the question about the size of areas intended to be served, and that of course occurs to me. Mr. COHEN. I think I see your point there. We might give some further consideration as to whether that couldn't be spelled out in a little more detail. Mr. BROWN. I was going to ask the same question that Mr. Rogers started to ask, and if I can pursue it just one step further, where do you anticipate the funds for section 4 emergencies will come from? Did I miss your explanation of that? Dr. STEWART. These funds in the past have come from reprogramed funds. If the amount became substantial, then we would have to seek recourse in the Appropriations Committee. Mr. BROWN. In other words, you will borrow them from some place else within the Department? Dr. STEWART. If it were a small disaster which was over in 3 hours, it wouldn't make much difference. But if the service we provide is one that takes a great deal of equipment and supplies, we would have to seek reimbursement. Mr. COHEN. If a program involves a substantial sum of money, we advise the Appropriations Committee. But it might well be that we give consideration to ask the Appropriations Committee for a separate item to take care of that, because our major argument about reprograming is that it does set back the program for which the Appropriation Committee gave the money. By the time you get it all going again, you have disrupted a program. And I think my own preference would be, at least within some margin of error, to ask for a modest appropriation from the Appropriations Committee. Mr. BROWN. Let me move to item (2) on page 10, "Definition of interstate commerce in the laboratories." If I live in Arlington, Va., and am being treated or analyzed by a laboratory in Washington, D.C., am I to presume that if I take a biological specimen at my home in the morning in Arlington and bring it to the laboratory in Washington, D.C., that that laboratory qualifies in interstate commerce? Dr. STEWART. Yes, sir. That is correct. Mr. BROWN. If I were in Arlington, however, and went to Richmond, Va., it would not be; is that correct? Dr. STEWART. That is correct. Mr. BROWN. If the laboratory is in a hospital, does that put it also in interstate commerce? Dr. SENCER. Not necessarily, sir. Dr. STEWART. Not just the fact of being in a hospital. Mr. BROWN. If the hospital treats people from out of State? Dr. SENCER. The laboratory has to receive specimens from out of State. Mr. BROWN. If it treats people from out of State? Let's put the example in a different way. If we have an accident case in a hospital on an emergency basis and the people come from out of State, and we have to send back and perhaps get some laboratory information from the persons' home for analysis in the laboratory where they are being treated on an emergency basis, does that put the laboratory in interstate commerce? Dr. STEWART. I think, Mr. Brown, the best explanation would be that if a specimen is transmitted across a State boundary to the laboratory, that comes under the definition. Mr. BROWN. Let me phrase the question. I think you are in a difficult area here, and I am trying to feel my way through it. I don't want to take the time of the committe in too much detail, but let's presume that we have a university with a university hospital and a student from out of State in that university hospital and the student goes home for the holidays and is asked to send a biological specimen to the hospital for the continuation of a series of tests. That puts the hospital laboratory in interstate commerce; is that correct? So that the laboratory never really knows when it may come under the classification of interstate commerce, because it treats people who may in effect move out of State or be residing temporarily out of State who have to continue a course of biological analysis. Dr. SENCER. I think many of these university laboratories would qualify as being in interstate commerce for other purposes. Many university laboratories accept specimens that are for analysis that will not be readily available in their laboratories in the area. As a physician, I know that I can send a specimen to the University of California. Mr. BROWN. What about the clinic that does not have a hospital and the doctor does some of his own analysis and gets a specimen from a youngster who has gone home for the Christmas holidays? Dr. STEWART. A physician taking care of his own patient is not covered. Mr. BROWN. A group of physicians? Dr. SENCER. That's exempted in this legislation, sir. Mr. BROWN. Where do you draw that line? Dr. SENCER. If in a laboratory a physician is taking specimens to use for the treatment of his patient and doing the examination under his own control in his own laboratory. Mr. BROWN. Suppose you have a cooperation of several physicians and one does the analysis but another treats the patient? Dr. SENCER. I think that our definition in the bill would include group practice or clinic-type practice. We are not trying to say that they automatically come into interstate commerce. Mr. BROWN. It is a thorny area. Dr. SENCER. Yes, sir. Mr. BROWN. And without standards so that nobody really knows whether he is covered. Dr. SENCER. I think there is a 13-month leadtime in which standards would be developed, would be published and would be reacted to. Mr. BROWN. After the enactment of the legislation? Dr. SENCER. AS Mr. Cohen said, we will be glad to submit for the record the tentative standards that would be used here. (See p. 41 for standards requested.) Mr. BROWN. One final question. I have heard figures extended over a period of 2 or 3 years. What provision is there for the State to take over any of the financing of these grant programs that the Department has in mind here for demonstrations? Is there any thought given to that? Dr. STEWART. Under the formula grant 70 percent of the money must be spent for local services that we talked about earlier. Thirty percent can be retained