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gram provides an excellent means of providing quality services at a lower cost to both the patient and the Nation.
Also, recent actions on the part of some States to dump patients from mental hospitals back into the community with insufficient alternative services available to them underlines the need for increased support of the CMHC program. Recent administration attempts to curtail future development of this program and to cut back on operating funds for existing centers is, in our opinion, counterproductive in terms of both the provision of these services and long term financial savings. The proposed legislation as stated in title II affirms, on the other hand, the need for continued support and further expansion of these centers, including construction of these centers, and we commend the sponsors for the many good provisions included therein.
The requirement for CMHC's under section 201, for example, provides a comprehensive list of services and clearly delineates the role of a center in relation to other agencies and programs within the community; and, in our opinion, the intention of the Congress in mandating that the centers work closely with schools, law enforcement and correctional agencies, and welfare and other health service programs within the community is equally important. Too often in the past mental health has been considered as a separate service, and thus many of the other societal factors involved have been ignored. Only through the kinds of coordination detailed in this legislation can these services be maximized and made an integral part of a total human service system.
This title also furnishes many provisions which will encourage the continued efforts and new development of centers that serve lowincome populations. We do feel, however, that the reasonable volume of care for the poor under section 202(a) (5) should be more specific: The negative experience relating to a similar provision in the HillBurton Act might be avoided if greater specificity were given to the provision of greater services to the poor.
We are pleased to see that section 201(c)(1) requires that the governing body of the center be representative of the residents of the community served. In order to carry this out, however, we believe it would be desirable to increase the minimum number of nonproviders on that body from a third to one-half. APHA believes that the consumer in these programs, as in other health service programs, is necessary in order to assure that services are of high quality and responsive to the needs of the population served.
Family planning programs have proved to be very valuable, not only in terms of providing direct family planning services, but as an entry point into the whole health care system and as a vehicle for improving that system. Many family planning programs have pioneered community participation in the decisionmaking processes of health services and have also provided for training and expanding utilization of a wide variety of new health workers, many of whom are from the low-income and minority populations of the community served. Although we agree that, ideally, family planning services should be an integral part of a total health care program, until public commitments for truly comprehensive services are made firm, and until necessary financing mechanisms are provided for, we support the continued existence of these categorical programs.
Title III of this bill provides, basically, for a continuation of title X of the Public Health Service Act and of the provisions of Public Law 91-572, with new authorization levels mandated through fiscal year 1976. We are pleased to see the continuation of this program as provided for by this title, but have some concerns regarding it. We believe that the services offered in family planning programs have been extremely valuable to those who have been fortunate enough to receive them. Nevertheless, there still remains a great need to increase the capacity of existing programs and to develop new ones in order to reach everyone who desires and would benefit from family planning services. The authorization levels established for project grants and contracts under section 302 (a) of the title do not represent an increase sufficient to accomplish the desired expansion. The notion, as expressed by the administration, that services can best be financed through reimbursement under titles IVa and XIX of the Social Security Act has not proved to be entirely valid. We believe that, until a more universal financing system is developed, title X moneys will be needed, not only to guarantee availability of these services, but to provide them in a manner that is most responsive to the needs of the low-income population served.
Section 302 (c) lowers the level of authorization for research grants and contracts for family planning. Although a great deal of progress has taken place in this field, very much remains to be done in both the technological and behavioral areas. A reduction in authorized funds as drastic as in indicated in this section appears to us to be indivisable at this time. Questions relating to the impact of services and their acceptance, and to cultural barriers that still exist, all require continued research, as do the areas of scientific study involving sa fe and effective means of providing both fertility and infertility services.
Over the past year, HEW has eliminated the National Center for Family Planning Services and has distributed the administration of the programs to the regional offices. APHA believes that the Center served as an important and needed national focal point for family planning and provided coordination, monitoring and a general overview of these activities that was beneficial in terms of both the quality of the programs and innovation in the field. In our opinion, the Center should be reinstated and, in order to protect it from political and administrative vagaries, legislation would be required similar to that which was proposed for the National Center for Health Service, Research and Development.
