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the long run, since insurance claims and administrative costs are to be borne from the fund. The initial appropriation will be needed for fiscal year 1956 to establish a working capital account from which to meet administrative expenses and provide the capital in the early stages of operations.

PRACTICAL NURSE TRAINING

Title III of the draft bill would authorize a 5-year program of vocational education grants to States for the extension and improvement of practical nurse training of less than college grade. Grant funds would be available for costs of instruction and professional supervision of training programs. The program would make possible an increase in the number of trained practical nurses by enlarging the number of schools and by expanding those already in existence. To stimulate and encourage their more effective operation and to improve the quality of training offered, the bill would also authorize the provision of technical assistance and nurse consultant services.

Nationally, we are urgently in need of more nursing personnel. This title of the bill, along with other proposals for strategic attacks on the nursing personnel shortage, suggests one of the quickest ways to increase the supply—the training of more practical nurses. The practical nurse is the trained worker who performs the simpler nursing functions and thereby releases the registered nurse to perform her professional duties.

After World War II the demand for nurses increased rapidly. The largest single factor in this increase was the greater complexity of medical care which requires so much more of the professional nurse's time. Large numbers of practical nurses are now required to assist her with the care of the patient. The practical nurse is trained before her employment and is, therefore, of most assistance to the nurse.

The need to expand the training of practical nurses is urgent. Some of this training is being done, but to date many States still have only 1 program graduating about 15-25 students a year; a few States have none.

Experience in the past has shown that the most progress was made in practical nurse training when nurse consultants were available at both State and Federal levels to give professional guidance along with grant funds earmarked for the increase and expansion of such programs. Both funds and professional leadership are provided for in this proposal.

PUBLIC HEALTH AND GRADUATE NURSE TRAINING

Title IV of the draft bill would add a new section to title III of the Public Health Service Act to provide separate specific authority for traineeships for two groups of specialized health personnel in which great shortages now exist. These are

1. Professional nurses trained for teaching or for performance of administrative and supervisory functions.

2. Professional public health personnel, including public health physicians, public health nurses, and sanitary engineers.

Like the existing authority for training in research activities, these new traineeships could be established either in Public Health Service facilities or in educational institutions. The traineeships could also be financed by grants made available to public and other nonprofit institutions. The money value of the individual traineeships would be established by the Surgeon General and would include a stipend and allowances for such expenses as travel and subsistence. The shortage of trained professional public health personnel is one of the most serious problems in the development and expansion of public health services today. The addition of health programs in new fields, the realignment of existing programs, the strengthening of local health services, all could move forward more rapidly and efficiently with a more adequate supply of trained public health workers.

There is likewise a serious shortage of professional nurses trained to teach or to supervise or administer the wide variety of nursing activities. Lack of such trained personnel has been a serious handicap to highest quality and most economical nursing services in hospitals and health agencies throughout the country.

PUBLIC HEALTH SERVICES

Title V of the bill includes amendments to title III of the Public Health Service Act which would strengthen the protection and promotion of public health

through improvement in the grants-in-aid to States and through special project grants addressed to specific public health problems.

Grants to States for public health services

The first major provision for Federal grants-in-aid to States for public health services was enacted in 1935 as title VI of the Social Security Act. To this original authorization for assisting in the establishment and maintenance of adequate public health services there have been added in subsequent years authorizations for several specialized grants. At the present time the Public Health Service administers such specialized grants to States for venereal disease control, tuberculosis control, mental health services, cancer control, and heart disease control in addition to a grant for general health services.

The impact of this Federal financial assistance on the protection and promotion of public health has been significant both through expenditure of the federally granted funds and through the stimulation which these grants have given to the appropriation of additional funds by State and local units of government. The results of this cooperative Federal-State-local attention to the public health problems of the United States are too numerous to mention in detail. They include, however, an increase in the number and quality of local health units, vigorous casefinding and control programs which have reduced the death rate from tuberculosis and the incidence of venereal disease and other communicable diseases, establishment of clinics for early diagnosis of cancer and heart diseases, and public and professional health education services.

