HEALTH SERVICES AND HEALTH REVENUE SHARING

THURSDAY, FEBRUARY 21, 1974

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON PUBLIC HEALTH AND ENVIRONMENT,

COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE,

Washington, D.C.

The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. Paul G. Rogers, chairman, presiding.

Mr. ROGERS. The subcommittee will come to order, please.

We will begin our hearings this morning continuing the committee's consideration of the Special Health Revenue Sharing Act of 1973. Our first witness this morning is one of our distinguished colleagues from California, the Honorable George E. Brown, Jr. We are pleased to have you with us. We know of your interest in these subjects and will be delighted to have the benefit of your thinking.

Your statement will be made a part of the record and you may proceed however you desire.

STATEMENT OF HON. GEORGE E. BROWN, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA

Mr. BROWN. I have a one-page summary I would like to read and the full statement, with your permission, can be inserted into the record. Mr. ROGERS. Certainly.

Mr. BROWN. I want to commend the chairman of the subcommittee for his legislation in this health field as well as for the many other notable contributions which he has made in the field of health and environment which I, for one, am very pleased with and which I hope I will have the opportunity to continue to support in the future.

As you indicated, I have been interested for a number of years in the total, overall field of population problems and I am going to speak specifically this morning merely on the problem of family planning services and the population research, those aspects of your legislation.

I appreciate this opportunity to appear before you today in support of the family planning services and population research provisions of H.R. 11511. My interest in this subject is of long standing and prompted me last session to introduce legislation which would have created an Institute for Population Sciences.

Although in the span of the last 10 years Federal assistance has risen from next to nothing to a total of $150 million serving 3 million women, there are still close to 11 million women in need of some degree of subsidization in their efforts to obtain family planning services. It has become the policy of the Federal Government to free

women from the burden of unwanted pregnancies, allow poor women to improve their economic standards by voluntarily limiting their families, and slow the population growth.

But at the very time that Federal activity needs to continue to expand in order to reach these women in need, the momentum in the research aspect of family planning is being lost. The Center for Population Research of the National Institutes of Health has not increased its budget for research and training in reproductive biology during the last 2 years.

In addition, Federal agencies have sharply curtailed research career development awards and training grants in the area of reproductive biology. The pharmaceutical industry has largely discontinued research in the area of contraceptive technology due to the expense of meeting the requirements of the Food and Drug Administration and these developmental costs are not likely to be defrayed by public funds or philanthropic institutions.

Private foundations are switching their support to other pressing problems and the universities are giving less emphasis to contraceptive research and more to the glamorous diseases.

In view of the above, I believe that if Congress wants a significant level of contraceptive research to continue, it would be most readily accomplished by assigning specific funds to reproduction, not making them part of the general research budget. I strongly urge the members of this subcommittee to earmark specific funds to finance critically needed research in the areas of reproductive biology, contraceptive technology, and social science research in reproductive biology and that these funds exceed the $65 million authorization presrcibed in the current law.

Without this aid, the search for new contraceptive methods will be abandoned by those who are responsible for the advances made in the last few years.

I might say, Mr. Chairman, of course this is not just a national prob lem, it is an international problem. The United Nations and international organizations in general are increasing their support and I hope they will continue to do so for research in this field because of the pressing need to slow down the explosive growth in population around the world. This country can and should, I think, make a greater contribution to that whole problem.

Thank you for this opportunity.

[Mr. Brown's prepared statement follows:]

STATEMENT OF HON. GEORGE E. BROWN, JR., A REPRESENTATIVE IN CONGRESS

FROM THE STATE OF CALIFORNIA

Mr. Chairman, members of the subcommittee, I appreciate the opportunity to appear before you today in support of the Family Planning Services and Population Research provisions of H.R. 11511.

It was just a short decade ago that the Johnson Administration first declared the prevention of unwanted births as a major national social and health goal. When that declaration was made there was no federal assistance for family planning. But in the course of the decade that has followed, we have successfully passed the first comprehensive family planning legislation and are now spending a total of $150 million a year to provide family planning services to more than 3 million women-90 per cent of whom have low or marginal incomes.

We remain, however, far down the road from achieving our original goal of preventing unwanted births on a national basis. Despite our past successes there are still some 5.7 million women in families with annual incomes below

11⁄2 times the poverty level who need total subsidy to assure them free and full access to modern family planning services. There are also an additional 3.4 million women with incomes somewhat above this level who need at least partial subsidy to obtain these services. And there are approximately 1.7 million teenagers many of whom are sexually active who do not come from low or marginal income families but who do not have the disposable income available to purchase services from a private doctor, or who cannot find a doctor who will provide these services without parental consent.

