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been a benefit to people, some of the problems that they have run into which according to GAO often are not of their own makingmight be worked out if some of those that are now approved and in existence had a chance to continue beyond the termination of their grant period.

I have proposed in my bill a very modest financial distress grant section in the amount of $10 million. I understand that $10 million might be substantially more than is necessary to continue these centers in operation until they get sufficient funding either locally or through national health insurance.

I wonder if you would care to address the question of the distress grant provision.

Dr. EDWARDS. I would only say, Congressman Heinz, that we did not include it, as you are well aware, in our proposed legislation. I think it is an issue that certainly we would be willing to sit down and discuss with you. We, like you, do not want good programs and good community mental health centers to go out of existence.

We have some evidence to indicate that this will not happen. We would like to discuss the evidence that we have so that you can judge whether you think it is truly necessary.

Mr. HEINZ. Let us talk for a moment about the catchment areas that have been identified but which you do not expect to approve any Federal investment for beginning new community mental health center projects. There are 1,500 catchment areas in the United States. You expected in your testimony there would be 640. That is 860 catchment areas that have been defined and, if your proposals were to hold sway, they would not be served by any community mental health center program.

Why do you feel it is realistic to assume that people other than the Federal Government will provide the resources, whether that be construction or staffing grants, to start such community mental health centers in these other areas? Your assumption, I assume, is that people will do so because they know this is a good program and have reduced the number of people in State mental health centers substantially and they know they save money overall in terms of the cost per patient and cost of treatment.

Dr. EDWARDS. There is evidence that certain areas are providing sufficient funding to continue the operation of their community mental health centers. We are hopeful that others will do likewise.

I must be frank to say that, in my judgment, the real issue here, is one of limited numbers of Federal health dollars. Just from a financial point of view, it is unrealistic for us, at least with the dollars that we have had provided to us and with the priorities we have in the health system, it doesn't make sense to attempt to fund all these 1,500 or 1,600 community mental health centers any more than it does to provide an HMO for every community in the United States. We have to allocate dollars according to our priorities, and this is the way we have come up with it.

The record is very clear that we certainly believe in the concept. We want to push this as hard as we can but we have limited dollars to do it.

Mr. HEINZ. I appreciate the fact that we have a limited amount of dollars. I would like to address that in a moment. What I think I hear you saying is-and correct me if I am wrong-is that we don't have

any evidence that some other jurisdiction, public or private, is going to pick up the ball, is going to establish any more community mental health centers.

Dr. EDWARDS. No; quite to the contrary. We have a lot of evidence that those community mental health centers whose 8 years are expiring I think there are some 20 or 30 this year-are going to continue with funds other than Federal funds.

Mr. HEINZ. Yes; but I am talking about the startup of additional centers in the catchment areas that are not yet served. Have you any reason to believe that, in fact, a program that the Federal Government has gotten into to the tune of establishing 43 percent of the centers necessary is going to be, in fact, a program that other jurisdictions are going to fund?

Dr. EDWARDS. I can't give you line and verse but I can only say this: If the community mental health center concept is as good as you and I believe it is and our colleagues believe it is, then, with State responsibilities being what they are, it is difficult for me to conceive that States won't assume the initiative in this regard. Dr. Egeberg might want to elaborate further on this issue.

Dr. EGEBERG. I would say only that traditionally mental health has been a State responsibility. For example, California, a State which has led in the community treatment concept, initiated a program of community mental health centers under the Short-Doyle Act in 1957, several years before the Federal Government effort began.

But it becomes a question of philosophy as to how much money one has and how one would distribute it. I feel as Dr. Edwards does there. Dr. EDWARDS. We do have evidence that States are emerging as the single largest contributor of community mental health centers budgets. They provide some 28 percent of the total revenues and an additional 9 percent is now being provided by local governments. So I think that is some indication of an appreciation on the part of governments other than Federal of the need for these centers.

Mr. HEINZ. Now the community mental health centers program has been in operation for about 10 years

Dr. EDWARDS. Yes.

Mr. HEINZ [continuing]. During which time you have approved 640 projects?

