APHA stands ready to provide any future assistance it can in assuring the maximum success of this legislative proposal which provides for so many basic and needed health services to our population. Mr. Chairman, the proposed bill covers a great many important subjects, not all of which I can claim to be an expert on by a long shot. I have had expert assistance in preparation of the testimony, and I would be happy to attempt to answer questions that you have; if I am unable to answer them, if you would allow I will return to my Association and come back to you with the expert opinions that we have available.

[Testimony resumes on p. 512.]

[The position paper referred to follows:]

"MIGRANT HEALTH SERVICES"

Position paper of the American Public Health Association

Migrant workers represent a segment of the population included in the category of the working poor. They not only face many of the problems associated with other groups in this category, but have unique difficulties as well. This is particularly so in the area of health, for they represent a high risk group as a result of the living and occupational conditions they are subjected to. This is compounded by the fact that, as a result of migration, they often cannot share in health services and financing mechanisms available to other medically indigent groups.

In recognition of the unique problems migrant workers face in securing health care, Congress and the Department of Health, Education, and Welfare have developed and implemented a Migrant Health Program which has served these individuals and their families over the last ten years. Yet, the resources available, although extremely valuable, have not been sufficient to fully meet the needs of the entire migrant population. The depth and extent of the need for migrant health services is so great that, according to former Assistant H.E.W. Secretary Merlin K. DuVal, it would require over $600 million to fully do the job. The appropriation, however, has never, to date, exceeded $30 million, and in light of these limited financial resources afforded to migrant health services, what is available has to be utilized as effectively and efficiently as possible. In order to achieve this, future emphasis must be placed on the development of more preventive and comprehensive health care programs serving the migrant at his home base and providing health services support upstream.

The target population of the program will be domestic seasonal agricultural workers and their families, consisting of two groups: domestic migratory agricultural workers and domestic agricultural workers who perform seasonal farm work in their home base area. The two groups share the same home base communities, work activities, occupational hazards, culture, and income; and their medical needs are identical. The domestic seasonal agricultural workers remains in the home base community if employment exists, but since there is not an adequate number of local jobs throughout the year, approximately one million of the estimated four million domestic seasonal agricultural workers are forced to do migratory work. Many members of the community area, thus, forced to shift from local seasonal to migratory work with changes in local employment availability based on economic and agricultural trends, and the agricultural worker cannot predict whether he will be employed locally or as a migrant in the future. As a result of the similarity in health needs, and the frequency in change between local and migrant work, it is essential that no differentiation be made between these groups in the financing and delivery of health care.

Under the present migrant health structure, in fiscal year 1972, 259,000 of four million domestic seasonal agricultural workers received health services in 460,000 visits to 101 migrant health projects. This was at a cost of $69.00 per person actually served, or $4.50 per migrant for the total population. The average cost per visit is also higher for migrants than for the general population, a fact due, in part, to efforts to provide transportation, environmental services, and health education as part of these programs. The remainder of the higher per visit cost can be attributed to some of the characteristics of the classical migrant health project: seasonal in nature, low utilization, duplication

of services, non-comprehenesive, and acute or emergency care oriented. The majority of migrant health projects are upstream, serving a small population for a short period of time, and thus cannot function in a sufficiently cost-efficient manner. The result of all this is fragmentary, incomplete care for the migrants, as well as low cost-effectiveness. Programs tend to emphasize curative services (which also tends to increase costs) with less attention paid to prevention. Care is espisodic; continuity, from year to year, is virtually impossible; and records are often not available which also leads to further duplication or gaps in services. The seasonal projects require resources to set up and close annually, and lack continuity in location, administration, medical staffing, equipment, programs, and medical care. Lastly, further diminishing the impact of the already limited migrant health funds, are poor administration at all levels, and a dissipation of monies through bureaucratic channels at both the state and local level. In the future, there is a need to focus resources directly on local comprehensive service programs, bypassing other administrative levels. In order to achieve this, APHA recommends the development of regional health centers located in high impact home base areas.

REGIONAL HEALTH CENTERS

Regional health centers serving domestic agricultural worker home base, high impact areas will be able to maintain a more adequate patient load to fully utilize the services and can be more permanent in nature. The Regional Health Center will provide services to all domestic seasonal agricultural workers and their families located within an identified impact area, and administrative procedures will be developed to provide services to individuals who are not domestic seasonal agricultural workers but reside within the geographic target area on a sliding scale basis.

These centers will provide a full range of comprehensive, primary services including internal medicine, pediatrics and ob-gyn. Supplemental care in the form of hospitalization and certain specialized care will be provided by referral to contracted sources. Ancillary programs such as social services, health education, environmental services, home health, and transportation will also be offered by the center. The regional health center will serve as a health maintenance organization type facility, serving a specified target population, emphasizinz preventive services and continuity of care. In view, however, of the high incidence of health problems caused by environmental and occupational hazards associated with migrants, these must also be given high priority in both the staffing and operations of the program.

