vid ed in th e form 

o f c o n tr a c t a u th o rit y o r by some o th e r mecha nism fo r te c h n ic a l a s s is ta n c e in 

both th e p re -a p p lic a ti o n and s ta r t- u p ph as es o f th e home h e a lt h g ra n t prog ram .

One l a s t a re a we wo uld lik e to a d d re ss, Mr. Ch airm an , co nc er ns th e p o te n ti a l fo r 

ex pa nd in g home h e a lt h prog ram s In to th e new are a o f h o sp ic e care fo r te rm in a ll y 

i l l p a tie n ts . The te rm , "h o sp ic e ca re ," r e f e r s to a co m pr eh en sive prog ram of 

s e rv ic e s , pr ovid ed In b o th th e I n s tit u tio n a l s e tt in g and a t home, wh ich has as 

I t s goal to ea se th e pai n of th e te rm in a ll y 111 p a t ie n t , to m ain ta in th e in d iv id u a l 

d ig n it y and p riv a c y , and to pro vid e n ecess ary co u n seli n g s e rv ic e s to both th e 

p a tie n t and h is o r h e r fam il y . A w ell pl an ne d h o sp ic e pr og ram can hel p to ea se 

th e em otional p ain o f appro ac hin g dea th an d, fro m an econom ic s ta n d p o in t, can 

hel p to p re v en t o r sh o rt en ex pensi ve h o s p ita liz a tio n s .

Hos pi ce s e rv ic e s th a t are b o th h o s p it a l- b a s e d and n o n -h o sp it a l- b a se d are bei ng 

e s ta b li s h e d in a number o f c i t i e s acro ss th e co u n tr y . The Am erican H o sp it al
Association believes that the circumstances of an Individual case and the Judgment

of the attending physician will determine whether or to what extent hospice services

should be provided in the home. In many cases, however, it will be possible to

provide hospice services to the patient at home, and, to this end, we would

recommend that federal assistance for the development of hospice programs (perhaps

by expansion of the section 602 grant program), be provided.

Conclusion

Mr. Chairman, this concludes the Association’s statement. I would like to express

the Association's appreciation for this opportunity to present our views to your

and members of the subcomaittee and we hope it will be of assistance in your

consideration of this legislation.
388

Se na tor K ennedy. On th at ra th er gloom y note, we will adjou rn. 

[W her eup on, at 12:15 p.m., the subcomittee adjou rned, subject to 

the call of the Ch air .]

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