Mr. WAXMAN. I would like to call a panel on public official involvement, the Honorable Mary Marshall, delegate, Virginia, chairwoman, National Conference on State Legislatures Committee on Human Resources; Mark Ravenscraft, commissioner of Summit County, Akron, Ohio, accompanied by Jon Weintraub, associate director, National Association of Counties; and James S. Robinson, chairman, Area Health Commission of Houston/Galveston Area Health Systems Agency.

Welcome.

STATEMENTS OF MARY MARSHALL, CHAIRMAN, HUMAN RESOURCES POLICY COMMITTEE, NATIONAL CONFERENCE OF STATE LEGISLATURES; MARK RAVENSCRAFT, VICE CHAIRMAN FOR HEALTH RESOURCES, HEALTH AND EDUCATION STEERING COMMITTEE, NATIONAL ASSOCIATION OF COUNTIES; AND JAMES S. ROBINSON, CHAIRMAN, HOUSTON-GALVESTON AREA COUNCIL HEALTH STYSTEMS AGENCY

Ms. MARSHALL. My name is Mary Marshall, and I am chairman of the Human Resources Policy Committee, National Conference of State Legislatures, and a member of the Virginia Legislature where I serve on the Health, Welfare Institutions Committee which considers our certificate of need law.

I have a statement which has a preamble about how fine health planning is, and I think you will be willing to accept that as read and I will go on.

Mr. WAXMAN. That is agreeable. We will include your testimony in its entirety in the record. We would like you to summarize within 5 minutes.

Ms. MARSHALL. There are several questions I want to address. I first want to point out that many of the States have acted in this field and have acted before the Congress did. So there has been a considerable initiative in this field. Both Virginia and Maryland had laws in place before the National Health Planning Act.

On the question of the coverage of physicians' offices we do cover them in Virginia. This is quite relevant to your deliberations. We covered every expenditure over $150,000 and we do that until July 30 of this year when the figure will rise to $200,000. The reason it will rise is that we revised our certificate of need law in January in response to HEW's demand that we change some of our definitions to fit better with the Federal law. As a result of this, the bill got loose on the floor and the floor amendment raised that ceiling. So that our certificate of need law is now a little weaker than it was as a result of our attempt to comply with the Federal mandate. One of the things we hope you will not do is preempt the State's ability to rise above the Federal standards if we wish to. The chief burden of my testimony is the need to include public officials more in the whole HSA process. There are several points I want to make.

The first one is that on the demonstration rate review the Senate has cut back the funds available to the States to fund rate review programs. We feel that certainly should be kept the way it is and possibly expand it.

It is the responsibility of the State legislatures to establish priorities for health care in their States. Being shut out of the HSA

process does not effectively shut them out of providing health care because at some point things come to the appropriations committee and there is a legislative review. We feel it is very important that there be certain changes. We would like to have the authority to review and approve State plans, that it be reviewed and recommended to the Governor and to the State legislature.

In summary, the Governor in consultation with the appropriate State legislative committee should have the final authority to approve or disapprove the State health plan and the subsequent annual revisions of it. The Governor should be able to appoint at least 50 percent of the members of a SHCC. The Governor should appoint with the advice and the consent of the senate, or possibly you could make that with the legislature because in Virginia the house also advises and consents.

The chairman of the HSC, this is a regulatory agency as powerful as any regulatory agency that any State has, and the heads of those agencies are almost always appointed through the Governor. So they are answerable through the political process. We need increased involvement of public elected officials on the governing bodies of the health assistance agencies, and that is the main point that we want to make.

The final one, the language should read, "each certificate of need in the State that is issued must be based solely on the administrative and judicial proceeding." We think you should take that out. We think that is a slap in the face of the State legislatures. It is my understanding that there are three State legislatures that have reversed a SHCC decision on granting the certificate of need, that in two of those cases the State court threw their action out. There are seven or eight States that have higher standards that have responded more positively than required. We think that the political process is working reasonably well and you should not throw a wrench in the works by just demonstrating a lack of faith in the political process.

Essentially that is the burden of what I am saying, and this is a philosophical argument that will go on in connection with this bill as to whether you are going to set up a fairly elitist group drawn from people knowledgeable in the field with the powers to make all of the decisions or whether you are going to include the elected officials who in the end must answer to the people and cope with meeting the bills in making those decisions.

I think the bill, as it is, was borne in, a good part of it, as distrust of the political process, and we all know cases where the political process has not worked. In every State we have had the examples. But in the end you have to rely on it for good public policy. There is no other way to reach it, and that is our chief argument.

[Testimony resumes on p. 562.]

