MENTAL HEALTH SERVICES

A special aspect of comprehensive health care is that of mental health services, including inpatient and outpatient therapy, partial hospitalization and after care. Delivery systems for mental health care must be designed to emphasize prevention and early treatment and to provide comprehensive services at a reasonable cost. The decline in psychiatric inpatient care means that the overwhelming number of mental health patients are living in communities where a wide range of therapeutic, rehabilitative and supportive services must be accessible both for those who have been hospitalized and for those whose hospitalization we wish to prevent.

Indications are that most individuals and families want and benefit most from brief services within a short time period. Among blue-collar, white-collar, lowincome and minority groups, the experience in many situations has been underutilization of mental health services, rather than over-utilization. According to the American Psychiatric Association:

"Studies seem to show a much greater incidence and prevalence of mental illness among the poor and less-educated than among the affluent and welleducated. Actually a serious problem with insurance coverage of psychiatric illness is apt to be underutilization by the groups most in need. Framers of any program need to grapple with this problem."7

The American Psychiatric Association estimated that in 1970, under existing insurance plans, less than two-thirds of the civilian population had any coverage of hospital care for mental conditions while less than 40% had any coverage of outpatient care.

Proposed legislation differs markedly with respect to mental health care. For example:

The Administration bill would only provide reimbursement for psychiatric hospitalization up to 30 days; consultation up to 30 visits, and treatment at a community mental health clinic to 30 visits.

The Long-Ribicoff bill would provide unlimited hospital care (after a substantial deductible is satisfied) under catastrophic coverage; while outpatient psychiatric would be sharply limited.

The Kennedy-Mills bill would limit inpatient coverage to 30 days (except for Medicare patients who would be unlimited); partial hospitalization in a CMHC to 60 days; outpatient psychotherapy to approximately 15 visits, and outpatient CMHC to the cost of 30 outpatient visits to a private psychiatrist.

The Health Security Act would provide up to 45 days inpatient care for children and adults and unlimited outpatient care in a community mental health center.

MULTIPLE ENTRY

A truly adequate and comprehensive system of national health insurance must provide a full range of mental health services available and accessible to all segments of our population. Moreover it must afford consumers greater opportunity to enter the system than now exists. Recognition of the social component of health care carries with it the notion of a multi-faceted system and correspondingly the need for providing multiple points of entry. No longer must any one group, one profession or one industry be permitted to control the avenues, the bridges and the gates to that system, nor unilaterally determine the price and conditions for admission.

Moreover, the concept of a many-sided, multi-tiered system requires that recognition be accorded to all key health professionals who provide services within that system whether under agency aegis or as independent practitioners. This is particularly true with respect to mental health care in which several disciplines provide services often closely related and at times totally congruent. Yet for the patient, access to care is frequently restricted, expensive and marked by delay.

In the field of mental health, social workers represent one of the three core professions providing private and public therapeutic services. In addition to generic therapeutic skills, Social Workers practicing in mental health settings as well as privately, offer their patients special skills, such as those related to

Reed, Louis S., Myers, Evelyn S., Scheidemandel, Patricia L., Health Insurance and Psychiatric Care: Utilization and Cost, American Psychiatric Association, Washington, D.Č., 1972.

preventive therapy, crisis intervention, the knowledgeable use of community resources to meet special needs, and outreach services of particular value to the homebound, the disadvantaged and the hard-to-reach patient.

As of January 1970, more than 15,000 social workers were employed in psychiatric facilities around the country. In examining staffing patterns in freestanding outpatient psychiatric clinics in January 1970, one finds more social workers (5,461) than any other profession; and, more full-time social workers than psychologists, psychiatrists and all other physicians combined: 3,014 social workers to a total of 2,042 for the other three professional categories."

In a comparison of the distribution of staff time, by discipline, in selected inpatient psychiatric facilities and in free-standing outpatient psychiatric clinics, statistics show that social workers again were spending more professional time in providing service at these facilities than the combined time of all psychologists and psychiatrists on duty."

10

When the number of full-time equivalent staff (i.e., those working a 40-hour week) is analyzed for the above facilities, it further is shown that social workers not only are in the greatest overall number (compared to psychologists and psychiatrists combined), but maintain that position in every setting measured-in state government, local government and in private (voluntary) non-profit settings.1

Social workers are also the most significant group of health professionals providing services to the poor, to minority groups and to people in areas of the country which are especially adversely affected by the maldistribution of mental health services. A study of the availability of such services in three relatively poor and remote areas of the country clearly reflects this:

Despite the far reaching and significant role of social workers in the mental health field, none of the bills as they now stand provide for direct payment to Social Workers for services rendered. As such, they would adversely affect hundreds of thousands of people currently receiving individual and group counseling, psychotherapy and related mental health services provided by clinical Social Workers engaged in private practice and within agency settings.

HEALTH INSURANCE AS A PUBLIC RESPONSIBILITY

We have steadily grown to realize the interdependent nature of our society, the interrelationships within our economy and the interplay between the public and private sectors of our national life. With this realization has come a gradual acceptance of the need for governmental oversight and public accountability

8 (Health Resource Statistics: 1971, DHEW).

