services, on a reimbursable basis, for Federal employees and their dependents at remote stations where other medical care is not available. Under present law, civilian field service employees of the Public Health Service are entitled to special medical benefits which are not available to other civilian employees of the United States. Whatever the basis may have been for this preferential treatment of a small number of Federal employees, changing times and the availability of the Government-wide Health Benefits Program have made its continuance inappropriate. This bill would assure that civilian field service employees of the Public Service would receive only those medical services which are available to other Federal employees similarly situated. At the same time, this bill would help to assure adequate medical care for Federal employees in isolated areas, such as Public Health Service field employees in the Indian Health program. The Bureau of the Budget advises that from the standpoint of the Administration's program there is no objection to the submission of this report and enactment of H.R. 6418 would be in accord with the President's program. By direction of the Commission: JOHN W. MACY, Jr., Chairman. ADVISORY COMMISSION ON INTERGOVERNMENTAL RELATIONS, Hon. HARLEY O. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, DEAR MR. CHAIRMAN: I am writing to comment on H.R. 6418, the "Partnership for Health Amendments of 1967." The bill would make a number of amendments to the Public Health Services Act, including extending and expanding authorizations for grants for comprehensive health planning and services. Our comments will be directed to this aspect of the bill only. The Commission has urged greater flexibility in Federal health grants and expressed support for last year's bills which established the Partnership for Health program. In a 1961 report, Modification of Federal Grants-in-Aid for Public Health Services, the Advisory Commission recommended that States be authorized to transfer up to one-third of Federal public health funds in any one grant category to other categories. The Commission took this position in the belief that States should be given more discretion in applying the grant funds in areas of greatest need and that the narrow categories of the then existing public health grant system imposed undue rigidity. The Commission was gratified, therefore, when the Administration proposed and the Congress enacted the Comprehensive Health Planning and Public Health Services Amendments of 1966 which provided for administering Federal health grants through State comprehensive health plans and the use of block grants for formerly categorical grant programs. The reaction to the new program has been most gratifying. It has been widely supported as providing a simplification of procedures and a greater adaptability to State and local needs. The President pointed out in his "Quality of American Government" message earlier this year that last year's Partnership for Health Act points the way***" to a consideration of fundamental restructuring of grant-in-aid programs. The Commission endorses the objectives of Sections 2(a) and 2(d) of this bill, which would extend for four years the comprehensive health planning and block grant features of the 1966 act. We urge that consideration be given by the committee to an additional proposal as means of strengthening the Federal-State-local partnership in public health administration; namely, modification of the "single State agency" requirement for various public health grant categories so that, subject to approval of an alternative arrangement by the Secretary of Health, Education, and Welfare, States would have flexibility to develop the administrative structure suited to their overall needs. This could be accomplished by the following amendment: "Notwithstanding any other Federal law which provides that a single State agency or multimember board or commission must be established or designated to administer or supervise the administration of any public health program, the Secretary of Health, Education, and Welfare may, upon request of the Governor or other appropriate executive or legislative authority of the State responsible for determining or revising the organizational structure of State government, waive the single State agency or multimember board or commission provision upon adequate showing that such provision prevents the establishment of the most effective and efficient organizational arrangements within the State government and approve other State administrative structure or arrangements: Provided, That the Secretary determines that the objectives of the Federal statute authorizing the public health program will not be endangered by the use of such other State structure or arrangements." The language suggested is similar to that contained in the proposed Intergovernmental Cooperation Act (H.R. 5522) which is strongly supported by this Commission. These views are those of the Advisory Commission and its staff and do not necessarily reflect those of the Administration. I hope they will assist the Committee in its deliberations on this significant legislation. Sincerely yours, FARRIS BRYANT, Chairman. The CHAIRMAN. Our first witness this morning is the Under Secretary of the Department of Health, Education, and Welfare, Mr. Wilbur J. Cohen, accompanied by Dr. William H. Stewart, the Surgeon General of the United States, and his associates. Mr. Cohen, we are very happy to have you with us today, and you may proceed with your statement in any way that you see fit. STATEMENT OF WILBUR J. COHEN, UNDER SECRETARY, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY WILLIAM H. STEWART, M.D., SURGEON GENERAL; DAVID