Rather than elaborating in great detail regarding the popularity of these services among the program's recipients or the crucial need for the expansion of these services, I will suffice to say that it would be criminal for us to cut back on a program which has proved its valuable potential for freeing women from the burden of unwanted pregnancies, allowing poor women to improve their economic standards by voluntarily limiting their families, and slowing the population growth rate of this country.

As the primary sponsor of legislation (H.R. 8114) to create an Institute for Population Sciences, I would like to now focus my attention on the need for increased federal participation in the field of population research.

Though the U.S., with the assistance of the federal government has had notable success in formulating a public policy on fertility control and in providing family planning services to the less privileged, both the Federal Government and the scientific community have failed in meeting the challenge of allocating higher program priority and greater financial resources to biomedical research designed to improve contraceptive technology.

For many years, progress in our understanding of the human reproduction function has been much slower than that made in other medical disciplines. There are many reasons for this relatively slow progress not the least of them the fact that research in the area of reproductive function has been mainly based in the departments of obstetrics and gynecology which traditionally have been devoted to research less firmly than other major medical disciplines. In the 1960's, due to the increasing concern about the population growth, there had been a rapid increase in research available to investigators in the field of human reproduction, at a time when, in fact, the expansion of research in other fields was slowing down or had even stopped. The attraction of such liberal support lured many excellent investigators into the area of human reproduction and the influx of new and often first-class talent resulted in a rapid progress in our understanding of the biology of human reproduction. Whereas a decade ago we knew more about the ovarian cycle of domestic animals, at the present time information about the reproductive function in women is much more complete and in fact expanding almost exponentially. Unfortunately the little and insufficient momentum that had been gained in the last 10 years is now in danger of being lost.

Government funding of research projects concerned with contraception and reproduction has come to a standstill. In the period of 1967 to 1972, the funds allocated by the Center for Population Research for research and training in reproductive biology increased fourfold from $7.1 million to $31.1 million. This increase of $24 million was more than the total made available from all other sources during this period, and comprises more than half of the total support for reproductive research and training. CPR's budget, however, did not increase in 1973 or in 1974. Since there has been no increase in the total available from other sources, and since none of the foundations or other U.S. agencies predicts larger contributions for reproductive research in 1974, the entire reproductive research effort appears to have reached a plateau.

The total current support of reproductive biology is only a small fraction of the required levels prescribed by experts both in and out of Government. The Commission on Population Growth and the American Future, for example, urged annual expenditures of $100 million for developmental work on methods of fertility control plus at least $100 million on research and training in the fundamentals of reproductive biology. This $200 million for reproductive research and training is 20 times more than H.R. 11511 proposes to spend on biomedical and social science research combined.

While testifying before the task force on population growth and ecology last year, Oscar Harkavy, program officer in charge of the Ford Foundation's population office testified that the primary locus of fundamental research and training in reproductive biology related to fertility control is in the universities. In fact, there is only one major research institute ouside the university exclusively devoted to reproductive biology and contraceptive development. The role of

the universities in fertility research is therefore crucial and a change in the priorities of the universities will have a direct and immediate effect on the amount work carried out in this area.

The quest for improved contraceptive technology is further jeopardized by a phenomenon affecting the entire scientific research community, namely, the sharp curtailment of research career development awards and training grants. Such awards not only provide stipends for graduate students and young scientists at the postdoctoral level, but also contribute significantly to the staff salaries and other expenses of institutions that provide their training. Such awards have been cut off as of January 29, 1973. NIH plans to offer fellowships as a partial substitute for training grants, but at less than half the level provided in 1972. Trainees in reproductive biology will be able to compete for some share of these diminished funds, but these fellowships will be awarded to individual trainees rather than to universities, and will contribute only a nominal $3,000 per trainee to university training expenses.

The threat of these events to future work in contraceptive development cannot be overestimated. As research support contracts, there will be an increasing tendency for the bright young graduates to go into private practice. Those remaining in research will be increasingly attracted to the more glamorous area of the "life-saving diseases" and human reproduction will go begging for talent.

