Commissioned to Explore the Relations Between the Department Of

DOCUMENT RESUME ED 021 9% VT 004 360 By- Corson. John J.; And Others ADVISORY COMMITTEE ON HEW RELATIONSHIPS WITH STATE HEALTHAGENCIES REPORT TO THE SECRETARY, DECEMBER 30, 1966 Department of Health Education and Welfare, Washington. D.C. Pub Date 67 Note-142p EDRS Price MF-$0.75 HC-$5.76 Descriptors-CITY GOVERNMENT, FEDERAL AID, FEDERAL GOVERNMENT, *GOVERNMENTALSTRUCTURE HEALTH FACILITIES HEALTH OCUPATIONS EDUCATION. HEALTH PERSONNEL*HEALTH SERVICE& *INTERAGENCY COORDINATION PUBLIC HEALTH, RESEARCH, STATE GOVERNMENT Commissioned to explore the relations between the Departmentof Health, Education, and Welfare (HEW) and state and local agencies in the fieldof health, the committee interviewed key HEW administrators, met with stateand selected local health officials in nine states and officials of health associations, and invited commentsfrom more than 50 professional health andwelfare organizations. Government functioning is complicated by (1) diffusion of responsibility through various agenciesother than HEW and within HEW through agencies other than the Public HealthService, (2) inadequate provision for coordinating fi)e health activities of the numerous agencies,(3) further diffusion, compartmentarizatiOn, 6nd lack -of coordination at the state andlocal levels, (4) inadequacy of regional approaches, and (5) the shortage ofqualified health manpower. Included in the 29 comprehensiverecommendations for strengthening the local, state, or federal health partnership are the (1) transfer ofOffice of Economic Opportunity demonstration prolects to HEW Administration after they haveproved their Health Manpower, ancr (3) expansion of training programsfor supporting personnel along with guidance, student aid, and eacher educationprogramssupported by the Office of Education. (JK) 7

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, ; U.S. DEPARTMENT Of HEALTH, EDUCATION& WELFARE

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PERSON OR ORGANIZATION ORIGINATING IT.POINTS OF VIEW OR OPINIONS

STATED DO NOT NECESSARILY REPRESENTOFFICIAL OFFICE Of EDUCATION

POSITION OR POLICY.

Advisory Committee on HEWRelationships with State Health Agencies

Report to the Secretary

December 30, 1966

) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE WASHINGTON

Honorable John W. Gardner Secretary of Health, Education, and Welfare Washington, D.C. 20201 Dear Mr. Secretary: We are in a period ofunprecedented promise for the healthof the American people.Our affluence as a Nation, ourgrowing store of scientifi:c knowledge, and ourtechnological capacity, coupled with a growing public demandfor high-quality medical services, give promise of the attainmentof unprecedented levels ofhealth care in the UnitedStates. Comprehensive, high-quality healthservices can, and should, be readily available and accessible toall Americans. Suchservices are providedin major part by the privatepractitioners of-medicine. But the people of this countryhave demonstrated that they expect their governments to do whateverneeds doing to assist, support, and supplement privatepractitioners.Hence, the extent to which Americans will enjoy the promiseof better health depends to a considerable extent upon theeffectiveness of the Federal-State- local health structure in thiscountry. That is why the assignment you gaveto this Committee isvitally interesting, challenging, and timely.You asked that we appraise' existing relationships betweenthe Department of Health,Education, and Welfare and State healthagencies.The accompanying report presents the results of oureffort.It identifies the problemsthat exist, recommends ways ofstrengthening local, State, andFederal health agencies and proposesactions that will improve therelationships among these agencies. II

Your objectiveto strengthen theFederal-State-local partnership for healthis an eminently worthyone. We are grateful for the opportunity you have givenus to assist in this endeavor.

Respectfully submitted,

( Leona Baurngartne M.D. Edmund F. Ricketts

Morris W.H. Collins, Jr.77f/

1/4V44/ 11 am G. Colman

orson, Chairman Alonzo S erby,

te..1 William J. 1eples, M.D. III

FOREWORD

The people of the United States depend for health services upon private practitioners and a wide array of institutions and agencies--public and private.

In recent years, the institutions involved have grown in number, size and complexity. They have grown because people needed the services they offer.

Individuals can be helped best if the institutions which serve them are clear as to purpose and task, are well organized, and work together effectively. If they work together in a creative manner, the health of the individual will be well served. If they do not, relationship itself can become a problem, and the health of the individual can suffer.

Almost all the constituent agencies of the Department of Health, Education, and Welfare have some health responsibilities. Together and separately, they deal with an astonishing number of agencies at the State, regional and local level. The problem of relationships among all these agencies is a huge one, calling for attention at every level of government.

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That is why I calledupon an Advisory Committee, headed by John J. Corson, to explorethe relations between V ji the Department and State and localagencies and to give us recommendations as to howwe might improve them. V The report of this Committeecontains a valth of provocative ideas,many of which should prove useful tous in the Federal Government andto officials in State and local government. It should serve asa source of lively discussion and subsequent action. V

TABLE OF CONTENTS

Page

Chapter I - Today's HealthChallenge 1

Chapter II - AssessingAdministrative Capabilities 17

Chapter III - Strengtheningthe Local Health Partner 41

Chapter IV - Strentheningthe State Health Partner 71

Chapter V - Strengtheningthe Federal Health Partner 89

Conclusions and Recommendations 113

Appendices

A. Secretary's Advisory Committee onHEW Relationships with State Health Agencies 123 127 B. Agencies and ProfessionalOrganizations Contacted Consulted by the C. Officials of the Federal Government Advisory Committee or ItsRepresentatives 131

D. Officials of State GovernmentsConSulted by Members or Representativesof the Advisory Committee 137

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CHAPTER I - TODAY'S HEALTH CHALLENGE

The Committee's V Mis sion The Congress has declared that --

V "Fulfillment of our national purpose depends on promoting and assuring the highest level of health attainable for every person, in an environment which contributes positively to healthful individual and family living; that attainment of this goaldepends on an effective partnership,involving close intergovernmental collaboration, official and voluntary efforts, and participation of individuals and organizations; that Federal financial assistance must be directed to support the marshallingof all health resources - national, State, and local - to assure comprehensive healthservices of high quality for every person, but without interference with existing patterns of private professional 'practice of medicine, dentistry, and related healing arts."1 Achievement of this national purpose is, in considerable part,

a responsibility of theDepartment of Health, Education, and Welfare and the State healthagencies2 with which the Department is associated in many ways. The relationships among these Federal andState agencies and the local health agencies in each Stateinfluence importantly -- -- thecontinuing assessment of the health needs of the Nation

1Sec. 2 (a), PL 89-749, Comprehensive Health Planning and Public Health Services Amendments of 1966. 2The term "State health agencies" is used to comprehendall agencies of the State government in addition to the State healthdepartment that receive financial support.from the Department of Health, Education, andWelfare (including such agencies as the mental health department, the vocational rehabilitation department, and the university medical school) andother agencies with similar health responsibilities. 2 -- many of the services available to supplement the efforts of private practitioners in combatting illness, disability, and death,t and in improving the standards of health care for people -- the development of health manpower and facilities to provide the needed personal and environmental health services -- the stimulation and support of research into the causes of sickness, the relationship ofman to his environment, the application of new knowledge, and the delivery of health services c -- the financing of the Medical and hospital care available for a considerable portion of the population. c

This report assesses those relationships and suggestsways of improving the effectiveness of Federal-State efforts in health.It is the report of an Advisory Committee created by John W. Gardner, Secretary of Health, Education, and Welfare to: I.Examine the nature of the.existing relationship between the Department of Health, Education, and Welfare and the State health agencies. 2.Identify the problems which exist and recommend proposals for their solution, taking into account the needs of local, State, and Federal agencies. 3. Recommend ways of improving the relationships. between the Department of Health, Education, and Welfare and State health agencies, in the interest of better health for the American people. The Committee's Approach .

