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Mr. SYMINGTON. I am sure that you seek this goal. That is clear from the testimony. The President, I think, has set as a national goal that by 1980 between one-third and one-half of all those institutionalized be deinstitutionalized. Isn't that so?

Mrs. MILLER. That is correct.

Mr. SYMINGTON. You are suggesting that the regulations of 50 different States plans in some mysterious way will result in this, with the continuing admonishment by the Federal Government to do right in this regard but without really having the power of the funding behind it to insure that this is done?

Mrs. MILLER. I think, as one of the earlier witnesses said, that formerly the care of individuals in mental institutions had primarily formerly been a State responsibility. I think as the States learning about the alternatives to institutionalization, they see it is better for the individual and more cost effective to place these people in communitybased facilities.

There are also efforts to educate so that when these people are allowed to function in the community, there is not community resistance to halfway houses and group facilities.

So it is a long process and not something that can be accomplished overnight by putting lots of money in it. The process involves coordination, planning, and community education. That is what this program is designed to do.

Mr. SYMINGTON. I wish you well. I think the committee will certainly follow very closely the experience of the DDA and we want to be helpful where we can. But we look to you for reports on what seems to work best and where there might be additional influences that we can give that will help it along.

Mrs. MILLER. We will be glad to help.

Mr. SYMINGTON. Thank you.

Mr. ROGERS. Thank you. Mr. Secretary, what were the HEW proposals that went to OMB on these programs? Did you include any proposals for new starts, construction, or financial distress for community mental health centers which have reached their 8-year cutoff? Did the Department submit those programs and proposals to OMB? Dr. EDWARDS. We did submit our recommendations on these health service programs to OMB. There were some modifications.

Mr. ROGERS. Some of which were programmatic, were they not, and not just budgetary?

Dr. EDWARDS. Yes; I suspect that you would say programmatic. Mr. ROGERS. It is very distressing, Mr. Secretary, that the OMB is again writing programs for health rather than sticking to budgetary concerns. We have been through this before. I guess we are going to have to start it all over again.

I think we are over the impoundment in the health field. So, we will address ourselves this year to get them out of writing the health programs. We got them out of withholding the funds so maybe we can get them out of writing the health programs which you ladies and gentlemen ought to be doing because you know a little more about it. I am sure you are aware that both Houses have passed legislation on alcoholism, yet, this doesn't seem to be reflected in the testimony anywhere. I know it has not yet become law but we have both taken very strong positions on this bill. I presume that if the bill becomes

law either by signature or an override of a veto, you would administer the program as called for by the law.

Dr. EDWARDS. Absolutely.

Mr. ROGERS. You state you are requesting $325 million for six programs which are covered by H.R. 11511. Could you list the amounts for each of these categories? How much of the $325 million are you requesting for 314(d)?

Mr. SOPPER. Mr. Chairman, the $325 million was only referring to the three special project grant activities; that is, family planning, migrant health, and the community health centers.

Mr. ROGERS. All right. Break that down for us into those three programs community mental health centers-how much of the $325 million goes there?

Mr. SOPPER. That is community health centers.

Mr. ROGERS. Not mental health?

Mr. SOPPER. No. The $325 million was arrived at by the following: $200 million is being requested in fiscal year 1975 for community health centers activities.

Mr. ROGERS. How many health centers will that cover? You can get your program people up here with you. I want to get into some details. Dr. BATALDEN. It is 157.

Mr. ROGERS. Any new ones this year?

Dr. BATALDEN. NO.

Mr. ROGERS. No new ones. You are going to hold where we are?
Dr. BATALDEN. Correct.

Mr. ROGERS. Is there any need for new ones? I won't ask you that. I know the answer.

Are you closing any?

Dr. BATALDEN. No. We don't think so.

Mr. ROGERS. What about Philadelphia?

Dr. BATALDEN. No. From time to time, we do bring together centers into other kinds of networks and have, in fact, done this for some years now with the migrant health program with some success in improving projected administration and management.

Mr. ROGERS. I thought you had a pretty good cost benefit record in this program. Do you agree?