J. SENCER, M.D., DIRECTOR, COMMUNICABLE DISEASE CENTER; AND PAUL Q. PETERSON, M.D., DEPUTY DIRECTOR, BUREAU OF HEALTH SERVICES, PUBLIC HEALTH SERVICE Mr. COHEN. Thank you, Mr. Chairman. Also accompanying me at the table is Dr. Paul Peterson, the Deputy Director of the Bureau of Health Services in the Public Health Service, to my right, and Dr. David Sencer, the Director of the National Communicable Disease Center, on my left. Mr. Chairman and members of the committee, I am pleased to be here with Dr. William H. Stewart, Surgeon General of the Public Health Service to give the Department's wholehearted and enthusiastic support to the Partnership for Health Amendments of 1967, H.R. 6418, introduced by the distinguished chairman of the committee, Mr. Staggers. I might ask, Mr. Chairman, to put into the record at the conclusion of my testimony a tabular analysis of the provisions of the bill. As you pointed out, there are several different subsections of the bill, and I think this summary of it would help the committee when it gets to reviewing the legislation. (See p. 22.) The CHAIRMAN. As a part of your testimony it will be carried in the record. Mr. Moss. Mr. Chairman, I wonder if we may have copies. Mr. COHEN. I have a couple and can give you one here. Does any other member of the committee wish one? In 1935 Congress passed the Social Security Act, and in 1936 the Congress first provided appropriations for a general health program to support any part of a State's public health program. Since that time the Federal Government has continued to be one of the major financial partners in the Nation's health enterprise because congressional concern and public attention has been aroused by a variety of urgent, specific health problems. Federal support was provided in the form of ear-marked grants. The result, over the past decades, has been a salutary growth in health resources and some dramatic breakthroughs in health protection. Thirty years of Federal-State cooperation in health programs has brought us to the point where the States can and should be given a larger role and a much greater measure of flexibility in planning and carrying out health programs. Two important changes in this direction were provided by the Comprehensive Health Planning and Public Health Services Amendments of 1966: first, a real opportunity and a mechanism for the States and localities to identify their own most urgent health needs; and, second, a change in Federal funding to help them meet those needs. I would like to also put in the record, Mr. Chairman, at the end of my testimony exactly the dates on which Congress authorized the different categorical programs that are replaced in this legislation, because I think it gives you an idea of the long history of the way in which Congress acted to get at the present stage of where some of these various categorical programs could be brought together. The CHAIRMAN. As a part of your testimony, it will be included in the record. Mr. COHEN. Last year we appeared before this committee in the closing days of the 89th Congress, as you indicated, to request that the Congress enact those amendments into law. We asked for your quick action at that time because we felt that it was of great importance that the principle embodied in the bill, which has now become Public Law 89-749, be made part of the structure of our national health effort. Your action was timely. We are grateful for it. I think our major concern at that time, Mr. Chairman, was to give every evidence that we wanted to strengthen the role of the State health departments with the passage of medicare and with the passage of medicaid. And a great deal of other legislation passed through this committee. It was imperative that we do everything possible to try to strengthen the role of the State health department in this rather substantial area of Federal-State health legislation that has been enacted since 1965. President Johnson specifically recognized the importance of your action in his February 28 message to the Congress on health and education when he said: The Partnership for Health legislation, enacted by the 89th Congress, is designed to strengthen State and local programs to encourage broad gage planning in health. It gives the States new flexibility to use Federal funds by freeing them from tightly compartmentalized grant programs. It also allows the States to attack special health problems which have regional or local impact. This is the heart of the new law: planning for the efficient use of resources, and sufficient flexibility to use resources efficiently. We have as a nation, Mr. Chairman, committed outselves to promoting and assuring the best level of health attainable for every person in this country. The magnitude and complexity of that commitment requires that we marshal all our available health recources, public and private, in a vital partnership to achieve this important objective. The bill be fore the committee would continue and expand the new partnership which the Congress created last year. In the intervening months, since you last considered the partnership for health, the Public Health Service and the Department have become more intimately acquainted with the possibilities and problems posed by this large effort. We have begun to lay the base which is necessary to move away from the restrictive effects of fragmented and outmoded patterns. We have begun the task of creating a new relationship which can enable every sector of the total health community to provide fuller service to our citizens. The Public Health Service has been consulting with representatives of State, county, and local governments; with university officials; with representatives of professional organizations such