., The Committee interpreted its assignment broadly.It viewed the health effort as the totality ofpers ,nal and environmental services, ==.1 3

provided on an individualbasis or in community programs.I Thus, the public concernwith health comprehendspreventive, diagnostic, therapeutic,and rehabilitative careof physical and mental illness.It includes personalhealth services, whether provided in the home,physician's office, hospital, clinic,health department, work place, orschool; and communityenvironmental services, whether providedat a public eatingplace, waste treatment plant, sanitary landfill, orby a local housing andurban renewal authority or regional planning agency.And it includes servicespaid for by the individualhimself, directly,through insurance, bypublic funds, or in his behalf byprivate agencies. To learn the nature andthe strengths andweaknesses of the prevailing relationshipsbetween the Departmentof Health, Education, and Welfare and the Statehealth agencies, theCommittee sought advice and counsel from avariety of sources.It interviewed keyFederal administrators throughoutHEW, both at headquartersand in the regions; visited nine representativeStates, and in each met withthe Governor's designee, with the chief healthadministrator, and withselected local health officials; met withofficials of the AmericanPublic Health Association and the Associationof State and TerritorialHealth Officers;

IThe Committee did not includewithin the scope of its studythe intramural or extramuralresearch activities of theNational Institutes of Health. 4 and invited comments from more than fifty professionalhealth and .--, welfare organizations.(See Appendix for details.) These visits, interviews, and meetings brought the Committee in contact not only with health officials but with welfareadministrators, mental health authorities, rehabilitation administrators, education officials, medical school deans, consumer protection agencies, air and water pollution control officials, departments of agriculture, and chief administrative and fiscal officers of several States. Promise for the Future An inquiry into the effectiveness of these health relationships comes at a propitious time.This Nation's scientific and technological advance gives promise that greatly improved health services -- both personal and environmental can be available to the people of this country in the years immediately ahead. And the current emphasis being placed upon "Creative Federalism" makes propitious aninquiry as to how Federal and State agencies can collaborate more effectively. a) Advance in medical technology Major advances in drug therapy, in the eradication of communicable disease, in the development of artificial hearts and kidneys, in rehabilitation of the disabled, are examples of the benefits that an advancing technology puts in the hands of those private and public agencies upon 5

whom the people depend forhealth services.The application of research over the next decade --particularly to the aging process, cancer, chronicdiseases, mental illness, andenvironmental hazards --portends equally beneficial resultsin these areas. r New developments in computertechnology make increasingly possible the use and extensionof automated techniques for masshealth screening, patient monitoring,medical diagnosis, laboratoryprocedures, record keeping, analysis of theenvironment, and improvement of systems for the delivery of medical care. b) Investment in research and training Since World War II this Nationhas made an annually increasing investment in medical research andin the training df health personnel. The National Institutes of Health, themain research arm of the Public Health Service, has gr ownuntil it now conducts or supports40 percent of this Nation's total medical researcheffort.Its annual investment in research has grown from $52 millionin 1950 to $10 2 billion in1966-1967. Another half billion dollars a year is nowdevoted to the development

and training of health manpower. c) Government assumption of responsibility The prospect for improved healthservices and for the improved ., health of the American people is furtherenhanced by Government's increasing acceptance of responsibilityfor the people's health.

) 6 In 1940, 22 percent of all expenditures for health and medical care were met from public funds; today this proportion has grown to 26 percent; Medicare]. and Medicaid2 will undoubtedly raise this ratio in the decade ahead.This progressive assumption of governmental responsibility -- and the prospect for the future medicalcare of individuals -- was strikingly illustrated in 1966 when the State of

New York decided to provide free medical care under thenew Medicaid program for families of four with annual incomes up to $6, 000. This assumption of re sPonsibllity by government has been prompted by numerous factors-- to name a few: the emergence of the problems of metropolitan areas, the quest for equal opportunities for racial minorities and for the poor, and pressures to conserve our naturalresources and enhance natural beauty that forced attacks upon environmental pollution. These, together with the recognized need for comprehensive health planning and less restrictive health program financing, underlay the enactment of the "Partnership in Health" Act3 during the closing days of the 89th Congress.This legislation offers a unique beginning stimulus to the setting of new national health goals and for the planning of improved health services.

1TheTitle XVIII of the Social Security Act-Health Insurance for the Aged, PL 89-97. 2Title XIX ofthe Social Security Act-Grants to States for Medical Assistance Programs, PL 89-97. 3ComprehensiveHealth Planning and Public Health Service Amendments of 1966, PL 89-749. 7

looked upon Health legislationand health programswere once not expected tohave as"technical" issues.Ordinary citizens were But, of late,,issues nor believedto be qualifiedto voiceopinions. matters of general such as Medicareand pollutioncontrol have become issues are tooimportant public concern.Society hasconcluded that health other professionals.The to be leftsolely in thehands of physicians or better health prospect is thatproposals and programsaimed at attaining and decidedthrough the will increasinglybe debated inthe public arena political process. d) Growing supportfor the health effort people is reinforced The promiseof better healthfor the American for healthmaintenance by the fact thatsociety has agreedto invest more and there isincreasing and improvement.The affluentsociety need not, standards for health evidence that it will not,content itselfwith minimal of society. care --ornO,health care at allfor the leastfortunate members and privateexpenditures This is Manifestin the increasein both public decades. Less than for health andmedical care overthe past three four percent of theGross $4 billion was spentfor health in1940, or only expenditure National Product inthat year. InFY 1965, thetotal health the Gross reached an estimated$38,4 billion, aboutsix percent of National Product,and about$200 per capita. 8 Public expenditures for health and medical care amounted to

$10 billion in 1965.That year, for the first time in history, the Federal share of these public funds ($5.1 billion) exceeded the contribution of State and local governments ($4.9 billion).However, of the $5.1 billion 0. Federal expenditures, over $1.1 billion was devoted to medical research and not to aiding the States and localities in providing health services. Indeed, the increase in State and local health expenditures has been greater than the increase in Federal expenditures other than the support of research during recent years.Yet as late as FY 1964 two-thirds of the States were still spending less than $3 per capita for health services. Obstacles to Better Health If, however, the promise of better health for all Americans is to become a reality, a number of obstacles must be overcome.

A.Urbanization generates new problems and brings with it environmental stresses. The massive migration of population during the last two decades-- from rural to urban areas-- and the middle-class exodus from the center city to the suburbs, with a resulting concentration of low-income families in the core city -- have aggravated our health problems. Such problems as air and water pollution, noise, crowding, accidents, and poor housing have been intensified by urban growth and increasing industrialization. 9

A substantial numberof physicians and somehospitals have moved to suburban areas.Critical health needs in the corecity, as a consequence., have remained unmet.Charity hospitals and clinics --inundated by great numbers of patients -- simplylack the resources to meet thegrowing

v demand for services. Theresult is suggested by thefact that in the 21 cities with populations over500,000 only 4 had significantlylower infant mortality rates in1963 than in 1960-1962; in most caSesthe trend was toward ahigher rate.

