HISTORY OF THE STATE-FEDERAL REHABILITATION PROGRAM

Efforts of the Federal Government to rehabilitate handicapped civilians began with the passage of the Vocational Rehabilitation Act in 1920. Before that time, a few States had demonstrated the possibilities of vocational rehabilitation. The act of 1920 was inspired by the Veterans' Administration Act which had been passed in 1918. Services, at first, were limited to individuals injured in industry. The program continued from 1920 to 1943 with meager appropriations, limiting its services principally to vocational training and counseling services. The Barden-La Follette amendments of 1943 broadened the scope of services and enabled the program to expand rapidly during the war years and immediately after. In order to make a handicapped person employable, a rehabilitation agency may now make available medical and psychological diagnosis, hospitalization and surgery, training supplies, placement equipment, and counseling services throughout the rehabilitation process. Approximately 1,500 professional workers now serve 200,000 persons annually, rehabilitating 65,000 each year. Reports from the Office of Vocational Rehabilitation, which will undoubtedly be made available to this committee, will indicate how the State-Federal program has grown in the number of persons rehabilitated and in the type and variety of services offered. Such reports also show the source from which cases are referred to the State agencies, the types of disabilities that are served and in what numbers, and the types of jobs into which these people are rehabilitated. Most significant, we think, is that these figures indicate that the philosophy of the State agencies is to serve all types of the handicapped, so far as their personnel and facilities will permit, and that each year shows a higher percentage than the year before of the number of cases which could be considered most severely handicapped,

RESPONSIBILITY OF THE FEDERAL GOVERNMENT FOR REHABILITATION

The Federal Government has long been concerned with the problem of disability in the country, but up to date most of its expenditures have been in public assistance for the handicapped rather than in rehabilitation. For instance, the Federal Government is participating in $140 million being paid annually to 140,000 disabled breadwinners of 370,000 dependent children; it is participating in the payment of $92 million to 159,000 permanently and totally disabled adults; it is contributing $63 million being paid to 98,000 needy blind. It is estimated that without something substantial being done to rehabilitate the persons who might be classified as "permanently and totally disabled" under this new category of public assistance that total expenditures may reach $300 million or $400 million annually. The greatest amount that the Federal Government has ever appropriated for rehabilitation of the handicapped is $23 million which has been made available for the 1953-54 fiscal year. Inasmuch as the values of rehabilitation in increasing the available manpower and production and in reducing dependency are well known, it seems axiomatic that the Federal Government does have a concern for the rehabilitation of the handicapped people of this Nation. It also appears that it has a responsibility to do more in the future to assist in the rehabilitation of the handicapped people than it has done in the past. Any other course would seem to be very shortsighted at this time.

STATE-FEDERAL PROGRAM OF REHABILITATION MUST BE MAINTAINED

Continued progress in the rehabilitation of the handicapped, in our judgment, depends upon the following factors:

1. The State-Federal program of rehabilitation must be maintained and strengthened. Almost everyone intimately acquainted with the work of the State agencies recognizes that they are doing a good job with what they have to work with, but few of them are staffed and financed to do anywhere near what is expected of them. Since it is unrealistic to assume that the private rehabilitation agencies are going to be able to handle the burdens of rehabilitation by themselvs, and since it appears that the demand for rehabilitation services is going to increase rather than decrease, it appears inevitable that the State-Federal program of rehabilitation must remain the heart of the Nation's effort to rehabilitate the handicapped. The State-Federal program carries rehabilitation into every crossroads in the country. In many areas, in whole States, in fact, the rehabilitation counselor of the State-Federal pro

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gram is the case finder, counselor, psychologist, and placement agent. knowledge of people and facilities enables him to do well an almost unbelievably difficult job. If rehabilitation is to move forward as we all hope it will, there must be more well-trained rehabilitation counselors and they must be given the tools to enable them to work more effectively.

In bills sponsored by the National Rehabilitation Association and now before this committee, we are making some suggestions with respect to amendments to the present State-Federal rehabilitation program which will remove certain restrictions that we believe serve to retard the progress of rehabilitation. They are in substantial agreement with similar proposals found in S. 2759. The problem is, however, fundamentally, one of money, and, of course, the personnel and services that money can make available.

