threatened by urban redevelopment, some old deteriorating neighborhoods, and elegant high-rise apartments. The median age is 43 years, but there are two subgroups-an older white population and a young black population. The mortality rate for the area is 15 percent higher than that of the total District. Registrants for Medicare, Medicaid, or D. C. Medical Assistance constitute 26 percent of the population.

The George Washington Community Care Center is visualized as a Health Maintenance Organization providing complete ambulatory services. Health maintenance is supervised by four health teams, each consisting of a physician, two medical students, and a nurse. Physician's assistants, social workers, and a dietician are available to the team at all times. Care is provided for over 50 patients per day. In addition to the primary care team, there is an admitting physician's office. Members of the medical school's full-time faculty provide specialty backup for the eight full-time physicians who form the medical group so that medical subspecialty, surgical, obstetrical, and orthopaedic consultations are provided when needed. Other services available are home care, multiphasic health testing, day care, and transportation.

The emergency room project began in April 1970. It has x-ray and laboratory facilities, plus specially equipped rooms for trauma, cardiac resuscitation and monitoring, and acutely disturbed psychiatric patients. There are three levels of emergency department care available: nine examining rooms for acute care, a seven-bed unit for observation and staging area for hospital admission, and medical intern and nurse screening teams for convenience care. It is expected that approximately 40,000 patient visits to the emergency department will be registered per year.

Eight full-time physicians and over 30 part-time volunteer faculty physicians serve in the total program. Aiding the physicians are 70 allied health personnel. An associate director of the hospital works with the director of the Division on a full-time basis to coordinate services. Ambulatory nursing supervision is provided by a nurse with a master's degree in public health. The three social workers also have master's degrees. Interns are assigned to the community care program for two months of the training year and sperid time in emergency care and in the admitting physician's office in the clinic building. Residents may elect two months in a supervisory capacity in emergency care. Each medical service resident spends a half-day each week as a physician on a team, caring for those patients he has seen in the hospital environment.

The faculty of the Division of General Medicine is supported principally through a grant from the Health Manpower Branch of the National Institutes of Health. The health services rendered are financed through patient charges on a modified fee-for-service system. The per-visit rates assessed at cost are charged to patients supported by District of Columbia welfare programs, Medicare, and Medicaid; other patients are charged according to their ability to pay. Approximately 8 percent of the target population does not have the means to purchase insurance and yet is ineligible for government assistance. For these persons, the program absorbs the cost since no person from the target area is refused medical attention. For the future, the Division is developing a prepaid system with Blue Cross-Blue Shield as the fiscal agent. It is hoped that contracts can be negotiated with Medicaid, the Civil Service Commission, and employers within the community.

NATIONAL MEDICAL ASSOCIATION FOUNDATION
Washington, District of Columbia

The National Medical Association Foundation (NMAF), a nonprofit corporation, was established in December 1967 as an entity designed to demonstrate the NMA's concern for the health of the poor and also to provide a means for contributing to the development of improved health care. In January 1968, President Lyndon B. Johnson announced a future NMA-sponsored pilot health project in inner-city Washington, D.C., that would receive technical and financial support from the federal government, the District of Columbia, and Howard University. In 1970, the NMA Foundation received a Community Health Services grant under section 314(e) of the Public Health Service Act to plan this medical care system in the Shaw Community of Washington, D.C. Two distinct medical care programs are visualized: the Shaw Community Health Program and the Northwest One Program.

The hub of the medical care system is a comprehensive health center. The Shaw center offers medical and supportive services on a sliding scale of payment for 50,000 residents in the area bounded by Florida Avenue, U Street, North Capitol, M Street, and 15th Street, NW.

The Shaw Program will function as a "group practice without walls," and each physician participating in the program will maintain his own office in its present location. The physician's office will serve as a satellite neighborhood health center, and it will be the primary center for coordinating patient care. The central health center will provide a broad range of medical care services as well as a full range of supportive services, such as home nursing, dental care, rehabilitation, family planning, mental health services, and nutritional services. There also will be out-reach health education, a pharmacy, social services, and transportation available. Backup hospital care will be obtained at Freedman's and D.C. General Hospitals. Twenty community health workers canvassed the neighborhood enrolling residents and informing them of the services offered by the center. The people from the Shaw community have depended on D.C. General Hospital, Freedman's Hospital, and health department clinics for health services, and private physicians have previously had to utilize a number of different agencies to obtain needed supportive services.

The health care center will be staffed by 83 employees. The health professional staff will include representatives of many health specialties. Of the 60 physicians practicing in the Shaw community, 40 have agreed to participate in the community health program. The program intends to begin with a small nucleus of interested and dedicated physicians and expand to involve larger numbers of physicians practicing in the area as additional expertise and coordination are obtained.

The program will serve both paying and nonpaying patients from the Shaw area. The payment to the private practitioners will be on a fee-forservice basis. Physicians will be reimbursed from grant funds for 50 percent of the cost of services rendered to those residents of the area who neither participate in the District Medical Program nor are able to purchase care for themselves. At the end of the present funding period, it is anticipated that further support should come through the evolution of a prepayment program that will involve capitation for the Medicaid population in the geographic - target area.