B.Obsolete governmental structuresmake advance in the provision of health servicesdilficult. Today's health problems do not respectyesterday's governmental jurisdictions or structures.Despite obvious advance inhealth conditions and notable instances ofcreativity, there is still evidence at everylevel of government of fragmentation,duplication, and outmoded administrative , and fiscal practices whichwast'e resources and frustrate effort. At the local level, it is commonfor essentially related services to be divided among separatecities, counties, boroughs,districts, and authorities which expendtheir resources in overlappingand uncoordinated activities.Effective planning for medical andenvironmental health service is all toooften impeded by a parochial outlook

. and jealousy among local politicalentities. 10 At the State level, reapportionment has begun to shift the focus from rural to urban problems. However, archaic laws and the continued domination of State boards of health by private practitioners whose interest and attention are traditionally focused on the personal care of patients (rather than on the health problems of a community) has tended to cir- cumscribe the freedom or desire of State health agencies to expand their services and to undertake new programs of medical care. At the Federal level, expansion and proliferation of health programs have resulted in a tangled web of health agencies with varied goals reflected

in over 100 separate financial grant-in-aid programs.Without coordination of Federal health activities and lacking the guidance of clear national health goals, this expanded Federal health effort is less productive than it can and need be. - C.An overly rigid medical care system inhibits new approaches to the provision of health services. The medical care system in this country is organized around solo practitioners and individual hospitals.This system has contributed substantially to the high level of medical care available to most Americans. But tradition has encrusted this system with restrictions, sometimes solidified in legislation, that make difficult adaptation to new circumstances.For example, the expensive equipment and specialized support now required for the efficient practice of medicine is not logically 11 accommodated to the solopractice of medicine. Bydiscouraging such innovations as groupmedical practice andextensive use of paramedical personnel,the.system tends to duplicateand waste scarce resources. Proper utilizationof medical facilities and manpoweris a major factor affecting the costand efficient deliveryof medical services. Extended care facilities canprovide services at afraction of the cost at hospitals, whilehealth care at home canbe provided for a fraction. of extended care facility cost. However, little has beenaccomplished and much remainsto be learned as to how utilization canbe reviewed and controlled, evenin our public medical care programs.Utilization review committeeshave begun to function in mostof cur hospitals and extended carefacilities as man- dated by the Medicare program,but nursing home utilizationis still entirely unregulated. D. Too little emphasis onthe application ofknowledge delays

health advance. Heart disease, cancer,and stroke togetherclaimed 1.2 million lives in 1963 -- more than7 out of 10,deaths in thiscountry.Yet a simple screening test candetect cancer of the cervix -- nowresponsible for 10,000 deaths each year --in its earliest stageswhen it is generally curable, and new developmentsin the early detectionof other forms of 12 cancer hold forth the promise of saving many lives.The same is true for other diseases -- among them diabetes, arthritis, and glaucoma. Open dumping and open burning of garbage and refuse are prevailing practices that create health hazards even though economical and safe refuse disposal methods are available.Similarly, some 1,000 deaths are caused each year by communicable diseases against which effective immunizing agents are available.Preventable tuberculosis and venereal disease account for an additional 12, 000 deaths.And, tragic episodes -- mosquito borne encephalitis in Dallas, hepatitis from the public water supply in Riverside, California, and from shellfish in New Jersey and Mississippi, botulism from smoked fish in Michigan -- still occur with costly consequences. The speed of transportation and the size of the population at risk make increasingly essential the more rapid and broader application of knowledge that now exists for the improvement of human health.

1, E.The shortage of manpower hampers the delivery.of health care to people. Manpower for both personal and environmental health services is in scarce supply. More doctors, nurses, engineers, and allied health workers are needed now and will be needed even more desperately in the future. , -1

The attainmentof the better healththat is achievablerequires is available the best possibleutilization of the trainedmanpower that people in ., and the attractionof more of thiscountry's talented young the colleges anduniversities to thehealth fields.While additional fields, as well as manpower isbeing developed inthe allied medical of qualified in the medical,nursing, and engineeringfields, the shortage citizens manpower isdestined to deny neededhealth care to some of our and and to limit theeffectiveness of publichealth agencies, hospitals, clinics. F. Rising coststend to make betterhealth care unavailable to

many people. The costs of medical carepersistently rise.Even though hospital stays tend to beshorter, spiraling wagesand the costs ofspecialized equipment and serviceFhave boosted hospitalcosts sharply -- 7 to8 percent annually overthe past decade,and perhaps as much as20 percent next year. Anexplosive increase isanticipated in the nextfew years because of salaryincreases to bring thelevel of earnings oflow paid hospital workers up to arealistic status, togetherwith an increaseddemand for services resultingfrom Medicare andMedicaid.. .

I Meanwhile new technicaldevelopments. in medicinetend to increase the cost of deliveringmedical services, e.g., anelectrocardiograph machine costs more than astethoscope, open heart surgerymore than 14

an appendectomy, and kidney dialysis more than any patientcan reasonably afford.These factors constitute a major obstacle to the attainment of the better health care that isnow available. C. Lack of public understanding of healthcare and inadequacy of health services limit advance.

Much of the improvement in healthover the last twenty-five years has come about because of improved standards of living,better education, and better nutrition rather thanas a consequence of advance in medical science. Better knowledge about health has helped to dispellong-standing attitudes which militated against early prenatalcare, dental care for children, and the like.

However, health education efforts have not beeneffective in reaching lower-income groups among which health problemsare most aggravated. Thus, many citizens are inadequately equippedto take advantage of all available health knowledge and health services.TT he low scores achieveJ zw. the recently televised national health quizare indicative of the poor knowledge of health of theaverage citizen and the vastness of the education task at both child and adult levels.

H.Health professionals and their associations havetended to focus narrowly on matters thatmay affect their own status. Physicians, nurses, and other health professionalsin their associations have tended to concentrateon their personal and financial 15

needs to the exclusion of mattersof broader concern. They have too seldom joined in commonefforts to attack larger health problems. This is robbing them of aneffective voice in developing new patterns for deliveringprofessional health services.Their active participation in a positive andcreative way is essential in planning and administering new programsfor providing comprehensive care,in the wider use of the alliedhealth professions, and in criticalevaluations of their own changing roles in the current health revolution.

