Senator CRANSTON. What is your opinion of the present State vocational rehabilitation fee system in terms of the variations and charges and income eligibility criteria?

Mr. STEARNS. Let me say I do not consider myself an expert on the specifics of the legislation, so I am afraid I am going to have to beg off on the question of the specifics of the legislation.

On general principles, let me say one thing: I hope that no one would be denied services who are handicapped, because they just cannot pay the money, because the day that comes, I do not think the vocational rehabilitation bill will be doing what it was set up to do. I could not support a fee system under any circumstances.

As far as specifics, I do not think I am qualified, Mr. Chairman, to give those to you.

Senator CRANSTON. You are very qualified to be a great help to us. You have been. I thank you very much.

I look forward to that report from you. Thank you a great deal. I regret to say we are going to have to take a brief break for two reasons: One, we have to give up this room to another group; second, I have to do something else briefly.

We will reconvene at approximately 4:30 in room 4232, which is right downstairs.

(Short recess.)

Senator CRANSTON. We have two remaining witnesses. The first is Dr. Robert Goldstein, president, American Speech and Hearing Association; accompanied by Frederick Spahr, deputy executive secretary.

We are delighted to have you with us. I am very sorry we had to delay things.

STATEMENT OF DR. ROBERT GOLDSTEIN, PRESIDENT, AMERICAN SPEECH AND HEARING ASSOCIATION, ACCOMPANIED BY FREDERICK SPAHR, DEPUTY EXECUTIVE SECRETARY

Dr. GOLDSTEIN. I am Dr. Robert Goldstein, professor of communicative disorders at the University of Wisconsin in Madison. I am here today as president of the American Speech and Hearing Association to offer support for the Vocational Rehabilitation Act Amendments of 1972.

We are in a position to evaluate only certain aspects of the proposed amendments, and I shall speak only to those issues on which the American Speech and Hearing Association can provide some definitive information. In the interest of time, I shall stress only a few of them.

Our field, which is speech pathology and audiology, deals with human communication and its disorders. We emphasize speech as an avenue of communication: The hearing of speech, the understanding of speech, and the production of speech. Our major goal is to help communicatively handicapped persons so they can become taxpayers instead of tax consumers. More importantly, we help them to lead more humanized lives. We are more than therapists, however.

We provide diagnostic and evaluative services. It is of inestimable importance that we have full insight into the person's problems so we

can channel the professional's efforts and the patient's energies into rehabilitative channels.

Speech pathologists and audiologists work in areas of residual skills and capabilities and in prevention of communicative disorders. We, therefore, talk about the total service, not just therapy.

What are some of the services rendered by speech pathologists and audiologists which lead to vocational rehabilitation? I will try to illustrate this in terms of the aspect of our work.

First, start with a person with handicapped hearing loss who is blocked from the start in the communication process. If a hearing aid is appropriately applied, guidance and use of amplified sound, instruction and understanding of speech, and so forth, can, let us say, get the classroom teacher to be able to understand his students, the salesman to understand his customers, the shop foreman to understand his subordinates, and so forth. We try to establish job security through improved communication, so that there is opportunity for normal advancement.

The stroke victim provides a good example of the handicapped in the understanding and the formulation of language. Even though the hearing may be intact and the speech muscles may not be paralyzed, the stroke victim acts as if he could not understand what is being said and suffers the terrible frustration of not being able to express his own thoughts. Stroke victims are given enough skills to be able to engage in productive occupations for which communication is essential.

Disorders of speech production are illustrated by those persons who have had their larynx removed because of cancer. It is amazing how much voice and speech production can be restored with proper help from speech pathologists.

I have been stressing only vocational benefits of rehabilitation. I am certain that you and others have had experiences in your own families or with close friends experiences which make you understand the dehumanizing effect of communicative disorders, and the terrible drain on the financial and emotional resources of family and friends, although we cannot quantify the success of our services in terms of rehumanizing. Speech pathologists and audiologists take pride in successes in this area.