Great as the progress has been to date in improving the public health, the opportunities for future improvement are even greater. Not only are there large gaps in public health services in terms of present scientific knowledge but our vast research effort is continuously adding to that store of knowledge.

One section of the draft bill is directed, therefore, at continuing and strengthening the legislative framework within which the Public Health Service provides the Federal financial assistance to the Federal-State-local public health program.

Section 314 of the Public Health Service Act would be amended to authorize a single consolidated public health grant to States in place of the present separate grants for venereal disease control, tuberculosis control, general public health, cancer control, and heart disease control. The grant for mental health would continue as a separate grant for 5 more years.

The new consolidated grant would be allotted among the States on the basis of the population, financial need, and extent of the health problems of the various States. On the basis of State plans submitted for approval by the Surgeon General, States would be entitled to receive a percentage of the cost of their public health services. These Federal shares would vary in inverse proportion to the State's per capita income within the range of 33-3 percent to 66-3 percent.

In order to encourage the extension and improvement of public health services, the Surgeon General would be authorized to provide that a portion (not to exceed 20 percent) of a State's allotment may be used by the State only for extending and improving its services. States would be entitled to receive 75 percent Federal participation in the costs of such activities for the first 2 years and 50 percent participation for the 3d and 4th years of such projects.

This proposal will provide a greater flexibility in the use of the grant funds by the States, encourage improvement and extension of public health services to the people, insure matching from State and local appropriations in accordance with the financial ability of the States, and provide for continuation of the Federal-State-local partnership in the improvement of health protection. Grants for special projects

Certain types of public health problems of special national concern do not lend themselves readily to solution through a type of grant-in-aid which requires distribution among all States. It is to assist in the effective and economical solution of such problems that the draft bill provides for special project grant authority.

This authority would enable assistance to be directed toward both operational and research activities which hold promise of making a significant contribution to regional or national public health programs. This is the type of "pinpointed" assistance which will insure progress in solving some of the more difficult problems through concentration of funds in selected areas on a "pilot plant" basis.

MENTAL HEALTH

Title VI of the draft bill would authorize separate grants for mental public health for a 5-year period, in addition to the general public health grants proposed under title V of the bill.

Mental illness is a major problem in the United States. One measure of its magnitude is that 47 percent of all the hospital beds in this country are occupied by mentally ill patients.

The Congress recognized the national importance of this problem by enacting the National Mental Health Act in 1946. In administering the provisions of that act, the Public Health Service has stimulated and conducted research, provided professional training opportunities through fellowships and traineeships, stimulated the development of community preventive programs through grants to States, and in other ways given leadership to improved services.

Title VI of the draft bill singles out for increased attention and priority two elements of the national program which hold great promise for reducing the magnitude of the mental health problem. It is proposed to continue and extend for 5 more years separate authority for a specialized grant-in-aid to States for community mental health services. Matching provisions and other administrative arrangements for mental health grants would be modified slightly to conform to the draft provisions relating to grants to States for public health services.

The Public Health Service Act would also be amended by this title of the bill to authorize special project grants for the development of improved methods of care, treatment, and rehabilitation of the mentally ill. The grants could be made to State agencies responsible for administration of State institutions for care and treatment of mentally ill persons, or to appropriate agencies for study of alternative or complementary methods of care and treatment. Because the nature of these special project grants does not permit any predetermined Stateby-State distribution of grant funds, there is no allotment formula prescribed in the bill. These grants would be made only upon recommendation of the National Advisory Mental Health Council.

The cost of the amendments to the Public Health Service Act proposed to be made by titles V and VI of the draft bill will vary with the annual appropriation determinations made by the Congress. No provision of the draft bill would make mandatory any given level of appropriation. The magnitude of the problems which the bill is designed to alleviate, the reductions in illness, disability, and premature death which would result, and the economic losses which would be curtailed thereby need be weighed, however, against the expenditures which might be contemplated annually under the provisions of the bill.