Dr. BATALDEN. Which program is that?

Mr. ROGERS. In the community health centers, neighborhood health

centers.

Dr. BATALDEN. I think it can be improved.

Mr. ROGERS. I would hope so but you are not improving it by not addressing the problem and simply holding steady where we are.

Mr. BUZZELL. I think you are correct, the performance has improved remarkably. It is getting better. We think we have a ways to go, that is conclusive of these centers as well as the migrant health program. Mr. ROGERS. I understood you had some studies which showed some pretty encouraging results. Could you confirm that?

Dr. BATALDEN. There have been a number of studies done. Just to cite two; the one done by Dr. Gordis and his colleagues in Baltimore. where they demonstrated that children who were cared for in the centers experienced a 60-percent reduction in rheumatic fever when contrasted with a carefully matched group.

Mr. ROGERS. Have you shown these figures to the Secretary and to OMB as evidence that community health centers represent a good investment of moneys?

Dr. BATALDEN. We have made that a part of our basic presentations. I think the success of those presentations are reflected in the fact that the budget

Mr. ROGERS. Stays steady?

Dr. BATALDEN. Steady, yes.

Dr. EDWARDS. If I can interject, I think this goes back to the question that Congressman Heinz raised and that is the development of health priorities.

Mr. ROGERS. I would agree. This committee wants to get some facts now so that we can judge where the money ought to be spent, where we are getting the best results and not just authorize blanket authority. We want to know what we're getting for the money.

Dr. EDWARDS. We in the Department have certainly clearly gone on record, if not before, certainly this morning, of our strong support of the programs we are discussing this morning.

Mr. ROGERS. I want the Congress to be aware of what is being accomplished in spite of some impediments that may be in the way.

What are the other benefits that have come about, aside from this 60 percent prevented from having rheumatic fever?

Dr. BATALDEN. I think another study recently done by Dr. Michael Klein in Rochester, N.Y., demonstrated a 50-percent reduction in the use of hospitals by children served in the neighborhood health centers. We would be happy to provide abstracts of these studies for the record if you wish.

Mr. ROGERS. I think that would be helpful.

[The information requested was not available to the committee at the time of printing-October 1974.]

Mr. ROGERS. Have you figured out how much saving there is to the taxpayer or the public when you can prevent 60 percent of the children from having rheumatic fever?

Dr. BATALDEN. Chronic rheumatic heart disease. There have been some projections made. Dr. Haggerty in the New England Journal of Medicine estimated over $100,000 of additional hospital costs that would accrue to the care for rheumatic heart disease in the project studied.

Mr. ROGERS. $100,000 per patient?

Dr. BATALDEN. The sum represented a total estimated cost for hospitalization during the acute phase, for all patients.

Mr. ROGERS. I think that could be extrapolated so we can find out what the real savings are. Can you do that and submit it for the record?

Dr. BATALDEN. Yes.

Mr. ROGERS. If there are any other benefits that come from a program like that, I think it is well to put them in figures so people who only understand health problems on the basis of figures can understand. I think if we do that we can make some progress.

It would be helpful to the committee if you can help us do that. Dr. BATALDEN. We will be happy to.

[The Department supplied the committee with several loose leaf books of material including information on this committee request for information. The material may be found in the committee's files.]

Mr. ROGERS. Does the bill's definition include family health centers and networks presently being supported?

Dr. BATALDEN. The administration's bill?

Mr. ROGERS. Yes.

Dr. BATALDEN. Yes.

Mr. ROGERS. How about the one we have?

Dr. BATALDEN. Not the way H.R. 11511 defines the neighborhood health center.

Mr. ROGERS. Will you submit by February 23 language which would include those programs?

Dr. BATALDEN. Yes.

[The Department supplied the committee with several loose leaf books of material including information on this committee request for information. The material may be found in the committee's files.] Mr. ROGERS. Let me just mention this now in passing: I remember when I was at NIH, I asked certain questions. We still have not received all the answers to those, Mr. Secretary. There are some other areas I understand where we need answers to complete the records. Would you give a list to them?

