STATEMENT OF HON. TERRANCE PITTS, SUPERVISOR, MILWAUKEE COUNTY, WIS., ON BEHALF OF THE NATIONAL ASSOCIATION OF COUNTIES, ACCOMPANIED BY MIKE GEMMELL, NACO ASSOCIATE DIRECTOR FOR HEALTH AND EDUCATION

Mr. PITTS. My name is Terrance Pitts. I am a supervisor for Milwaukee County, Wis. I am also chairman of its health and education policy steering committee, and I am also a member of the National Association of Counties. With me is Mike Gemmell, the associate director for health and education for the National Association of Counties.

In the interest of time, Mr. Chairman, we are submitting for the record a detailed statement of our proposed amendments to the National Health Planning and Resources Development Act. I shall confine my remarks to our major concerns.

The National Association of Counties is strongly in support of a truly local health planning system. These agencies, we believe, should play a key role in the containment of costs and the implementation of a national health financing system. They must also provide the stimulus for providing services in underserved areas and encourage the kind of public health and prevention activities which offer the greatest potential for long-term improvement in health status.

However, planning in general and health planning in particular are intensely political activities. It is the process by which scarce resources are allocated-the classic definition of politics. As such, the process of planning is far more than the mere development of technically competent plans, reports and analyses. Of at least equal importance is the development of a broad based community support for the process and for the specific policies which are embodied in the health systems plan and annual implementation plan. Without broad public support, neither public nor private HSA's can withstand the political pressure which inevitably will result from policies aimed at making the health care system more efficient and effective.

There is clearly no large constituency now in existence for restricting the health care system. The some 50,000 responses to the recently issued national guidelines for health planning make this absence abundantly clear. If this constituency is to evolve, it must be developed at the local level-and the HSA's are critically important participants. These local agencies must be credible and have the understanding and, hopefully, the support of all segments of the community which have an interest in improving the efficiency and effectiveness of the health care system.

Our concern is that elected officials and other major groups are alienated from the health planning process. Their alienation is caused by the structure and processes of many HSAs which are established to avoid the significant and meaningful involvement of the local official and other major consumer and provider groups. Yet, their involvement and political support are critical for the successful implementation of the plans and policies of the HSA.

The amendments we are pronosing are based, in part, on intensive on-site studies of some 12 HSAs around the country. They focus on assuring that elected officials and other major consumer and provider groups have a meaningful-as opposed to token-participation in the

health planning process. While these changes will not assure community support, they will remove one of the major factors disintegrating such support.

First, we believe that the public regional planning body, joint powers agency or unit of local government which is an HSA should have the authority to approve the major policy documents of the agency, as well as the budget. It should have the authority to set the rules and regulations of the agency and appoint the governing body for health planning. Presently, after the governing body is appointed, the HSA governing board has nothing to do-yet, it is responsible for the policies which are incorporated in the HSP and AIP.

S. 2410 gives the governing board of the HSA the power to appoint the governing body for health planning and approve the agency's budget. Budget control, we think, is critical, and we fully support the inclusion of this provision. However, if the governing board is to be truly accountable, and if the public agency is to play a truly meaningful role, then it must have the power to approve the HSP and AIP, the criteria for project, institutional and appropriateness review, set the operating rules and regulations for the agency, and act as an appeal board for decisions made by the governing body for health planning.

A second major concern relates to the closed, often self-perpetuating nature of many HSA's. The present law allows a subcommittee of the existing governing body to choose new members of the body. In addition, it allows virtually any member of a group to represent that group. Therefore, any minority member can be deemed to represent minorities, any elderly person can represent elderly, and so on. The problem of elected officials is particularly difficult. A public health nurse, a faculty member from a public community college in health sciences, or even the coroner can be considered a public official representing the city or county. A study of the first 136 HSA's showed that only 9 percent were local elected officials.

An additional problem, relatively unique to elected officials, relates to the need to clarify all governing body members as consumers or providers. Many elected officials are classified as providers solely because the county board also serves as the county health board, board of trustees of the county home or hospital, or sponsors of funds programs providing county alcohol, drug abuse or mental health services. However, elected officials are not providers as the act contemplated. They are public officials who represent the public-both consumers and providers.

While S. 2410 prohibits the selection of new members of the governing body by the existing governing body or a subcommittee of it, we believe that the bill should go further.

Because of their significant role in the provision of health care, their role in paying for health care, particularly medicaid, and because they can show a direct constituency relationship to all segments of the community, we believe that one-third of the seats on an HSA governing body should be reserved for local elected officials or their designees from units of local government with substantial health interests.

We believe that elected officials should be identified as a separate category from consumers or providers.

Senator SCHWEIKER. I just want to say I think that is a very valid point, and I take cognizance of that. There was some testimony yesterday along similar lines. I do not think we have a clear-cut position yet. I think that is clearly important. Thank you.