The Northwest One Program is a three-fold operation: (1) skilled nursing home operation; (2) home health agency; and (3) prepaid group practice. This program is visualized as a comprehensive ambulatory health center within an extended care facility. This combination nursing home and ambulatory health care facility is intended to form the basis for a Health Maintenance Organization.

Mr. ROGERS. Our next panel is representing the Association of State and Territorial Health Officials. Dr. Maurice S. Reizen, president of ASTHO, and director of public health, Michigan Department of Public Health, Lansing, Mich.; and Theodore R. Ervin, deputy director of public health, Michigan Department of Public Health. We welcome you gentlemen to the committee.

We will be pleased to receive your statements and if you desire, if you have long statements we would make them a part of the record at this point and you can highlight what you think this committee really needs to know.

STATEMENT OF THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS, PRESENTED BY DR. MAURICE S. REIZEN, PRESIDENT, ASTHO, AND DIRECTOR OF PUBLIC HEALTH, MICHIGAN DEPARTMENT OF PUBLIC HEALTH; ACCOMPANIED BY THEODORE R. ERVIN, DEPUTY DIRECTOR OF PUBLIC HEALTH, MICHIGAN DEPARTMENT OF PUBLIC HEALTH

Dr. REIZEN. Thank you, Mr. Chairman.

I am Dr. Maurice Š. Reizen. I am director of public health of the Michigan Department of Public Health. With me is Theodore R. Ervin, deputy director of public health, Michigan Department of Public Health.

It was 8 years ago that representatives of our organization appeared before this very subcommittee to voice their total support to the promise of a new arrangement for Federal support of State and local public health programs. Public Law 89-749, the Partnership for Health Act, resulted. The intervening years have proven a bitter disappointment to us and, although prevention is our credo, in this instance we are of the opinion that radical surgery is indicated.

Example Increased Federal financial support for public health services which we anticipated and which HEW projected would total $300 million by 1972, has not materialized. There has been an actual $2.7 million increase since 1966 for section 315 (d) grants. Details are on page 2 of my supplemental statement.

You will be pleased to hear that we do not propose to read from that but would like to have it made a part of the record.

Mr. ROGERS. Without objection, it will be made a part of the record. [See p. 615.]

Dr. REIZEN. Example-Despite those Department projections, HEW has but with one exception, never requested other than miniscule increases for the 314(d) grants.

Example-The U.S. Congress has never throughout these 8 years appropriated a single dollar more for 314(d) grants than requested by the administration-this despite our entreaties to the contrary.

The thought occurs that there exists a breakdown in communications or understanding as to just what State and local public health departments are legally responsible for and what their services, both existing and possible, are and can accomplish. A lack of understanding can be most destructive and I am compelled to attack this problem head-on, both because of the circumstances listed previously and the comment of a former official of the planning operation of HEW, who

remarked that with the advent of National Health Insurance there would be no need for public health agencies. This excessively simplistic view is, I regret to say, all too indicative of those who should be our friends in HEW but who simply have no idea of what is going on in the real world.

Let me deal with the issue of effectiveness. Since the turn of the century, there has been an almost 50 percent reduction in our Nation's death rate. Between 70 and 80 percent of this reduction is due to community health measures, and health departments-Federal, State, and local-have contributed greatly to the elimination or severe reduction of deaths from diseases of infants and mothers, typhoid and paratyphoid, dysentery, diarrhea and enteritis, tuberculosis, malaria, hemolytic streptococcal infections, smallpox, measles, diphtheria, pertusis, plus syphillis and its sequellae. We were actively involved in protecting the health of man from ecological hazards before "environmental protection" became household words.

Parenthetically, the first law on the books in Michigan dealt with environmental protection, such things as the arsenic in the paste they used to stick wallpaper to the wall. Prevention of illness through pure water, milk and food has probably been more responsible for the reduction of infant mortality than any other factor.

May I expand upon this word-prevention. It can and it should be more encompassing than the usually thought of immunization procedures. This procedure is one of intervention between a bacteria or virus and the individual. Fluoridation is another proven effective form of intervention. In addition to medical or dental intervention, there can be intervention in the economic sense-the prevention of unnecessary health expenditures. Proper health care given at the proper time and in the proper place can serve to level out skyrocketing health care costs. Public health departments, with their long experience in operating ambulatory clinics and home health services have in varying degrees the potential for a greatly expanded role in providing health care in sites far less costly than acute care hospitals.

Please make no mistake as to the intent of my statement. Medicare and medicaid benefits in hospitals, ICF's and SNF's are clearly justified. But we believe that for whatever the reason, inordinate reliance upon the hospital is economic nonsense. Disregarding completely humanitarian considerations, simple economics indicate the wisdom of keeping people well and out of institutions.

Public health departments have, as I stated previously, the capacity in varying degrees to provide out-of-institution services but unless this capacity is recognized and nurtured a valuable potential may well be lost. It was this kind of support we expected from the Partnership for Health Act. Our surveys indicate, however, that the $90 million 314(d) grant constitutes about 5 percent of the total local, State, and Federal funds expended on programs for which section 314(d) funds may be expended. This is not the role of a partner-it is that of a minor stockholder.

Here is a situation revealing no inclination on the part of the executive branch to increase support for services by public health departments and where there is clearly no incentive to State or local governments to increase appropriations in order to take advantage of a favorable Federal matching arrangement as is the case, for instance