[Ms. Marshall's prepared statement follows:]

Statement of Mary Marshall, Chairman, HUMAN RESOURCES POLICY
COMMITTEE, NATIONAL CONFERENCE OF STATE LEGISLATURES

MR. CHAIRMAN, BEFORE I BEGIN THE FORMAL PART OF MY TESTIMONY, I
WOULD LIKE TO READ A BRIEF QUOTE WHICH I BELIEVE CAPTURES SO WELL IN
A FEW WORDS WHAT THE PLIGHT OF THE STATE LEGISLATOR IS WITH RESPECT TO

HEALTH POLICY. THE QUOTE IS BY KATHARINE BAUER, PRINCIPAL ASSOCIATE
AT THE HARVARD CENTER FOR COMMUNITY HEALTH AND MEDICAL CARE, AND WAS
RELATED IN A SPEECH BY HER TO A HEALTH CONFERENCE FOR STATE LEGISLATORS

LAST YEAR.

"YOUR GOVERNORS WANT TO PUT THE LID ON RISING HEALTH CARE
COSTS BUT DON'T WANT TO TAKE THE POLITICAL HEAT OF REDUCING
BENEFITS OR SERVICES. YOUR CONSUMERS DON'T WANT MORE TAXES
OR HIGHER BLUE CROSS PREMIUMS, BUT THEY DO WANT A FULL
SERVICE HOSPITAL DOWN THE STREET, COMPLETE WITH AN OPEN HEART
SURGERY UNIT JUST IN CASE. AND THEY DO WANT JOBS CONSTRUCTING
HOSPITALS AND NURSING HOMES, SUPPLYING THEM AND WORKING IN
THEM. ALSO, BOTH THE PROVIDERS OF SERVICES AND THOSE THAT
ATTEMPT TO REGULATE THEM BRING YOU THEIR ACCOUNTS ALAS,
OFTEN TRUE ABOUT THE INEQUITIES AND INIQUITIES THE OTHER
PARTY PERPETRATES. FINALLY, AFTER LISTENING TO ALL THE EXPERTS,
YOU PASS APPARENTLY SENSIBLE, SIMPLE LAWS THAT YOU THINK WILL
HELP STRAIGHTEN OUT OUR HEALTH CARE PROBLEMS ONLY TO
WATCH MANY OF THEM BECOME FISCAL OR ADMINISTRATIVE DISASTERS."

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MR. CHAIRMAN, I AM SURE YOU AND THE MEMBERS OF YOUR SUBCOMMITTEE CAN

RELATE TO THOSE REMARKS BY MRS. BAUER SINCE YOU FACE MANY OF THE SAME

EXPECTATIONS AND FRUSTRATIONS BUT ONLY AT A DIFFERENT LEVEL IN THE FEDERAL

SYSTEM.

MY NAME IS MARY MARSHALL AND I AM A DELEGATE IN THE VIRGINIA

GENERAL ASSEMBLY WHERE I SERVE ON THE HEALTH, WELFARE AND INSTITUTIONS

COMMITTEE. I HAVE SERVED IN THE GENERAL ASSEMBLY FOR THE PAST TWELVE YEARS. I APPRECIATE VERY MUCH THE OPPORTUNITY TO APPEAR BEFORE YOU TO OFFER OUR

VIEWS ON THE REAUTHORIZATION OF THE NATIONAL HEALTH PLANNING AND RESOURCES

DEVELOPMENT ACT (PL 93-641).

THE OBSERVATIONS AND RECOMMENDATIONS INCLUDED IN THIS TESTIMONY GREW

OUT OF MEETINGS CONDUCTED BY THE HUMAN RESOURCES COMMITTEE OF THE NATIONAL

CONFERENCE OF STATE LEGISLATURES.

THAT COMMITTEE, OF WHICH I SERVE AS

CHAIRWOMAN, IS CHIEFLY RESPONSIBLE FOR MAKING RECOMMENDATIONS ON HEALTH
AND WELFARE POLICY TO THE STATE-FEDERAL ASSEMBLY (SFA) OF THE NCSL. THE

HUMAN RESOURCES COMMITTEE IS COMPOSED OF CHAIRMEN AND RANKING MEMBERS OF

STATE LEGISLATIVE HEALTH AND WELFARE COMMITTEES.

THE HUMAN RESOURCES COMMITTEE MET ON SEVERAL OCCASIONS OVER THE PAST

YEAR AND DEVELOPED A SERIES OF RECOMMENDATIONS WITH RESPECT TO THE RENEWAL

OF THE HEALTH PLANNING LAW. IN THAT EXERCISE, WE WERE GRATEFUL FOR THE PARTICIPATION OF MR. BOB CRANE AND MR. BILL CORR, PROFESSIONAL STAFF MEMBERS FROM THE HEALTH SUBCOMMITTEE, WHO ASSISTED US IN OUR UNDERSTANDING OF WHAT

THE KEY ISSUES WOULD BE DURING THE DEBATE OVER REAUTHORIZATION.

