ORGANIZATION OF PUBLIC HEALTH SERVICE

TUESDAY, MAY 14, 1963

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON PUBLIC HEALTH AND SAFETY

OF THE COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE,

Washington, D.C. The subcommittee met at 10 a.m., pursuant to recess, in the caucus room, Cannon Building, Hon. Kenneth Roberts (chairman of the subcommittee) presiding.

Mr. ROBERTS. The subcommittee will please be in order. We are resuming hearings today on H.R. 2410, which has for its purpose the reorganization of the Public Health Service, and other purposes.

Today we will hear from Boisfeuillet Jones, who is Special Assistant to the Secretary (Health and Medical Affairs), Department of Health, Education, and Welfare.

Tomorrow we will hear from Mr. Staats of the Bureau of the Budget, and later, at a date to be announced, we will hear from Dr. James Wiesner from the White House.

Mr. Jones, you may proceed with your statement.

STATEMENT OF BOISFEUILLET JONES, SPECIAL ASSISTANT TO THE SECRETARY (HEALTH AND MEDICAL AFFAIRS), U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Mr. JONES. Mr. Chairman and Mr. Nelsen, the Department of Health, Education, and Welfare appreciates the opportunity to appear before this committee as it undertakes a broad review of the health activities of the Federal Government. We appreciate, too, the interest which prompts this review.

The Federal Government has a vital role in the health of the American people. Its increasing concern about health and health protection has been reflected in strengthened programs, primarily within the Department of Health, Education, and Welfare, but also in other Federal departments and agencies.

A review of the organizational and administrative structure through which the Government discharges its health responsibilities can be very helpful in charting future national directions and goals. It can also help the Department appraise our stewardship of the programs which have been entrusted to us.

You have reviewed the programs of the Public Health Service and the Food and Drug Administration in considerable breadth and depth. The health activities of the Department are concentrated principally in these two agencies, but important health programs are located in other constituents of the Department. A review of these other pro

grams will complete the picture of the health activities of the Depart

ment.

Before proceeding with this review, however, a brief sketch of the health, education, and welfare activities of the country-and particularly the Department's contribution to this total national effortappears necessary to give a context to the examination of our programs. Although health, education, and welfare are thought of as separate fields, they are intimately related, and many of our programs involve more than one of these fields. The Federal role in health, education, and welfare is but one segment of a much larger national effort in which enormous contributions are made by private individuals and organizations and by State and local governments. All of these activities combined accounted for an estimated total of $95 billion in 1962. Of this total, about $31 billion were spent for health purposes25 percent by the public sector (government at all levels) and 75 percent by the private sector.

The scope and complexity of activities of the Department of Health, Education, and Welfare in fiscal year 1963 are suggested by its almost 80,000 employees, its over $5.3 billion in appropriations, its over $15 billion in benefit payments from trust funds, and its more than 100 separate programs.

A large proportion of the Department's budget-almost 90 percentgoes to agencies, institutions, and individuals outside the Federal Government. Funds are allocated to the States in the form of grants-inaid to match or supplement State and local expenditures for health, education, and welfare programs, and to colleges, universities, hospitals, and scientific institutions as grants for research and training programs.

Of the Department's total estimated expenditure in 1963 for health activities, the Food and Drug Administration and the Public Health Service account for $1.6 billion.

The remaining $600 million will be expended by the other constituents of the Department for health and health-related purposes. These activities will be highlighted briefly.

WELFARE ADMINISTRATION

Through grants-in-aid to the States, the Federal Government helps meet the needs of dependent children who are deprived of parental support or care, and the needy aged, blind, and permanently and totally disabled. This support includes payment for medical care to the extent provided in the various State plans for public assistance programs. The importance of medical care in these programs is illustrated by the fact that during fiscal year 1963, medical vendor payments will account for some $860 million of the estimated $4.2 billion which will be spent for assistance under the federally aided programs. In addition to these payments made directly for medical services, part of the money received by recipients will go toward the purchase of medical care.

In recent years there has been an increasing emphasis on the medical care elements in the public assistance programs. In 1960, the Congress increased the Federal aid for medical care expenditure made by the States on behalf of persons receiving old-age assistance and estab

lished the medical assistance for the aged program. Under this program, the Federal Government aids the States in providing medical care for older persons who have sufficient resources to meet their everyday needs but require help with their medical expenses. At the same time, the Bureau of Family Services, which administers the public assistance programs, was charged with the development of guides and standards in the medical care area.

In other programs, which fall within the jurisdiction of the Children's Bureau, assistance is given the States in extending their services for promoting the health of mothers and children and for locating and providing required medical, surgical, and other services for crippled children. Grants to the States for maternal and child health services will total $25 million in fiscal year 1963. Grants for crippled children's programs will be $25 million. In addition to this financial assistance, advisory and consultative services are made available to the States.

VOCATIONAL REHABILITATION ADMINISTRATION

Several aspects of the work of the Vocational Rehabilitation Administration involve medical and related services in preparing handicapped people for useful occupations. This year it is expected that more than 110,000 handicapped men and women will be rehabilitated and returned to work through the Federal-State program of vocational rehabilitation.

About $25.5 million in Federal and State funds will be used for diagnostic and evaluation purposes, for medical, surgical, and hospital services to reduce or eliminate the disability, and for the purchase of artificial limbs and other appliances. Of this amount, about $16 million are Federal funds. Such health activities will account for approximately 22 percent of the total expenditures by the States, with the remainder allotted for such services as vocational evaluation, job training, placement, and tools and licenses.