Mr. HYDE. Yes, again.

Mr. ROGERS. I hope we can get those. I know we demand a lot but would you help us in closing out some of these records? If we go too long, we can help you with a resolution of inquiry which I can file on the floor of the House where the inquiry is to be answered within 2 weeks.

Dr. EDWARDS. We can certainly give you either an answer or let you know where the question stands. Mr. Chairman.

Mr. ROGERS. Even that might be helpful. If you don't have the answer, if you will just tell us "we don't know" that would be helpful, and we will look elsewhere.

How much money is going for migrant health in your proposed budget? That is not included in the $325 million.

Dr. EDWARDS. Yes; it is.

Mr. SOPPER. $24 million is being requested in fiscal 1975.

Mr. ROGERS. What was it in 1974 ?

Mr. SOPPER. $24 million.

Mr. ROGERS. Same figure?

Mr. BUZZELL. Approximately the same figure.

Mr. ROGERS. What has happened to the migrant programs? Mr. BUZZELL. Let me briefly comment on the migrant program and, then, ask Dr. Batalden to elaborate.

We are quite pleased with the progress we have made. I think it is well illustrated by the homestead situation that you are familiar with. As you know, the grant project there played the key role in that crisis. As you also know, there have been no deaths resulting from it.

There is no evidence now of typhoid carriers. It is an illustration of how our center for disease control working with this project and others can act quickly to correct a health problem.

In addition to that, the migrant program that now benefits from good rules, good regulations and good guidelines. The numbers of encounters have gone up although we are operating at roughly the same level as we have in the past.

As Dr. Batalden indicated, there has been some consolidations. We now have 104 projects and we do have some concerns with your proposed bill particularly with reference to the high-impact versus lowimpact question.

You have already addressed that yourself and we will be providing you our comments in that regard. Do you want to add anything?

Dr. BATALDEN. Other than to speak briefly on the question of environmental services that are also spoken to in your bill, the requirement that every project develop environmental health services activities, we think would only partly address the problem of environmental health because as you know, the statutory responsibility for environmental health rests with the county and State governments and the projects have only a hat-in-hand kind of posture that can be taken with respect to that.

It is our belief that that problem is best addressed through the statutorily determined authorities at the State and county levels through a program rather than asking the projects to do that. I think there are some things that projects can do. In fact, we already have $120,000 roughly of our total appropriation and some 60 people devoted full time through our projects to environmental health advocacy and consumer education.

I think it is illustrative of what can be done at the project level. What happened in the aftermath of the homestead activity when our project in cooperation with the comprehensive health planning agencies pulled together the environmental sanitarians from the B agency and in that context visited the 13 other camps in the area and closed five of those camps and achieved adequate sewage and water supply in the others.

So, there is no question in my mind that some action can, in fact, lead to good results by the projects.

Mr. ROGERS. Yes. I am concerned. When I went down and looked at it, I was told there were no sanitation facilities out in the fields. Why shouldn't our people be concerned with that? That is absurd. We say let's leave it to somebody else. We want you to get in there and produce some changes in cooperation with them. That can be done.

Mr. BUZZELL. Mr. Chairman, we have some other equally pressing needs such as the hospitalization for the migrants.

Mr. ROGERS. Yes, I would like to discuss that. You are trying a new hospital demonstration program there; are you not?

Mr. BUZZELL. That is correct.

Mr. ROGERS. Would you describe it?

Mr. BUZZELL. That is off to a fine start. We have contracts now with five hospitals and another half a dozen contracts in the negotiating stage. This is a good example of an endeavor where we can work with the Bureau of Health Insurance in Baltimore and we are doing so.

The point I want to make is that we do not want the legislation to cause us to inappropriately get into some areas with some of our projects. We do not want to get into such areas if it will force those projects to close because they don't have that capability or the funds to cover them or into an area that is perhaps not as pressing from the health side.

The demonstration program is off to a good start. We do need to continue it because it will only deal with a portion of the hospitalized need.

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