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There are no data available to determine how much of these opportunity costs are borne by government in the form of increased expenditures for public assistance, day care, social, health and housing services, and how much are borne by the individual and her family. If only half were a charge to government it would add more than $550 to the savings attributable to each averted birth.

Since we do not yet have data with which to make an estimate of the cost to government, the opportunity cost represented by lots earnings will be excluded from this analysis. This exclusion, like the earlier ones, understates the shortterm savings to government as a result of births averted due to the federal family planning program. d. Summary of savings, 1966–71

For purposes of this analysis, then, the minimum short-term savings in governmental expenditures will be calculated to include only $504 per birth averted for costs of medical maternity and pediatric care, and $128 per birth averted in public assistance and food stamp costs, with no savings attributed to loss of earnings during pregnancy and the early child-rearing period.

The total savings of $632 per birth, which represents costs during 1970 and 1971, is reduced for the years 1966 through 1969 in accordance with changes in the Consumer Price Index for those years. The order of magnitude of the shortterm savings in governmental expenditures as a result of the organized family planning program can be estimated by applying these savings to the estimated number of births averted (Table 8). TABLE 8.-2 ESTIMATES OF SAVINGS IN SHORT-TERM GOVERNMENTAL EXPENDITURES FOR MEDICAL CARE AND PUBLIC ASSISTANCE AS A RESULT OF BIRTHS AVERTED BY ORGANIZED FAMILY PLANNING PROGRAMS, 1966-711

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1 The computation assumes that savings are proportional to births in the absence of any information on economies or diseconomies of scale or of utilization of a fixed capacity for services. The savings per birth averted is estimated at $63 2 to 1970 ans 1971; for 1933 tronzi 17), tris eitimate nx; b??10311:21 in accordance with changes in the Consumer Price Index for those years. ''Statistical Abstract of the United States," 1971, p. 339.

2 Derived from using ratio of 1 birth averted per 10 patient years. 3 Derived from using ratio of 1 birth averted per 7 patient years.

FEDERAL EXPENDITURES FOR FAMILY PLANNING SERVICES AND BENEFIT/COST RATION

To estimate the benefit/cost ratios for these short-term savings, it is necessary to determine the level of federal expenditures applicable to each year's savings. Federal funds for family planning service projects have typically been awarded in the last quarter of each fiscal year and are used in the following fiscal year to finance expansion of a project's capacity to serve additional patients. The time lag between a grant award, delivery of family planning services and a birth averted is therefore at least nine months before the grant could prevent even one birth. Grants awarded at the end of FY 1970 (May-June, 1970), for example, were used to increase services between July 1970 and June 1971; their impact in terms of births averted began to be reflected only in March, 1971, and continued throughout calendar year 1971 and into the first quarter of calendar year 1972. The appropriate relationship, therefore, is between FY 1970 grants and calendar year 1971 births averted. The benefit/cost ratios for federal family planning expenditures, based on this time lag, are shown in Table 9.

For the four-year period from FY 1967 through FY 1970, the federal govern. ment estimated that it spent $174 million for family planning services. The savings to government in medical care and public assistance costs in the single 2 These benefit/cost ratios apply to the federal investment in organized family planning services, not to total public and private expenditures for these services. Federal outlays since 1967 have both financed the cost of services directly and stimulated investment of other funds in family planning by state and local government, private philanthropy, and in some cases, partial fees paid by patients. Systematic data are unavailable on the extent of financing through these non-federal sources; a reasonable guess would be that nonfederal funds amounted to 20-25 percent of the federal investment. The addition of these non-federal funds on the cost side would reduce somewhat the ratios of return presented here.

year following these expenditures are estimated to range from $368 to $524 million, for an overall short-term benefit/cost ratio between 1.8:1 and 2.5 :1." TABLE 9.-SHORT-TERM BENEFIT/COST RATIOS OF FEDERAL FAMILY PLANNING EXPENDITURES,

FISCAL YEARS 1967-70

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1 Derived from ''Special Analyses, Budget of the United States" for fiscal years 1969 and 1972.

