OTHER PROVISIONS

The various provisions relating to comprehensive health planning and services which I have just described are the major features of the bill. Additionally, however, the bill would:

(1) Preserve the authorization now contained in section 314 (c) of the Public Health Service Act for making training grants to schools of public health by transferring and adding this identical authorization to section 309 of the act;

(2) Incorporate in section 311 of the Public Health Service Act the authorization now in section 314(c) for the Surgeon General, as part of the direct operating responsibility of the Public Health Service, to train personnel for State and local health work;

(3) Carry over into the new legislation various provisions now in section 314, such as those relating to consultation with State authorities in the development of grant regulations and to the conditions under which and procedures by which grant funds shall be withheld from States;

(4) Authorize and prescribe the conditions under which exchange agreements may be entered into between the Secretary and State and local governments for the temporary interchange of Federal and State personnel engaged in work related to health. This provision, Mr. Chairman, is patterned closely along the lines of a similar provision in the filed of education enacted last year as part of the Elementary and Secondary Education Act of 1965, Public Law 89-10.

Senator YARBOROUGH. The Elementary and Secondary Education Act of 1965, would allow for a schoolchild in the State of New York $340 a year, and for a State down at the bottom in education, like Mississippi and Alabama, $120 and $140 a year, for children, as against $340 in New York State. I hope this doesn't have a similar allocation of money-that you pay three times as much for service in New York as you do in a State that has a lower health level, because it has lower income.

Is this patterned on that kind of allocation?

Dr. GEHRIG. Senator, this just relates to an authority for the Secretary to arrange for exchange of personnel working in State health departments and permitting them to come to the Federal Government

Senator YARBOROUGH. I assume what you read didn't relate to allocation of money.

Dr. GEHRIG. No, it didn't.

Senator YARBOROUGH. Knowing what happened last year, in that bill, hopefully we will get some reform in the allocation in that bill this year. I don't want to see another bill go through with such great disparity.

Dr. GEHRIG. Before concluding my testimony, Mr. Chairman, I should like to emphasize that we view this bill as a means by which the concept of cooperative Federal, State, local, and private effort, which has for so long been a dominant characteristic of public health in the United States, can be further strengthened to meet the needs and expectations of the American people in the years ahead. This bill has been called by some the partnership-for-health bill. I be

lieve that is a very accurate and descriptive identification. That concept has certainly been dominant in the development of the legislation, and will characterize the operation of the program when

S. 3008 becomes law.

My colleagues and I will be pleased to answer any questions which you and members of the subcommittee may have.

The CHAIRMAN. Senator Yarborough?

Senator YARBOROUGH. Mr. Chairman, I have been reading through Secretary Cohen's statement on this. Perhaps this has been covered. This reference to allocation that has come up has stimulated a question.

I believe section 3 (a) says-page 5: "State allotments."

Mr. COHEN. Senator, there are several allotment formulas in the bill. There is one that relates to the planning grants, and then one that relates to the comprehensive services.

The central one is the comprehensive services, and I believe that is the one you have reference to, is it not?

Senator YARBOROUGH. It says on page 11:

determined in accordance with regulations on the basis of population and financial need of the respective States.

Are those regulations to be drawn in the future? Is there no formula spelled out in the bill?

Mr. COHEN. That is correct. Those regulations would be developed in the future. I can tell you the general principles upon which we propose to do so.

First, let me say that with respect to the allotment to the States for the planning grants, that would be based on population and per capita income with a minimum allotment of 1 percent of the appropriation to any State. And I submitted, before you and Senator Javits came in, a series of tables to show how these work out for individual States.

Senator JAVITS. I notice in your summary you say, "determine by the Surgeon General on the basis of population and per capita income."

But you just said population.

Mr. COHEN. I thought I said per capita income, too. If I didn't, I misspoke. I am sorry.

Senator JAVITS. All right.

Mr. COHEN. If I did omit it, I should have stated it.

Senator YARBOROUGH. Have these tables been put in the record, Mr. Chairman?

The CHAIRMAN. They have been.

Senator YARBOROUGH. In the interests of time, I will study those tables and may have questions later.

I want to express my regret for not having been here from the beginning, but we are marking up a bill in executive session in the Appropriations Committee, a very important bill. That being executive session, it was necessary that I be there-but not through any lack of interest in this important subject.

60-955-66-5

Mr. COHEN. With regard to the allotments for comprehensive services in the section you referred to, at page 11 of the bill, our intent under that section is subject to the amount of money that Congress would appropriate.

