Senator WILLIAMS. On a needs basis it should be extended for at least 5 years?

Dr. STEWART. I think there is no question that the need will continue for a variety of mechanisms.

Senator WILLIAMS. I certainly support your comment on the last page of your statement that we authorize such sums as may be necessary. The practical fact around here is we can't get away with that. We have to put the dollar figure in. So we have done it for 3 years and then for the last 2 years we used your phrase, but it is not an accepted way of legislating, as you know.

Dr. STEWART. Yes; we are aware of that.

Senator WILLIAMS. To some degree we have to be practical and conservative. Fred Blackwell lives 15 hours a day with all of the complex problems of migrant farm families and is the staff director of committee. I think he has some questions to ask you, Dr. Stewart. Mr. BLACKWELL. Dr. Stewart, will you be submitting estimates of need for the first 2 years of extension that you have recommended? Dr. STEWART. We will be very happy to supply the committee with our estimates of what it looks to be needed for the 2 years that we are recommending.

Mr. BLACKWELL. Could you also submit estimates on the 3 years beyond that?

Dr. STEWART. Yes; we could, I think.

Mr. BLACKWELL. Ás the chairman has pointed out, the practice in this committee is to indicate ceilings at least in the immediately foreseeable years, and your estimates would be very helpful to the subcommittee and the full committee.

Dr. STEWART. We will be glad to give you the Department's estimates.

Mr. BLACKWELL. Thank you.

Doctor, in regard to overall need which you have not touched upon in your testimony, the most reliable data indicates that the migrant farm family population throughout the country is at least 1 million. Would you comment on the amount or the dollar formula for determining adequate medical care for this population?

Dr. STEWART. Well, you have a population of a million, which includes the women and children in this group who move with their employment, who do not have any location that they call home, although they have a home base. They may spend a year in three of four locations and then many different camps within those locations. They have more disease and more death. They have the disease patterns of 30 years ago. They do not have the means to deal with these. They are required to live in an environment which enhances the infectious diseases rather than protects against them, and they are also a population which by their movement and by their not having roots and by their seasonal employment do not fit into all of the methods we have of trying to provide various forms of care or prevention, and what we are providing is probably somewhere in the order of, oh, 20 percent of what goes to an individual who is living normally in a city as an average worker. The expenditures for health under our program for the Nation as a whole, including local and State contributions, is around $12 per capita for the one million migrants. If you narrow that down to health expenditures per capita for migrants residing temporarily in areas that are actually served it is about $20.

If you get it to the person actually served, the amount gets up to around $35 per person actually served with a medical dental or nursing service.

In the population as a whole the amount ranges, depending on the age of the individuals, somewhere between $125 and $200 per capita, so even though there are some problems in comparison here they are of such extremes that the need is quite apparent. We have had trouble in the hospitalization program because even though we have had 160 hospitals cooperating because in order to spread the money we pay only 60 percent of the cost to the hospitals.

I don't know what the hospitals do about the rest of it, but this I am sure works a hardship on some hospitals.

Then there are environmental areas which need correction, which will take some time and effort, particularly the housing and the sanitation, the supply of water, et cetera, so it is a neglected population. They do not have the means of taking care of themselves.

Mr. BLACKWELL. Experience to date indicates that the per capita expenditure for the migrant farm individual is about $12 per capita compared to the national average of $100 to $200 per capita?

Dr. STEWART. Yes; that is about it if you assume that there is nothing else providing medical services for the migrant other than the program we are talking about and the 40-percent contribution from the communities. There are some other sources of funds, but they are very small and so it doesn't really change the conclusion one arrives at.

Mr. BLACKWELL. In your prepared statement you mentioned that about two-thirds of the migrant population was currently not within reach of the existing projects.

Dr. STEWART. That is right.

Mr. BLACKWELL. Do you have an estimate of the cost of reaching that two-thirds with roughly the same amount of care that exists throughout the other programs? Of course, the present amount of care is not up to what you might call adequate care.

Dr. STEWART. Well, if you were going to expand the present project system so that it covered all the migrants at the level that we are now covering those that are covered, you would have to have in the order of $20 million to $25 million rather than the present $8 million that we have. This is a minimal kind of coverage. It does a lot of good, but it is not comparable to what a nonmigrant citizen gets.

Mr. BLACKWELL. To make the level of care in the existing projects of Florida, for example, available nationally, you would have to go immediately to about $20 million? Is that your estimate?