Another reason that we feel that the Federal Government can afford to be liberal in financing vocational rehabilitation is that it is a pioneer program in so many respects. Although there has been a rehabilitation program since 1920, it is only in recent year that the potentialities for many of the severely handicapped have been realized. Important as the dividends of the present program may be, they are small, indeed, in comparison with the possibilities. For instance, the No. 1 problem of disability in this country is mental illness. It affects more people and costs taxpayers more money than any other disability. Medical science is making wonderful strides in curing mental illness. Mental health authorities agree that rehabilitation following definitive treatment is a must, if most desirable results are to be obtained. Yet, the rehabilitation of this group is in its infancy. Some States are hardly touching it at all. The Federal Government could profitably spend $10 million per year, matched or unmatched by the States, to encourage a determined effort to rehabilitate the mentally ill. The same might be said for other large groups that are hardly affected by rehabilitation as yet.

In our judgment, it will be many years before the Federal Government can assume that it has done its part to promote rehabilitation and consider a stabilization of the program.

REHABILITATION CENTERS

2. In the second place, progress in rehabilitation will, to a considerable extent, depend upon the availability of rehabilitation facilities wherein the severely handicapped may be rehabilitated. The rehabilitation center is such an

institution.

Reduced to its simplest terms, a rehabilitation center is a place where the various members of the rehabilitation team, physician, therapist, counselor, social worker, appliance fitter, etc., can cooperate in the practice of their special skills in the rehabilitation of the handicapped. All of us can remember when the fitting of an artificial limb, a relatively simple procedure in a rehabilitation center was a matter of great difficulty. The poor amputee was pushed from counselor, to physician, to limbmaker, until he was dizzy. If the limb didn't fit, the limbmaker blamed it on the physician for not having the stump in good condition, the physician was likely to blame the situation upon the limbmaker and the amputee was lost in the shuffle. As a result, surveys of the use of artificial limbs revealed that a high percentage of them were not being used at all. This team approach to the rehabilitation of the amputee has cleared up this problem to a great degree. Some types of the severely handicapped, the paraplegics for instance, need the services of the rehabilitation center even worse than the amputees, if this is conceivable.

The Federal Government has already demonstrated its interest in helping States to finance a hospital-construction program. It is not too much to expect that the Federal Government should now concern itself with assisting the States in the establishment of rehabilitation centers which can do so much to assist in the rehabilitation of the 2 million severely handicapped people of this country.

SHELTERED WORKSHOPS

3. In the third place, the expansion of workshop facilities for the severely handicapped will be of great assistance in assuring forward progress in rehabilitation.

Despite the progress in rehabilitation, there remain many people, 300,000 it has been estimated, who are too severely disabled to be placed in competitive employment. With respect to these people, this question must be answered. Shall they

be left idle and helpless in their homes or in tax-supported institutions, or shall they be given the opportunity to work to whatever degree they are able? From the standpoint of economics, the rehabilitation of this group is not as profitable as the rehabilitation of those who can take their place in competitive employment. They do not earn as much. They do not pay as much in taxes. The sheltered shops which we are suggesting for such individuals are not moneymaking institutions, in fact, they may lose considerable sums at times. It is usually necessary to have some sponsoring agency in the community which is willing to take the responsibility for such deficits as may exist.

On the other side of the picture, a considerable number of people who are employed in sheltered workshops develop to the extent that they can move out to other employment.

The human values are self-evident. We cannot allow human beings to be cast aside just because they cannot produce at normal rates. The respect we have for human dignity in this country demands that we give every citizen an opportunity to do his best.

Incidentally, in the management of sheltered workshops, care must be exercised to see that they do not become filled with people who could make a living elsewhere. Careful planning and firm administration are necessary to prevent such a situation from arising.

PERSONNEL FOR REHABILITATION

4. Fourth, it is axiomatic that rehabilitation work cannot be done unless there are people to do the work. At the present time, there is a great shortage of personnel in practically all professional areas of rehabilitation. Rehabilitation is unique in that there is no one profession whose members are trained to do a complete rehabilitation job. The successful rehabilitation of the severely handicapped depends upon the combined efforts of the physician, the physical therapist, occupational therapist, nurse, vocational counselor, and numbers of other professional people with equally specialized skills. In practically all of these areas, there are serious shortages. In any program designed to advance rehabilitation in the immediate future, provision must be made for recruiting and training professional workers.

