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I wonder if you would comment on that?
Secretary Hobby. Mr. Rockefeller, will you comment on that!

Mr. ROCKEFELLER. Senator Lehman, I think your illustration using New York and the tremendous expenditure of funds there is really a perfect illustration of the very thing the Secretary is reaching for here. You mentioned $100 million a year being spent in New York on it. Now, the grant in this field to New York State from the Federal Government in 1952, which is the last year we have recorded here, shows $271,000. The State is spending $100 million. That is a little less than two-tenths of 1 percent.

Therefore, for that amount of money to be the basis on which New York State kept that program separately identified and in front of the people would be difficult to see. Whereas what New York has to do is the thing that the Secretary had in mind for all of these States: Not to measure their concern for a particular disease of a particular problem in terms of Federal assistance, but to measure it in terms of their own appraisal and judgment as to what the States should do.

As New York State has done, they have gone ahead with the tremendous program and the Federal contribution is really a token. That money would be available to New York now in the form of support and extension and improvement.

New York State might want to take a much larger percentage of the money for mental health than the $200,000, and blow it up. This would give them the opportunity to use the total funds if they saw fit; and as you say, New York spent more on mental health than all of the others put together.

Senator LEUMAN. My figures are even greater on Federal aid than yours. I have just been handed a memorandum that in 1954 New York State received $186,300 for mental health.

Mr. ROCKEFELLER. That is right.

Senator LEHMAN. As against an appropriation by New York of approximately $100 million. It may be somewhat more or less than that.

It does seem to me that this is a case of the tail trying to wag the dog in a very vigorous way. What worries me even more is the fact that there is no uniformity throughout the matching in regard to the responsibility for the care of the mentally ill.

We have assumed that responsibility—am I right, Dr. Scheele! Dr. SCHEELE. Yes, sir.

Senator LEHMAN. And many States have not assumed that responsibility for mental health.

Dr. SCHEELE. I believe they have all assumed it, but some have assumed it in a greater degree than others. It has been assumed to a very small extent in many States.

Nr. ROCKEFELLER. The figures which you quote I think are correct. The ones we have here are 1952-54, and the figures have been coming down since 1950, you know.

One of the arguments made previously, Senator, was that if you eliminated the categories it would reduce the appropriations because Congress would be less apt to appropriate to the general health program than it would to special categories. That was asked of the Secretary in the House and she got some tables together which I think might be interesting to look at for the members of the committee, if I may produce them, Mrs. Secretary.

Secretary Hobby. Yes. Mr. ROCKEFELLER. These show the history of the appropriations for these various grants. The interesting thing to note is that the grantin-aid program that has stood out—you can put the chart up, if you will—the grant-in-aid program that has stood up and held its own has been the general health. Whereas in categories, while moneys were appropriated and they went up into large figures, as you will note, Congress has progressively since 1950 cut these, so that they have been going down with a very rapid descent.

So I do not think the argument of Congress being more sympathetic to categorical grants as far as appropriations are concerned is borne out from the history of the appropriations.

Senator LEHMAN. In the very interesting statement of Secretary Hobby—which unfortunately I did not hear in full-on the last page

she says:

Finally, it would more clearly identify and define the objectives of Federal grants and would enable congressional appropriations to be directly related to those objectives. My feeling is it is exactly the opposite. I do not have it all in mind,

of course.

Secretary HOBBY. The objective, Senator Lehman, being support, extension and improvement, and special projects.

Senator LEHMAN. What I am fearful of is in the first place I want to say I was very strongly opposed to these cuts by Congress in 1950. They were unwise. But if you bunch everything into the six categories described here and into a lesser number of appropriations, then some may seem very large to the public. But when you appropriate, let us say, $10 million for cancer research and $15 million for mental health activities, and some other figure for hygiene research, or X number of dollars for heart disease control, then I think people can see how hideously small these appropriations are for each one of these activities. It may seem large in the aggregate but I think people will be able to see and that it will be possible to dramatize much more readily the insufficiency and inadequacy of these individual amounts of money being appropriated to individual activities. I be in error in my fear, but I very definitely have it. Mr. ROCKEFELLER. Interestingly enough, it has not been the history in the Congress. In the research grants and categories, yes. There the identification of the individual cancer or heart research program has been an important factor in maintaining and increasing appropropriations. But in these public health aspects of those categories that has not proven to be the case.

It was the Secretary's feeling that it would be better to go before the Congress with recommendations for general health, or support of general health work, and then to identify that portion of the grant or appropriation which she would recommend with the Surgeon General for support

, and then clearly identify those moneys which were needed for extension and improvement and justify them on that basis, rather than just on the names. Based on State plans, which cover the overall picture and which had been developed by the State offices and county offices working together on the basis of a thorough review each year

may

and which represent their own recommendations, she felt that that gave greater promise for State initiative and State responsibility with Federal cooperation than the present system.

Senator PURTELL. Without objection, the Public Health Service grant charts which you have just referred to will be included in the record, Mr. Rockefeller.

Mr. RocKEFELLER. May we submit the figures that go with it? Senator PURTELL. Thank you. They too shall be included.