I would like to comment briefly at this point on title IV of the bill, which deals with developmental disabilities. We believe that the proposed legislation represents an excellent effort to deal with this very difficult problem both by continuing the authority for the existing program and by making some positive changes in it.
There is, for example, a more clear-cut definition in this bill of what is meant by a development disability. Given the broad area covered by this program, there was a need for specifically defining what disabili ties should be covered in order to provide some standardization and to prevent certain conditions from “falling between the cracks” and thus being overlooked. We are also pleased in this regard by the specific inclusion of autism as a covered disability.
There also appears to be a concern for promoting the deinstitutionalization of care, and we support the stipulation under section 405 (b) (4) of a 10-percent-minimum allotment for fiscal year 1975 for noninstitutional services development and implementation and for improving the quality of care and surroundings for those who are in institutions. We also concur with increasing the allotment to 30 percent for subsequent years.
Providing care in noninstitutional settings is important both in terms of financial savings and of maximizing the dignity and independence of disabled persons; and the need to improve the quality of care and the environment in which that care is given to inpatients is equally vital in guaranteeing their well-being.
The 30-percent set-aside provision under section 131 (b) for projects that might be determined by the Secretary to be of national significance is an increase from 10 percent in the original legislation. This represents in our opinion a positive step, for it provides a means to increase innovation and coordination in developmental disabilities programs.
Lastly, we would like to comment on the amounts authorized under this title. This program, as with many other health service programs, is an excellent concept and has proved very beneficial to those who have been fortunate enough to receive services under it. However, large segments of the population in need of these services remain without adequate care, for there are not enough funds available for the development and implementation of a sufficient number of these programs. Funds authorized under section 131 (a) must cover both program and construction costs and cannot provide for the necessary continuation or expansion of these important services. We urge both this subcommittee in setting authorization levels and the Appropriations Subcommittee to reconsider the amounts made available so that all those who should benefit indeed do so.
Title V of this bill, which provides for health services for domestic agricultural workers, represents an important step toward providing health care for a segment of the population which in the past has had to depend on a fragmented, episodic system of health services. Although Congress has over the past decade attempted to provide health services for migrants, the migratory nature of the population and the high incidence of morbidity and mortality of this group make provision of this care both difficult and expensive. This bill, by providing for the development of migrant health centers located in high impact, home base communities, offers a new approach to deal with this problem in terms of providing quality, comprehensive care and maximizing the resources available. As well, this title offers a number of other features that are important to the improvement of migrant health services:
First, section 310(a) (1) expands the target population served by also including domestic seasonal agricultural workers. It is difficult to separate those who are migratory from seasonal workers in general because, depending on work possibilities in any given year, a worker may or may not migrate. To provide services only for migrants, particularly in the home base community, would appear to us to be unrealistic and counterproductive. Second, this title defines specifically what services should be included, and acknowledges, and provides for, the
environmental needs of this population. Problems concerning water, sewage, solid waste, pest infestation and housing, as well as the hazards associated with the occupation of these workers, are as important to their health and well-being as are primary medical services.
We are pleased that this bill has included provisions for these ancillary services as part of the total health package. We are also pleased that provision is made to financially assist in the implementation of acceptable environmental health standards, including enforcement of those standards in labor camps.
The scope of services, as stipulated, appears to be comprehensive, although we would suggest that the primary services should include some dental care, as well as programs in the areas of health education, family planning, and nutrition.
We also find commendable the provision of this title which requires that a majority of the members of the governing body be consumers and which clearly delineates the role of that body. We realize that this is difficult to achieve, but we believe it is important to give consumers an active role in the decisionmaking process in order to guarantee that the services provided by a program be of a quality and character responsive to their needs.