DISCUSSION

A method of calculating the short-term savings in governmental expenditures as a result of the funding of U.S. family planning programs has been presented. There are a number of reasons to believe that the benefit/cost ratios derived above understate the actual savings in government expenditures. In addition to the possible underestimate of births averted already noted, the analysis may understate the true situation because :

It computes as savings only the costs to government of medical care during pregnancy and the first year of a child's life, and the first year of public assistance for a child born to a family already receiving public assistance.

It does not include as savings the short-term costs to government of lost earnings to women who have to give up their jobs during pregnancy and the early child-rearing period, nor does it attempt to estimate the number of families who become public assistance recipients as a result of the birth of an unwanted child.

It excludes entirely the medium- and long-term costs to government of raising a child-the cumulative costs of education, housing, health services, care of the mentally retarded, public assistance, and other public services after the child is two years old.

Even in this limited framework, however, it is clear that the short-term benefits of family planning to public funds alone are high, without taking into consideration the economic, social and personal benefits to the individuals and families themselves. There are few public programs in the U.S.-and possibly none which have the potential of saving a minimum of two dollars in governmental expenditures in Year 2 for every dollar expended in Year 1. It is noteworthy that the bulk of these savings derive from the costs of medical care associated with pregnancy; only about one-fifth derive from the cost of public assistance.

These savings are in addition to the long-term savings, and the health, social and demographic benefits to government and individuals, from the prevention of unwanted births. The governmental resources saved would of course be freed up to finance other urgent health and social needs in the year following the program expenditure.

Dr. HELLMAN. The maternal mortality is lower than it has ever been in the United States. The infant mortality is lower. Now, it is hard to relate these figures directly to family planning but infant mortality and maternal mortality are related to women with large numbers of babies and older pregnant women. The number of older women having babies in the United States has decreased materially, for example, about 50 percent in New York City.

The number of women having three or four babies has decreased about 30 percent. You can't do that without planning your family so I think we can take some credit there. I think we can take a little credit for the diminution in the birth rates among the poor but not the total decline in birth rates in the United States.

Mr. Rogers. I think any facts or figures you have along these lines would be helpful for the record.

How much of the research moneys are you spending under the authorities of title X?

Dr. HELLMAN. Under title X we plan to obligate $2.6 million for service delivery research in fiscal year 1974. This activity is conducted by the Bureau of Community Health Service. The family planning and population research conducted by NIH is funded under section 301 of the Public Health Service Act.

Mr. Rogers. Should you be spending some?

Dr. HELLMAX. Under other authorizations we are spending at NIH about $51 million in fiscal year 1974 for population research. I think we have ample amount of money in medical research and behavioral research to meet the demands of any project that promises some success.

Mr. Rogers. Would you let us have a list of your research projects, funding and what is happening in those areas?

Dr. HELLMAX. Yes.
[The following information was received for the record :]

GEOGRAPHIC REPORT OF GRANTS AND CONTRACTS ACTIVE DURING OCTOBER 1973 BY

STATE OR COUNTRY, CITY, AND INSTITUTION-NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT CENTER FOR POPULATION RESEARCH

Research Grants, Training Grants, Fellowships, Research Career Program Within each section, the domestic grants are shown first, arranged alphabetically by state, city within state, and institution within city. The foreign grants are arranged in a similar fashion alphabetically by country.

Awards, and Research Contracts and Interagency Agreements

NOTES AND DEFINITIONS

This report lists, by state or country, all institutions receiving support through NICHD grants or contracts active during October 1973. It indicates the amount and the various types of awards being received by each institution.' Organization of report

The first section of the report covers the total Institute portfolio, and the following sections cover the five programs individually. The page numbering system shown below will assist the reader in locating programs.

Program

Letter code

Pages

Total NICHD.
Population and reproduction..
Perinatal biol and infant mortality.
Growth and development...
Adult development and aging.
Mental retardation..

PR
PBIM
GD
AR
MA

1 to 79.
1-1 to 1-45.
2-1 to 2-26.
3-1 to 3-30,
4-1 to 4-13
5-1 to 5-15.

1 The complete list may be found in the committee's files.

Number and money totals, separate for domestic and foreign grants, are shown for each institution, state or country, program, and total NICHD. These totals may be identified on the printout by asterisks as follows:

* Institution or Campus total.
** State or Country total.
*** NICHD or Program total.