(The tables referred to are as follows:) PUBLIC HEALTH SERVICE GRANTS 1936-1954

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Federal grants-in-aid for public health services (appropriations, fiscal years

1936–54)

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1936... $3,333,000
1537. 8.000.000 $4, 667,000
1938.. 8.000.000
1839 10, 400,000 2, 400,000
1940... 13, 839.836 3, 439, 836
1941 16, 481, 537 2,641, 701
1942. 18,658, 167 2, 176, 630
1943 20.998,099 2, 339, 332
1944, 20. 431, 257 -566, 842
1945 21.623, 997 1, 192, 740
1946... 30, 247, 876 8.623, 879
1947 36,002, 990 5, 755, 114
1948 39,038, 685 3,035, 695
1919 38, 901,070 -137, 615
1950
1951 38 696, 100-4, 438, 900
1952 36, 449, 300 -2, 246, 800
1953 32. 011.881 - 4. 437, 419
1954. 22,086, 500-9, 925, 381

$3,333,000
8,000,000
8,000,000
8,000.000 $2,400,000
9,500,000 4, 339, 836
11,000,000 5, 481, 537
11, 000, 000 7, 658, 167
11,000,000 9, 998, 099
11,000,000 9, 431, 257
11,000,000 9, 253, 883
11,000,000 14, 017, 976
14. 250,000 14, 872, 990
11, 217, 039 15, 531, 646
11, 214, 666 14, 846, 404
14, 200.000 13, 095, 000
13, 540, 500 10, 705, 600
13, 500,000 9, 449, 300
13,000,000 6,061, 881
10, 135, 000 1, 976, 500

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Senator PURTELL. Have you any questions? Senator COOPER. I would like to ask a few questions. I would like to start out first with the total amount of money that might be appropriated by the Congress.

Assume as an example that the Congress should appropriate $100 million for the complete program. Is there any provision in the bill, or is there any formula which would determine the apportionment of a lump sum of money by the Congress between support, extension and improvement and specific projects?

Mr. ROCKEFELLER. The answer to your question is the money would not be appropriated in a lump sum, but in three separate sums, the amounts of which would be determined by the Congress each year.

Senator COOPER. I know that. But there is no formula set up in the
bill to determine the apportionment of the appropriation.
Mr. ROCKEFELLER. There would be three appropriations.
Senator COOPER. I know that.
Mr. ROCKEFELLER. There would be one for support, which would be
considered and justified and acted on by itself.

Senator COOPER. And the Congress would determine what sum of
money would go for support, what sum of money would go
tension and improvement, and what sum of money would go for special
projects.
Mr. ROCKEFELLER. If any.
Senator COOPER. Assume the Congress appropriated $65 million for
support, $25 million for extension, and $10 million-I think I am
right-for special projects. Let us take the $10 million for special
projects

. There is no formula for the apportionment of that money to the States.

Mr. ROCKEFELLER. That is right. Senator COOPER. Once it is in the State there is no formula for the way it shall be spent in the States. That is purely a determination by agreement between your Department and the States. Mr. ROCKEFELLER. The money would not be actually allocated to the

States.

Senator COOPER. I know. Any place in the United States.

Mr. ROCKEFELLER. The money would go to a specific project or a specific program in a State, and only after the State health officer had been consulted, so that he was in concurrence with the allocation. But there would not be a general distribution of the funds to States.

Senator COOPER. There is no formula. It is just a matter of determination by the Department.

Mr. ROCKEFELLER. That is correct.

Senator COOPER. Take the next one. Extension and improvement. Suppose you had $25 million appropriated by the Congress for that. I understand that the apportionment to the States would still be based on the population formula.

Mr. ROCKEFELLER. Exactly.
Senator COOPER. In the States you have a
Mr. ROCKEFELLER. A State plan.
Senator COOPER. Seventy-five percent and twenty-five percent.
Mr. RoCKEFELLER. Seventy-five, fifty, and twenty-five.
Senator COOPER. Over a 6-year period.

Mr. ROCKEFELLER. That is correct. But each year there would be rew money

available to the State. Senator COOPER. Now, the support is the one I really wanted to inquire about. I do not understand the formula. Assume $65 million is appropriated by the Congress for support. The formula is changed from the present formula.

Mr. ROCKEFELLER. The formula is changed.
Senator Cooper. That applies to all of your grant-in-aid programs.

Mr. ROCKEFELLER. The Secretary will be back tomorrow recommending or supporting legislation on vocational rehabilitation, and you will find the same formula recommended there.

Senator COOPER. Without going into the details by which you arrived at the apportionment to the State, the theory is that the larger States now would receive smaller amounts and the poorer States would receive perhaps larger amounts.

Mr. ROCKEFELLER. We did not develop a formula in the Secretary's office. This was a formula which, I think, one of your committee members is importantly responsible for having developed, Senator Hill. It is a formula on which I know Senator Taft spent a great deal of time. It is apparently the formula which the States feel across the board most effectively reflects what is sometimes called equalization—to give special help to those States which have a lower per capita income.

Senator Cooper. I am not from a rich State, but supposing you had a State like New York or Massachusetts, one where there are great hospitals and where they have perhaps started great programs in mental health, cancer, and heart disease. This would mean, I assume, that those States would receive smaller sums.

Do you think that this would affect the programs which they may have already instituted in such fields ?

Mr. ROCKEFELLER. I think this chart here is the best answer. The matching formula, as it now exists, is two Federal dollars to one State dollar. This is the average Federal contribution to State and local contributions in the 48 States for general health. Therefore, it would be clear that the wealthiest States would be spending far more or a far larger proportion of Federal to State funds than the average.

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