The Next Steps Scientific knowledge, econoraic affluence, publi.c demandfor better health, and government's increased acceptance of responsibilityfor doing

. what is needed, underwrite the promise of better healthfor all Arriericans The achievement of that promise, however, requires moreeffective performance on the part of Federal, State, and local health agenciesin the application of increased funds, greater facilities and improving technology; requires increasingly effective coordination among private and public health forces; and requires the development of newand improved systems relating facilities and manpower in moreeffective methods of the delivery of medical care to indivi.duals.Money alone is not the answer; equally required is the better use of the resource,3 now being invested. 16 More effective relationships among Federal, State, and local governments in the use of these resources are essential to meet today's health challenge. Chapter II evaluates the present capability of government to meet the task ahead, and the later chapters offer our recommendations 4 for improvement. 17

CHAPTER II - ASSESSINGADMINISTRATIVE CAPABILITIES

Is this country'sgovernmental health structureequal to the task of formulating and thenattaining the health goalsthat scientific advance and increased resourcesmake possible? The answeris - No. s. The existing structure --consisting of the Departmentof Health, Education, and Welfare, andState and local health agencies --cannot bring to reality theimproved health servicesthat are both feasible

and expected. Available evidence indicatesthat the rapid rise in health expenditures has not beenaccompanied by an efficient useof public levels of government i or private resources;that health services at all are fragmentedand uncoordinated; thatconflicting standards, varying

1 matching ratios, and competing programslimit the ability o! financial grant-in-aid assistance; thathealth agencies are currentlylocked in a costly competition withwelfare agencies and sometimeswith each other; and that the scarcity andinefficient use of manpower handicaphealth programs at alllevels. Fragmented Organization Diffusion throughout the Federalgovernment -- At the Federallevel the responsibilities forimproving the health of the people aredistributed . among severaldepartments and agencies.The resulting fragmentation 18 of effort wastes scarce resourCes anddoes not provide clear leadership for State and local agencies.

The Department of Health, Education, and Welfareis the primary focal point of the Federal Government'shealth effort, and currently administers healthprograms involving the expenditure of

some $2.6 billion. A score of other Federal agencies,however, have important health responsibilities,accounting for an additional $2.5 billion.These include the following:

FY 1967 Expenditures Medical and Health Agency in million dollars Related Programs Dept. of Defense 1458 Hospital and medical care of military personnel and their dependents, retired personnel and their families andoverseas civilian personnel; military health research, training and facilities construction. Veterans Administration1386 Hospital and medicalcare for veterans.

Dept. of Interior 163 Water Pollution Control Administration activities,care of Aleut Indians, grant to territories and American Samoa. Dept. of State 143 AID and Peace Corps health assistance to underdeveloped countries, medical care of Foreign Service personnel and their dependents, inter- national organizations, and military assistance.

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Dept. of Agriculture 128 Plant and animal research and disease control, meat and poultry inspection, loans and grants for rural community water and waste disposal systems.

Atomic Energy 102 Research on the effects of Commission radiation and protection from the use of nuclear materials.

Dept. of Housing and 87 Loans and grants to communities Urban Development for sewer, water and health related facilities.

National Aeronautics and 76 Research on health factors and Space Administration human capabilities in advanced aerospace systems.

Office of Economic 75 Development of neighborhood Opportunity health centers, Head Start, Community Action programs.

National Science 36 Support of basic research in Foundation health-related fields.

Civil Service 32 Government contribution for Commis sion health benefits for retired employees.

Dept. of Labor 20 Hospital and medical care for Federal employees injured in line of duty, occupational health.

Dept. of Commerce 10 Small Business Administration loans for nursing homes and other health related facilities.

Dept. of Justice 8 Medical care of Federal prisoners.

Canal Zone 7. 8 Medical and hospital care for Government civilian and military personnel, sanitation and quarantine. 20

Federal Aviation I. 7 Research on health aspects Agency of aviation. United States Information0. 4 Medical care of Foreign Agency Service Officers abroad.

The departments of Housing and Urban Development, Interior, and Agriculture are all involved in environmental health responsibilities, as is HEW. The development of health manpower is a concern both of HEW and of the Department of Labor. The Office of Economic Opportunity administers a sizable program of health services for thepoor, a fully appropriate program area for HEW also. No truly effective means of coordinating these healthactivities now exists within the Federal establishment. Diffusion within HEW-- A similar dispersion of responsibility exists within the Department of Health, Education,and Welfare. The principal agency within HEW charged with protectingand improving the health of the .American people is the Public HealthService.But five other HEW constituents-- the Welfare Administration, Social

Security Administration, Vocational Rehabilitation Administration,Food and Drug Administration, and Office of Education--administer important health programs. The health activities of the WelfareAdministration are carried out in two separate units-- the Childrents Bureau and the Bureau of Family Services. 21

Each of these agencieshas its own legislativeauthority, and employs its own programstandards, criteria, fiscalformulae and administrative mechanismsin dealing with State andlocal agencies. They have developed separatepatterns of relationships,often with the same Stateand local officials.They compete for the sameclientele -- e.g., mothersand children, or thehandicapped, while otherpopulation groups areneglected because the agencies areoriented to specific diseases, or to financial status, age,or occupation.All of the agencies compete vigorouslyfor an insufficient numberof trained doctors,dentists, nurses, andothers. Some attempts have beenmade recently to coordinatevarious HEW health activities.The Surgeon General,for example, is chargedwith advising the Social SecurityAdministration on the health aspectsof Medicare and the WelfareAdministration on the Title XIX programof medical care for the medicallyindigent.With regard to the latterMedicaid - program, evidencesuggests this effort tocoordinate health andwelfare aspects is not successfulbecause at the State leveleach agency strives to gain responsibility and controlwithout changing its traditionalpattern of administration. There is reluctance 'onthe part of welfare a:genciesto get away from theirtraditional "vendor paymentgestalt." Similarly, the Public Health Service and theFood and Drug Administrationhave not developed effective approachesthat would interrelate theiroverlapping , 22 responsibilities for consumer health protection, particularly with respect to the control of food, pesticides, and biologicals. The attempts at coordination have been piecemeal and fragmentary. For the most part, the HEW structure is so rigid as to make it difficult to develop a unified, comprehengive, national approach to meeting the a. health needs of all the people of the United States. Agents for coordination -- The President has indicated that he looks to the Surgeon General of the Public Health Service for the establishment of national health goals and for providing leadership in the health field. The Assistant Secretary for Health and Scientific Affairs, who serves in a staff capacity to the Secretary of Health, Education, and Welfare, has a related responsibility.His assignment is to coordinate the health 1, activities of various HEW agencies, and to relate these activities with i the health functions of other Federal agencies. Yet, the heads of HEW agencies-- i.e., the commissioners of Vocational Rehabilitation, Social Security, Welfare, Education, and Food and Drug-- have a stature and direct responsibility that gives them strength and independence along with their own separate paths to Congressional committees and sources of public support. For this and other reasons, neither the Surgeon General nor the Assistant Secretary 1 separately or jointly are able to fulfill the President's expectation.1

10ne mitigating (and suggestive) factor is the circumstancethat two HEW agencies--the Food and Drug Administration and the St. Elizabeths Hospital i --are now headed by Public Health Service Officers on detail.

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Diffusion at the State level --The compartmentalizedand agmented Federal structureis paralleled at theState level. A artial listing of Stateagencies which have healthresponsibilities

ouId include the following:department of health,welfare, agriculture, ducation, and vocationalrehabilitation; mental healthand separate ental retardationauthorities; hospital constructionauthorities; special oards and commissions,such as those concernedwith industrial ccidents, alcoholism,narcotics and drugs; riverand water authorities; ublic works agencies; andhousing and planningorganizations. The health functionsof State governments aredistributed ainong

any agenciesand related in varying waysState by State.In a few States hese activities arecoordinated under an"umbrella-like" State agency. However, in most States,all or at least someof the health functions are conductedindependently of each otherand are unrelated. The success of States where healthfunctions are integrated isdependent, not sirn,ply upon theestablishment of a strongorganizational arrangement,but also upon anaccompanying and carefullyietermined philosophy ofcoordination and utilization of services,facilities, and manpower.In those few States like California, where thisphilosophy, was implementedby an umbrella- like agency, the results appearparticularly significant. Diffusion at the local. level --The tangled web of programsthat exists at both Federal andState levels perpetuatesand augments lack of .)

integrationamong health agenciesat the local level, whereservices reach the people.At the local level,there are threetypes of fragmentation:(a) dispersal ofprogram responsibilityamong various governmental agencieswithin a singlejurisdiction, (b) dispersal of programs among jurisdictionswith overlappingauthority-- school districts, air pollutiondistricts, sanitarydistricts and municipalities, and (c) dispersal ofprograms among official,private, and voluntary health agencies.Local governmentalhealth servicesare, by and large, poorly organizedand incomplete;hence, they tendto waste scarce resources and donot meet the citizen'sneed for comprehensive and continuingcare.

