Senator KENNEDY. As I understand the Javits approach, it is keeping it within the communicable disease program, as we kept the heart program within the NIH.

They are not going way outside the authority. As I understand it, they are targeting in on communicable disease. But in sharing this responsibility with the administration, we want to reflect the congressional sense of priority about it, rather than leaving it as a floating question, albeit the good intentions of the administration, as to how they are going to divide up the pie between the various programs.

Dr. DUVAL. I believe our record is consistent since the passage of the Partnership in Health Act. The ideal way to be responsive to the needs of the community, we think, is to take advantage of the combined provisions of 314(d) and 314(e). We can target, and at the same time leave certain money in the hands of the administrative officials in the States, so that each State can meet its own problems.

With a single authority such as 314, we are able to accomplish all of the objectives that others would accomplish by adding new authorities that don't give us anything but additional pieces of bureaucracy.

Senator KENNEDY. I suppose the real question is whether you are dividing that pie up so thin in the sense of health centers, rat control, and communicable diseases that you might not get the job done. As one who offered an amendment in terms of the Neighborhood Health Corps, I remember that we introduced at that time amendments to the OEO program and put them on a permanent basis. Then it was moved over to the comprehensive health centers under 314 (e), and that, as I understod, was supposed to be the purpose and the thrust of the legislation.

Now it has been spread out to include all these other factors; and as a result there is a real question, certainly in our minds, about how effective all of these programs are going to be.

Dr. DUVAL. I would be delighted to relieve the chairman of any concern that we would not be responsible or responsive even if the programs were spread out thin in 314 (d) and (e). I would submit that this year we believe 314 (e) has been spread too thin and we are coming back with a specific request that the authorization in 314(e) be increased.

There is testimony to the fact that we do not wish to spread the resources too thin over 314(e).

Senator KENNEDY. What is the request? You are mentioning 314(e). How much budget request is for that?

Give me (d) first. You have $165 million authorized.

Dr. DUVAL. I think we will have to supply that for the record. None of us know this year's request for 314(d), Mr. Chairman. For 314(e) I think it is $179 million.

(The information referred to follows:)

Dr. DUVAL. The authorization is $157 million. We are asking it be increased.

Senator KENNEDY. Section 314 (d) is the formula grant.

Dr. DUVAL. Yes.

Senator KENNEDY. That entitles all the States to a certain amount. Dr. DUVAL. That is correct. I think it is $90 million. I am quite sure it is $90 million.

Senator KENNEDY. That is the figure we have got. How does that work in terms of something like TB, which can be targeted as a particular problem, if you have a formula grant and have to distribute a certain amount to other programs. How effective is the use of funds through that particular device?

Dr. SENCER. The way the formula is structured at the present time, it does not necessarily reflect the extent of the problem of the diseases not evenly distributed throughout the country. Diseases such as mental disease, heart disease and cancer are quite evenly distributed across the country, and therefore a capitation approach flavored a little by the per capita income of the State does make it equal.

But the capitation formula is not adequate for venereal diseases as a means of distributing money.

Senator KENNEDY. Couldn't you target a program more effectively or, as a health expert, couldn't you get more effective utilization of funds if you could pinpoint it?

Dr. SENCER. In the project grant authority in the past we have been able to do that better, yes, sir.

Dr. DUVAL. I might add we can still do the same thing under 314. As a supplement to what the States get under (d), and his answer, of course, is not consistent with that.

Senator KENNEDY. Could you give us at least some idea what goes out under (d) and (e) in these programs so we get some idea, on a State by State basis? Could you do that for us?

Dr. SENCER. We can do that for (e) easily.

Senator KENNEDY. What about (d)?

Dr. SENCER. We can give you the State allocations, but not necessarily what it is used for. The reporting system is such that we don't have that information.

Senator KENNEDY. Could you give me that again?

Dr. SENCER. Under (d), 15 percent by law goes for mental health, 70 percent of the funds that are available to the States have to be used for community services. They cannot be used for a central office type of activity. Beyond that, we have relatively poor information on specific disease categories.

