WITHOUT FEDERAL HELP THE PACE WILL BE SLOW The question has been raised whether the States would go it alone. They have and they will continue to encourage this revolution, but the pace will continue to be agonizingly slow. We are particularly interested in the provision for short-term assistance from the Federal Government in financing the staffing of the new centers because there are ample justifications for optimism that within a few years we will have accomplished the goal of financing the cost of services to the mentally ill and retarded in the same way as other medical and hospital costs. In the meantime, we cannot afford the extravagance of having to use oldfashioned methods of care which have been proven more expensive per patient treated than the proposed programs. What is being proposed here today is comparable to what our great industries do all the time-invest substantial sums to build modern plants and install new equipment and better skilled personnel, so that they can produce a better product at less expense. RETARDATION AND MENTAL ILLNESS ARE MEDICAL CONDITIONS House bills 3688 and 3689 (and the campanion bills introduced by Congressmen Halpern, Boland and Farbstein) give due recognition to the fact that the needs and medical problems of the mentally ill and mentally retarded, although having much in common, are not identical. The extent that separate programing can be advantageous may be determined by the States. Although it is clear that mental illness and mental retardation are medical conditions, ample recognition is given to the significance of adequate resources for special education, training, day care centers, guidance, and counselling services. CONVERSION OF OLD FACILITIES Although these bills propose the basis for a radical new approach, there is full recognition of the progress which has been made by the States in converting the large, often remote, institutions into more acceptable facilities. We particularly like the proposals which would give aid and encouragement to those who are going to have to continue to meet the need with the old style facilities. It would be a tragic error to discredit the immense contribution which these institutions will still have to make during the period of transition. We hope the committee will amplify certain vague sections of the bills. For example H.R. 3688, section 102, and H.R. 3689, section 202 provide that the Secretary make allotment from sums appropriated "in accordance with regulations". We are concerned about who is going to be consulted on, and review, these "regulations". H.R. 3688, section 103 and H.R. 3689, section 203 provide that the Secretary shall, by regulation prescribe-after consultation with the Federal Hospital Council. H.R. 3688, section 205 envisions consultations with the National Advisory Mental Health Council before prescribing regulations. Can we assume that Congress in making annual appropriations will review the regulations governing the allotments to the several States? OUR CONCEPTS OF THE KINDS OF SERVICE NEEDED MAY BE EXPECTED TO CHANGE We might question whether these bills give adequate recognition to the fact that the kinds of service in mental health centers and facilities for the mentally retarded vary widely in different parts of our large country. This is caused by radical differences in population characteristics and density, and in needs and resources. Your committee may wish to consider amending H.R. 3688, section 103, line 7, and section 205, line 4, and H.R. 3689, section 203, line 8 after the parenthesis and before the comma, by adding in each place: "and after due consideration of individual variations in needs and resources among the several States and within the several States." PLANNING FOR STAFFING IS IMPORTANT Experience in some States under Hill-Burton programs for aiding hospital construction has shown that it is often easier to plan and construct a building than it is to develop a staffing pattern, recruit personnel, provide the necessary supplemental training and plan for the establishment of actual services. In short, it would be well to have assurance that planning for the administration of a program of services in a mental health center or facility for the retarded was as far advanced as the plans for construction before funds are granted to pay a part of the cost of construction. The committee may wish to consider amending H.R. 3688, section 105 (a) and 3689, section 205 (a) by inserting a new paragraph (7) which would read: "Plans and specifications for the staffing and operation of the mental health service of the center and reasonable assurance of the availability of appropriately trained professional and other personnel to enable the center, or facility, to become operational as planned upon completion of construction." PERIODIC REVIEW OF REGULATIONS H.R. 3688, section 104 (a) (10), page 8, and H.R. 3689, section 204(a)(10), page 11, provide for a review of State plans and for the reporting of modifications in these plans at least annually. We believe this points out the probability that as the States gain more experience through intensive planning activities and through the establishment of centers and facilities, we may expect changes in concepts and changes in needs and resources. The present wording of 3688, sections 103 and 205 and of 3689, section 203 could be interpreted to mean that within 6 months of the passage of the bills, regulations will be prescribed which will govern for the duration of the act. We suggest that this might be reworded to assure that the regulations of the Secretary will be reviewed often enough, in consultation with appropriate councils, to avoid unnecessary enshrinement of unworkable or outmoded concepts in the brick and mortar of mental health centers and facilities for the retarded. LOCAL AND STATE AUTHORITY PRESERVED We are impressed with the manner in which these bills provide for a maximum of authority at the State and local