Neither would there be adequate financial support for the health care systems agencies to allow them to plan, develop, and coordinate health services in rural areas-at least, that is our judgment.

To deal with these lingering problems, I am introducing today, with Senators Leahy and Anderson as cosponsors a package of six rural amendments to the Health Planning Act, and I will attach a copy to my statement. These are intended to build upon the efforts that you have begun, and of course, I ask this committee to consider them carefully, as I know you will, and to support those that you feel are worthy of support.

The amendments focus upon national health planning guidelines, adequate representation of rural interests, and financial support for health planning in medically underserved areas. Let me speak about each one, just a sentence or two.

First, national health planning guidelines must deal with issues unique to rural areas. Our amendment mandates special attention within the overall guidelines to the needs and concerns of rural people.

These are not separate guidelines, obviously, but they are a consideration within the guidelines. Now, this amendment precludes the imposition of inflexible national standards on rural and medically underserved communities.

In fact, in my judgment, if this amendment had been law, I am convinced that we could have completely avoided the recent small hospital controversy.

Second, rural consumers of health care should be assured of representation on the National Council on Health Planning and Development-the body that advises and consults with the Secretary of HEW.

Our amendment requires broader representation of population groups, including residents of nonmetropolitan areas, on the National Council, much as is required of the health systems agencies.

Since the Department of Agriculture has major responsibility for rural development, this amendment also adds the Department's Assistant Secretary for Rural Development as an ex officio member of the National Council.

I might say, in talking with the Assistant Secretary from time to time, they are very interested in the health area. Obviously, they have no jurisdiction over it. But they realize that rural development is quite incomplete without the health component.

Our third amendment would assure adequate representation of the same groups on statewide health coordinating councils-in other words, representation on statewide, as well as the National Council.

Fourth, the amendment that I consider most significant requires the development of subarea councils, which are smaller divisions of HSA's. The Secretary of HEW would be authorized to make grants to health system agencies for the development and operation of subarea councils. The size of the grant would be related to both the square mileage and geographical barriers within a particular health services area.

This amendment would make sure that geographic isolation and barriers do not restrict active citizen participation in the health planning process.

Subarea councils especially promote the involvement of rural people who have, up until now, sometimes been discouraged from participation.

This amendment also requires health system agencies to consider subarea views in the planning process. It insures that interests at the local level will not be lost.

And fifth, the funding mechanism for health system agency grants should include extra assistance for those areas with medically underserved populations.

While S. 2410 increases the overall level of health system agency grants, we feel another increase is needed to accommodate the special planning requirements of medically underserved populations. And here, of course, we are not speaking just of rural areas, but of medically underserved urban and rural areas. Specifically, the amount of any grant should be increased by 10 cents per medically underserved person in the health service area.

Needless to say, there is nothing automatic about that figure, but it seemed a reasonable one to us.

And finally, our sixth amendment strengthens the S. 2410 provision requiring centers for health planning to develop consumer education packages. We think that is an excellent idea, but under this amendment, these centers would emphasize the needs again of the medically underserved.

These six amendments embody the views of several organizations that are active in the cause of rural health care. I have received valuable input from a number of agencies-for example, the Appalachian Regional Commission, the Health Planning Council of the Midlands, the Iowa Health Systems Agency, Inc., the National Farmers Union, the National Rural Center, the National Rural Electric Cooperatives Association, Rural America, Inc., and the Department of Agriculture. All of these people, I know, are interested in these particular

amendments.

Finally, Mr. Chairman, like you, I look forward to the day when access to high quality health care is a fact for all Americans, rural and urban alike, rather than just a promise. And, I believe the adoption of these amendments will help to bring that day closer.

Senator CHAFEE. Thank you very much, Senator, for that excellent statement, and certainly, we will look forward with the greatest of interest in reviewing the six amendments which you have submitted. We appreciate your input, and we will be working with you personally-you and Senator Leahy-as we continue with the consideration of these.

Senator Javits, do you have any questions?

Senator JAVITS. Yes. Senator Clark, before you leave, I just have one thing I would like to ask you. We have two big problems in the cities, and I wonder whether they are shared in the rural areas.