I would like to address the topic of manpower needs. First of all, certain geographic areas of this country simply have too few or no speech pathologists and audiologists for the number of patients needing services. In some large cities, particularly in communities whose universities have large training programs, the needs are not so obvious. However, too many communities, large and small, have urgent problems. In all areas, there is still a strong need for professionals to truly understand our field from the viewpoint of impairment of communication and consequent impairment of productivity, and not as a field concerned primarily with the refinement of pronunciation or with the beauty of the voice.

Where do we get professionals who share this understanding? From the training programs in our colleges and universities.

RSA has been extremely helpful to our training programs. Recent cutbacks in training programs in communicative disorders, however, have hurt those programs. The hurt is especially stinging because more

money was appropriated to our areas than the social rehabilitation services chose to distribute to our programs. Some supplemental support was offered, but it came very late. Programs lost faculty, they lost good students, and they lost some of their overall stability.

Diminution of overall support, coupled with inflation, has placed training programs in serious jeopardy. Two issues emerge here.

The American Speech and Hearing Association urges you to consider both of them. The first of these is the adequacy of support. Funding should be at least equal to the maximum levels of past years and should be expanded if at all possible.

The second issue is that of forward funding, which unquestionably deserves support. Even when money is allotted, notification comes too late for effective planning and for wise utilization of funds. I speak from painful firsthand experience as a member of the faculty of a training program.

I now turn to the issue of professional independence and how it works toward the best and most economical services for the communicatively handicapped-to our association's insistence that speech pathology and audíology be looked at in terms of totality of services, not just in terms of therapy.

Secondly, I bring to your attention the fact that professionals are prepared not only as competent clinicians, but also as independent clinicians. We interact with many other professions: medicine, education, psychology, counseling, social work, and so forth.

Nevertheless, we have a unique and independent role. That independence is recognized publicly in Federal regulations, State licensures, university instructors, and many other ways.

Speech pathologists and audiologists consult with colleagues in other professions when they work with communicatively handicapped persons. We have high regard for our medical colleagues, but we do not work under medical prescription.

In our written testimony, we point out that the cost of service is usually greater when the patient must have a medical prescription before he can receive our services. But that is not the main concern. We feel very strongly that speech pathology and audiology services given to patients will be the best when they are recommended or prescribed as well as administered by speech pathologists and audiologists.

Now quickly on to two other issues pertaining to the Rehabilitation Act of 1972.

The first of these relates to who sets standards for quality control of services. We concur with the need for quality control and the need to guide standards through some accreditation process.

However, we feel that at this stage it does not seem appropriate to specify only one of the several possible accrediting agencies to the exclusion of others, which may be more effective.

I call the committee's attention to the standard setting and accreditation efforts of our association, the American Board of Examinations and Speech Pathologists and Audiology. It has a longer history of accreditation than any other national health accrediting agency and has been eminently successful in its efforts. We do hope that any standards established for quality service by anybody will be considered

minimal and that all facilities and individuals will be encouraged to exceed those standards.

Finally, I want to speak to the needs of the low-achieving deaf. Incidentally, recent careful studies show there are probably at least twice as many deaf persons in the United States than were estimated in previous studies cited in our written testimony, about a half million and, unfortunately, its significant numbers of the total deaf population are low achievers.

The need clearly exists for centers for research and demonstration in this area to help us make up for all that has not been done for this grossly neglected group.

A principal of a school for the deaf once told me that he never had to read the financial page to know the economic status of this country. The deaf and, particularly the low achievers, are among the first to be laid off.

Why are we so unaware of the human problems of the deaf; largely because deafness has no overt signs. Someone once said it would be fortunate for the victim if his ears would turn a vivid blue as his hearing diminished.

Mr. Chairman, no one dies of a hearing loss. Even severe stuttering is not painful. Why, then, all of this fuss about disorders of communication? The members of the American Speech and Hearing Association firmly believe that disorders of hearing, language, and speech, are the most distinctively human of human diseases. I am certain that you and others have experienced in your own families, among your own close friends, examples of social as well as vocational debilitation of deafness, of severe speech impediments, and so on.