The regionalvacuum -- Some urban healthproblems defy solution by existing local and separategovernments. Theseproblems involve a wide range of personal andenvironmental healthservices-- water supply and pollution control, airpollution control, milkdistribution refuse disposal, medical and professionaleducation, hospitaland speciali , medical facilities planning.Since these problemsdo not lendthemselves to attack by separate local governments oflimited jurisdiction,they persist inan organizationalvacuum.

In contrast, considerthese examples of howlocal governments have banded together in successfulregional approaches.Interstate efforts include those of the Ohio River SanitationCommission, DelawareRiver t

Basin Commission,Metropolitan WashingtonCouncil of Governments; intrastate examples maybe seen in the activitiesof the Association of Pollution Bay Area Governments(San Francisco) and theBay Area Air Control District, theNortheastern IllinoisMetropolitan Area Planning Commission, theSoutheastern New YorkHospital PlanningCouncil. Regrettably, most regionalefforts have been restrictedto a single problem and are notmulti-purpose in nature.Thus, they do not have the broad base oftechnical competence andsupport needed to planand coordinate comprehensivehealth services within aregional framework.

Segmented Financial Aid The Department ofHealth, Education, andWelfare now makes financial aid available toState health agenciesfor health through More than 100 separategrant-in-aid programs.These grants provide support for four major categoriesof activity:research, training,construction, and health services.The grants are of two types:formula grants, which , are allotted amongthe States and usuallyrequire matching funds; and project grants, which areawarded to both publicagencies and private support, nonprofit organizations,often without therequirement of matching and often for a limitedperiod. More than 20categorical grant programs

support State and localgovernment efforts inthe field of public health. These include, in addition tothe grant for generalhealth purposes, 26 grants for maternal and child health services, for crippled children's services, for cancer, heart disease, and tuberculosis control, for air pollution control, for mental health, for chronic diseases and health of the aged, and for radiological health. Twenty years ago general health and specific disease control support grants accounted for the vast bulk of Federal financial assistance to the States for health.This has changed drastically.Today, most Federal financial assistance for health purposes supports research, training, the construction of health facilities, and the payment of medical care for low-income people.The ratio of Public Health Service grants for research and training in relation to grants for health services is now 10 to 1.In fact, less support is made available through the general health grant today (FY 19 66 - $10 million) than was made available five years ago (FY 19 61 - $17.9 million). During these two decades the agencies eligible for aid have also changed.In the late 1940's most grant funds were allocated to the State health department.Today, funds are distributed among numerous State health agencies, and large support is provided for research and services by the medical schools.Funds are also channeled directly to local health agencies, bypassing the State agencies completely. 27

li The Costs of Grant Fragmentation Each grant program wasestablished to meet a specific need.Each reflects a concern with and adetermination that a particular healthproblem should receive concentratednational attention.But this multiplicity of grant programs has broughtwith it a diffusion of effort and complexity in administration even whileit created and supported a varietyof services for citizens. The diffusion of effort among manyseparate programs is aggravated by the natural tendency of Stateagencies to employ specializedprofessional personnel to work with the samekinds of professional personnel inFederal agencies. The result is a lackof horizontal communication, whichimpedes coordination and comprehensiyeness.This is accompanied by administrative confusion growing outof the need of accounting separatelyfor funds derived from each separate grant programand the inability to shift personnel flexibly from one programto another. The problem of coordination isalso aggravated by the increasing number of separate agencieswhich need to be interrelated atthe State and community level.At the State level, there aresimultaneous paths of assistance to the health department,the welfare department, the medical school, the mental health agency,and the vocational rehabilitation agency. At the local level,there are separate and unrelated 28 community health centers, mental health centers, mental retardation centers, maternal and child health centers, along with community hospitals and regional centers for heart disease, cancer, and stroke. Most individuals and families make multiple use of such health services.In addition to requiring continuity of care -- prevention, diagnosis, treatment, and rehabilitation -- they must be viewed in terms of their entire environment -- social, economic, physical, and

biological.The present proliferation of health agencies and centers affects all classes of the population and makes it costly and difficult, if not impossible, effectively to deliver the needed health services. Varying Federal Administrative Standards These several grant programs are administered in differing ways and with differing standards by the various agencies. For example, the Children's Bureau has set high standards and insisted that the State agencies conform. The Public Health Service, on the other hand, has permitted the States greater latitude in establishing their own standards and has accepted less rigorous criteria in the performance of health functions by the States. Another problem is presented by the Federal requirement that a , single State agency be responsible for administering certain programs. An outstanding example of this is the vocational rehabilitation program. This requirementoften handicaps the extentto which the State government may stimulateits departments toccoperate on health activities, since the"single State agency"must always be incharge of any joint activities. , The matching ratios --that is, the proportionof State to Federal funds -- varies amongthe 100 grant programsof the Department of Health, Education, andWelfare. They are sometimesbased on the attitude of the particularCongressional committeewhich reviews the agency's programs ratherthan on a rationaljudgment of relativeneed. At the least, thesevarying ratios causeconfusion and administrative complexities for Stateagencies. More important,these varying ratios tend to distort theallocation of State resources.For example, States sometimes redirect theirefforts in order to takeadvantage of the more favorable matchingrequirements of a particular programwithout regard to need or to thereturns in relation tothe investment of resources. Finally, categoricalfinancing tends to discourage o-rprevent planning for theinterrelation of attack uponall health problemsin a State. Specialized programstend to operate apartrather than in concert with other health programs.This is oftentimes goodduring the experimental stages, but in later stagesthey should be brought back intothe more comprehensivehealth program. 30 The field of mental health exemplifiesthese administrative problems.It needed a separate identificationand special emphasis to attract the financial support and talentrequired to get underway. In the process of growth and development,however, it has substantially remained outside the mainstream of otherhealth activities despite general professional agreement that thementally ill need morecom- prehensive health care.Mental retardation has also developed inthis fashion outside of the health framework. New Patterns and Relationships

New channels (channels other than theFederal-State financial grant-in-aid) are emerging through which Federalsupport for health activities flows.These include:(a) direct Federal-metropolitanarea relationships, (b) Federal-medical school-hospitalrelationships, and