level in the determination of the center in the needs and the types of facilities to meet these needs. We believe that this will assure a maximum of creative thinking in devising new and more effective methods of meeting our Nation's No. health problem. We recognize a valid exception to this principle in section 201 of H.R. 3689. In that bill, appropriations are authorized for grants for the construction of facilities for the mentally retarded "which are to be associated with a college or university hospital." It is important that the medical care of the mentally retarded be brought back into the main stream of medical practice and that the training and education of the retarded be brought into the main stream of education, both within the community. SUMMARY The State mental health program directors are solidly behind the concept of the diversion of patients from isolated mental hospitals to mental health centers in the patients' community and within the main stream of medical practice. We are perhaps more keenly aware than any other group in the United States of the needless suffering and waste that will continue until we are able to put into full utility the skills which we now possess. H.R. 3688 and H.R. 3689 propose a program of Federal assistance to the States which would provide aid in the place, and in a manner in which it can be most effective. We will welcome the impetus which the proposals would give in each of our States. We hope that the experience and present planning of the various States will be helpful to this committee in its consideration of these bills Dr. DAVIS. I have with me a telegram from Governor Hughes of our State of New Jersey which I would like to read in which he states that he strongly supports passage of H.R. 3688 and 3689 which would implement significant parts of President Kennedy's program on mental health and mental retardation. The New Jersey Legislature is currently considering proposals for amendments and recodification of statutes pertaining to the mentally ill and the mentally retarded which are oriented in the directions of the President's proposals. Passage of all these bills would give impetus to new programs and planning already well underway in New Jersey as a result of the combined leadership of physicians and other mental health professionals, organized citizen groups and legislative and executive officials in our State, county, and local governments. RICHARD J. HUGHES, This morning the question was asked, had the Governor done anything in addition or subsequent to the resolution which was passed in the special mental health conference in November of 1961. This was a resolution at the Governors' conference in the spring of 1962 urging each of the States to pursue comprehensive planning for mental health programs. And I think it is pertinent at this time to emphasize that these two bills which we are considering today are possible, it seems to me, only on the basis that each State has undertaken and accomplished a planning for a program of mental health services in the State. And it is for this reason that the fund for the mental health centers and for the facilities for the retarded are not requested until 1965, which would give each of us time to accomplish this planning, which it seems to me represents the big revolution in the concept of the care of the mentally ill. Heretofore we have been working on a crisis-oriented administrative approach, when the crowding becomes too stinkingly unbearable, then we have a bond issue and build more facilities. And this has been what has been the program in the past, although we have begun in the last 10 years to put it on a more organized basis. In addition, I would like to read a telegram from Governor Scranton of Pennsylvania: The proposal for development of the community mental health centers has our hearty endorsement. The Office of Mental Health of the Commonwealth of Pennsylvania has been programing for the past several years toward a development of resources within the community for a continuium of care in the treatment of mental illness. We would like to encourage the development of more community resources for the mentally retarded as well as greater efforts in the field of prevention, but we see little hope of moving as rapidly as necessary through this transitional period from a State hospital centered program to a community centered program without financial help. The knowledge and the skills are at hand. Citizens interest and support are at their highest. And all that is needed is the means to mobilize these skills and this support to productive activity. There is a real danger of much of the existing momentum being lost by failure to act boldly and decisively. Your effort toward favorable action in support of the development of community mental health centers is strongly urged, so that the fight against mental illness can move forward with new vigor. We have heard questions about the availability of staff for this expanded program of mental health centers. One of the strongest arguments for the concept of the mental health centers is the fact that it will bring the patients that will be cared for in these centers back into the main stream of medical practice and back into the community where we will have more professional resources, and where there will be more unskilled and nonprofessional personnel to provide the staff which is so necessary to care for these individuals. The question of whether or not the States could proceed on this program alone has also been a question of interest to all of us. And I think the record on careful examination will indicate that a great majority of the States have already begun to proceed in this direction. But the pace already painfully slow, and the expense both in human suffering, and in continuing to pour good money after bad in our antiquated facilities is the thing that we hope to overcome by this assistance from the Federal Government through