For research in reproduction, the future looks even bleaker. The pharmaceu tical industry does not have a sufficient incentive to enter this field. At the present time, requirements by the federal Food and Drug Administration for the approval of new contraceptives stipulate a series of studies which cost between $8 and $30 million. Having expended this amount, one faces the unpredictability of sudden withdrawal of FDA approval, or a Senate hearing on the cost of medication. As a result, many drug firms have discontinued all research in the realm of contraceptive technology. As one expert has pointed out: "It can be expected that the interest of the international pharmaceutical industry will rapidly diminish during the '70's as far as the development of fertility controlling agents is concerned, unless a part of the developmental costs will be defrayed by public money or by philanthropic institutions." The result is that industry-normally the agency which would be interested in applied technologic contraceptive research-is currently less of a resource than in other drug development areas.

The private foundations are also switching their support to other pressing problems such as poverty, the minorities and ecology. The universities, finally, in which most of the fertility research is done are reconsidering their priorities. With a limited amount of federal support for research, the more "glamorous, life-saving" diseases are attracting the best and the brightest. If Congress wants contraceptive research to continue, it will have to make it attractive to the scientific community. I think this can best be done by assigning specific funds to reproduction, not making them part of the general research budget. I appeal to the members of this subcommittee to earmark specific funds to finance critically needed research in the areas of reproductive biology, contraceptive technology and social science research in reproductive biology and that these funds exceed the $65 million authorization prescribed in the current law. Without this aid, the search for new contraceptive methods will be abandoned by those who are responsible for the advances made in the last few years.

Mr. ROGERS. Thank you. The committee appreciates your being here and pointing out these specific areas that need attention. The committee will certainly consider them, as you have brought our attention to them.

Mr. Nelsen?

Mr. NELSEN. You used the term "glamorous diseases," I don't know of any effort we put forth because of the glamour, I think it is because of the devastation.

Mr. BROWN. That may not be a well chosen word. I am using it merely in the sense they attract research funds more readily. I am well aware of the need of research in multiple sclerosis as was pointed out by the Commission you just heard this morning. I have been deeply concerned because of problems in my own family with problems of kidney disease.

I doubt seriously if this Congress will be able to authorize more funds than are really necessary in any of these fields, but I wanted to focus my attention, because of my longstanding interest in this field, on population research.

Mr. ROGERS. Thank you, we appreciate your being here this morning.

Without objection, the chair wishes to place in the record, as though read, statements submitted by Congressman Edwin B. Forsythe of New Jersey, and Congresswoman Patricia Schroeder of Colorado.

STATEMENT OF HON. EDWIN B. FORSYTHE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY

Mr. FORSYTHE. Mr. Chairman, I am most grateful for the opportunity to testify in support of Title II of H.R. 11511, which is similar to legislation which I introduced early in the 93rd Congress, H.R. 11271. Both bills support the concept of Community Mental Health Centers, a concept which has been proven successful in providing the most humane and effective form of care for the majority of mentally ill and mentally retarded individuals.

The success of these centers, which provides community-based comprehensive care systems, cannot be disputed. Neither can the need. It is estimated that 20 million Americans suffer from some form of mental or emotional illness which requires treatment. This is one in every ten Americans. Some 500,000 children suffer from many of the most serious forms of mental and emotional illness.

Since the Community Mental Health Centers Act was originally passed in 1963, the program has been hailed as greatly reducing the number of mental patients shut away in hospitals and institutions. In 1965, the Act was changed to provide support for staffing of new services in mental health centers. In 1967, the authorization was extended by Congress for the two preceding pieces of legislation. In 1968, the Act was again altered to provide specialized services to alcoholics and narcotics addicts. In 1970, the scope of services was broadened.

This legislation had been preceded by a nation-wide planning proram. The budgets of the National Institute of Mental Health for 1963 and 1964 provided an appropriation for each state to carry out a survey of its mental health needs and to make an appropriate plan to meet the needs. Each state had published a plan by 1965 which formed the basis for the community mental health centers plan required by the legislation. Basic to the scheme is a system of regionalization of population units ranging from 75,000 to 200,000 people. These service units form the basic units for planning of services. As a result of this unprecedented legislative activity, 626 community mental health centers have now been funded. These units are located in all 50 states, Guam, Puerto Rico and the District of Columbia.

The centers have noticeably caused the focus of care to shift from in-patient to out-patient service. In 1955, 71 per cent of the patient care episodes occurred in hospitals and 22 per cent in out-patient. clinics. In 1968, the figures were 43 per cent for hospitals and 45 per cent for out-patient clinics. Indications are that this trend is even more pronounced now.

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