(c) Federal-regional andFederal-community relationships. Thesenew channels have developed because of theinadequacy of the existing Federal-State-local structure toovercome the obstacles cited in Chapter 1 and to provide the broadenedscope of health services that are now necessary and expected. Direct Federal-metropolitanarea relationships -- Today's greatest health challengecomes from the metropolitan centers.The u'rgent demand for assistance from the cities foraid in meeting the health problems of largelow-incomept-p'ulations has given rise to an local increased varietyof relationshipsbetween Federal and governments. Urbancommunities, engulfedby environmental efforts were problems, haveincreasingly heldthat Federal-State combat air not meetingtheir needs. RecentFederal legislation to additional channels pollution and tocontrol solid wasteshas opened local political of assistancefrom Federalagencies directly to subdivisions in urban areas. only out The increasingFederal-local relationshipsgrow not of the failure 1 of the more apparentneeds of theurban centers but out with the of State governmentsin many instancesto cope effectively have been reluctant evolving needs ofthe large cities.State legislatures overlapping two or moreStates. to deal withmetropolitan problems problems Reapportionment mayattrt.,ct a greaterinterest in the health problems demand of metropolitanareas-by Statelegislatures, but the other prompt efforts todevelop and to supportregional mechanisms or metropolitan cooperative venturesby which the localgovernments in regions can copewith urgent problems. Federal-medical schoolrelationships -- Thesearch for better also led to thedevelop- meansof delivering personalhealth services has programs ment of newchannels for Federalsupport.The regional medical schools for heart disease, cancer,and stroke suggestthat the medical 32 may become a channel through which Federal support is channeled to their affiliated hospitals and used to improve the private practice of medicine. Through this channel, the Federal Government may strive to make the new knowledge and new techniques emanating from the medical schools more promptly available to hospitals and private practitioners in local communities. This approach has great potential for upgrading the quality of medical care provided in the local community.In its present stage of development, however, it has several deficiencies:it is limited in scope to the three categorical diseases; it tends to be oriented toward education rather than service; it is not fully coordinated with related community programs of State and local agencies; and most importantly in perhaps half of the States for which State plans have been submitted, the State health departMents have played little or no part. Federal-regional and Federal-community relationships-- Still other channels of assistance are developing in response to problems that are at the extreme ends of the spectrum of Federal-State-local relationships.At the one end, Federal-regional approaches are developing to attack problems that affect a group of States in common, such as the Appalachia development program and the river basin pollution control programs. 33

At the other endof the spectrum, theurgent need todirectly urban attack the pocketsof decay and blight inthe slum areas of our centers has givenrise to a directFederal-neighborhood relationship. Between these endsof the spectrum,relationships are evolvingthat enable the FederalGovernment to work withmulti-county and multi- 'municipal groups such asthe Area Planaing andDevelopment Agencies with in Georgia.Additionally, there aredirect Federal relations single jurisdictions --cities, counties, andmunicipal authorities. Thus, the Departmentof Housing and UrbanDevelopment has for aimed at a long timeadministeredcommunity-oriented programs improving the physicalenvironment within whichpeople live in our core cities,particularly throughpublic housing and urbanrenewal. Although its projects areaimed at neighborhoodimprovement, they must be part of anoverall, comprehensiveworkable program for the entire city. 0E0 is the first Federal agencyto adapt a healthservices program experi- to thisneighborhood-oriented approachthrough an imaginative mental programestablishing neighborhoodhealth centers andthrough other community-orientedprojects such as "HeadStart. " These 0E0 projects are designed to meetthe needs of just one segmentof the population -- the poor. 34 One may well ask whythese two Federal agencieshave been able to develop such programs,while HEW has apparentlybeen unable to do so? , Although both of thesechannels, Federal-regionaland Federal- neighborhood, are alreadywell established patternsof contact, they

pose difficultproblems in the maintenanceof effective Federal-State relations.If the State re,,3ponsibility tomeet these same regional

1 and neighborhood challengesis not considered andprovided for in the evolution of these new channels,the effectiveness of Stateefforts to meet regional and localneeds may be materiallyweakened or even destroyed. Weak Links in the Health Structure In only a few States arethe governmental healthagencies now so organized as to providecapable leadership.In each.of these States a single strong State health agencyis a vital force. Unfortunately, in most Statesthe responsibilityfor-administering needed health activities isdispersed among a numberof independent health agencies, as well as amongwelfare and education agencies. The dispersal exceeds thatwhich might be attributed tothe influence of divisive categorical grantsand the activities of separateFederal

agencie s. 35 The weakness of these State health agencies is also attributable to the fact that they are generally inadequately staffed. Low professional esteem and the failure of the State health agencies to become involved in the exciting social and technical developments on the frontier of government's services to people have resulted in a failure to attract an adequate supply of imaginative and talentedpeople and a failure to seek out and find solutions for the health problems of the people. The problem is how to strengthen those State health agencies which are lacking in leadership and in staff, and which are under-financed. The problem is also how to overcome the fragmentation that destroys unity of effort. The Insulation of Health Agencies Much of the weakness that now obtains in most State health agencies, in addition to the diffusive and complex factors already listed, can be attributed to insulation (a) from the public needs and desires for health services and (b) from the political mainstream of State government. This insulation is due to:(1) an excessively narrow view of what public health is all about, (2) a misguided concept as to what the responsibility of public health officials is for the health care of all citizens in the community, (3) subordination of their views to agree with the opinions of organized private practitioners, and (4) the inability of public health officials to maintain the delicate balanc'e between getting political support 36 and protecting the health services from embroilment in partisan political struggle. These factors have made it difficult for State health officials to

feel the public pulse and to respond aggressively to public needs.This separation from public needs and desires has been reinforced in a number of States by boards of health-- usually composed of private practitioners -- interposed between the Governor and his State health officer and sometimes exercising administrative authority. A consequence of this insulation, therefore, has been the assignment of health programs of great public concern (e.g., Medicaid, mental health, mental retardation, pollution control) to more aggressive State agencies. This insulation is further compounded by the lack of effective mechanisms for comprehensive health planning at State and community -tevels. As a result, there are great gaps in services and existing resources are ineffectively utilized.The resources of medical schools, hospitals, voluntary agencies, and the private sectorare generally not linked into a collaborative community effort.As already noted, the categorical nature of Federal support tends to fostera segmented approach. Many of the deficiencies cited at the State level-- fragmentation, lack of comprehensive planning, lack of aggressive leadership-- apply to local health agencies as well.Moreover, the metropolitan proliferation of local governments further aggravates the organizationand delivery of health services. 37

The Shortageof Qualified Manpower in this chapter areovercome,the If problemspreviously cited people will befrustrated prospect ofbetter healthfor the American health manpower.Professionally trained by the shortageof well-trained of the American and skilled manpoweris scarcein many segments and thesubstantial costsof society.But the longperiod of training physicians anespecially grave medical educationmake thescarcity of of health manpowercuts and difficult tosolve problem.The problem agencies, and programs.Shortages acrossall levelsof government, positions unfilled orfilled byinadequately arechronic, with many trained menand women. inability of publichealth An even morecritical problemis the doctors, dentists,nurses, to attractfrom the limitedsupply of trained of men and womenof superiorability. and engineers anadequate number graduates who enterthis field today arecoming A largeproportion of the classes of the from the middle orlower segmentsof the graduating CommissionedCorps medical, nursing,and engineeringschools. The with theadvantage ofbeing system ofthe PublicHealth Service, even difficult timerecruiting and able to offermilitarydeferment, has a trained manpower. retaining anadequate supplyof professionally 38 In recent years, the salaries of Federal health officials have been increased and made more competitive with the private sector. Most State and local health agencies have not taken similar action. Because of this and the lack of challenging opportunities, these agencies are unable to attract a sufficient number of qualified, vigorous,imaginative people. The Public Health Service, some State governments, some local agencies, and universities support a variety of programs to attract and train new people and to sharpen the skills of people now working in the field.At present, however, the total effort -- both government and university -- is insufficient to meet the growing demands for qualified people.Increased training opportunities and additional Federal funding will not relieve the problem unless substantial changes are made in personnel administration and utilizktion at all levels. For example, health agencies, hospitals, and private practitioners have been reluctant to utilize fully paramedical or auxiliary personnel. From Here Forward Our Nation is committed to the ideal of high-quality health services for every individual.In major part the achievement of this goal will depend upon the efforts of private practitioners of medicine, but, in addition, the attainment of that goal requires that the-Federal Government, S.