putting capital resources into the operation so that we can do in this facility what all of our American industries do, put new capital into new improved facilities based on newer concepts which can provide a better product at less expense to the taxpayer. And I can think of no better product than healthier American citizens. We have, I understand, received word that 22 States have sent telegrams to the committee supporting these two bills. It don't think this is an exhaustive list, but it does indicate that this many have already sent them in. Those of us responsible for the professional leadership at the State government level welcome this proposed legislation involving the Federal Government for many reasons. Among them we welcome the fact that the program embraces the principles on mental health of the American Medical Association, and the program of the council on mental health of that association. And because of this it augers well to mobilize the full constructive energies of physicians throughout the land to provide the type of leadership in this field which is essential. The concepts that these bills would promote are not new. They are put together in what to us is an eminently workable program. They are different from the concepts as originally spelled out in the joint commissions' report, which was a remarkable milestone in the assembling of data and giving us essential decisionmaking data in this important field. These proposals do not envision the Federal Government embarking on a long-term partnership in financing the care of the mentally ill in large institutions, but they envision a period of Federal Government assistance roughly for about 10 years, after which the facilities will be carried along and financed in the same manner as other medical and educational services in the community. The question was asked of Dr. Pratt about the need for a similar program for the Federal Government to assist in the staffing of facilities for the retarded. I think it would be helpful to point out that the mental health centers, in which there is provision for such a program of assistance in staffing, will provide some basic services for the mentally retarded in addition to basic services for the mentally ill. So, by strengthening mental health centers, we are strengthening some of the professional staffing and programs for the mentally retarded. In addition, the Federal Government has programs of assistance to the State in vocational rehabilitation and in aid to education which will have indirect benefits in improving the care of the mentally retarded. The concept of specialized centers for the mentally retarded envisions our further progress in keeping as many of the mentally retarded in the community as possible outside of residential facilities through the provision of special education facilities in the public schools as was pointed out earlier. I would like to comment also on another matter raised by Dr. Pratt, and indicate at the outset that I don't think there is any disagreement in principle with regard to where the Hill-Burton-where these construction funds should be administered. I think the important point here is one of timing. In some States I would agree with Dr. Pratt that the existing Hill-Burton agency might be the most appropriate agency, and the hospital advisory council might be the most appropriate agency for the allocation of these construction funds. In other States, for reasons appropriate to those areas, another program might be better. One of the strongest arguments in favor of these bills from our point of view is the fact that they are so designed that it leaves the authority as well as the responsibility at the State level to determine what type of a program can best meet the needs of that particular area. And in this connection I would like to call the committee's attention to several areas where the committee might wish to consider clarifying some of the present wording, or to amplify certain vague sections. For instance, section 102 of 3688 and 202 of 3689 provide that the Secretary make allotment from sums appropriated "in accordance with regulations." We are concerned about who is going to be consulted by the Secretary in making these "regulations" which are going to apply to all 50 States. And in contrast, we see in sections 103 and 203 and 205 that the Secretary shall prescribe after consultation with the Federal Hospital Council in the one instance, and after consultation with the Advisory Mental Health Council in the other instance. Can we assume that the Congress in making its annual appropriations will review the regulations governing the allotments to the several States and thus provide this type of a facility for consultation? And as I suggested before, we have questions as to whether these bills give adequate recognition to the fact that the kinds of service in mental health centers and facilities for the mentally retarded will vary widely in different parts of our large country. This will be caused by radical differences in population characteristics and density, and in needs and resources. And your committee may wish to consider amending 3688, section 103, line 7, and similarly in 3689, by adding "And after due consideration of the individual variations in needs and resources among the several States and within the several States." No one type of facility or institution in our judgment is going to be ideal for every area, and there must be provision for this variability. One other thought that we had has to do with the problem of, when you make money available, and there is a real need for services, it is easier to build a building than it is to organize the staff and set up the administrative structure. The bills as now written propose the requirement that plans be submitted before moneys be allocated for the construction of mental health centers, and we would suggest that the committee might wish to consider inserting another proposal, that |