The title of this is "Comprehensive Health Services," and it is very difficult to say what part of a public health nurse is being devoted to tuberculosis and so forth. So it is not kept in that way.

Senator KENNEDY. It is hard to tell how much of that money is really being charged to any particular disease?

Dr. SENCER. At the present time, the community health services has a contract with the State health officers to try to develop a uniform reporting system for the State health departments for the use of their Federal funds.

I have not seen the reports as yet, but they are working on this for venereal disease and rubella among other things.

Senator KENNEDY. When will that report be available?
Dr. SENCER. I don't know.

Dr. DUVAL. I believe it is the second year of a 3-year contract. We are at the end of a second year now, Mr. Chairman. The issue has been well explained by Dr. Sencer. The answer to the question you are asking is there, not here. That is, it resides in each health department. Each of the 50 State jurisdictions may keep its books differently, so it is difficult to draw a specific answer with regard to one disease.

I might add that is one reason we hope to have a flexibility as in 314(e), so that we can correct faults in the distribution.

Senator KENNEDY. I suppose one of the problems in (d) is leaving it completely up to the States on the question of communicable disease, so Massachusetts might decide one way and New Hampshire another; and although disease transfer knows no State boundary, when you have different approaches on different diseases, you wonder how effective a more consolidated approach would be. There are serious questions as to whether that is the most effective way of distribution of the funds to do the job.

I guess we don't know that until we get the results of the report or study.

Dr. ĎUVAL. If I could suggest, Mr. Chairman, we agree with you completely. This is the defect at the moment in the 314(d) program, but as I have already indicated, we can accommodate to that with 314(e), but without the extra regulations and the bureaucracy.

Senator KENNEDY. Can you tell us, is the position of the OMB that this is a more efficient way in terms of allocating these funds? What can you tell us about that?

Dr. DUVAL. I think it is the posture of the administration as a whole that it is best to enjoy the opportunities of both formula and project capability in the administration with the least irreducible number of authorities necessary to achieve the objective.

The point I am making is that each time you add a new authority, you have to make up a new bureaucracy, advisory committee, new procedures, and so forth, and this is what complicates and slows down the machinery.

Senator KENNEDY. Senator Dominick?

Senator DOMINICK. Thank you, Mr. Chairman.

Doctor, I am sorry I was not here to hear you give your testimony. I have had an opportunity to scan it. You will recall that sometime ago we were discussing possible changes in the organization and the strength of the Public Health Service. Do you feel that without this bill that you really have sufficient money and manpower and training and ability to handle the vaccination programs that are talked about in the proposed bill?

Dr. DUVAL. Yes, Sentor, we feel we do under the existing authority. Senator DOMINICK. I have had information from a number of areas that I happen to be pretty closely acquainted with which would indicate that the ability to get people to come in for public health service programs for innoculations or vaccinations simply does not work, that you don't get them in.

About the only way you can do it is to outreach and go out to the respective homes, particularly in the lower income ones, and try and do it by personal visits through the medical associations and things of this nature.

Dr. DUVAL. I think that is quite true. I think that would be true irrespective of whether the authority was 314 or 317.

Senator DOMINICK. Yes; but in 314(e) we don't know what you are going to do.

Dr. DUVAL. Yes, it is also targeted in projects.

Senator DOMINICK. It is not targeted with respect to the kinds of vaccinations you should do.

Dr. DUVAL. We could break down any program in 314(e) you would wish. That is completely within our jurisdiction. It is the same as 317.

Senator DOMINICK. I gather with respect to communicable disease, your opposition to that, you are also opposed to the venereal disease bill we have up. Is that correct?

Dr. DUVAL. We are with you in principle and purpose, Senator. I think our objective in being opposed to the bill itself is only that it adds additional authority and another piece of bureaucracy to an authority we already have. It adds nothing new.