Dr. EDWARDS. Yes.

Mr. HEINZ. Do you have any idea how much money you have spent in those 10 years?

Dr. EDWARD. I am sure we do.

Dr. Brown?

Dr. BROWN. Approximately three-quarters of $1 billion roughly. Mr. HEINZ. 793 million Federal dollars. That means you are spending something under $80 million a year over this 10-year period on the average. How much did we spend on comprehensive health planning this year; fiscal 1974?

Dr. EDWARDS. I will have to look that up.

Mr. HEINZ. I think you requested $100 million.

Dr. EDWARDS. We can certainly supply that figure. It is $42 million. Mr. HEINZ. How much will we spend on the regional medical program this year?

Dr. EDWARDS. That is a difficult question to answer because we have the impounded funds.

Mr. HEINZ. I guess certain court decisions have made life miserable for you.

Dr. EDWARDS. We have the impounded funds plus 1974 funds, so we are talking about $164 million.

Mr. HEINZ. How much do we spend on biomedical research as just one kind of research each year?

Dr. EDWARDS. We will spend this year close to $2 billion.

Mr. HEINZ. How much do you anticipate the national health insurance program that was revealed to us 2 days ago will cost the Federal Government annually beyond

Dr. EDWARDS. Beyond what we are already spending?

Mr. HEINZ. Yes.

Dr. EDWARDS. I don't want to get into that argument but probably about $6 billion.

Mr. HEINZ. About $6 billion. Yet we are talking about a program that in the scheme of things has averaged $80 million a year. Your main point was that we don't have enough health dollars. Would you care to have equal time?

Dr. EDWARDS. I would love to have equal time. I think you have nailed the issue; namely, we didn't draw up the priorities. We have too many special interest groups drawing up our health priorities. I can assure you if I had the responsibility to draw up health priorities and, as a result, allocate dollars according to our priorities, the funding would look considerably different than it does.

Mr. HEINZ. May I take that as a statement of support?

Dr. EDWARDS. I wouldn't want to carry it any further than that but I think it is a fact. In the final analysis, when you look at any annual health budget, there are reflections of the OMB, the Congress, and far too many reflections of the professionals involved but, nonetheless, many people are involved.

Mr. HEINZ. Well, I have taken far more than my 5 minutes. I appreciate the patience of the chairman and the other members. I thank you, Dr. Edwards, for some helpful and useful comments. I appreciate having you all here.

Mr. ROGERS. Mr. Preyer.

Mr. PREYER. Thank you, Mr. Chairman. It is good to have such a distinguished panel here today.

The administration's bill does point up the continuing difference between the administration's approach and this subcommittee's approach to these matters. The administration's bill again emphasizes the desire to consolidate programs and the importance of block grants. As a matter of organization and logic, I can see there is a lot to recommend in that approach. But our concern has been that, when we go to general grants, we end up with OMB too often making the decisions on priorities to the exclusion of HEW and the Congress. Where we don't specifically pinpoint the programs, they have a way of disappearing.

Mr. Heinz has pointed up that, originally in HEW's bill, there was a financial distress plan for community mental health and that that was eliminated by OMB.

Dr. EDWARDS. We have obviously discussed that at great length internally. The final version did not contain it, that is correct.

Mr. PREYER. But he also brought out the problem of the new starts and construction. There are no authorizations in your bill for that as I understand it.

Dr. EDWARDS. That is correct.

Mr. PREYER. That would seem to me to be a clear example of where OMB, by vetoing that kind of provision, would be interfering with the programmatic considerations which ought to be the province of HEW and the Congress. I think that indicates where we have some differences of opinion respecting this general desire to consolidate programs.

Let me ask if I understand you correctly on the family planning and migrant health provisions that, under the administration's bill, you would allow those to lapse as far as being specific programs but you would mention them in the language under section 314(e), that you would change that language to mention those programs.

While mentioning them is better than no mentioning them-can you give us any assurance that specifying them is indeed enough to insure the continuance of the family planning and the migrant health programs? What sort of level of funding might they receive?