Ibid., p. 402.

10 NIMH, "Staffing of Free Standing Outpatient Psychiatric Clinics." Statistical Note No. 56. August, 1971, p. 5.

11 Ibid., p. 11.

12 Sources for statistics: Ibid. It should be recognized that there is a slight variation in the effective dates for which most recent statistics were available, as follows: PsychiatryJuly 1970; psychology-January 1970; social work-December 1971.

in areas affecting our national well being. Less than two years ago this Committee gave leadership to enactment of the Supplemental Security Income program-a program that represents a significant step toward Federal assumption of responsibility for meeting the basic income needs of many of our Nation's aged and disabled citizens. Despite certain flaws in the design and implementation of S.S.I., the concept of social insurance is both valid and timely.

The initiative taken with respect to income security must be extended and redoubled in the area of health security. Our present medical care systemincreasingly the sole province of the private insurance industry-has been marked by inadequate services and escalating costs. National health expenditures were about $94 billion in FY '73. They are estimated to exceed $103 billion this year and rise to $115 billion in FY '75. The average American worker spends a month's wages each year just to pay for health insurance. Millions of others lack insurance coverage altogether.

Despite huge outlays, the lack of public responsibility and accountability has permitted gross inequities in access to care to persist. Approximately 10% of the counties in the U.S. have but one doctor or none at all. In some inner city ghettos the ratio of physicians to residents is 1:5,000, while in some more affluent communities the ratio is as much as 100 times higher.

As you are aware, claims that the U.S. enjoys the highest standards of health care are belied by the facts. Thus, for example, we rank 27th among industrialized nations in life expectancy for males and are also far down the scale with respect to mortality rates for mothers and infants.

Clearly effective reorganization and basic changes are needed in our health care delivery system. An assertion of greater Federal responsibility coupled with a viable voice for consumers is needed. Currently the individual has prac tically no say in decisions affecting the structure of the present system. Under most of the bills before this Committee, consumers will remain outside this system insofar as participation in policy formulation, monitoring or evaluation goes.

The Administration bill, makes no provision for consumer participation. Benefits are left largely to the private carriers for administration under state regulation, within Federal guidelines and certain standards. The chief Federal role, other than administration of the Medicare program for the aged, consists of subsidizing premiums and administrative costs with minimal responsibility for cost and quality control.

The Long-Ribicoff approach gives the Social Security Administration major responsibility for administering the program including accountability to the public for expenditures. No provision is made for consumer participation, however.

The Kennedy-Mills proposal, provides for limited participation by "representatives of the general public" on the National Health Insurance Benefits Advisory Council. A new independent Social Security Administration would administer the program and be accountable for public funds. Private health insurers would also be used in administering certain aspects of the program. Cost control efforts would rely on PSRO's to limit physician fees to the 1973 level.

The Health Security Act would be fully administered by a Federal Health Security Board, which would issue regulations and guidelines for all providers and determine allocation of funds. Payments to hospitals and nursing homes would be on the basis of annual prospective budgets based on reasonable costs; physicians and other professionals would be reimbursed on a per capita or salary basis if practicing within an HMO; independent practitioners, on a fee for service or fee schedule subject to Federal budget limitations. Consumers would comprise majority membership on the National Advisory Council, regional, and local advisory councils.

FINANCING

Integrally linked to the concept of a universal, single track national health insurance system equally accessible to all, is the need for broadly based public financing. We recognize that the Social Security system affords an attractive vehicle for raising and administering the substantial sums needed for national health care. We note, however, that problems posed by overburdening that system coupled with the regressive nature of the Social Security tax itself, militate against placing undue reliance on this structure. In 1971 the Delegate Assembly of this Association recommended establishment of a mandated trust fund. It

recognized the differences as compared to the OASDI program in population to be covered and purposes to be achieved via national health care, and suggested that a major portion of funding for such program be derived from general tax revenues. We continue to urge that this approach be adopted as one of the cornerstones of a truly national health care system.

Each of the four bills on which we have focused our attention today would rely on multiple sources of funding, including employer and employee taxes and general revenues.

The Administration proposal is heavily geared toward enforced contributions to cover the cost of private insurance premiums. The regressive aspects of this tax-premium system are such that the medical cost burden on a person earning $10,000 a year would be the same as that of the $100,000 executive. The family with a sub-poverty level income of $2,500 per year would be required to pay $225 for care. In some instances the Federal government would actually subsidize employers and thereby indirectly help subsidize the insurance industry. Voluntary enrollment features, co-insurance, deductibles, state options and other variables that directly relate to the financing provisions of the bill, coupled with the lack of any effective cost containment measures, ensure that health care will grow ever more expensive, that the cost burden will increase for those who can least afford it and that millions of Americans who are most in need of care will still fail to receive it.

Under Long-Ribicoff, the catastrophic plan would be financed by a Federal payroll tax on employers, employees, and self-employed with a trust fund for Federal Catastrophic Health Insurance completely separate from other trust funds operating under Social Security programs. The Medical Assistance Plan would be financed from general revenues and State funds. The initial $2,000 of medical fees would be borne by the individual before the catastrophic coverage came into play. Optional private insurance would have to be relied upon to cover the deductible as well as various basic health services for many families. Cost containment measures are limited.