In cases where institutions have grants at more than one campus, the institu-
tion totals shown are actually campus totals. For example, grants to the State
University of New York are listed and totaled separately at New York (City),
Buffalo, Oswego, etc.
Cutoff date

The cutoff date for this report was October 23, 1973. That is, all award statements and other documents used in the coding preparatory to the report which were received in the Program Statistics and Analysis Branch through that date are reflected in the report. In the case of committed (Type 5) grants for which the award statement for the current project year had not yet been received in this Branch, the amount for the preceding budget period was used. New (type 1) or competing renewal (Type 2) grants would not appear in the report if the award statement had not reached the Branch by the cutoff date. Definition of "active" grants

"Active" grants are defined as those whose project period includes the specific date chosen--for this report October 1973. The use of the project period for defining active status, instead of the budget period, retains in the active category grants with commitments for future support even when there is a hiatus between the end of one budget period and the issuance of the next award statement because of some administrative problem. However, only awards beginning before or during the month of the report are considered active.

The activity status of fellowships is based on activation dates; thus, fellowships which have been awarded but not yet activated are excluded from this report. Institution names

The usage of institution names and locations in this report conforms in general with that of DRG in its publication, “Public Health Service Grants and Awards." This may be summarized as follows:

1. The name of the parent organization is used, rather than that of a component or subdivision, such as a school of medicine.

2. The location shown is that of the component or subdivision in which the professional responsibility for NICHD-supported research lies, even if the location differs from that of the parent institution.

3. The institution having professional responsibility is shown, rather than a foundation which may have been set up to administer grant funds.

4. In the listing of awards to governmental organizations, Federal and nonFederal, the name of the parent department is used. Grant number

Only the program code and serial number are shown for each project. Since each project occupies only one line, with one dollar figure covering all active awards, and since more than one type of application and more than one suffix might be represented, the type and suffixes are omitted.

As indicated above, research contracts and interagency agreements are included in this report. They may be distinguished by the program prefix which is a part of the grant number, as follows:

Y01 Regular Research Contracts.

X22 Contracts under U.S.-Japan Cooperative Medical Science Program (NIAID).

Y01 Interagency Agreements. Total award

The number totals shown throughout the report are counts of projects rather than counts of awards. In other words, a grant and its supplement are counted as one project, and the money awarded on a supplement is included in the money shown. Supply allowances are included with the amount of the parent fellowships.

The NICHD totals would be expected to equal the sum of the program totals. However, two scientific evaluation grants (identified by the prefix R09) are not assigned to a program. There is, therefore, a difference of $350,776 between the NICHD research grant totals and the sum of the program totals.

Grants and contracts awarded under the U.S.-Japan Cooperative Medical Science Program and bearing HD grant numbers appear in this report. They are as follows:

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These projects, which are all in the Growth and Development program, appear in this report because they come under NICHD program responsibility. However, they were not funded by NICHD and are not included in any totals.

Similarly, the NICHD research grant portfolio includes 13 projects funded from Special Genetics Funds of the NIGMS. These, too, are listed in the following report but excluded from totals. By location and program, they are identified as follows:

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Future support

The column headed "FUT” gives the number of years of committed support remaining for each project.

Mr. Rogers. Is there anything new or innovative that you feel is developing?

Dr. HELLMAN. I think we ought to have an injectable contraceptive that is much safer than depo-provera.

Mr. Rogers. Do you think that is possible within the next 2 years? Dr. HELLMAN. I think it is possible

Mr. Rogers. We would like to have something on that for the record. [The following information was received for the record :]

LONG TERM INJECTABLE CONTRACEPTIVES FOR WOMEN The possibilities of a new injectable method of contraception have been extensively studied in clinical trials both under an IND in the United States and under the extended research program in the United Nations. The contraceptive action is based on the anti-ovulatory effect of a progestin. Suspensions of a new progestational agent, nor-ethindrone enanthate are injected in doses lasting three months. Preparations lasting six months or longer are being tested. Some safety issues and reversibility remain in doubt.

The implants of long acting contraceptives continue to give increasing promise of clinical utility. They are now in clinical trials and some have an indicated effective life of up to 10 years.

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