3. Recommended deletions of services restraints from overlap in medical and educational assisted programs may unintentionally lead to the funding under Title XX of substandard facilities and abusive practices; and, 4. the proposed shifting of responsibility for defining the parameters for the use of social services funds merits careful scrutiny. Inasmuch as the states are already in their planning cycle for their FY 1977 Social Services Plan, the changes proposed in this legislation may have a disruptive effect. We would prefer more experience under present law prior to changing the established relationships. Our Associations are most concerned that the legislation proposed by the Department of Health, Education and Welfare neglected to address several of the most serious issues concerning the implementation of Title XX. Foremost of these issues is the insufficiency of funds to address adequately the service needs of the eligible population. The reason why most states have been forced to restrict their service population is to meet service demands. This committee must take forthright action to increase the ceiling that was imposed on social services funds. We recommend that serious consideration be given to the alternatives of either raising the ceiling by a minimum amount of $1 billion, and/or, by cost-indexing the present $2.5 billion ceiling retroactive to its 1974 enactment. While the Department proposal has recommended the deletion of certain restrictions on medical and remedial services, it fails to address the issues of the quality of service which is being purchased through this new mechanism. We find this oversight especially odd given the much cited initiatives of the Department to rid Medicare and Medicaid of fraudulent and abusive providers. It would appear that the Region IX audit of home health contractors in San Francisco County which has received wide media attention has not been called to the attention of Department policy markers. Likewise, we are seriously concerned about the marketing of this legislation. The Secretary's statement before this committee on May 21, 1976, is shrouded in catchy phrases that are open to multiple interpretations. This raises two concerns. Firstly, the Secretary praised the active citizen involvement in developing Title XX state plans while at the same time his staff is rewriting those sections of the Title XX regulations which ensure that participation. Attached as appendix 1 to this testimony is a copy of our response to the Department regarding the proposed changes to the regulations mentioned in the Secretary's statement. Secondly, the Secretary overly dramatized the pressures for group eligibility as a contributor to the attitude which developed H.R. 12175. While we will discuss this issue of group eligibility in greater detail below, let the record clearly show that the pressures for group eligibility should not be confused with those which support the realignment of federal responsibility for social services to qualifying individuals and families. Following the precedent set by the Secretary we shall take the liberty of expanding our remarks to address a more pressing piece of legislation affecting Social Services under discussion by this committee, H.R. 12455. Our Associations have endorsed the stance which was transmitted to members of this committee by a letter from the Social Services Coalition. In essence, this correspondence to the conferees sets forth the following positions: 1. We urge the House conferees to adopt Section 2, 3, 4, and 5 of the Senate amendment to H.R. 12455 dealing with day care. These provisions contain much of the content of H.R. 9803, which the House passed and sustained over the President's veto. 2. We urge the House to accept those provisions making permanent certain changes in Title XX relating to services for alcoholics and drug addicts (Section 6 of the Senate amendments). 3. We urge the Senate to recede on its amendments concerning eligibility. This action would restore provisions (Section 2002 (a) paragraphs 4,5, and 6 of the existing law PL 93-647. 4. We would recommend a section permitting services to be provided on a group eligibility basis in circumstances where the state may reasonably conclude that most of the persons receiving the services meet the 115 percent of median income requirement limitations, without requiring even as much as a simple declaration. Appendixed to this statement is a second letter which is from our Associations and the National Council on the Aging (NCOA) explaining our stance vis-a-vis eligibility. We believe this is an understandable explanation of our stance on group eligibility and the necessity for maintaining present law restrictions on other requirements for eligibility as mandated by Public Law 93-647. It was never the intent of our Association in raising the issue of group eligibility to see it misconstrued as a mechanism for dissolving the compromises that achieved the partnership that is Title XX. We brought the issue to this committee and to the Department emphasizing the necessity of meshing our Title XX services programs to the Congressionally supported service delivery system developed under the Older Americans Act. The Departmental move toward oral declaration has partially defused the issue. An expeditious conference committee settlement of H.R. 12455 containing the recommendation which we have set forth in both the Social Services Coalition letter and in the joint letter with our allied aging organization, NCOA, will resolve the immediate issue. Until Congress addresses the all important issue of raising the ceiling on Social Services monies, our Associations are compelled to support the other eligibility criteria of present law. We believe PL 93-647 provided sufficient balance to address both the needs of the categorically needy and those who are struggling to escape the bondage of poverty. In closing, our Associations wish to extend our appreciation to this committee for undertaking its studies of both Title XX and of the Title XVI Supplemental Security Income Programs. You are confronting similar problems in both programs where the criticism from the public sometimes tempts the soul to seek the easiest route away from the controversy. We encourage your continued efforts to constructively reform these valuable programs which, while not perfect, are improvements over past attempts to meet human needs. ATTACHMENTS Mr. MICHIO SUZUKI, NATIONAL RETIRED TEACHERS ASSOCIATION, Acting Commissioner, Public Services Administration, Department of Health, Education, and Welfare. DEAR MIKE: On behalf of the American Association of Retired Persons and the National Retired Teachers Association, I wish to express our appreciation for the opportunity which you have given to comment on the draft amendments to the Title XX Regulations which are under consideration by the Public Services Administration. While our constituency continues to have difficulties with the arbitrary means tests imposed under Title XX and while our Associations shall continue to press for statutory changes to facilitate this barrier to needed services for many elderly, we shall limit our response to the proposed changes as you requested. In reviewing the proposed changes, three issues are raised: 1. Will the increased flexibility allowed to the state in developing its plan restrict the opportunity for public involvement? 