The Vocational Rehabilitation Administration also supports research into the problems of disability and rehabilitation, as well as a training grant program to expand the supply of trained workers to provide services to the disabled. In 1963, the medical phases of these programs will account for about 36 percent of the total costs, or some $8.6 million.

ST. ELIZABETHS HOSPITAL

The total mission of St. Elizabeths Hospital is, of course, health related. St. Elizabeths Hospital provides treatment for several categories of mentally ill persons, including residents of the District of Columbia, beneficiaries of the Veterans' Administration and other Federal agencies, and mentally ill persons charged with or convicted of crimes in U.S. courts.

The hospital has an average in-patient population of 6,700 and a staff of 3,900 employees. Extensive research and training programs are carried out in conjunction with patient treatment activities. In fiscal year 1963, St. Elizabeths Hospital is operating on a budget of $25.7 million, of which the Federal appropriation accounts for $6.3

million.

U.S. OFFICE OF EDUCATION

Through grants to State departments of education, the Federal Government provides financial help in establishing and operating educational programs for the preparation of a variety of health service. workers, including licensed vocational or practical nurses, dental and medical assistants, surgical technicians, and the like. Of the more than $15 million expended in 1962 for such training programs, approximately $5 million, or one-third, were from Federal funds.

In addition to such training programs operated under public vocational education for many years, in 1956 the Congress initiated a specific 5-year program of Federal assistance to States for the training of practical nurses and other similar health workers. This program was extended in 1961 through June 30, 1965.

DISTINCTIONS IN HEALTH MISSIONS AND PROGRAMS

The programs I have just described, along with those you have reviewed previously, have several similarities. Since they are all health programs or include health components, they contribute to the total well-being of the people of this country They require the skills of highly trained professional and technical personnel from a variety of scientific and medical disciplines. And they use certain basic resources and facilities in common.

On the other hand, the health programs of the several agencies of the Department differ in many important respects. Each has been established by the Congress in response to a specific national need.

The first difference is historical. The Public Health Service, for example, dates back to the very beginnings of our Nation, when the needs of commerce and national defense prompted the Federal Government to take action to safeguard the health of merchant seamen. The Food and Drug Administration, the Vocational Rehabilitation Administration, and the Welfare Administration, however, are all products of the technological and social developments of the 20th century. Aside from the obvious difference in stages of development resulting from the dates of their establishment, these agencies have developed strong traditions of their own. They utilize channels with the public and with the professions which have developed separately over the years.

The second point of difference is that each agency has a mission in the health area which is distinct from the health missions in the other agencies. This distinction affects the organization, methods of operation, and relationships of the agencies. Let me illustrate with a few examples.

Health activities, as we have seen, constitute a significant proportion of the work of the Vocational Rehabilitation Administration. The goal of VRA, however, is to reach a specific kind of individualthe handicapped or disabled-and to rehabilitate that individual for productive employment. Health activities, therefore, are a means to carry out that objective. The goal of the Public Health Service, on the other hand, is the health of the public in general. For the Service, health is an end in itself.

Later in this presentation, the health protection activities of the Food and Drug Administration and the Public Health Service will be

discussed in some detail. Within the context of their respective missions, however, the point should be noted that the enforcement activities relating to health protection differ significantly in each agency. The objective of the Food and Drug Administration is to protect the consumer as an individual. The objective of the Public Health Service environmental program is to provide a healthy environment for individuals in the community at large.

The different health missions of the agencies of the Department derive from different authority, even different constitutional authority. The several programs are under the jurisdiction of different committees of the Congress. And relationships vary significantly, not only with the Congress but with affected individuals and with participating groups or agencies. Some programs of the Department deal primarily with State agencies, or with interstate and regional bodies. Others work directly with local authorities. Still others have important relationships with universities, medical schools, research institutions, and professional groups. And finally, some programs involve the general public directly.

If we examine the health activities of the Department in a framework other than organizational, however, we can group them functionally in three major categories: (1) Protection; (2) service; and (3) research. Under each of these broad headings, we are concerned not only with the end product but with the necessary ways and means of attaining it notably, with the adequacy of skilled manpower and with the physical facilities and resources that are needed.

Several agencies have programs which come under one or more of these groupings. It follows then that coordination of similar activities is essential. In a Federal agency with a large element of decentralized responsibility, certain programs must be coordinated in order to meet common purposes.

Coordination is built into the work of the Department of Health, Education, and Welfare. It ranges froin informal exchanges among our professional and technical personnel to the creation of formal and continuing intradepartmental committees and coordinating groups. Agencies of the Department collaborate in research and investigation, in demonstration and pilot projects, and in training programs. Exchange of information is fostered through professional organizations and through symposia and conferences.

One of the principal functions of the Office of the Secretary is to provide mechanisms for coordination or to insure that these mechanisms are established. Society is changing so rapidly, however, that new health problems are arising constantly, requiring new approaches to coordination.

It appears desirable, therefore, to examine the factors in American society which have contributed to the health problems we face today, and their relationship to the functional groupings of protection, service, and research.

HEALTH PROTECTION

In recent history, science and technology have completely transformed man's concept of the universe, of his place in it, and of his own physiological and psychological systems. Man's mastery over nature has been vastly extended, including his capacity to cope with