participateeffectively. all of the States,and allcommunities shall various levelsof After assessingpublic opinionand views of , set our national government, thePresident and theCongress 'should local healthagencies that canand goals.But it is theState and/or health servicesthat should renderthe personaland environmental To play their properrole, will bring thesenational goals toreality. be strong andvigorous. both State andlocal healthagencies must t level -- Federal,State, and t There must bestrong partnersat each assessing is to beeffective. local -- ifthe relationshipthat we are those actionsthat are Hence, subsequentchapters recommend Since the proving required tostrengthen eachof these partners. delivery of health ground and theprimary sitefor the ultimate chapter recommends services is thelocal community,the following health agenciesand improve what needs bedone tostrengthen local local healthservices. 41

CHAPTER III - STRENGTHENING THE LOCAL HEALTHPARTNER

The local community provides a mirror in which theeffectiveness of the relationship between the Department of Health,Education, and Welfare and the State health agencies can be viewed.That mirror reveals a literal maze of poorly related health agencies --public and private -- and a range of health services which in most communities fall short of our expectation and capability. Private physicians engaged in solo practice or group practice and the community hospitals provide most of the personalhealth care available. Voluntary organizations focus attention, raise money,and provide specialized services, according to disease categories(e.g., multiple sclerosis, heart disease, and cancer) to serve particular groups (e.g., crippled children, the blind, and the aged).Labor unions and industrial firms provide still additional health services for limited

segments of the population.At the same time, official local health programs are often carried out throughschool health agencies and welfare departments.Federally supported mental health, neighborhood health, mental retardation, and vocational rehabilitation centers are found in many communities, frequently operating 'apart from other local health services.In addition, Federal health installations of the Veterans Administration, Public Health Service, and the Department of Defense are 42 scattered throughout the Nation in manycommunities. The Federal facilities oft en operate independentlyof other community health resources. Sometimes hidden in this literal mazeof agencies is the local health department -- the basiclink in the system of services that includes the Department of Health,Education, and Welfare and extends through the State health agencies.Its task is to assess the community's health nr,eds, identify those that are unmet,develop or stimulate the development of health services to meetthose needs, and finally provide a wide variety of personal andenvironmental health services for the pcople of the community. Together, all of these several agenciesand institutions, official and voluntary, and individualpractitioners do not now make available the range and quality of both personaland environmental health services that can now be provided. Picturing Potential Health Services Advances in science, our increasingaffluence, and our national commitment to improve health now makeincreasingly possible in each community:

I.High quality health services readily available and accessible to all -- to promote positivegood health, prevent disease, diagnoseand treat illness promptly, andrehabilitate the disabled. 43

2.The opportunity for eachindividual to learn about andthe acceptance of responsibility onhis part to use wisely the services necessary for hishealth and the health of hisfamily.

3.A healthful environmentin the home, in the neighborhood, at work, and at play.

4.The mobilization of allcommunity resources -- wealth, knowledge, technology, and manpower --in a concerted effort to

-he-alth__leye.L__o_f_all the -people.

In this chapter we recommendthe steps that need to betaken if the HEW-State health agencyrelationship is to be effective inseeing to it that the healthgoals now attainable areachieved. Local governmental units, to copewith today's health problems, must be consolidated oreffectively interrelated in a jointeffort, that establishes a governmental service a,reacoterminous with the health problem area. The effectiveneis of localgovernments in coping with health problems is drastically limited byth ,-imple fact that each serves too small a geographic areain many instances. In metropolitan areas legalauthority to cope with healthproblems is usually fragmented among manylocal jurisdictions.The individual jurisdictions are neither coterminouswith the problem area nor withthe population to be served.In most of the country, thisnecessitates health 44 administration on a county rather than on a city level.But in the larger metropolitan areas, a single county usually will not encompass

enough of the problem area to be effective.In those areas means are i r needed for coordinating health services on a multi-county or regional basis if health problems are to be dealt with effectively.Similarly, ".,) in rural areas regional organizations are needed if resources sufficient to support the provision of comprehensive health services are to be assembled. Environmental health hazards particularly transcend the bounds of existing political jurisdictions.Air pollutants follow whatever path the wind takes them and do not honor jurisdictional borders. As a result, a multiplicity of agencies -- sanitary districts, water commissions, air pollution control departments, refuse disposal authorities -- have been established to deal with theseproblems.Frequently, the population base or function is so limited that they do not have adequate budget, personnel, or laboratory facilities to do an effective job. Moreover, effective management of the environment requires a comprehensive systems approach which interrelates attacks upon air, water, and land pollution throughout the entire problem shed area. Local government health structures must be recast to permit the provision of essential health services over the problem areas. HEW 45 should encourage the States to incorporate intotheir health plans now being developed under the Partnership inHealth legislation the ways and means for encouraging local health units todevelop regional relationships and to serve larger geographical areas.1 Federal and State assistance should be made available to encouragethe development of local health agencies authorized to draw resourcesfrom and to serve larger geographical areas.Onty if such regional organization can be evolved, will effective comprehensive health planningbecome a reality. Health Planning at the Local Level A health planning council should be established to assesslocal needs, to hear citizens' views, and to formulate p)ansin all local areas sufficiently large to cope effectively with health problems. Planning for better health is that part of our.grass rootsdemocratic process by which citizens state whatthey want and are willing to pay for. To be effective, however, the planning of eachcommunity must be related to the health planning of other communities thatmake up the relevant area and to the planning for other functions or goals.Hence, health planning may require mechanismsthat effectively assemble the needs and views

I-See Sec. 314 (a) Grants to States for Comprehensive State Health Planning, and Sec. 314 (b) Project Grants for Areawide HealthPlanning, PL 89-749. 46

of a large cityor a whole county or a group of counties.Increasingly, the evolution of our democraticprocesses incorporates mechanisms to permit citizens thus toexpress themselves, andassumes that planning is both feasible and desirable.

In metropolitanareas the health plans for each community within the metropolis should bea segment of the metropolitanor regional health plan.And the health plans for thecommunities and for the metropolis, to be effective, shouldbe integrated with comprehensive

planning for other iunctions-- transportation, schools, landuse, recreation, economic development,and the like. Unless health planning is fullycoordinated with other metropolitan planning activities, there isapt to be created just anotherlocal governmental body, adding to theexisting- confusion.To ensure that health planning is consistent withcomprehensive metropolitanplanning, the areawide health planningcouncil could in fact operateunder the aegis of the recognizedmetropolitan planningagency or council of elected officials. Cooperation andplanning coordination mustnot merely be 47 encouraged, it shouldbe required.Federal legislationis moving in this direction.1 The product ofcomprehensive healthplanning is more than a finite master plan.Planning is a dynamic processto develop goals and strategies, to setpriorities, to allocateand marshall resources Plans will towards objectives,and to evaluateacc.)mplishments. public policy require re-evaluationand revision in thelight of evolving decisions, knowledge,and accomplishment.