We support the national efforts on behalf of other professional services to help with those other disorders to be rehabilitated, and we support the kinds of efforts spelled out in the Rehabilitation Act of 1972 to conquer the most distinctively human of human diseases, those of disorders of communication.

It is very fortunate that those persons with these most distinctively human diseases are also most rehabilitative in terms of their social and rehabilitation lives.

They return to our economy far more money than is spent on their health, and return so much humanity that is lost.

Dr. Spahr and I thank you most sincerely for the time you have given us.

Thank you.

Senator CRANSTON. Thank you very much.

What would be your definition of the low-achieving deaf for the purpose of this program?

Dr. GOLDSTEIN. It is the deaf person who, despite efforts at education, has not been able to achieve communication, has not been able to achieve useful language with the hearing population particularly, and sometimes not even with the deaf population, has not been able to acquire skills that he can use for a productive income; and even having achieved some skills, may not stick with the position and find himself pretty much in economic isolation.

Senator CRANSTON. Would any particular age group benefit in your opinion from enactment of the section for the low achieving deaf? Dr. GOLDSTEIN. I think all ages would benefit. I see the low achievers start their pathway relatively young, and if hit at a young enough age, may be moved in a somewhat different direction. The low achiever

who probably has passed his 35th or 40th birthday may perhaps not benefit nearly as much as the younger deaf person might.

Senator CRANSTON. Do you feel that we would be able to give comprehensive services to the groups, say 16 to 18 years of age?

Mr. GOLDSTEIN. Yes. I would say this particular age group is a very painful group, both educationally, vocationally, and socially. They have had somewhat intensive education and close care in schools or classes for the deaf and then they are suddenly in this inbetween age, as most teenagers are, without the kind of support that they should have had. I think they would benefit especially well from an intensive program.

Senator CRANSTON. Have you ever used or thought of any term other than "low achieving" to describe the people that you mean to describe by that term?

Dr. GOLDSTEIN. No, I have not. In fact, most of us for a long time were searching for any term to be used. My academic career started in the school for the deaf, and I saw students who did achieve and students who did not achieve, and we could never pinpoint a particular term for them. They were not mentally retarded. They were not social outcasts. They sort of defied description.

Senator CRANSTON. The term is sort of derogatory. I wondered if there was some other way to describe the degree of disability?

Dr. GOLDSTEIN. I think it is incumbent upon us as professionals to find something that does not have that kind of implication. Most of the other expressions that were used unfortunately had worse implications. The words were almost not spoken because of the negative impact.

To me, the term "low achiever" means at least there is potential for achievement that may not necessarily be recognized.

Senator CRANSTON. When you spoke of so-called low achievers, were you referring to just general education or special education?

Dr. GOLDSTEIN. No; even special education. There are a very few who can get through a regular education program without a lot of help. So I am speaking of people who have had intensive programs and still have not been able to achieve what the measures of intellectual capability seen to indicate they should be able to achieve.

Senator CRANSTON. I have asked several witnesses their view of the present fee system in terms of variations and charges and income eligibility criteria.

Do you have any thoughts to express on that subject?

Dr. GOLDSTEIN. It is very difficult for us in this field to answer this question because of the great diversity of settings in which our services are being rendered.

For instance, look at the education of the deaf, the mode of payment is entirely different from that that would be handled through a freestanding agency. Perhaps Dr. Spahr might be able to elaborate. I am afraid my own personal knowledge is not sufficient to give a definitive answer as to the adequacy and nature of the present fee existing. Senator CRANSTON. Do you have anything to add to that?

Dr. SPAHR. I think it depends on a wide variety of factors, Senator; one being the extent of rehabilitation services needed, another, the duration of treatment, another having to do with the number of children in the family, and other factors that would be involved, rather than just a cutoff point.