Dr. EDWARDS Again I think in my statement, Mr. Preyer, we have indicated, and I know all of us feel very, very strongly, that in no way are we trying to move away from these programs. We all recognize that the migrant health program, family planning, community health services are and have to continue to be major Federal health initiatives. We are on record as certainly favoring that.

We do have specific funds available for each of these programs in our proposal in section 103 of 314(e):

There are authorized to be appropriated such sums as may be necessary for the fiscal year ending June 30, 1975, and each of the next 2 fiscal years for grants to any public or nonprivate entity to pay part of the cost

Then we go into a fair amount of detail

providing or operating health services, clinics, improving health care or conditions of these workers or their families.

It goes on to some length.

Mr. PREYER. There is a word at the end of the line that worries me. Your statement reads:

When it contributes to improving the health condition of migratory workers or providing services in the field of family planning.

When you say "or," you give yourself a pretty good opportunity to eliminate that program, do you not?

Dr. EDWARDS. That is unfortunate. Again I am not very knowledgeable in the specific language, but that certainly would not be our intent. Maybe the word should be "and."

Mr. PREYER. Perhaps we could take the word "or" out and substitute "and." It is your strong intention to continue those programs-family planning and the migrant health program?

Dr. EDWARDS. Absolutely. As I mentioned a few moments ago, I think there are certain programs that are and must continue to be Federal service responsibilities-Indian health, migratory workers, community health programs, family planning. I think these are truly Federal responsibilities at least in the foreseeable future. I can't see anything that would change this particular situation.

Mr. PREYER. Let me just mention one other program that I was unsure about. You mentioned in the development disabilities program, in which we seem to share substantial agreement with your bill and our bill, H.R. 11511, except that we, in our bill, H.R. 11511, we earmark the deinstitutionalization by the States, which, I gather, is not included in your bill. Is there some specific reason why you dropped that provision?

Dr. EDWARDS. Could I ask Mrs. Miller to speak to this?

Mrs. MILLER. Yes; there are a number of reasons why we dropped the earmark. First of all, it limits the State flexibility, depending on their plans. It is also very difficult to define what deinstitutionalization consists of and how you monitor whether the State actually is implementing the set-aside you described in your bill.

So we felt that requiring the States to have a plan and strong requirements for deinstitutionalization in their plan would be far more effective. The States would set their own specific requirements.

Mr. PREYER. All right. I was just seeking information on that. That is something I am not very familiar with. Thank you very much, Mr. Chairman. I don't believe I have any further questions.

Mr. ROGERS. Mr. Symington.

Mr. SYMINGTON. Perhaps, Mrs. Miller, we could pursue that just another step. I understand there have been a couple of studies by HEW or commissioned by them-one that Rand did and another a group called Community Sciences, Inc., did last March. They were very critical, as I understand it, of the lack of coordination in the developmental disability programs and other programs for the handicapped. The flexibility that you suggest would arise, if that premise is correct, from just admonishing the States; rather the flexibility that would arise from allowing them to do what they wish in this regard, it seems to me, is not likely to result in the kind of coordination and fragmentation that was criticized by these studies. Is that a fair statement?

Mrs. MILLER. I have not seen the Rand study, myself. I read of it in the newspapers just a day or so ago. I think the study found that there are a number of separate programs serving the handicapped in this country. Many of them are public assistance type programs under the Social Security Act and other authorities.

I think one of the reasons why the administration felt the DDA program was not needed was that there were other authorities available. However, it is now using this authority to coordinate the other programs. Many of those programs are run by different agencies in the States.

So with the creation of the advisory committee within the State and with creation of a State agency which will bring the other agencies together, we are hoping to better coordinate those numerous programs.

This is a relatively new effort. Now most of the States do have these States administrative plans. But this has been a criticism of the numbers of programs serving the handicapped.

I might add that just recently under the Rehabilitation Act of 1973, a special office for the handicapped is in the process of being established in HEW. Through that we hope to better advise the Secretary of HEW and the other agencies on coordination.

31-151 O 74 Pt. 1 - 31

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