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well-defined independent mission.

However, as these emphases were given up and the program began to take on a responsibility to serve the needs of its community and to respond to health planning, it became increasingly necessary to consider first its appropriate coordination and then combination with health planning programs. Not only did the Department [HEW] move the RMP program mission toward that of the CHP program, it did it in an ambiguous and inconsistent manner which made it increasingly hard to say what the program was supposed to be doing and defend it. . [emphasis added]?

The Comprehensive Health Planning (CHP) legislation, passed in 1966, was designed primarily to help state and local communities develop the best possible health care system where quality health care would be accessible, available, and affordable to all persons. Grants for the assistance of development of comprehensive health planning services were authorized by Section 314(a) of the Public Health Services Act. In order to qualify for these grants, states were required to offer a plan which would designate a single state agency as the planning process administrator. Also, it acted as the review agent of federal grants to areawide planning agencies. The plan also included a health planning council whose responsibilities were advisory in nature. Membership would be primarily composed of consumers, with broad representation of public and private state health organizations.

Smoother coordination among the 314(a) agencies, 314(b) agencies and other health groups occurred after Congress passed subsequent amendments. The addition in 1972 of Section 1122 of the Social Security Act further strengthened the CHP programs. The legislation gave authority to a designated state planning agency to deny reimbursement by Medicaid and Medicare for capital expenditures which were inconsistent with state or local health facility plans. This authority was the only real control mechanism available to most of the state and areawide agencies in the implementation of their plans..

The House Interstate and Foreign Commerce Committee and the Senate Labor and Public Welfare Committee extensively reviewed the

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program during 1974.

Although progress was made and several achievements noted, the Congressional Committees concluded that there were serious drawbacks which hindered the program's effectiveness and progress. Federal support, assistance and monitoring were inconsistent and irregular. Because of inadequate funding and staffing, many agencies could not fully respond to the broad spectrum of community health planning needs. Like the RMP, the CHP program did not receive adequate support from state and federal governments or from the medical establishment. The conclusion of both Congressional Committees was that:

...the CHP program is one which began with great enthu-
siasm in 1967 and 1968, flagged without substantial Fed-
eral financing or support until approximately 1971 and
is now again receiving substantial support and initiative
from the Department. It is a program which in many com-
munities has been very effective but in others has either
never existed or has lacked adequate funding, staffing
and authority with which to make substantial changes in
the health system. It holds many important lessons for
the design of a new program but has enough deficiencies
that it needs to be rewritten and combined with other
Federal health planning and resource development programs
in order to achieve the most effective possible program. 4

By the early 1970's, health planners and policy-makers alike had begun to realize that existing federal health programs were unable to plan effectively or to contain the spiraling costs of health care. In an attempt to replace the older ineffective programs, the 93rd Congress passed PL 93-641, the National Health Planning and Resources Development Act of 1974. The legislation allows HEW to enter into agreements with eligible local agencies and designate them as health systems agencies (HSAs). Their main objectives are implementing effective health planning and developing health services, manpower, and facilities within their respective

areas.

The legislation describes the purpose and functions of the HSAs as follows:

a) improving the health of residents of a health services

area;

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b) increasing the accessibility and quality of the health
services provided the residents;

c) restraining increases in the cost of providing these
residents with health services; and

d) preventing unnecessary duplication of health resources.

The National Health Planning and Resources Development Act is a result of an increasing involvement by the federal government in virtually all areas of health care. Particularly within the last ten years, Congress has enacted a variety of laws related to medical research, medical education, and the financing of health care. In devising the most recent comprehensive legislation, Congress attempted to combine the best features of the Hill-Burton program, the Regional Medical Program, and the Comprehensive Health Planning Program. Continuity extended from the older programs to the new one. Many of the same personnel, the same kind of policy decisions, and the same operating procedures carried over to the HSAs. Consequently, many of the problems and deficiencies of the old programs are now evident in the new program.

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STRUCTURE AND FUNCTIONS

OF HEALTH PLANNING AGENCIES

One of the primary advantages of PL 93-641 is that it establishes a unified and systematic approach to health planning. The legislation provides for a health planning network in each state consisting of local health systems agencies (HSAs), a state health planning and development agency (SHPDA), and a statewide health coordinating council (SHCC).

The Health Systems Agency may be either a private nonprofit or public corporation, a regional planning body, or a single unit of local government. It must have a governing body of ten or more members and executive committees comprised of no more than twentyfive members. The governing body must consist of a majority of consumers but no more than 60%. The consumers are supposed to represent the social, economic, linguistic, and racial populations of the health service area. The board must include both direct and

indirect providers and representatives of local governments.5

The HSA has the responsibility for developing a long range health system plan (HSP) and an annual implementation plan (AIP) for the area it serves. It reviews and comments on applications for federal funds to be used for health programs. It also has the responsiblilty for reviewing, at least every five years, existing institutional health services. States are obligated to establish Certificate of Need (CON) programs to prevent the development of unneeded services.6 Under these CON programs, the HSAs review and comment on recommendations to the state agency on the need for new institutional health services. For example, an HSA can recommend against funding a new hospital or against funding a project dependent on a federal grant. Thus, local health planning agencies do have limited authority whereas the preceeding planning bodies were virtually powerless.

In the strictest sense, PL 93-641 gives the HSAS simple advisory powers. Yet this role is an extremely important one because final approval for funds for many projects is dependent on initial approval by the HSA. The HSA's influence is further felt in its

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obligations to allocate selected federal health resources, regulate health facilities construction, and devise future planning of comprehensive health care. The potential power of HSAs is even greater. Under authority granted by three federal acts: the Public Health Services Act, the Community Mental Health Centers Act, and the Alcohol and Drug Abuse Education Act Amendment of 1974, the HSAs have the development and expansion plans of clinics, nursing homes, mental health facilities, and ambulance services under their jurisdiction. Potentially, the agencies could control locations, construction, and additions to virtually every type of health care facility.

The rationale behind the requirement for consumer majorities on HSA boards was that provider majorities would have less incentive to work to contain costs. The majority requirement for consumers means that they conceivably can control the growth and development of the local health care system.

State Health Planning and Development Agencies (SHPDAs) have been established under regulations proposed by HEW in March, 1976. They are agencies of state government designated by the governor and approved by HEW. They are responsible for integrating area health plans into a statewide health plan, establishing priorities within the state, and performing regulatory functions by administering the Certificate of Need program. It is not unusual for state agencies to have been former state health departments or planning agencies, such as 314(a) agencies. Their most important function is administering the Certificate of Need program.

The Statewide Health Coordinating Council (SHCC) is responsible for reviewing and coordinating health system plans and the annual implementation plans of the HSAs. It is possible for member HSAS to have control over the SHCC because 60% of the board members come from individual HSAs while 40% are governor appointees. The SHCC must consist of at least sixteen representatives appointed by the governor. The potential for consumer control of the health system also exists at the state level. At least one half of the council must be consumers. SHCCs review the state health plans and the