2. Will the proposed definitional and service changes expand or contract availability of services to recipients? and, 3. By facilitating manpower development, will the proposed changes strengthen or weaken the response to direct service needs? 1. PLAN FLEXIBILITY Our Associations are cognizant of the increasing costs burdens/to the states of the procedures set forth in the original Title XX regulations, and, therefore, we can appreciate the need to revise these requirements. Our review of the proposed changes to Subparts B and C raised the following points: S. 228.25 Availability of services by geographic area The proposed change to S 228.25(a), i.e., changing the word "shall" to "may" constitutes a potential weakening of efforts to encourage congruency of state service delivery mechanisms. We request additional discussion of the rationale for the proposed change. S. 228.26 Services We are pleased with the proposed change of definition for cluster services. The revised language is similar to our original suggestion in responding to the April 14, 1975 draft Title XX regulations. With respect to the proposed deletion of $228.26 (e), we ask for further explanation of the rationale for the change. S. 228.29 Program coordination We have advocated in the past and continue to emphasize the need for S228.29 to specify Titles III and VII of the Older Americans Act as human service programs which should be coordinated with Title XX programs. There is a need for specific reference to the meshing of the service delivery system under the Older Americans Act with the Title XX service program to ensure the success of the Area Agency on Aging concept. We emphasize our fear that unless the regulations clearly spell out this special relationship between the Older Americans Act programs and the State social services program, coordination will not take place; and, more importantly because of the dependency of the Area Agency on Aging on Title XX resources, the failure of coordination would lead to disruption in the delivery of services to the aged. The proposed change to $228.29 (2) i.e., changing the introduction, provides a potential for overlooking important service coordination components. Our Associations must oppose this weakening of the requirements for attention to categorical service delivery structures and programs. S. 228.31 Needs assessment We strongly oppose the proposed change suggested in the revised draft regulations. Needs assessment is an essential tool for ensuring public involvement and we emphatically stress the need for retention of the present standard. S. 228.32 Planning, evaluation, and reporting As with our above cited opposition to the proposed changes to $228.31, we believe the lack of specificity suggested in the proposed changes to S228.32 will be an albatross to public involvement in the development of the state plan. One of the essential goals of the Title XX enactment was to facilitate public involvement in the development of service delivery programs. The only manner in which this goal can be achieved is by requiring attention to public input and through the sharing of available information with the citizenry. To lessen the details required in a state plan for the sharing of information would be a serious handicap to the public advocate. S. 228.33 Proposed service plan While our Associations have no disagreements with the proposed changes in the presentation of the plan to the public, we question the specific change $228.33 (d). The details required in the present plan summary appear to be of greater value to the public than the abbreviated requirements suggested in the proposed changes. We favor retention of the present standard for plan summaries. While we generally support the widest distribution of plan information, we must question whether the Government Paperwork Commission would be in full agreement with the requested seven copies of all changes required by the Federal government of the states. The monies to print the government's copies could be well spent in providing the abbreviated summary of the plan to the public. 2. IMPACT ON SERVICES While the proposed revisions generally constitute procedural changes, we do preceive impact on services in changes suggested for Subparts A, D and F. The following are our observations: S. 228.1 Program definitions The proposed definition of medical or remedial care ties such care back to phisician approval. This limitation has important consequences with re spect to home aide, chore and environmental assistance remedial care. Such care might be available under Titles XVIII and/or XIX if the individual is eligible for such services and has the physician approval. Requiring physician approval might be a restriction that will seriously limit the use of the services. S. 228.40 Medical and Remedial Care and S. 228.41 Room and Board In response to the proposed Title XX regulations promulgated in 1975, we urged flexibility in determining the services under Sections 228.40 and 228.41. We are pleased with the proposed changes. At the same time, we must en courage Departmental consideration of steps to assure quality in the delivery of such services. We have witnessed shocking abuses and fraudulent practices in the delivery of care sphere removed from the strictly medical setting. While the roots of these horrors stem from lack of a unified system for long-term care, failure to police our reimbursement systems and neglect in coordinating service delivery, we should not allow another avenue for continued thwarting of efforts to monitor the qualify of care. Consideration must be given to standards particularly for residential care and homemaker services provided through the Title XX program. One need only point to the documented news