THE RECOMMENDATIONS ADOPTED BY THE HUMAN RESOURCES COMMITTEE WERE

CONSIDERED AND ACCEPTED UNANIMOUSLY BY THE FULL CONFERENCE AT ITS ANNUAL

MEETING LAST YEAR. AS YOU KNOW, THE NATIONAL CONFERENCE OF STATE LEGISLATURES

IS THE ONLY OFFICIAL PROFESSIONAL ORGANIZATION REPRESENTING THE CONCERNS AND

INTERESTS OF THE NATION'S 7,500 STATE LAWMAKERS.

MR. CHAIRMAN, WE BELIEVE THAT THERE ARE FEW PUBLIC POLICY ISSUES TODAY MORE IMPORTANT THAN THE ASSURANCE THAT OUR NATION'S AVAILABLE HEALTH

RESOURCES ARE DISTRIBUTED ON THE BASIS OF NEED AND IN SUCH A MANNER AS TO

ENSURE THE MAXIMUM EFFICIENCY AND COST-EFFECTIVENESS OF OUR HEALTH CARE SYSTEM.

THE ENACTMENT OF THE HEALTH PLANNING AND RESOURCES DEVELOPMENT ACT (PL 93-641)

REPRESENTED A GOOD STEP IN THE FURTHERANCE OF THAT GOAL. THE CONCEPT OF

PLANNING FOR A MORE EFFECTIVE AND EFFICIENT ALLOCATION OF OUR LIMITED HEALTH

RESOURCES IS ONE WHICH WE FULLY ENDORSE. THE CONGRESS DESERVES CONSIDERABLE

PRAISE FOR ATTEMPTING TO BRING THE VARIOUS INTERESTED PARTIES TOGETHER THROUGH

PLANNING MECHANISMS DESIGNED TO PROMOTE GREATER ORDER AND COORDINATION
TO WHAT HAS HERETOFORE BEEN A FRAGMENTED AND VERY COSTLY HEALTH CARE SYSTEM.

WHILE STATE LEGISLATORS EAGERLY SUPPORT THE GOALS AND PURPOSES OF

PL 93-641, WE HAVE MANY CONCERNS WITH SOME OF THE SPECIFIC STRUCTURES,
RELATIONSHIPS, AND PROCESSES CREATED BY THE ACT TO FULFILL THOSE GOALS.
IN GENERAL, WE BELIEVE THAT THE RESPECTIVE ROLES OF THE PLANNING AGENCIES

AND EACH LEVEL OF GOVERNMENT SHOULD BE CAREFULLY RE-EXAMINED WITH A VIEW

TOWARD GREATER STATE GOVERNMENT PARTICIPATION IN HEALTH PLANNING AND REGULATION.

OUR INTEREST WITH PL 93-641 GROWS NOT SO MUCH OUT OF A CONCERN THAT

THE FEDERAL GOVERNMENT IS ATTEMPTING TO SUPPLANT STATE HEALTH DECISION-MAKING

AUTHORITY, BUT RATHER FROM A PERCEPTION THAT STRUCTURES AND AUTHORITIES
CREATED BY THE ACT TEND TO CIRCUMVENT OR BY-PASS STATE HEALTH ROLES AND

THEREBY CONTRIBUTE TO CONFLICTS WHICH ARE LIKELY TO PROVE COUNTER-PRODUCTIVE

TO THE ACHIEVEMENT OF HEALTH GOALS.

IN SPITE OF THE FAR-REACHING EFFECTS OF THE HEALTH PLANNING LAW, THE

LEGISLATIVE AND EXECUTIVE BRANCHES OF STATE GOVERNMENT STILL RETAIN MAJOR

RESPONSIBILITY FOR SUCH IMPORTANT HEALTH FUNCTIONS AS LICENSING OF HEALTH

CARE PERSONNEL AND FACILITIES, COST CONTAINMENT, HEALTH MANPOWER EDUCATION, REGULATION OF HEALTH INSURANCE, PROVIDING PUBLIC HEALTH, AND FUNDING A VARIETY

OF PROGRAMS PROVIDING HEALTH AND MEDICAL SERVICES TO THEIR CITIZENS.

GIVEN THE RANGE AND THE DEPTH OF STATE INVOLVEMENT IN THE HEALTH CARE

SYSTEM, AND THE NEED FOR GREATER COORDINATION AMONG THE VARIOUS COMPONENTS
IN THAT SYSTEM, IT IS PUZZLING WHY FEDERAL POLICY CHOSE ORIGINALLY NOT TO

SUPPORT A STRONG STATE ROLE AT THE CENTER OF THE HEALTH PLANNING PROGRAM.