RESTRICTIONS IN PRESENT VOCATIONAL REHABILITATION ACT

5. Fifth, there are certain restrictions which should be removed from the Vocational Rehabilitation Act in order to allow the State agencies to do a more complete job of rehabilitating the handicapped of the various States. For instance, an arbitrary limitation of 90 days hospitalization for any one disability mitigates against the rehabilitation of the severely handicapped who may require a longer period of hospitalization. The removal of this restrictive language would in no way endanger the basic operation of the program and would undoubtedly enable many of the severely handicapped persons now being denied service an opportunity to be rehabilitated.

The present law has also been interpreted so as to mean that Federal funds cannot be used to reimburse State agencies for personal services in connection with the management and supervision of homebound or other small-business enterprises. Neither can Federal funds be used to stock inventory for such business enterprises. A clear-cut statement in the law authorizing the agencies to render such services would be extremely helpful.

PRINCIPLES THAT SHOULD GOVERN FEDERAL PARTICIPATION IN A PROGRAM OF VOCATIONAL-REHABILITATION CENTERS AND SHELTERED WORKSHOPS

In our judgment, the following principles should prevail in a program of Federal assistance to the States for the purpose of establishing rehabilitation centers and sheltered workshops.

1. Federal financial participation should be based upon the needs of the States for assistance. We recommended the formula used to distribute funds under the Hill-Burton Construction Act.

2. Funds should be available to State governmental units and to private nonprofit corporations.

3. Preference for services in rehabilitation centers and workshops established with Federal assistance should be given to persons referred by the vocationalrehabilitation divisions, crippled-children services, workmen's compensation com

missions, public-welfare departments, and other State and federally supported organizations in the rehabilitation field.

4. Rehabilitation centers should be defined in such a way as to insure that funds will go to centers offering well-rounded programs of rehabilitation services. 5. The Secretary of the Department of Health, Education, and Welfare should have authority to set up regulations to assure provision of services in accordance with professional and business standards.

ADMINISTRATION OF REHABILITATION ON FEDERAL LEVEL

At various times the question arises as to how vocational rehabilitation shall be administered on a Federal level. The viewpoint of the National Rehabilitation Association is that the Office of Vocational Rehabilitation should continue to administer the Federal end of the State-Federal program and that this office shall continue to be in the Department of Health, Education, and Welfare, with its status improved by having it made legally a bureau in the Department. These recommendations are embodied in H. R. 5562, which is before the committee. The question of the administration of the Federal functions in vocational rehabilitation has been raised a number of times and always with the same results. The first important study along this line was made by the Kelley committee to investigate aid to the physically handicapped in 1946. The report of this committee included a recommendation that OVR remain in the Federal Security Agency and serve as a base for an expanded program for services to the handicapped. The report of the Hoover Commission also stated that the functions of rehabilitation should continue to be administered in this agency. A number of times, the Bureau of the Budget has studied this question and has never yet seen fit to recommend any change. The most thorough recent exploration this matter has received was before the Senate Committee on Public Welfare in 1950. Following these hearings, the committee reported unanimously and the Senate passed, also unanimously a bill containing substantially the administrative provisions that we are recommending today; that is, that OVR remain in the Department of Health, Education, and Welfare, and that it be given bureau status.

We fear the controversy over jurisdiction of the program on the Federal level has prevented the passage of legislation which would improved the rehabilitation of the handicapped. We sincerely hope that this will not be allowed to interfer again this year.

ADMINISTRATION AT STATE LEVEL

Present laws require that State boards for vocational education be the administering agencies in the States, except where a State agency for the blind has legal authority to rehabilitate the blind, in which case this agency shall be the rehabilitation agency for the blind. We notice that S. 2759 provides that the agency for administering rehabilitation in the State shall be either the State board for vocational education or a State rehabilitation agency (primarily concerned with rehabilitation). The National Rehabilitation Association feels that administration of the program in the States can be opened up to this degree without jeopardizing the stability of rehabilitation programs.

There are many reasons why State boards for vocational education have been considered the logical authorities to administer rehabilitation. In the first place, they have the experience of administering the program since their inception in 1920. In the second place, State boards for vocational education, which are sometimes the same as State boards of education, are highly respected bodies in all of the States, carrying great prestige. Third, State boards for vocational education are less likely to be hindered by political interference than most other departments of State government. State rehabilitation agencies have a right to be concerned, we believe, what might happen if the administration of the program in the States is thrown wide open. Controversies such as have existed on the Federal level for several years over the administration of vocational rehabilitation could easily follow on a State level. On the other hand, NRA feels that if any State is so much concerned with the progress of rehabilitation that it wants to set up an independent agency to administer the program, that the State should be allowed to do this.