by the State. Mr. BROWN. You are missing my point altogether, I think. What provision is there for the State to take over self-financing of some of 80-641-67- -5 these demonstrations and programs for comprehensive medical plan, and so forth; in other words, to relieve the Federal Government of the necessity of financing a portion of the State effort? Is there any provision for that? Mr. COHEN. Well, no; there really isn't. Mr. BROWN. In other words, you presume that indefinitely the Federal Government will be assisting the States through Federal re sources? Mr. COHEN. Yes; and I think that that is what I tried to say before. I think that is what is going to happen. The States and localities are spending in the neighborhood of $700 million in this area per year. Mr. ROGERS. Will the gentleman yield? I think it is true that this money is not just automatically allocated. Must there be now with the State plan a request from the State? Dr. STEWART. That is correct. Mr. ROGERS. So your action in allocating certain monies to the State is a result of a State's request for the Federal Government to participate. So that really, I presume, the basic decision as to whether a State will contribute in the program or continue to rely on Federal funds comes down to a State decision when they present their plan. Mr. COHEN. Yes; and I was assuming that. What I think Mr. Brown may have been getting at, if I understood his question correctly, is that we are going to be putting $100, $200, $300 million into this area. The States, as I said, are putting in $700 million a year. I would expect the States and localities to have to continue to increase their share as the Federal Government increased its share, so that in a few years. from now I think the total expenditures in this whole area would be well over a billion dollars a year. And I think with a growing population we need to spend more too on family planning services, the need for the training of more nurses and physicians, and the organizing of local health services. I know in my State of many places where they do not adequately exist, and I would have to say that both the Federal Government and the State and localities are going to have to increase. Mr. ROGERS. I am surprised to see that there is nothing in this act, as in the Mental Health Facilities Act, to encourage the States and localities to take over the responsibility of their own demonstrations or comprehensive medical plans. Mr. COHEN. Only to the extent that they are already spending so much more than the Federal Government is spending already, and we would expect them to continue to do so. Dr. STEWART. This is what I was going to say. There is another way to say it. Federal-State-local expenditure for public health services amounts to about $4.25 per capita: $2 is State, $1.50 is local, and 75 cents Federal. From all the studies and State surveys that we have seen, we think that the level we should approach is around $6 per capita within the next few years. This is really a shared expenditure to carry out services. While the services may change as techniques and problems change, there are so many great needs that as far as we can see this shared effort will continue. Mr. ROGERS. Do I understand that the dollars and cents in this whole thing is $182 million? Mr. COHEN. Well, if everything in this bill were under the present law, it would be $157 million. We are asking for $25 million more in 1968. The comparable total for 1969 would be $284 million. Mr. ROGERS. 1968 was $192 million; is that correct? Mr. COHEN. Yes; $182 million. That is both sections 314, 305, and 309. It doesn't include anything that is involved in the regulation and licensing of the clinical laboratories, however. Mr. ROGERS. No expense figure for that? Mr. COHEN. No expense figures for that, no; or the 51 additional people that Dr. Sencer mentioned as the additional number of people. This will only have to do with the grants and other factors. Mr. ROGERS. Is it your thought to come in with a supplemental request for that later? Mr. COHEN. Either a supplemental or in the normal appropriation for the National Communicable Disease Center. Mr. ROGERS. Let me pursue that for just a minute. You say there will be 51 additional personnel required to administer the laboratorylicensing provision? Dr. SENCER. Yes, sir. Mr. ROGERS. And I think it would be well to submit for the record the number and cost. (The information requested follows:) "PARTNERSHIP FOR HEALTH AMENDMENTS OF 1967" CLINICAL LABORATORIES IMPROVEMENT-LICENSING OF LABORATORIES-PERSONNEL AND COST ESTIMATES Budget summary, 1st year Personnel Payroll benefits_ Travel Transportation Communications (telephone, postage, parcel post). Rent (300 gross square feet per person times $3 per square foot). etc.) reference labs for evaluation__ Supplies and reagents--‒‒‒ Equipment (1st year cost-subsequent years 10 percent). Total $457, 648 45, 765 71, 500 15,000 20,000 46, 900 250,000 293, 187 300, 000 1, 500, 000 BUDGET NOTES 1. Budget based on an estimated 1,000 laboratories transacting business in interstate commerce. 2. An Annual cycle for reviews and certification is planned. 3. Evaluation of performance will be carried out throughout each year. 4. Resurvey of approximately 90 laboratories where correctable deficiencies are found. 5. Review of 150 laboratories per year per man is estimated. (260 gross work days less 20 days less annual leave, 7 days sick leave, and 13 holidays=220 net work days. At 4 reviews every 5 days, 176 reviews per man-year would be performed. This is rounded to 150 reviews to allow for travel, report writing, and general in-house administrative duties. 6. Travel and per diem costs estimated on basis of seven travelers making 2 trips per week for 44 weeks during the year, as follows: 14 trips times $100 per trip times 44 weeks_ 3 days per diem times 7 people times $16 per diem times 44 weeks___ Total $61, 600 9.900 71, 500 |