Senator JAVITS. Mr. Secretary, if you are not ready to give an opinion on the amendment, would you give us an opinion as to whether we might usefully provide for a planning stage, say, this fiscal year which will look toward a definitive participation in staffing-that will enable you to get going on the preliminary stages and also to get the report of whatever the committee of the President was? Suppose we gave you a year for that? At least you save that year, because you actually begin to do something in the way of a program. Would you think about that?

Mr. COHEN. Yes, I would be glad to.

NEED FOR FORMULA RESTUDY

Senator JAVITS. The other thing I would like to ask you is this: We are going to go after all these formulas. And I would hope very much that the Department could also begin to rethink this question and give some recommendations to the President and ultimately to the Congress. It is a very serious one. Cities are strangling. The great bulk of the population has moved to the cities. Formulas are pretty much what they were for 30-odd years, and most of them are quite inflexible. I notice now more and more you people are tending to a little bit of administrative discretion.

Now, it seems to me, just curbstone, that a greater emphasis will now have to be placed upon population, that you have to be much more selective, so as to take care of the factors of density and cost, and so you would have to have at least some part of these appropriations discretionary. And we will just have to rely upon the legislative oversight power of the Congress, and the screams of the minority, to be sure that you don't use it politically. I am being very frank about it.

But really it seems to me, Mr. Chairman, regarding the ratio of effort, a stimulus to people to do better, that I am delighted that the poorer States are likely to do better. That is great. It suits me fine.

But I think here are the things, Mr. Secretary, which I would like to use this hearing to present to your Department, because this is the beginning of an effort to begin to modernize this situation. Mr. COHEN. I would like to say something off the record. Senator JAVITS. I ask unanimous consent.

The CHAIRMAN. So ordered.

(Discussion off the record.)

CENSUS DATA

Senator JAVITS. We solved that problem in the Civil Rights Act of 1964, by giving the Attorney General the authority to call upon the Director of the Census for interim information.

Now, we knew that that would not be statistically completely accurate, but it would be a guide. And, therefore, there is no reason why-as this is a discretionary matter for the Secretary of Health, Education, and Welfare that he cannot have the best resources of the Federal Government for his use. And the Director of the Census agreed. They do have continuing surveys and studies. Also, if necessary, the Census Director would go out and do something special

about it, if he really felt he could not give reliable advice based upon what he had or through extrapolation.

But they seemed to be satisfied that they could comply with the spirit of what we directed.

So I would suggest that you have a look at that, that we have dealt with that problem exactly in the Civil Rights Act of 1964.

The CHAIRMAN. Any questions, Senator Pell?

Senator PELL. Thank you, sir.

Mr. Secretary, how many States have these planning councils now-how many do not have them?

Mr. COHEN. No States have the type of planning council that we have envisaged in this bill, Senator Pell.

Senator Pell. No States at all?

Mr. COHEN. None have them in this form. I am sure there are some States that maybe one or two State agencies have gotten together to focus on planning for State health. But the kind of planning council we envisage, which would presumably include not only all of the State agencies, but also the local agencies with the participation of the medical societies and the voluntary health agencies and lay participation-I don't believe any State in the Union has that kind of a planning council at the present time, sir.

Senator PELL. Would this planning council only be for this particular bill, or would this be a general planning council?

Mr. COHEN. I think what we are trying to do is while giving them some money and encouraging them to do it for this bill, it would then be a focus for rationalizing, improving, and expanding all health services for each State, and therefore for the Nation.

Senator PELL. One other point. I found myself a little dizzy trying to follow these formulas.

How many different formulas does HEW have with regard to grants to the States, roughly?

Mr. COHEN. Oh, I would say 150. And I think that is probably on the low side. Every statute that has been passed provides either directly by law or by authorization to the Secretary and the Commissioner to set up some type of formula and some type of matching. And these have become quite different and quite varied, quite complicated, and might I say one has to be very mathematically minded to be an administrator of one of these programs, because they get very complex.