The regional health center will assume the responsibility of identifying and meeting the health needs of this target population, while the domestic seasonal agricultural workers remain in the home base community. The regional health center will additionally be responsible for the planning and arrangement of follow-up and continuing services for its patients during the period of time while they are in the migrant streams. Continuity in care will be accomplished by use of medical referrals, medical record transfer, and arrangements for acute and chronic care treatment at existing upstream migrant health centers, satellite, modular units from the home base regional health center (see below), and other community health facilities located in those areas.

Modules from the regional health center (see Facilities section) can be sent to high impact upstream areas when the migrants leave the home base. A health team would be utilized during non-migratory periods at the regional health center, and would relocate with the modules during the migratory season to provide care for the migrants in that area. A coordinator from the home base area would be trained and assigned to each upstream module to provide for administration, patient advocacy, and facility maintenance. As well, new and allied health professionals will be used on these teams in order to reduce dependence on the already limited supply of physicians available to these programs for upstream services. Nurse practitioners, public health nurses, and family health workers are some of the types of manpower that could be deployed, both upstream and at the home base. While the module is upstream, it will continue to be under the responsibility of the regional health center administrator as overall director of all the modules in order to guarantee continuity of medical services and administration.

FACILITIES

A major cost factor in the implementation of the Regional Health Center concept will be the construction and equipping of health and medical facilities. Problems associated with the development of permanent medical facilities include:

1. Long construction time.

2. High cost.

3. Underutilization during the migration season.

4. Inflexibility, in terms of expansion or modification once the facility is completed.

Thus, as an alternative to the permanent facility, modular structures should be considered. A grouping of medical modules may be designed for a regional health center, possibly in conjunction with a permanent or existing facility. The cost of modules is lower than permanent structures, and the construction time is considerably shorter, thus allowing the programs to become operational more rapidly. The modules are not mobile medical vans that would travel daily to domestic seasonal agricultural worker living areas, but are fixed-site facilities that would be supported by a local transportation system and would be attractively designed, and should be viewed by the migrants not as a makeshift operation, but as a modern, fully-equipped, on-going facility. As seasonal population variation occurs, the demand for health care will be reduced and examination room/laboratory/waiting room modules may be detached and transported as satellite clinics to previously identified high impact upstream areas, where they will remain during the migrant's stay in that area.

Additionally, modular construction will allow for flexibility with variations in demand and population trends at the home base area. If the domestic seasonal agricultural worker population of the region changes, additional modules may be moved in or out of the region to provide services. Also, if a satellite facility close to the home base program is desired for added accessibility to the patients, it may be simply moved from the central facility to an outlying area. Specialized modules might also be developed, to be shared by several regional health centers. While the cost of a multi-phasic diagnostic screening module or a dental hygiene module would be prohibitive for a newly developed regional health center, interregional cooperation would allow for the shared time use of these services.

UPSTREAM SEASONAL PROGRAMS

As a result of the level of health obtained through concentrated services provided in the home base regional health center, medical services in the upstream areas will be limited to more supportive care. These services would include treatment for acute and emergency problems, and continuing or follow-up maintenance for chronically-ill patients. In upstream areas, where a high concentration of domestic seasonal agricultural workers are located, the services will be provided by an existing upstream project, another regional health center, or a satellite clinic of the home base program. In upstream areas with a small domestic seasonal agricultural worker population or where workers are there for a short time, limited health services will be provided for acute or chronic health problems for migrants utilizing local medical resources (to be paid for by the home base program) or through a local health department.

In low and medium impact areas upstream, planning and managerial practices must be refined to utilize more effectively the existing resources. The availability of a limited number of administrative consultants experienced in the opening and closing of programs, in developing medical record keeping and financial systems, and in community organization would facilitate and standardize program operation. To obtain the best utilization, the consultants would be located within HEW regions serving a number of states, or within the coordinating agency (See Coordination Section).

In home base and upstream areas where the domestic seasonal agricultural worker population is low, the purchase of services in existing facilities is more practical than the development of a new program. Dependent on the resources available in the community, supplementing existing services might be considered. In some areas transportation outreach programs or patient advocates might be added to purchased services. Given the competition for cost-effective allocation of resources, however, such endeavors would become reasonable only at quite high levels of funding.

In upstream areas where health services are purchased, or areas where agricultural worker health clinics operate, migrants should be employed for the work season as patient advocates as a method of developing contacts within the community, bridging gaps caused by language, culture, medical professionalism and unfamiliarity with the area. The patient advocates will often be more effective in interacting with the migrant community than the medical professionals.

Problems or friction can exist where a migrant health program is placed in an upstream community in which there are limited resources for health care available to local residents. In order to prevent antagonism between the migrant and permanent population, every effort must be made to integrate local residents into migrant programs when developed, and to improve existing facilities and services if the migrants are to make use of them. Use of a sliding scale for this purpose would be appropriate.

An additional mechanism to improve health upstream would be the development of more stringent occupational health and safety, and environmental regulations. Standardized and enforced federal regulations would guarantee continuity in conditions from state to state. Particular areas of importance are the regulation of minimum housing standards, use of pesticides and insecticides, and occupational hazards.