The provision under this title which stipulates that only 30 percent of the funds authorized for fiscal year 1974 and 15 percent in fiscal year 1975 may be used for programs not located in high impact areas, might be a bit premature. There presently exists a large number of upstream projects, and such a rapid conversion to the migrant health centers might leave large gaps in health services for migrants. We would suggest a slower rate of conversion: Possibly 50 percent for 1974; 30 percent for 1975; and 15 percent in 1976. We concur that the 15-percent limit should then be continued, for no matter how effective the centers might be, there will always remain a residual need for the kind of upstream services outlined in section 310(d).
Lastly, the level of authorization provided for under this title, although representing a marked increase in funds presently available, are still very much less than what is needed. Two years ago, for example, the then Assistant Secretary for Health, Dr. DuVal, estimated that $600 million would be required to fully support these services. Present third party reimbursement mechanisms, including medicaid and medicare, have been of little assistance to migrants and, until a more universal system of financing is developed, funds under the migrant health program will have to serve as the basic mode of payment for health care for this group.
Mr. Chairman, we have a separate position paper on migrant health services and I would like to submit that at this time.
Mr. Rogers. Without objection it will be made a part of the record. [See p. 508.].
Dr. MILLER. The Neighborhood Health Center program has been a source of comprehensive quality health services for many low-income communities; an agent for socioeconomic improvement in those communities; and the source of development and training of a number of new types of health manpower of benefit to health services to all people everywhere. These programs have also included a wide range of other essential services, such as health education, nutrition and environ
mental programs, and have provided for the participation of consumers on their decisionmaking boards.
The program, not funded under its own title in the past, has been subject to the political and administrative uncertainties of both OEO and HEW, and because of a lack of a secure financial base has never been able to assure its future with any certainty. This lack of security, plus an insufficient level of administrative and technical support, has impeded the full development of many of these centers in the past. We are, therefore, very much encouraged by title VI of this bill which provides specific enabling legislation and authorization for the Neighborhood Health Center programs and eliminates funding uncertainties of section 314(e) which, although used to fund these programs in the past, has provided no guarantee that the total funding under that section would support these centers.
Over the last 2 years the need for this specific authority has become increasingly evident, both because some 314(e) funds had been rechanneled for support of HMO development and, more recently, as a result of attempts made by HEW to severely curtail funds for these centers, claiming erroneously that they would become self-sufficient through Government and other third-party reimbursement mechanisms. We are pleased that this title makes provision for greater use of reimbursement, including, we assume, arrangements on a prepaid basis, but does not make full self-sufficiency mandatory for continued operation of the programs. As more universal financing mechanisms develop, it is important that Neighborhood Health Centers are administratively prepared to utilize them and, with the recent HMO legislation, to convert to a prepayment system, but this should be a transitional process and not an abrupt change.
The definition of primary services contained in section 330(b) (1) is excellent, although we would suggest that certain other preventive services be included, such as health education, nutrition and environment programs and dental care (at least preventive care for children). We include these for two reasons: First, most of the centers are presently providing those services and should be encouraged to continue doing so; and second, some of those services are considered as basic benefits under the HMO legislation and, if conversion of a Neighborhood Health Center is to be facilitated, they should be geared up to provide those benefits (these specifically include some dental care and health education).
The authorization levels provided appear sufficient, particularly as the centers become better equipped to utilize other reimbursement mechanisms.
One last comment which applies to not only title VI but to CMHC's and the migrant centers as well: Provision has been made under these titles for the development of quality assurance mechanisms, and we are pleased to see this included. There is some question presently as to whether effective mechanisms for assessing quality exist, and we hope, as we are sure you do, that the study provided for in the recent HMO bill will meet this need, and its resultant recommendations will be applied to all these programs.
In conclusion, we find H.R. 11511 to be an important bill which acknowledges the continued value of these programs and which makes some important changes in their direction and future implementation.