These six titles of the draft bill sent to you herewith make up the main body of the Department's recommendations to give effect to the administration's health program. We shall appreciate it if you will be good enough to refer the draft bill to the appropriate committee for consideration.

The Bureau of the Budget advises that enactment of this proposed legislation would be in accord with the program of the President. Sincerely yours,

OVETA CULP HOBBY, Secretary.

UNITED STATES DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Washington, April 12, 1955.

Hon. LESTER HILL,

Chairman, Committee on Labor and Public Welfare,

United States Senate.

DEAR MR. CHAIRMAN: This is in response to your request of February 7, 1955, for a report on S. 929, a bill to provide for aid to the States in the fields of practical nursing and auxiliary hospital personnel services.

This bill would amend the Vocational Education Act of 1946 to establish a new and permanent categorical grant program for the training of practical nurses and of auxiliary hospital personnel. It would authorize an appropriation of $5 million annually, and provide for allotment of sums appropriated to the States on the basis of the equalization formula used in the Hospital Survey and Construction Act. No State and local matching of the Federal funds would be required for the fiscal years 1956 and 1957; 25 percent of the cost of the program would be borne by State and local funds in the fiscal years 1958

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and 1959; and at least 50 percent of the cost would be so borne in the fiscal year 1960 and thereafter.

In his state of the Union message of January 6, 1955, the President referred to the need for new measures to help reduce shortages in trained health personnel, and in his special health message of January 31, 1955, he specifically recommended a 5-year program of grants to State vocational education agencies for training practical nurses.

S. 929, therefore, parallels in its basic objective and its general approach the President's recommendations on practical nurse training. We believe, however, that the provisions of S. 929 are not as well designed to accomplish these objectives as are the provisions of title III of S. 886, which title embodies the administration's legislative proposal in this area. The most significant respects in which S. 929 differs from title III of S. 886, and the reasons why we believe the provisions of the latter bill to be preferable, are discussed below. 1. S. 929 would establish a permanent categorical program for practical nurse training, whereas title III of S. 886 would set a 5-year limitation on the duration of the new categorical grants for this purpose. We agree that the need for more trained practical nurses is sufficiently emergent and national in scope and import to warrant the establishment of a new categorical vocational education grant for this special purpose. However, a 5-year period should be ample to accomplish the Federal objective of encouraging and helping the States extend and improve their practical nurse training programs to the extent necessary to meet present and anticipated demands for trained practical nurses. At the end of this period practical nurse training should be sufficiently expanded and sufficiently well established as part of each State's vocational education program to warrant termination of the restriction on State use of Federal grant funds inherent in the categorical grant approach.

2. S. 929 would provide no State and local matching funds whatever during the first 2 years of its operation (fiscal years 1956 and 1957). Title III of S. 886, on the other hand, would provide for 75 percent-25 percent FederalState sharing during these 2 years and 50-50 sharing during the next 3 years. We agree that a higher percentage of Federal financial participation is desirable at the outset of a program such as this in order to facilitate State and local action in getting the program underway in all States as rapidly as possible. However, this Department is firmly of the view that some substantial State and local matching of Federal grant funds is essential to the successful functioning of any grant-in-aid program to maintain the principle of maximum State and local initiative and responsibility.

3. S. 929 would authorize the use of grant funds for the training not only of practical nurses but also of "auxiliary hospital personnel"—including "ward aids, nursing aids and assistants, and assistants in laboratories and clinics and dietary departments of hospitals." Although the training of such auxiliary personnel does present some problems from the standpoint of the hospital, we do not believe that the inclusion of such training in this special program is desirable. Typically, these auxiliary personnel need and receive on-the-job training only, with no special preemployment preparation comparable to that included in practical nurse training. The only assistance which State vocational education agencies are able to provide is instructor training courses for supervisors and some consultative services. Such assistance is being provided under existing legislation, and little would be gained through the specific authorization in the instant bill.