RECORDS

As a method of providing continuity of health care, patient medical records must be transferred from the home base facility to upstream projects and other health providers. To date, difficulty has been encountered in this type of information transfer which has impeded optimum services and has caused duplication and gaps to exist. The development of regional health centers will provide a vehicle for improved record-keeping, and the use of the modules as upstream facilities during working seasons will allow for increased transferability. Also, increased funding support to groups like ASTHO to develop compatible records systems and to coordinate the transfer of records will aid in this process, particularly for other than high impact areas. By developing computerized medical records as well, information retrieval can be made possible at any domestic seasonal agricultural worker health center. As a secondary benefit, the medical records in computer storage may be utilized as a data base on domestic seasonal agricultural workers in a management information system for the evaluation of programs and for planning.

FUNDING

We are aware that the regional medical center approach will not, due to necessary development and construction time, quickly provide services to significant portions of the migrant population. For these reasons, APHA feels that the development of the regional programs should not consume, initially, the bulk of migrant health funds, but should be phased in over the next few years, with an increasing proportion each year being allocated for the comprehensive projects. Existing migrant programs should be continued in low impact areas until more comprehensive services can be provided or a system of financing, such as national health insurance, is instituted that will cover the cost of migrant services through local providers and clinics. APHA appreciates the fact that funds are limited and that it is thus impossible to serve the entire migrant population. Large numbers of migrants are located where home base or upstream communities are not high impact areas and, thus, will not be covered by these centers' services. Monies must be distributed to provide maximum services to as many people as possible, even if some groups are still not covered. Presently, the system is spreading funds too thinly, and not reaching large segments of the migrant population, nor providing adequate care for many of those who do receive services.

The fiscal year 1973 authorization for the migrant health program was $30 million dollars and the appropriation $23,800,000. It is recommended that the F.Y. 1974 appropriation be set at the level of $60 million, with 75% of this to be used to continue funding of traditional, existing migrant health projects. The remaining 25% should be used for the initial development and construction of regional health centers. An additional $25 million should be provided to cover in-patient care costs for migrants.

An estimated five hundred thousand to one million dollars will be necessary for the planning, construction, expansion, and first year operations of a regional health program. The first year appropriation would provide, then, for the

development of between eight to fifteen of these centers both through enlargement of existing clinics and the creation of new health centers in presently unserved, high impact areas. (Regional Health Centers would continue to be developed yearly until all high impact areas were served). Ten percent of construction and operational costs will be provided through local in-kind services. In 1975, as the first group of regional health centers becomes fully operational, the demands on existing upstream programs will be shifted towards more limited and ancillary services. The migrant health budget authorization for F.Y. 1975 would then be distributed 50 percent to traditional projects (within the context of their new, modified role), and 50 percent to regional health centers. In fiscal year 1976, the ratio would not exceed 20 percent to traditional projects and 80 perecnt to regional health center development and operations.

In addition to increasing the percentage of funding earmarked for the centers, there should also be an increase in the total appropriation level. As these centers expand in numbers, the total migrant population served will increase, thus requiring the greater funding levels. In its evolution, the regional health center will have to develop arrangements for reimbursement through Titles XVIII and XIX as well as through other forms of third party payments. As these and other payment sources such as participation on a fee-for-service or repayment basis for other local residents, or a system of national health insurance are instituted the regional health center will concurrently develop independence from the initial source of funding. This evolution will result in four positive effects: 1. Provision of medical care to presently underserved rural people.

2. Development of a program that integrates domestic seasonal agricultural workers into the mainstream of health care.

3. Reduced costs for medical delivery based on the stressing of preventive medicine.

4. A model network of interlinking modular facilities.

COORDINATION

Following the opening of regional health centers, one additional method of assisting the programs, ensuring their responsiveness to the communities they serve, and helping to evaluate and plan services, would be the development of three overall coordinating agencies-one for each of the three major migrant streams. Each group will be designated as the controlling group for domestic seasonal agricultural worker health services in that area and will be governed by a board composed of a majority of consumers, plus other health personnel from the programs, and representatives of state and local health departments. The agency will participate in the planning of all upstream health care delivery systems as well as the operation of regional health centers. As a result of consumer participation, the board will bring needed continuity to the services provided by facilities in the travel stream. These three bodies will as as the regional arms for the main office of the Migrant Health Service in Washington, and as well as providing coordination and administrative continuity, these groups will also assist in the establishment and enforcement of health, environmental and housing standards for the migrant programs.

Mr. ROGERS. Thank you so much. We appreciate the precise statement you have given and the recommendations will be very helpful to the committee.

I think you have set forth the points which your group are most concerned with, so the subcommittee will consider those and take your recommendations.

Dr. MILLER. Thank you.

Mr. ROGERS. Mr. Preyer.

Mr. PREYER. Thank you, Mr. Chairman.

I think yours is a very clear and excellent statement and summary. It would be a pleasure to go through it and point to a lot of things and agree with most of them. I think in looking at the number of witnesses we have here today I will forgo that pleasure and thank you for a very good presentation.