as the American Medical Association, the American Hospital Association, the American Public Health Association, the American Institute of Planners; and with many voluntary organizations which have a longstanding interest and involvement in health affairs. Some of them, for example, are the American Heart Association, the American Cancer Society, the National Tuberculosis Association. These meetings have done much to shape our initial thinking and indicate the direction we must take in launching this nationwide program. Early in January, Secretary Gardner wrote to each of the Governors of the various States and expressed his belief that Public Law 89-749 is one of the most significant health measures passed by the Congress. The response from the States to the Secretary's letter has been most gratifying. The Honorable William L. Guy, Governor of the State of North Dakota and chairman of the National Governors' Conference, wrote to the Governor of each State, saying: This new health legislation could be a milestone in our continuing progress toward improved Federal-State relations. Then, Governor Guy wrote this to President Johnson: When you signed into law Public Law 89-749, known as the "Comprehensive Health Planning and Public Health Services Amendments for 1966," you gave Federal aid an historic turn for greater Federal-State relations. The act will now permit total comprehensive planning in the field of health. The Honorable Hulett C. Smith, Governor of the State of West Virginia, wrote to say that "West Virginia is eager to take full advantage of the comprehensive Health Planning and Public Health Service Amendments." Governor Harold LeVander, of Minnesota, concluded his letter to the Secretary by saying: ** This program will undertake to assess the present level of health programming and health resources. This assessment, I am confident, will lead to improved and more efficient programs and to fruitful working relationships between the health consumer, the governmental, the private and the voluntary health agencies in our State. I might add, Mr. Chairman, that Secretary Gardner, the Surgeon General, and myself, and various members of our staff, met with the executive committee of the Governors' Conference of which Governor Guy is chairman, with about eight or nine other Governors, and they evidenced the most complete cooperation in making this new law a success. They are very enthusiastic about its potentialities, as are we. Thirty-seven States, the territories, and Puerto Rico, each have already designated a comprehensive health planning agency. We believe that the remaining States will take action to designate an agency within the very near future. I might say, Mr. Chairman, that I am hopeful that more States will designate it, because with the reporting out by the full Appropriations Committee of the supplemental for 1967 I think other States will be encouraged rapidly to designate the State agencies. We are greatly encouraged, Mr. Chairman, by the very deep interest and marked enthusiasm which the States have shown in this new program. Section 2 of this comprehensive bill which deals with the comprehensive changes embodies no major changes in philosophy, direction, or emphasis from Public Law 89-749. It extends and expands the authorizations for grants for comprehensive health planning and services which were provided last year. The important innovations enacted last year are preserved in full in the bill before you The concept of comprehensive health planning to be undertaken by the States with Federal grant support; The extension of areawide planning of facilities to encompass all health services; The training of the personnel necessary for these planning efforts; The new program of flexible assistance through State formula grants, without categorical restriction, for the public health services the States need the most; The broad project grant authority for the stimulation of new kinds of services, and for dealing with special types of problems. The bill extends the authorization for each of these aspects of the program through fiscal 1972. It would increase the authorizations for assistance to the States for planning activities, under section 314(a) of the Public Health Service Act, from the present $5 million to $7 million for fiscal year 1968. It would extend for an additional 4 years, the authorization for grants to schools of public health. It would also increase the authorizations for both formula grants under section 314(d) and project grants under section 314(e) from the present $62.5 million to $70 million for fiscal 1968. Funds to support these increased authorizations are included in the President's 1968 budget request. Formula grants to the States in fiscal 1967, under the previous Public Health Service Act authorization, were at a level of approximately $55 million annually, and assistance under the project grant authorizations was at a level of $58 million annually. A large proportion of the funds authorized under the Partnership for Health Amendments for fiscal 1968 are likely to be committed by the States to programs approved and begun in earlier years. Therefore, the $70 million authorization for fiscal 1968 will thus allow for only a modest expansion in these activities, and result in a roughly constant Federal share of of the total cost. There is little doubt that diversity of needs and resources extends down into the localities within the States: and the partnership for health legislation recognizes this, both in the planning and funding of health services. Local planning is an essential base for the statewide planning effort. Local participation and knowledge of the area to be served can best come from the area wide planning groups. The |