much money into both medicare and medicaid in the payment of actual services that the Federal Government has a real dollar interest as well as quality of care in being sure that (a) the services and facilities are available and (b) that they are not overbuilt because we are going to be helping to pay for them."

On the national point don't forget that under the legislation for the construction of medical schools and under the Nurse Training Act there still is a Federal responsibility and a congressional responsibility for determining the kind of priorities and emphases because what do you do with regard to the Medical School Construction and Educational Assistance Acts and the Nurse Training Act determines national priorities with regard to those manpower as well as construetion aspects so that there is still that aspect remaining.

Mr. ROGERS. Let me ask a couple of questions on section 11 (a) where it broadens the definitions of students eligible for loans. Does this put them in the category of no payment, or what is the purpose of this?

Dr. STEWART. What this does is correct an oversight, Mr. Rogers. The intent of the Nurse Training Act was to provide a grant to the school for the federally sponsored student. In that act the definition of federally sponsored student covered the contributing loan fund. The Allied Health Professions Act added the revolving loan fund, and since the language did not take into account that those students are not covered in the grants to schools, this is corrective.

Mr. ROGERS. In section 11 (c) why is it that you need another higher education representative to the National Advisory Council on Education for the Health Professions?

Dr. STEWART. Mr. Rogers, I don't know the answer to that question. Mr. ROGERS. Will you let us know and supply it?

Dr. STEWART. We will supply it for the record; yes, sir. (The information requested follows:)

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON SECTION 11(c) OF H.R. 6418-MEMBERSHIP OF THE NATIONAL ADVISORY COUNCIL ON EDUCATION FOR THE HEALTH PROFESSIONS

The Veterinary Medical Education Act of 1966 amended Sec. 725 of the Public Health Service Act to add one member of the Advisory Council on Education for the Health Professions. The former membership of the Council was divided between four members from the general public and 12 members from among leading authorities in the fields of higher education. No change was made in this division at the time an additional member was added to the Council. The proposed amendment-Sec. 11(c)-would change the language of the second sentence of Sec. 725(a) so that the division of the Council would be between four members of the general public and 13 members from among leading authorities in the fields of higher education, the effect being that the additional member who was to represent the veterinary profession would come from among leading authorities in the fields of higher education instead of the general public.

Mr. ROGERS. I think that is all.

Thank you very much for your testimony and for your patience. You have been most helpful to the chairman.

Mr. COHEN. Thank you, Mr. Chairman.

Mr. ROGERS. The committee will stand adjourned until 10 o'clock in the morning.

(Whereupon, at 1:05 p.m., the committee adjourned, to reconvene. at 10 a.m., Wednesday, May 3, 1967.)

PARTNERSHIP FOR HEALTH AMENDMENTS OF 1967

WEDNESDAY, MAY 3, 1967

HOUSE OF REPRESENTATIVES,

COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE,

Washington, D.C.

The committee met at 10 a.m., pursuant to notice, in room 2123, Rayburn House Office Building, Hon. Harley O. Staggers (chairman) presiding.

The CHAIRMAN. The committee will please come to order.

This morning we continue the hearings on H.R. 6418, a bill to amend the Public Health Service Act to extend and expand the authorizations for grants for comprehensive health planning and services.

Our first witness this morning will be John H. Venable, M.D., president of the Association of State and Territorial Health Officers. Dr. Venable, will you take the chair, please, and identify yourself and the gentlemen that are accompanying you. You may proceed in any way you see fit.

STATEMENT OF JOHN H. VENABLE, M.D., PRESIDENT; RUSSELL E. TEAGUE, M.D., PRESIDENT-ELECT; AND ALBERT HEUSTIS, M.D., SECRETARY-TREASURER, THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICERS

Dr. VENABLE. Thank you, Mr. Chairman.

Mr. Chairman and members of the committee, I appear before you today as president of the Association of State and Territorial Health Officers, with Dr. Albert Heust is, of Michigan, our secretarytreasurer, on my right, and Dr. Russell Teague, our president-elect, on my left. This indicates the importance which we give to this legislation. We want to present our association's views on H.R. 6418, the bill to extend the authority of Public Law 89-749, to require the licensing of clinical laboratories which do business in interstate commerce, and sundry additional proposals. The burden of my statement to you today will deal with the extension of Public Law 89-749.