commentaries on the alledged abuses of certain homemaker service agencies under Title XX contract to see the seriousness of monitoring quality. Not only will the public suffer from inferior service, but also public officials will be held accountable for allowing such a situation to develop. S. 228.60 Persons Eligible Our Associations are uneasy with the proposed changes to S. 228.50 (c) (2) to allow for geographic fee differences. As you know, we have had expressed difficulty in the fee provisions, and, we would oppose proliferation of the options for fees. 3. MANPOWER DEVELOPMENT With due consideration to the necessity for the development of qualified personnel to deliver the services under Title XX, our Associations are forced to raise the question does the scare resources which are available under Title XX permit utilization in other than direct services? Obviously, we are sensitive to the argument that manpower development is an essential component of the delivery system, and, therefore, it should be a reimbursable expenditure for purposes of matching funds. However, until such time that our resources are broadened to allow attention to both direct service needs and manpower development, our Associations suggest a ceiling should be imposed upon the sums which the state can use of Federal funds for the manpower development function. It would appear that a limit of not more than five percent of the state's social services allotment for manpower development is not an unrealistic limitation inasmust as the primary purposes of the program as set forth S. 228.0 is for direct services to eligible individuals. Again, our Associations are grateful for this opportunity to comment on the proposed revisions prior to the administrative formalities where ideas are often laid in concrete. With respect to the issue of processing these particular amendments as proposed rules or as interim-final regulations, we see merit in continuing with the formal administrative procedure. While our comments concerning the proposed changes clearly indicate that most of the revisions are acceptable, the sizable response to the 1975 regulations illustrate that the public is keenly interested in perfecting the service delivery system. The formal comment period allows many interested parties outside of the District of Columbia to respond to the changes. In closing, allow me to reiterate our Associations gratitude for having this opportunity to comment on the draft revisions. Needless to say, we stand ready to work with you in improving the Title XX program. With best wishes, LAURENCE F. LANE, Legislative Representative. JUNE 11, 1976. Hon. JAMES C. CORMAN, U.S. House of Representatives, DEAR CONGRESSMAN CORMAN: The undersigned organizations representing some ten million older people, as well as those working in the field providing services to the elderly, call your attention to the following recommendations with regard to H.R. 12455. Because we fear that some proposals under discussion will pose serious problems in the provision of essential services to older people, we urge your support for our recommendations. The law should include a section allowing services to be provided on a group eligibility basis in circumstances where the state may reasonably conclude that most of the persons receiving the services meet the 115 percent of median income requirement limitations, without requiring even as much as a simple declaration of income. Unlike the social service program it replaced, the Title XX legislation precludes the possibility of applying group eligibility procedures for Federal financial participation. As a direct result of this provision, older American service programs which received public social service monies under the previous program's group eligibility provisions face massive increases in administrative costs, the administrative nightmare of attempting to coordinate the Title XX programs with those provided by Titles III and VII of the Older Americans Act (which prohibits any income means testing), and the loss of program participants in need of services because they are unwilling to undergo demeaning income means testing. We are convinced that the provision of group eligibility under Title XX is essential to protect the ability of thousands of older people to maintain their independence with dignity and self-respect. -the Senate should recede on its amendments which would eliminate all eligibility requirements, and, instead, retain the eligibility provisions of the existing law (Section 2002 (a) paragraphs 4, 5, and 6 of PL 93-647) Our concern is ensuring that services under Title XX continue to focus on those most in need. The abolishment of key provisions regarding eligibility in the existing law is a bitter disappointment to all who believe that social services should be directed at individuals and families who need such assistance the most. Given the current limited resources under Title XX, the eligibility provisions must be retained. Thank you for your consideration of our views on this matter. JOHN B. MARTIN, National Retired Teachers Association, Mr. RANGEL. Mr. Rudolph Danstedt. STATEMENT OF RUDOLPH T. DANSTEDT, ASSISTANT TO THE PRESIDENT, NATIONAL COUNCIL OF SENIOR CITIZENS Mr. DANSTEDT. I am glad to appear before you again, though I am getting tired of walking up the Hill on the services legislation, and I am sure you are, too. Since I am coming on late-the tail of the dog-I will skip through my testimony. Mr. RANGEL. It will be inserted in the record at the end of your testimony. Mr. DANSTEDT. The Federal Government seems to want to "cop out" as far as social services are concerned, and just act as a transmission belt for the money. As was pointed out by Mr. Saucier from Georgia this morning, this block grant proposal it is a dropout as far as the States are concerned. If the State matching disappears, the legislatures are going to capture that money back for other purposes other than social services, and you are going to have the same situation we had with respect to SSI. Now, there are some States that are doing a good job in supplementation on SSI, but most of them are not, and the same thing will happen in the social services. I want to point out, also, that we are deeply concerned about the provision of 75 percent of the Federal funds going to the elderly who are recipients of SSI and medicaid. The issue is not solely the income status of the elderly. People, as they get older, have multiplying problems. They live on fixed incomes, and if you largely continue this program a number of the low income |