We would first allot an amount to every State on the basis of population, and then for those States whose per capita income was below the national average, we would allot an additional amount within the total.

So that there are approximately now, I would say, about 31, 32 States below the national average about 17 or 16 in a given year that are above, and about 30, 32 that are below. A very primary amount of this allotment would be based on population, and then a residual amount would be based on per capita income. We would use those two factors.

But I think I should make this point. It uses them in-while using both factors, it uses them in a somewhat different way than is used, let's say, in the Hill-Burton formula with which you are all familiar. In the Hill-Burton formula you use population times per capita income squared, which, of course, gives a very high degree of the allotment based upon the per capita income, because the per capita income is used in inverse relationship with the per capita income of the States, and thus you give the poorer States more than you do the richer States. But every State is ranked in relation and weighted in relation to per capita income.

Under the formula that we are proposing in this bill, while you use both factors, every State would get its money by population, and then only those States which are below the national average on per capita income would get the additional amount based on per capita income. That tends-if I can oversimplify it-to restrict the element of per capita income to a lesser proportion of the total than you do when you use per capita income for all States.

Senator YARBOROUGH. Mr. Chairman, it might be well, so we have this described for the record-a comparison of how this formula would work in comparison with the Hill-Burton formula.

The CHAIRMAN. Without objection.

(The information referred to follows):

TABLE 8.—Comparison of illustrative allotments to States under formula contemplated in subsec. 314(d) of S. 3008 and under the Hill-Burton formula

1 From column labeled 75 cents on table 2, submitted to subcommittee on Mar. 15, 1966. 2 For comparison purposes, no adjustment has been made for minimum allotments prescribed in HillBurton program.

Senator YARBOROUGH. The average annual per capita income is $2,588. What is the national average?

Mr. COHEN. It is something like that. I happen to have here this might be, just for the sake of getting into the record the relationshipI don't have the last one here, but I happen to have 1962 figures, in which the U.S. average is $2,366 and 1963 was $2,443, so that sounds about right.

Senator YARBOROUGH. It is $2,500 and something now.

Mr. COHEN. This is what I think is the significance, and what we will be talking about. It ranged in 1962 from $3,278 in Nevada, to $1,285 in Mississippi. And using the United States as a hundred, that meant Nevada was 138.5 percent; namely, per capita income in Nevada was 38.5 percent higher per capita than for the United States as a whole, and Mississippi was 54.3, in other words, was a little bit more than one-half of what the national average is.

Texas, for instance, was in the middle of that range; it was 85.1. New York was 123.8 and Alabama was 66.2.

Senator YARBOROUGH. Well, I think if you take the 10 States now that are above 3,000, the 10 highest States, drop out the small areas of population like the District of Columbia, Delaware, that you will find New York, California, and Illinois now are among the top 10 with over $3,000 apiece.

We congratulate them on that high income and envy them. We hope that other States, through their health and educational improvements, can catch up.

Senator JAVITS. I might say I am completely unmoved by that propaganda.

Senator YARBOROUGH. Mr. Chairman, I should think that the distinguished Senator from New York would appreciate the fact that the 31 States below the median average are pouring their riches of talent, not only money but talent, into New York, to help them keep up that high average, and that they would want to bring up the hinterlands and provinces to some level like theirs.

Senator JAVITS. You have fine provinces in Houston, Tex.-that is great hinterland.

The CHAIRMAN. Senator Javits?

Senator JAVITS. Now, Mr. Secretary, this allocation formula will come under a great deal of scrutiny from now on, I assure you.

In the first place, will you tell us how this chart was made up? In other words, what percentage of the estimated appropriation in the different categories did you put on a per capita basis, what percentage on an income basis?

Mr. COHEN. I believe that it worked out so that for the allotments on the comprehensive health service about 85 percent was based on population, and roughly 15 percent on the per capita income.

Senator JAVITS. Now, to what extent do you compensate, or do you feel you compensate, for the following variables let me list the variables, and then you can answer them all.

One is density of population, which presents health problems. The second is the cost of the services, which are called for under the bill.

And the third is the cost of living in a particular area, as a good deal of this money naturally goes for personnel.

Those are the three criteria, as I see them.

The other question, I think, that always presents itself in these matters is where is a variable, if there should be one, for any special problems that you might have in a particular community?

Take New York for example, with narcotics addiction, which is a special health problem. Do you at all compensate for that?

Mr. COHEN. Well, you are raising some very fundamental questions I would like to comment on each of them. Also may I say in connec