Senator DOMINICK. It strikes me, and maybe I am being oversimplistic in this, that that is part of the usual situation where an agency or executive department says, "Just give us the money, and we will decide what to do with it," whereas Congress is supposed to be determining what you are going to do with the money.

Isn't that really the basis of your objection? You want to have the money, but you don't want to have any controls over what you are supposed to do with it?

Dr. DUVAL. So that there is no confusion, could I reiterate, Senator, that, apropos of the allocation of funds under 314 (e), this is all done with the budget submitted to Congress so you know precisely what is going out.

Senator DOMINICK. The Appropriations Committee does. We don't here.

Dr. DUVAL. There is no reason you could not have access to that. If we have been delinquent in supplying it, we want to make sure you have it.

Senator KENNEDY. Do you have a defined venereal disease prevention and control program?

Dr. DUVAL. Yes.

Senator DOMINICK. Where?

Dr. DUVAL. I will ask Dr. Sencer to give that.

Dr. SENCER. We have a program, Senator Dominick, which provides grants to States and local health departments. This will amount to $22.3 million this year in project grants to State and local health departments to specifically increase their activities in screening of individuals for gonorrhea. We have approved treatment facilities in which they are being treated to be sure they get adequate treatment. Senator DOMINICK. This is all through the States and local public health departments; right?

Dr. SENCER. Right.

Senator DOMINICK. You don't make any to local medical associations or other groups that happen to be trying to do something about this?

Dr. SENCER. The State and local health departments do work closely with the local professional societies.

Senator DOMINICK. Some do; and some don't.

Dr. SENCER. I am sure that is the case, but I think the sort of concerted efforts we are seeing this year between organized medicine and organized public health indicates that they are coming closer together in their goals, and the working climate between local health departments, local medical societies, local specialty groups, all indicate that everyone has a stake in this and are devoting their resources to it. Senator DOMINICK. It indicates that anybody in the medical profession would have an interest in this, I am sure, and try to do something about it. The question is, if you have a program or if you have an organization which wants to focus in on this type of a problem, in most cases I know the State or local public health personnel are already overstressed, I guess is the best word, in terms of manpower and ability to perform a job, and if you can give a project grant to someone who wants to make it a specialty, what is wrong with that? Dr. SENCER. The provisions of the bill that you are considering, Senator Dominick, do make provisions for these grants to be made to State health authorities and with concurrence of the State health authorities to political subdivisions of the State.

It is the feeling that venereal disease is a public problem and that the public health departments have a statutory responsibility in this area. There is nothing that restricts further subcontracting by the State and public health authorities to assist them in this fight.

Senator DOMINICK. Do you know any examples where they do in fact subcontract with others?

Dr. SENCER. Yes. I think we could give you many examples.
Senator DOMINICK. In VD?

Dr. SENCER. Yes, in VD in Florida, they have started a VD Awareness Month where the health department is working with a variety of voluntary agencies, the broadcasting association, the State medical society, local medical societies in Dade County, providing them with materials and getting their help in an awareness program to improve public knowledge of venereal diseases.

Senator DOMINICK. Good. That is great for Florida. Do you know anything going on in Massachusetts or Colorado?

Mr. SENCER. I do know that specifically now in Massachusetts, Dr. Fiumara, who is the director of communicable diseases control and also venereal disease control, is very close with the medical society there, and that the medical society in Massachusetts takes a leading role in the venereal disease program.

In Colorado we have this coming year, an increase in the amount of moneys available to the State health department by almost $200,000 to do something about venereal disease.

(At this point Senator Dominick assumed the chair.)

Senator DOMINICK (presiding pro tempore). You say you are going to give $200,000 to the State health department to increase their efforts?

Dr. SENCER. Yes. This will go for new manpower, laboratory services, to support the program for screening, and public education.

Senator DOMINICK. We have four diagnostic clinics in Colorado now. We are not going to get money in this. It is going into the public health service.

Dr. SENCER. It can function through the diagnostic clinics. Part of our strategy is to increase the hours clinics are available, and having