On October 11, 1966, it was my privilege to represent our association and the State of Georgia before this committee when hearings were conducted which resulted in Public Law 89-749. That brief hearing, the committee will recall, was necessitated by the need for immediate congressional action to extend the authority of the old section 314 (c) of the Public Health Service Act, the basis for Federal support of public health programs throughout the States. At this point, I wish to express our appreciation to the chairman of the committee, Mr. Staggers, for scheduling these hearings on H.R. 6418. You gave us your assurance last October, Mr. Chairman, that you would take this action

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and we are deeply appreciative of it. You may recall, too, that we promised on that occasion to present to your committee at this time the result of our studies over the past years relative to this grant program. I am now prepared to do so.

Our association believes that by the action which this committee and the Congress took last year in the enactment of Public Law 89-749 that you are convinced of the necessity for (a) the careful planning of health services which need to be provided to the people of this Nation, and (b) the need for flexibility in the grant arrangement between Federal, State, and local jurisdictions, whereby States and localities will have necessary freedom of action to expend these grants in a manner which will be most responsive to the health needs of their own particular State or locality. I shall not, therefore, press upon you our convictions that this was and is a necessary and proper action. We are looking now to the extension of this authority for the next 3 years; and it is my purpose today, together with my colleagues, to discuss with you in specific detail the level of health needs that we have found in our respective States and the level of Federal support necessary if these health needs are to be met.

We pointed out last October that the relatively small increase of but $6.5 million each for the formula and project grants would not enable us to make any significant impact on some of the needed programs which must be implemented. We agree with the comment of Congressman Watson, made at the time of my appearance, in which he expressed his view that a role of full partner did not seem to be accomplished when there was such a meager increase in the appropriation. You may recall, too, at that time it was the recommendation of the ASTHO that $100 million be authorized for the formula grants to States and an additional $75 million be authorized for the project grant authority-a total of $175 million rather than the $125 million which is authorized for health services in Public Law 89-749.

We have been very busy since the enactment of this law. We set about to make an assessment in each State of the total health needs. We asked each State health officer then to list these needs by priority, to report the amount of financial support available from State and local sources for the programs at the present time, and to program over the next 5 years the level of increased activities possible, taking into account available health manpower and anticipated increases in financing from State and local sources. We then asked them to report the level of Federal support that would be needed to carry on these programs at an optimum level. We asked further that each State report on three sepcific health programs: family planning, cervical cancer, and dental health, in order to provide a nationwide measurement of the problem level of these three health programs. This meant that in each instance we have received from each State a priority evaluation of health programs which could be funded through section 314 (d) of the Public Health Service Act, the formula grants, consisting of not less than six areas and not more than nine. This careful scrutiny has revealed that we were much too conservative in our request of last October, because the surveys indicate that programs are needed and that we are in a position to implement programs at a level requiring $400 million annual Federal support. This is over and above State and local support which greatly exceeds the Federal contribution.

Let me give you some examples of what I am speaking of by reference to our own program in Georgia. For family planning programs, we have a potential caseload presently of approximately 210,000. Family planning services could be provided for 21,000 people with the expenditure of $196,000. We have State and local funding at the level of $146,000. We, therefore, would need $50,000 additional Federal support for this activity. In 5 years' time, when the caseload has increased to approximately 225,000, we can reach 70 percent of the objective or 136,000 with the expenditure of $1,380,000. It can be seen easily that there needs to be a great increase in the level of support from the Federal Government for this very necessary activity.

In respect to cervical cancer control, approximately 30 percent of women in Georgia are screened by private physicians. We have established a limited program, which has been budgeted and is being implemented for approximately 25,000 patients, which is only 4 percent of the total population with incomes under $3,000. The cost of this program presently is $56,000 for supplies and cytology readings. We could expand this program in 1968 to a level of $72,000 and in 1969 to a level in excess of $1 million. While the level of support from the State and local sources can be increased, it could not be of the magnitude necessary to implement the program which could and should be carried on.