One is the use of the emergency room for outpatient services because of the paucity of doctors. And the other is the breakdown in our public hospitals, which in many cases cannot even meet health standards, accreditation standards.

Do you have either of those problems in the rural areas?

Senator CLARK. Well, I think the problem in the rural area is somewhat different. You see that problem occasionally, depending upon the local situation. But it is harder to generalize in the rural areas, because they are so different-even from one part of our State to another, for example.

We might have problems in meeting standards, for example, in the very smallest hospitals; or again, if we have a real physician shortage in certain counties or very rural areas, then going into the hospital outpatient care might be necessary.

But it is harder to generalize, really, in rural areas, it is such a variety of problems.

Senator JAVITS. Thank you very much.

Senator CLARK. Thank you.

[The prepared statement of Senator Clark and amendments intended to be proposed by him follow:]

THE HEALTH PLANNING ACT AND RURAL AMERICANS

SENATOR DICK CLARK

FEBRUARY 6, 1978

SENATOR KENNEDY AND MEMBERS OF THE HEALTH SUBCOMMITTEE, THANK

YOU VERY MUCH FOR PROVIDING ME WITH THIS OPPORTUNITY TO SHARE

SOME THOUGHTS ON HEALTH PLANNING AND RESOURCES DEVELOPMENT,

THE ISSUE OF HEALTH PLANNING IS OF GREAT CONCERN TO ME,

TO THE PEOPLE OF IOWA, AND TO ALL RURAL AMERICANS, IN THE PAST

TWO YEARS, THE SENATE RURAL DEVELOPMENT SUBCOMMITTEE

WHICH

I CHAIR HAS HELD EXTENSIVE HEARINGS ON RURAL HEALTH CARE IN

VARIOUS PARTS OF THE COUNTRY. THESE HEARINGS HAVE LED ME TO THE

CONCLUSION THAT HEALTH PLANNING CAN AND SHOULD HAVE A CRITICAL

IMPACT UPON THE MEDICALLY UNDERSERVED.

EQUAL ACCESS TO HEALTH CARE IS THE TOP PRIORITY OF THE

HEALTH PLANNING ACT, IT'S ESSENTIAL, THEN, THAT WE STRUCTURE

THE PLANNING PROCESS TO ACCOMPLISH THAT GOAL

ESPECIALLY AS

IT RELATES TO THE UNIQUE HEALTH NEEDS OF RURAL PEOPLE.

BECAUSE I HAVE A DEEP SENSE THAT THE PROCESS IS NOT WORKING

ADEQUATELY TO MEET THESE NEEDS, I COME BEFORE YOU TODAY WITH

PROPOSALS TO STRENGTHEN THE HEALTH PLANNING ACT.

SENATOR KENNEDY, YOUR BILL, S. 2410, CORRECTS SOME OF THE

EXISTING INEQUITIES IN THE HEALTH PLANNING ACT, IT REPRESENTS

AN IMPORTANT FIRST STEP TOWARD PROMOTING ADEQUATE REPRESENTATION

WITHIN THE PLANNING PROCESS, CONSUMER EDUCATION, AND MORE

EFFICIENT USE OF UNDER-UTILIZED FACILITIES. BUT, THERE IS

MUCH MORE WE CAN DO TO FULFILL THE PROMISE OF THE ACT,

THE RECENT CONTROVERSY OVER THE NATIONAL HEALTH PLANNING

GUIDELINES DEMONSTRATES THAT THE ACT IS NOT OPERATING AS IT

SHOULD. THE RURAL COMMUNITY PERCEIVED THEM TO BE A DIRECT

THREAT TO THE EXISTENCE OF THEIR HOSPITALS. THESE GUIDELINES

WERE SEEN AS A LACK OF GOOD FAITH ON THE PART OF THE FEDERAL

GOVERNMENT, BECAUSE RURAL AMERICANS FELT THAT THEIR NEEDS

AND DESIRES HAD BEEN NEGLECTED.

THIS KIND OF SITUATION MUST NOT OCCUR AGAIN. UNTIL WE

RESTORE THE FAITH OF RURAL AMERICANS IN THE HEALTH PLANNING PROCESS,