Senator PELL. Is any thought being given to the idea of maybe having half a dozen basis formulas instead of all these varieties?

Mr. COHEN. Well, I would say this, that was the original intent when they first started. I had the opportunity to work on the original Hill-Burton one of 1946. But what has happened, I think, in the course of time is each one of these formulas has come to a congressional committee, and at that particular moment and in the light of the problem as they saw it, they tended to modify either the formula or the matching in relation to their evaluation of the problem. And so the formulas began to get more disparate and different. And when you finally look at the formula that is in the public assistance program, which originally started in 1935 as a very simple one—50-50, dollar for dollar-if you read the formula now, it is so complicated-it starts with 83 percent for the first $37, plus 50 to 65 percent of the next

amount, but notwithstanding 15 percent additional for this-and you are lost before you can even describe to anybody what the formula is. But that is a result of the Congress over 30 years of amending and trying to improve it, trying to take care of special circumstances, to see that certain States didn't lose money, and the money right in the right programs at the right time. And I think we ought to take a look at it now.

Senator PELL. In connection with the bill under discussion, have you submitted a table as to what would go to each State?

Mr. COHEN. Yes, sir; that is in the record.

Senator PELL. Thank you.

The CHAIRMAN. Mr. Secretary, do you think you would like to add anything?

Dr. LEE. No, sir; thank you, Senator Hill.

The CHAIRMAN. How about you, Mr. Huitt?
Mr. HUITT. No, sir; thank you.

The CHAIRMAN. Dr. Peterson?

Dr. PETERSON. No, sir; thank you very much.

The CHAIRMAN. Any other questions, Senator Pell?

Senator PELL. No, thank you.

The CHAIRMAN. Gentlemen, we want to thank you very much. We appreciate your presence and your testimony.

Now, we will hear from Dr. William J. Peeples, of the State of Maryland, a member of the Legislative Committee of the Association of State and Territorial Health Officers, and commissioner of health, Maryland Department of Health.

STATEMENT OF WILLIAM J. PEEPLES, M.D., M.P.H., COMMISSIONER, MARYLAND STATE DEPARTMENT OF HEALTH, ON BEHALF OF ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICERS

Dr. PEEPLES. Mr. Chairman, and members of the subcommittee, it is a pleasure for me to be here, to be able to testify before this subcommittee for the State and territorial health officers of this Nation.

Our association has served for many years as a sounding board for the Surgeon General of the Public Health Service and the Chief of the Children's Bureau; and as a mechanism for presenting the consensus of the thinking of the heads of the State-level health agencies of the Nation to the Federal health authorities. In essence, we have a Federal-State partnership for the discovery of knowledge in the health field and for developing arrangements for the delivery of health services throughout the Nation. We believe very strongly that health services can best be delivered to the people by organizations which are responsive to neighborhood needs; so really, we are intimately involved and keenly aware of the opportunities for health at the crossroads and the corners, as well as at the Capitol. We are also keenly aware of the forces which limit the exploitation of those opportunities for health.

The Association of State and Territorial Health Officers is most appreciative of this opportunity to present its views concerning S. 3008. At the outset, let me make it clear that we strongly urge your favorable consideration of this legislation.

The core problem which this bill is designed to overcome is that the health industry, to which more than 6 percent of the gross national product is devoted, does not operate as cohesively as it must, if it is to take prompt and maximum advantage of rapidly developing research outputs.

The CHAIRMAN. We do not have the team we should have; is that right?

Dr. PEEPLES. The team effort has not been there. We have not gotten together and talked enough as you do in your committee meetings.

The CHAIRMAN. It has all sort of grown up like Topsy; is that right?

Dr. PEEPLES. Yes, sir; I think you are absolutely right.

Each of us holds health high in his value scale, but unfortunately only when we are sick or disabled.

One of the keys to a strong economy is a high level of health of the citizenry.