In respect to dental health, of the approximately 1.7 million children in Georgia under 18 years of age, 1.3 million have experienced dental caries, which affect over 8 million teeth. Less than 35 percent have been treated, leaving almost 512 million untreated carious teeth. Thirty percent of this population lives in areas not served by public water supplies, and 40 percent lives in communities where public water supplies still are nonfluoridated. We have a further problem with the shortage of dental manpower and its uneven distribution wherein rural areas and areas of economic need have the least availability to dental care. The ratio of dentists to the population of Georgia is approximately one to every 3,750, compared to one for every 1,750 for the United States as a whole. Our dental caries rates in the nonwhite population are approximately 20 percent less than in the white, but 94 percent of the nonwhite dental needs are untreated compared to 58 percent of the white. To correct this problem, we would like to fluoridate each year 100 of the 1,000 municipal water supply systems and 85 of the 425 schools with individual water systems. To accomplish this, our level of expenditure in 1968 would total $742,000 of which $120,000 would come from State and local sources, requiring a balance of $622,000 from the Federal grant.

Another priority in Georgia is the establishment of an aftercare program for State mental hospital patients. Approximately 10,000 patients each year are released through furlough or direct discharge from State mental hospitals. Each hospital operates an outpatient clinic, but many patients live great distances from the hospital, some up to 200 miles. At present, the pattern of offering assistance to patients released from mental hospitals is through county health departments. We are making some progress in establishing clinics in these county health departments staffed by a physician who reviews the progress of former patients and who changes and renews prescriptions as needed. Drugs are made available to the medically indi

gent. At the present time, 12 of our county health departments operate such clinics, although most are not yet able to handle the volume of patients returning. The level of expenditure and the number of patients seen for the present fiscal year is approximately 750 patients with a drug expenditure approximating $50,000 and expenditure for personnel approximately $26,000. Of the 10,000 patients returning to the communities in 1967 from State hospitals, 5,500 are known to be without aftercare services other than minimal access by visitation of public health nurses, 3,750 can be seen at the outpatient department of the State hospital, and 750 can be seen in the present 12 aftercare clinics of county health departments. We plan and need to increase to a total of 45 the community care clinics. This number, serving each at population of not more than 100,000, would make statewide coverage possible. We also need to increase the range of services provided from the present emphasis primarily upon the supervision of medication to the total range of care necessary. This would require the services of a physician, preferably a psychiatrist; a mental bealth professional; a social worker or a nurse full time, public health nurse time equivalent to two full-time nurses; and a secretary. The level of this program presently is $169,000, all from State and local sources. If in 1968 an additional $400,000 could be realized from Federal sources, this could be increased together with the State and local funding, to a level of $600,000.

I might say parenthetically here, Mr. Chairman, that of the admission rate to our State hospitals, about 35 percent are readmissions. Most of these could be avoided if we had aftercare such as I am talking about.

Another of our serious public health problems is that of controlling tuberculosis. We have approximately 1 million persons in our State who have the tubercle bacilli in their bodies. Approximately 3.4 percent of the 1,269 newly active cases reported for Georgia in 1965 could be attributed to endogenous (internal) reinfections or breakdowns. We have a program in Georgia which attempts to follow cases of active tuberculosis who are not hospitalized to see that they are under medical supervision and are taking their drugs and other necessary precautions. We continue surveillance of inactive cases for 5 years to guard against reinfection. We also have prompt examination of contacts of active cases, medical examination and surveillance of suspects, identification and periodic examination of persons at greatest risk, and specific efforts to prevent children from becoming exposed to tuberculosis. The level of our support for fiscal year 1967 for this program is $1.7 million, of which $1.1 million is from State and local sources with a Federal share of $560,000. In our projected increase in the level of activity in tuberculosis control, at no point would the Federal contribution be greater than one-third of the total expenditure on this problem.

I believe these examples provide to you an idea of the specificity with which we have gone about our task of evaluating the health needs of our States, and the pricing out of the costs of the services which are needed to bring about bettered health conditions. Please understand that in each of these instances we are dealing with the application of known medical knowledge in making available to the people the fruits of research and experience which have been forth