Dr. STEWART. That would be my estimate which I would like to leave open for correction later on. Some of it depends on where the uncovered people are. It may be that they are in areas where resources are even scarcer than the ones that are already providing services. I would think the projects now are going where there are resources to work with.

With respect to some of them, in many areas it doesn't make any difference how much money you have. There is nothing to put together to provide a service for the migrants. So it may be more difficult. I think one of the things we must understand and I am sure you do— is that the project grants that we have act as an impetus to organization. The project sponsors organize resources. They provide extra funds for payment of these services. They provide people who work

in a sense as the advocate for the migrant, such as the nurse who works with the migrants, the camps, and so forth, the sanitary aide who works with the grower on improving the plants.

When it gets into the payment for the actual hospital service, or the physicians' service, or the drugs, we will-I think-in the long run have to find ways of developing adapting to migrants methods we have in this country for paying for services for other people. At the presen time, this method for needy people is through Title XIX of the Social Security Act. Title XIX has a lot of problems as far as being used adequately for migrant labor, and it may be that as time goes on this will have to be fitted together with other mechanisms, but I can't believe that we will ever reach the level of payment for real hospital service, physicians' services, drugs, the medical care of the migrants, through the project system.

Now, I don't want to say that the project system is not necessary, because it adds to this the real true health component, the preventive services, the seeking out, the advocacy for the migrant, the thing that makes service come about. This is long range I am talking about, but I think this is the area that we hope, over time, to begin to work together on this with the States in developing this.

Senator WILLIAMS. Doctor, we are now working with the project system. This is in a sense opening the door to regular health care for people who prior to this met only closed doors for better health. Are you suggesting a future regularization of care in terms of perhaps insurance like Blue Cross-Blue Shield.

Dr. STEWART. I think that to really bring up the level of health services I am talking about personal health services now to the migrants-eventually to the level that is comparable to that for the employed person in an industrial town, will require some form of prepayment program or tax-supported program or others. The project system has brought attention. It has developed the program. It has opened doors. It has added that component which would not be there even if you did have the prepayment system, that is, the public health component, the advocate for the migrant, the health education, the immunization, all of these things which may have to continue as a project, but to really bring up the care to the level that is acceptable, and that the average American in this country receives, is going to take, in addition to the projects, other mechanisms. This is longer range. It is going to be more difficult. We have some mechanisms which have problems with them, but we haven't had a great deal of experience yet with the implementation of the Title XIX section of the Social Security Act and we will have to see. The same thing is true of the rural farm worker.

Mr. BLACKWELL. Doctor, the State of California has been one of the most forward-looking States in establishing programs for migrant farm families, and also for the general populace. In recent years California has enacted the Medi-Cal program and continues to give medical care to all of their people. Isn't there an economic effect or offset that occurs when such a State also has a migrant health program? For example, doesn't every instance of care extended to the migrant farm family in California result in an economic advantage to the State of California law under its Medi-Cal program?

Dr. STEWART. It is possible that the payment of hospital and physician services under this program is an offset against what would

have been paid out of Medi-Cal. I am not familiar with the details of eligibility in the Medi-Cal program and whether the migrant worker would be eligible or not. This I just don't know. But it is possible, quite possible, that you have a choice here of paying it out of this program or paying it out of another program in California.

Senator WILLIAMS. Gene Mittelman has a question, I believe. Mr. MITTELMAN. Dr. Stewart, in your discussion with Mr. Blackwell on the disparity between expenditures for migrant workers and those for all other citizens in America, you seem to have assumed that given the same level of per capita expenditures the same level of health might be achieved.

Isn't it true that because of the conditions under which migrant workers are forced to live and work they are actually more susceptible to various types of diseases and injuries than the general populace in the country, so that actually to bring them to the same standard of health more expenditures per capita would be required?

Dr. STEWART. Yes. I thought Mr. Blackwell was talking about the payment of personal health services, hospitalization, and physicians' services. What you are talking about is how do we improve the environment of living and working so it has an impact on how often one gets sick and what diseases one has. I would agree with you entirely that, as long as the environmental situation is as it is in many places, there will always be an increased prevalence of disease and mortality among the migrant workers. These things go hand in hand.

Mr. MITTELMAN. The point that I was trying to emphasize is that the disparity is actually greater when you view it in terms of actual levels of health because migrants require proportionately more expenditures on personal health services to bring them to the same level of health as other citizens.