We work and pursue happiness only to the extent that our health permits. Lacking health, a society functions as though it were on a treadmill-and fades into mediocrity. On the other hand, if we have the will to invest our talents and other resources toward the enchancement of health, our society will be able to take major steps forward. Two years ago, it was manifestly clear that new scientific discoveries would stagnate unless we developed some mechanism to overcome the fragmentation which had come upon us because of our enthusiasm for addressing ourselves to a wide variety of individual goals-each within a narrow field of health-without paying enough attention to coordination of those efforts.

It doesn't do much good just to clean up the air, if the water we drink or play in, or the food we eat, is disease producing. We serve nobody's interest by using resources which the public has entrusted to us to build hospitals, if the professional personnel to staff those hospitals are not available and cannot reasonably be expected to become available. A program for rehabilitating children must be aimed at educational goals as well as optimal physical function and mental health. It becomes increasingly apparent that our efforts must be focused on the entire problem rather than in specific entities. The Association of State and Territorial Health Officers joined with the Association of State and Territorial Mental Health Authorities and the Public Health Service in studying the present situation and developing a proposal under which we could embark on a new course which would give us greater potential for success. The result of those efforts is embodied in S. 3008. This proposal is predicated on the fact that health agencies are potential centers of excellence for the delivery of health service to the public and that they are uniquely in that position. It embodies a mechanism for progressively reducing the gap between personal and environmental health services actually available and those which can be provided by practical exploitation of existing scientific knowledge changes in methodology and future discoveries.

Public health has changed markedly since the Society Security Act in 1936 established the Federal-State financial partnership in health. The act provided a general health grant which was available to support any part of a State's public health program. At that time,

programs were simple and consisted mainly of environmental health services, communicable disease control, and limited services relating to maternal and child health.

Knowledge and techniques have expanded significantly over the years. The scope of public health responsibility has expanded with new knowledge and the increased complexity created by metropolitan development, urbanization, and population expansion. From time to time, attention has been focused on a specific public health problem isolated for attack with an earmarked grant. This has been repeated time and time again, until today we have many such separate categories, with little attention being given to providing a base from which even categorical services can be given.

Effective use of the tools at hand in the health field requires that the parts be synthesized into a functional entity, focusing on the individual, as he functions as a member of a family unit, and in a geographic community. We have come in public health to the place where the numerous categories into which we have subdivided impede a balanced logical attack on the entire health problem.

Conceptually, the proposal before you will require us to develop firm and practical health plans, by the joint efforts of all of the health interests public, private, professional, and institutional at the local, metropolitan and regional, State, and Federal levels. This planning will be comprehensive; it will include preventive, as well as treatment and rehabilitation services and environmental health services. It will take the several echelons of health services and key resources manpower, money, and facilities-into account.

Local, regional, State, and Federal health forces will be synchronized. Within broad guidelines set at the Federal level, State, regional, and local jurisdictions will take the initiative in designing their programs and in proposing future goals and guidelines. A true partnership in planning will be the result if this bill is adopted.

A financial structure which is predictable and known to all parties at interest will be established.

More briefly stated, S. 3008 proposes a system of planning, programing, and budgeting for health, in a fashion which we in the States are confident is sound, timely, and necessary.

The key features of the proposal are:

A mechanism for planning and updating of plans;

A system for delivering comprehensive health services; Provision for focusing resources on projects with limited scope (adapted to special circumstances) and for limited time periods; Emphasis on training of essential manpower;

An innovation whereby key personnel may be interchanged between the Federal and the State scenes; and

Provision to insure that operations will be governed by the plans which are developed well in advance.

Now that I have indicated to you the fact that the ASTHO, as a body, supports this legislation, let me make a few specific suggestions for improvement:

(a) We strongly believe that the statutory language should require that the health officer of each State be a member of the planning agency in his State.

The CHAIRMAN. Do you think a State would set up an agency, a planning agency, on health and not include the State health officer?