4. S. 929 contains a provision which would authorize the use of grant funds "for payments to public or nonprofit hospitals *** to meet costs incurred by them in affording opportunity to practical nurse or auxiliary hospital trainees for supervised experience in such hospitals * We would strongly recommend deletion of this provision for two reasons. First, it is contrary to the established practice of State vocational education agencies to make payments to hospitals or other agencies for any such costs incurred by them. Sufficient incentives have always existed and will exist here to induce employing establishments which need trained personnel to provide on a nonreimbursable basis such accommodations as may be needed for the on-the-job experience incident to vocational training.

Second, the bill does not make clear, and probably could not make clear, what cost incurred by the public or nonprofit hospitals are to be reimbursed out of Federal grant and State and local matching funds. The determination of the amount or ratio of the ordinary administrative expenses of a hospital to be allocated to practical nurse training and paid for, would be most difficult and liable to wide variation and possible abuse.

5. S. 929 would require that the practical nurse training program be supervised in every instance by a registered nurse. Such a requirement might tend to defeat the purposes of the bill in those States receiving an allotment at or near the State minimum of $10,000 per annum which S. 929 would provide, since such a large part of the annual allotment would be required to pay the salary of the supervisory registered nurse that only a small amount would remain to cover the costs of instruction. It was for this reason that the analogous provisions of title III of S. 886 provide the State agency the alternative of making the consultative services of a registered professional nurse available to the official supervising the practical nurse training program.

6. In several respects S. 929 would impose unduly restrictive Federal controls over State and local planning and administration. Thus, under the bill a State plan would have to conform to 12 specific Federal requirements, and even if found to meet all 12, could still be disapproved by the Commissioner of Education on the ground of nonconformity "with the provisions and purposes of this title." While existing vocational education laws contain analogous provisions, this Department believes that many of these are no longer necessary or desirable in so well established a field of Federal-State cooperative action as the field of vocational education. Analogous provisions of title III of S. 886 set forth 5-plan conditions and require Federal approval of a State plan if it meets these 5 conditions. In addition, title III of S. 886 provides opportunity for judicial review of Federal action in withholding payments from a State for nonconformity with Federal requirements.

A particularly onerous provision occurs in section 209 (a) of the title proposed to be added by S. 929. This provision would appear to provide for double withholding of payments by the Commissioner in case any portion of a State's allotment were not expended in accordance with the provisions of the bill. Such a sanction, in the nature of a penalty, is contrary to established practice under the existing vocational education laws and other grant-in-aid laws administered in this Department.

7. We do not believe that the equalization allotment formula in S. 929 patterned after the allotment formula in the Hospital Survey and Construction Act, is appropriate for the allotment of funds for the proposed new vocational education program. Where, as here, the primary objective is to encourage and help States to expand and improve existing training programs for practical nurses, rather than to provide continuing financial support for their vocational education programs, we believe that an allotment formula based on the relative populations of the several States is more appropriate. An allotment formula based on population will distribute the funds more nearly in accord with the need of each State to extend and improve its practical nurse training programs and will be more readily understood and accepted by the States in view of the fact that a similar basis is now used in the allotment of Federal grants for the general Vocational education programs.

In view of all these considerations, we recommend that S. 929 not be enacted by the Congress and urge instead the favorable consideration by your committee of title III of S. 886.

The Bureau of the Budget advises that it perceives no objection to the submission of this report to your committee. Sincerely yours,

OVETA CULP HOBBY, Secretary.

EXECUTIVE OFFICE OF THE PRESIDENT,

Hon. LISTER HILL,

BUREAU OF THE BUDGET, Washington 25, D. C., March 8, 1955.

Chairman, Committee on Labor and Public Welfare,
United States Senate, Washington 25, D. C.

MY DEAR MR. CHAIRMAN: This is in response to your recent requests for the views of the Bureau of the Budget on S. 886, a bill to improve the health of the people by encouraging the extension of voluntary prepayment health services plans, facilitating the financing of construction of needed health facilities, assisting in increasing the number of adequately trained nurses and other health personnel, improving and expanding programs of mental health and public health, and for other purposes; S. 434, S. 929, and S. 1076 which are related bills.

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