Having set forth in the preceding parts of this testimony an outline of the history and scope of rehabilitation programs in this country and having stated some principles upon which we believe that sound growth can proceed, we shall now undertake to refer specifically to bills which are before this committee for consideration.

AMENDMENTS TO HOSPITAL SURVEY AND CONSTRUCTION ACT (S. 2758)

S. 2758 would amend the Hospital Survey and Construction Act to make Federal aid available to the States to assist in the establishment of treatment and diagnostic centers, chronic-illness hospitals, rehabilitation facilities, and nursing homes. We wish to comment on this bill as it relates to rehabilitation facilities. Since 1949, the National Rehabilitation Association has been sponsoring legislation which would make Federal assistance to the States for the establishment of rehabilitation centers possible.

The purposes of S. 2758 appear identical with the purposes of the National Rehabilitation Association sponsored bill S. 2437. Accordingly, we are supporting S. 2758, but would like to make a few comments with respect to certain phases of the bill which we think to be extremely important.

In the House of Representatives, we notice that an effort was made to throw together in 1 fund appropriations for the 4 types of facilities envisaged in this bill. We insist strongly that funds be earmarked for rehabilitation facilities. If this is not done, we fear that the pressure for other types of facilities may result in the neglect of this very important area of unmet need. If, after the categorical approach has been tried for a few years, reasons develop for combining 2 or more of the funds into 1, consideration can be given to this at that time. In the second place, we approve heartily the amendment which was added in the House of Representatives which allows 1 State to assign its allotment of funds to another for the purpose of establishing a facility to serve the handicapped of more than 1 State. Certain types of rehabilitation facilities, particularly the more comprehensive type, may not be needed in everyone of the States. The assignment by one State of its allotment to another should facilitate the establishment of regional facilities. Third, we want to emphasize the importance of maintaining in this piece of legislation the definition of rehabilitation facilities which encompasses both vocational and medical aspects of rehabilitation. In our judgment, the definition of the rehabilitation facility found in S. 2758 is satisfactory. Several times while hearings were being conducted specifically on S. 2758, the question was asked as to whether rehabilitation centers could not be built under the Hospital Survey and Construction Act as it is now written. Such queries seem to question the necessity for additional legislation. It is undoubtedly true that a certain type of rehabilitation center could be built under the present statute. This would be a center which is a part of a hospital, as a hospital is defined in the Hill-Burton Act. It is significant that some of our finest rehabilitation centers in the country could never have been built under this definition. Notable among these are: The Institute for the Crippled and Disabled in New York City, which is not a part of a hospital and which carries on a broad program of vocational training along with medical services; the Woodrow Wilson Rehabilitation Center at Fisherville, Va., which was built in connection with a large vocational-training school, and where physical medicine facilities were brought to the vocationaltraining school, rather than vocational-training facilities being brought to the hospital; and the Okmulgee Rehabilitation Center at Okmulgee, Okla., established by Oklahoma A and M College in connection with a huge vocational school. Again, physical medicine facilities were brought to the vocational school. All such centers, of course, have staff connections with medical institutions.

It is also important to point out that in communities having several hospitals, not all of them could afford to have rehabilitation centers, even if they could be built under the definition of a hospital. Rather than to have several competing rehabilitation centers, it will be preferable in many instances that 1 comprehensive rehabilitation center be built in the community, probably not connected administratively with any hospital, but having staff service from 1 or more hospitals; and this rehabilitation center could then serve patients coming from all of the hospitals in the community.

It is significant, I think, that even with the great need for comprehensive rehabilitation facilities which has been evident for several years, not a single such facility has been established under the present act, although some departments of physical medicine may have been included in teaching hospitals built under it.

One other comment I would like to make, that is, that $10 million a year is very little money to distribute among 48 States for the purpose of establishing rehabilitation facilities. With this allotment base. Connecticut's yearly apportionment would be $73,000, New York, with one of the highest allotments, would have about $450,000 a year, while many of the smaller States would fall in the $50,000 minimum allotment class.