Kennedy-Mills represents a forward step insofar as it relies on Social Security financing and administration. The tax approach is less regressive than under H.R. 12684, the scope of coverage is significantly wider, and there would be a certain measure of cost control. The private insurance industry would serve as fiscal intermediaries similar to Medicare. As such their role would be somewhat more restricted than under the Administration plan. To the extent that financing depends in part on use of deductibles and co-insurance, the shortcomings previously discussed-the oppressive cost burden on low income families, the disincentive to seek early diagnostic and preventive care, the exclusion of many from access to treatment-will remain.

The Health Security Act is designed to restructure the health delivery system. Fifty percent of financing would be derived from Federal general revenues; the remainder by 3.5% employer payroll taxes, 1% tax on employees wages and 2.5% tax on the self-employed. These rates are similar to the Kennedy-Mills bill (3%; 1% and 2.5%). However, under the Health Security Act employer payroll taxes would have no maximum base as compared to a $20,000 maximum under H.R. 13870. All funds would be Federally administered through a Health Security Board. Cost containment would be effected by establishment of areawide annual prospective budgets based on reasonable costs by use of capitation or fee-for-service payments based on schedules of allowances and by means of negotiated budgets with hospitals, skilled nursing homes and other agencies. Elimination of deductibles and co-insurance requirements would enable all Americans to have open access to all benefits covered by the program.

RESOURCE DEVELOPMENT

Measures must be taken to vastly increase the facilities and programs for training physicians, dentists, nurses, social workers and other types of allied health personnel. Special emphasis should be placed on development of minority group manpower. Creative redeployment and utilization of the various professional and allied specializations must be carried out in order to make the most effective use of the potential contribution of each, working as an interdisciplinary team.

Both the Kennedy-Mills and the Health Security proposals address the need for resources development. The former would provide for a national Health Resources Development Board, semi-autonomous in HEW, to assure availability of

services in all parts of the U.S. to study adequacy of facilities, make recommendations on legislation and policy encourage development of HMOs and other alternative forms of service delivery; promote and support continuous health planning. The Health Security Act calls for a Health Resource Development Fund, financed with 5% of the Health Security Trust Fund, to improve delivery and increase resources via incentives to providers; emphasis on outpatient services; preventive services; HMO's; and grants and student assistance for training health personnel especially in areas of need.

The Administration bill calls for the states to review plans for hospitals and other institutional facilities "to redress current overemphasis on institutional care." No provision is made for training personnel. The President's recent statement 13 that "The Nation's manpower supply will be able to meet the demands that will be placed on it” has the ring of self-fulfilling prophecy. Indeed, if we remain deaf to the demands for a universal, comprehensive system of care, then the need for resource development does not arise.

The Long-Ribicoff proposal does not address the need for resource development.

CONCLUSIONS

Mr. Chairman and distinguished members of this Committee, the legislation which you have been considering will not of itself solve the multiple health care problems that confront us. We cannot with a single stroke, no matter how bold, undo generations of neglect nor meet the massive need for care, services, personnel and facilities which exists. Moreover, we will undoubtedly experience sizable increases in expenditures under any viable new national health program as previously unrecognized health needs emerge. We urge, however, that you permit neither the scope of the challenge nor the cost of the response to become insurmountable barriers to enactment of this essential legislation.

You have before you both a significant opportunity and an awesome responsibility. The time is ripe for a major overhaul and massive redirection of our health delivery system. As we approach the Nation's bicentennial anniversary, you have an opportunity to help enact a "health bill of rights" for all Americans. Legislation which fails to embody the principles which we have discussed today will deprive another generation of an opportunity to receive the best health care that we as a Nation are capable of providing. At a time when our natural resources are fast being depleted, we cannot afford to also allow our most precious resource the people of this country-to be afflicted by illness, weighted down by medical costs, and subject to the inadequacies of our present health care delivery system.

Thank you for affording us this opportunity to present our views.

Mr. BURKE. Our next group of witnesses are the American Association of Medical Clinics: Dr. Loman C. Trover, president; James Cobb, executive director; and Lawrence Hoffheimer, legislative counsel.

You may identify yourselves and your associates and proceed with your testimony.

STATEMENT OF LOMAN C. TROVER, M.D., PRESIDENT, AMERICAN ASSOCIATION OF MEDICAL CLINICS, ACCOMPANIED BY JAMES COBB, EXECUTIVE DIRECTOR, AND LAWRENCE HOFFHEIMER, LEGISLATIVE COUNSEL

Dr. TROVER. Mr. Chairman and members of the committee, I am Dr. Loman C. Trover of Madisonville, Ky., where I hold the position of medical director of the Trover Clinic. I am also privileged to serve as president of the American Association of Medical Clinics which represents physicians in group medical practice across the country.

With me are James B. Cobb, executive director of the association, and Lawrence S. Hoffheimer, who is counsel to the association. We are

13 Feb. 6, 1974.