Dr. STEWART. That is true. The increased prevalence of the respiratory diseases, the increased prevalence of diarrhea disease, which is in every area, is probably a function of environmental living rather than a function of whether one is more susceptible to disease or something like that.

Mr. MITTELMAN. Thank you, Doctor.

Senator WILLIAMS. Doctor, we are grateful indeed. I only apologize for taking so much of your time from your other duties, but you have been most helpful to our committee in our deliberations on this bill. It is still our hope that we can in the closing hours of this session report this bill out.

Dr. STEWART. Thank you, Mr. Chairman. It has been my pleasure. Senator WILLIAMS. You are a frequent visitor before this committee and we are always grateful to you.

Dr. STEWART. Thank you, sir.

Senator WILLIAMS. And for your "Girl Friday," Helen Johnston. Thank you, Helen.

Miss JOHNSTON. Thank you.

Senator WILLIAMS. Our next witness is Dr. C. L. Brumback, project director, Palm Beach County Health Department, which is located in West Palm Beach, Fla.

When people hear the name Palm Beach, they think of the luxury on the waterfront. Those of us who have been to West Palm Beach know that that is one of the thriving agricultural parts of our country. That is where you work out in the field.

STATEMENTS OF DR. C. L. BRUMBACK, PROJECT DIRECTOR, PALM BEACH COUNTY HEALTH DEPARTMENT, WEST PALM BEACH, FLA.; AND LEONARD E. WHITE, VICE PRESIDENT, FLAVOR PICT CO-OP, INC., DELRAY BEACH, FLA.

Dr. BRUMBACK. Thank you, Senator Williams. This is Mr. Leonard White here with me.

Senator WILLIAMS. Yes; I was just going to suggest that Mr. White come up at the same time so we have a double-barreled Florida here all at once. Thank you.

Dr. BRUMBACK. This is a real privilege for us to be here, Senator Williams, and we both appreciate the opportunity of speaking in support of the extension of the Migrant Health Act and also hopefully increasing its potential through more adequate funding.

Senator Williams, I have a prepared statement. However, I will summarize this in the interest of time, with your permission. (The prepared statement of Dr. Brumback follows:)

PREPARED STATEMENT OF CLARENCE L. BRUMBACK, M.D., DIRECTOR, PALM BEACH COUNTY HEALTH DEPARTMENT, WEST PALM BEACH, FLA.

Palm Beach County continues to require agricultural workers in large numbers despite some tendency toward mechanization, the effects of which have been largely offset by the development of new acreage for agricultural use. Information obtained from the Farm Labor Office, Florida State Employment Service, showed a population of nearly 30,000 domestic migrant agricultural workers and dependents in the county at the peak of last season. Figures for Florida showed approximately 100,000 migrant workers and dependents in the State during January, 1967. These figures do not include foreign workers. Information obtained for the season ten years ago indicated that migrant populations in the State and Palm Beach County were at approximately the same levels as at the present time. No great change in total requirements for agricultural migrants is anticipated in the foreseeable future.

The tremendous health needs of agricultural migrants in Palm Beach County were recognized many years ago. However, attempts to meet these needs had been sporadic and limited until approximately 12 years ago. At that time a series of studies and service programs were initiated with the help of Children's Bureau grants. These special projects added much to our knowledge of the migrants' health problems and the most effective ways of solving them. Furthermore, they substantiated the necessity of a Federal, State, and local partnership in the development of health services equivalent to those available to the resident population.

Our early experience showed that traditional public health services, inadequate to meet needs of residents, were totally unable to cope with problems of agricultural migrants, especially if the latter constituted a sizeable number of people. The situation was further complicated by the mobility of the migrant population, lack of qualification for local welfare services, their distance from health centers, and the fact that their work made it difficult for them to attend clinics at regularly scheduled times. Obtaining continuity of care was most difficult in the absence of interstate or intercounty referral systems. Lack of health knowledge and unwillingness of migrants to accept traditional services was as great a probelm as lack of understanding or motivation on the part of the professional workers.

In Palm Beach County, Federal project funds were combined with State and local money to provide the means for developing special services available at such times and places that migrants could take advantage of them. The services themselves were designed to take the migrants' cultural background and attitudes into consideration for increased acceptability.

Referral mechanisms were developed in cooperation with other agencies so that continuity of care was promoted as migrants moved from one geographic area

1 Koos, E. L., "They Follow the Sun", Florida State Board of Health Monograph, 1957. Browning, R. H., and Northcutt, T. J., "On the Season", Florida State Board of Health Monograph, 1961.