Mr. PITTS. Thank you, Mr. Chairman.

Local elected official seats be filled by direct appointments by units of local government or combinations with substantial health interest. Senator SCHWEIKER. One question.

Do you have a recommendation on the percentage of local officials you would like to see on the board?

In other words, we have different opinions obviously of what percent of the board should be made up of local officials. Anything from 15 to 25 percent. I wonder if you have a view on that.

Mr. PITTS. Our position, Mr. Chairman, is one-third. Of course, nothing is magic or sacrosanct about that.

We feel that that is an optimum goal because we think that the elected officials in the local communities represent the broad constituency in all segments of society, and we feel that would be a reasonable number. To some, of course, that may be high, but we feel that that is an adequate and reasonable amount of representation of public elected officials on the board.

Senator SCHWEIKER. OK. Go ahead.

Mr. PITTS. Finally, there are 12 single State or virtually single State HSA's. In addition, there are several States, such as Iowa and Nebraska, with HSA's of 50 or more counties. In these areas and others. participation by local officials and others is difficult, if not impossible. As a result, we believe that the act should contain a strong endorsement for subarea councils with the indication that, where possible, they should follow existing recognized boundaries. We also believe that the HSA's should be given the authority to delegate elements of plan development and project review authority to the subarea council.

In closing, on behalf of NACo, I would like to congratulate you, Senator Kennedy and your staffs for the fine job you have done in preparing S. 2410. We support many of its provisions, including the permissive language to increase rural representation, the easing of the criteria for area redesignation, the provision permitting the Secretary to return the HSA to a conditionally designated status from full designation, and other provisions.

We are particularly pleased with the provision of $75, $100 and $125 million for fiscal year 1979, 1980 and 1981, respectively, for the upgrading of public general hospitals. Many of the large urban public general hospitals suffer from old and inadequate physical plants which are often in violation of life safety codes. This money would allow the refurbishment and upgrading of these facilities.

Mr. Chairman, we also strongly endorse the proposed grant program in S. 2410 to assist in the phasing out of unneeded medical facilities. We strongly supported this provision when it was part of the administration's cost containment program and we support its inclusion in the health planning law.

These amendments, and those we have offered, will go a long way to remedying the structural and procedural elements which have served to undermine local political support. With these changes, HSA's

can become the strong credible agents for change in the health care system that Congress intended.

Thank you.

Senator SCHWEIKER. You have mentioned in your statement a few paragraphs back, about there being 12 single State-I believe there were 14 single State HSA's. One suggestion we heard yesterday is that we ought not to permit single State HSA's in every State.

Another suggestion was that when we had a single State situation, we might define the role of a single State HSA somewhat differently so that there would not be conflict with the State agencies on a 1-to-1 basis.

Do you have any suggestions along those points?

Mr. PITTS. Yes. We think there should be subarea councils so that the different portions of the States which have different interests can have proper input to the HSA at the top, and at the beginning on the State level. We feel that single State HSA's are not in the best interest. We feel that they should be broken down. We feel that there should be different regulations to apply to single State HSA's-and we feel, Mr. Chairman, that if we would follow-if you would follow the recommendations that we have made in our testimony about subarea councils, that they would go a long way to alleviate the problems found in States that are single HSA's or virtually single HSA's.

Senator SCHWEIKER. If you did not permit a State to have a single HSA, if they had at least two, would that not be doing the same thing? Mr. PITTS. I do not believe so, Mr. Chairman, because I think you could have three, maybe four subarea councils in order to deal with the varying areas in a particular State which have different interests. Senator SCHWEIKER. On page 2 of your testimony you state that the public HSA governing board should have final approval of the HSP and the AIP as opposed to their governing body.

Could you give us data or information on this which describes the types of problems that have arisen due to the Board's not having that power now?

We have tried to improve the lot of the public HSA board by giving final authority. But I wonder if you have any to approve the AIP, the agency budget and to remove, with cause member of the board, specific data or information which might describe the difficult problem because the board did not have this power?

Mr. PITTS. On that particular question I will defer to Mr. Gemmell. Mr. GEMMELL. Senator Schweiker, we, as our testimony indicated, conducted the onsite studies of 12 areas very intensely so we do have data back in the office that can substantiate some of the problems that you refer to. The reason why we are asking for approval of the HSP and the AIP is simply because those are the major policy documents of an HSA, and budget control is not enough in order to keep HSA's accountable.

The elected officials of the HSA board still would be accountable to the public without any major say-so as to how the plan is developed. So we feel that it is urgent that we work with your staff and provide you that information.

Senator SCHWEIKER. All right.

Thank you both very much. We certainly appreciate your being here and we will pay a lot of attention to your very practical suggestions. Thank you.

Representative Czerwinski will not be able to attend but we will put his statement in the record for the proceedings.

[The proposed amendments referred to by Mr. Pitts and the prepared statement of Representative Czerwinski along with additional material supplied follows:]