"DemonstrationCities and MetropolitanDEvelopment L. 89-754, aid in metropolitan Act of 1966,"provides forcoordination of Federal areas asfollows: Sec. 204. (a) Allapplications made afterJune 30, 1967, for Federal loans or grantsto assist incarrying out open-space land projects orfor planning orconstruction of hospitals, airports, libraries,water supply anddistribution facilities, seweragefacilities and waste treatmentworks, highways, transportation facilities,and water developmentand land conservation projectswithin any metropolitan areashall be submitted forreview -- (1) to any areawideagency whichis designed toperform metropolitan or regionalplanning for the areawithin which the assistance is tobe used, and whichis, to the greatest practicable extent,composed of orresponsible to the elected officials of aunit of areawidegove,rnment or of the units of generallocal governmentwithin whose jurisdiction such agencyis authorized to engagein such planning, and (2) if made by a specialpurpose unitof local government, to the unit or unitsof general local governmentwith authority to operate in theareawithin which theproject is to be located. In addition, the recentsolid wastes actrequires conformitywith the overall plan as a conditionfor grants under that program. 48

Similar to the requirements inthe Partnership in Health Act for the State health planningbody, the local community health planning

council should includeconsumers of health services as wellas .. representatives of local governmentalagencies, nongovernmental #

_ organizations, and private practitioners.For interstate, intrastate, 1 and metropolitanarea planning bodies, there should also berepre- sentation from the Stategovernments involved. Some provision has been made inthe Partnership in Health Act for Federal and Statesupport of local health planningcouncils.1 The amounts authorized willnot likely be adequate (FY 1967-.$5 million; FY 1968- $7.5 million) to support the planningwe envisage. We urge s) that the Department seekadditional support. ,

'A. Sec. 314 (b) Project Grants forAreawide Health Planningstates, "The Surgeon General isauthorize.d, during the periodbeginning July 1, 1966, and ending June30, 1968, to make, withthe approval of the Stateagency administering or supervising theadministration of the State plan approvedunder subsection (a), projectgrants to any other public or nonprofit privateagency or organization tocover not to exceed 75per centum of the costs of projects fordeveloping (and from time to timerevising) comprehensive regional,metropolitan area, or other local area plans forcoorqination of existing andplanned health services, includingthe facilities andpersons,required forpro- vision of such services;except that in the case of projectgrants made in any State prior to July1, 1968, approval of suchState agency shall be required only if suchState has sucha State plan in effect at the time of such grants. For thepruposes of carrying out this subsection, there are hereby authorizedto be appropriated $5,000,000 forthe fiscal year ending June 30, 1967, and $7,500,000 for the fiscalyear ending .. June 30, 1968. "

''t 49

A communityhealth plan should provide afull range of personal health services forall people and suchenvironmental health services as plan should are susceptibleto solution on acommunity-wide basis; this the include:a systemfor coordinating andintegrating health services, optimum geographicdistribution of facilities,the establishment of neighborhood serviceand comprehensivehealth care centers, the con- the duct of healtheducation programs andexperimental projects, and _ application of improvedmethods for controllingmedical costs. The purpose ofhealth planning is tomale comprehensiv-e-health services easilyaccessible to all the peoplein the communityregardless of income, race,location, or otherforces. It should be stressedthat fragmented care isnot only the fateof the poor. The well-to-doalso go from physicianto physician with no one to integrate orinterpret the differentprocedures he is told to accept, with little or no socialservice to help himin necessary jobadjustments, in after care at home orin an extended carefacility, and in the hostof problems that accompanyillness. Achievement of the envisionedgoal requires thecoordination of all health services, aneffective integrating force,the geographical distribution of facilities,communicating healthinformation, and the control of rising costs. Services to be coordinated --Mental,health, mentalretardation,

the treatment ofalcoholism, school healthrehabilitativeprovrams; housing, and pollutioncontrol -- which generally operate outside the 50 classic public health framework -- need to be brought back into the health orbit and made part of a unified effort.And, such environmental health activities as foo(! and drug protection, insect and ro(!ent control, radiation protection, accident prevention, poison control, and community

sanitation nee ,:z. to be incorporated in the community health planoWithout all of these, personal health services may be ineffective. Accomplishment of the central purpose further requires that all resources in the community -- private physicians, clinics, neighborhood health centers, large medical centers, hospitals, diagnostic services, nursing homes, welfare, housing, and public works agencies -- form a part of a community health system.The system should make available to each local community the assistance of regional medical facilities, capable of providing for such advanced techniques as open heart surgery, kidney dialysis, and cobalt bomb therapy. The newly passed Demonstration Cities legislation offers an outstanding opportunity for HEW, in concer with HUD, to develop and jointly fund projects designed to improve health care services and information programs in the demonstration cities.New systems of administering and of coordinating hospitals, clinics, nursing homes, nursing services, and private practitioners should be investigat ed. 5 1

be 'Innovations shouldbe stimulated; we urgethat Federal support made available to encourageresearch and experimentationin the design of such healthsystems. The integratingforce -- The NationalCommission on Community health services Health Services hasstressed the nedfor comprehensive should perform the for all people :,,ndsucigests that apersonal physician integrating role for every:.ndividual.To achieve the goalof comprehen- all citizens, webelieve s-ive-he-alth-se_r_vic_es_amailableand accessible to in. the future that the personalphysician willincreasingly need assistance health in bringing theneeded facilities and resourcesto bear on the of problems of his p?_tients.This in no waydeprecates the services the physician in solopractice.This view is bar;ed onrecog:dtion of the fact that modernmedical practiceincreasingly iavolvesthe complemen1:ary servicesof allied specialistsusing expf-;nsive and scarcee-iuipment. It is still possiblefor a particularphysician or nurs:.! to serve health system involving as familyliaison and healthcoordinator within a neighborhood health centers,hospitals, clinics, andextended care continue to rely facilities,.Of course, the bulkof the population will and entry point upon theirpersonal physician asthe integrating force 52

into the community health care system. For anincreasing number

..- of individuals, entry into the system may be through aneighborhood health center, voluntary, union, or industrial health service orother instrument that integrates the specialized health personnel andthe facilities required. , The scope of assistance that need be available and accessibleto the people of each :-,omniunity -- if their health is to becared for to greatest advantagt: -- must include those services that canaid in meeting the related social and economic problems of the family.The victim of a heart attack may rieedassistance in finding alternative .....mployment, and counseling for his wife as well as medical care. Geographic distribution of facilities -- Comprehensive health care for the individual not onlyrequires that related rehabilitative, counseling, placement, and other services be available, but that their accessibility not be limited because of their provision by separate. and geographically dispersed agencies operatingwithout knowledge of the other's involvement. Moreover, the best health care for the individual will requireconsideration of the cntire setting, of which the individual is a part (e.g., family, job, home, recreation).For these reasons we believe that increasingly health services should be made available to individuals through neighborhood 53

or similarcenters that providecoordination with other related social services --welfare, employment, andlegal aid.These centers would be the entrypoints to the communityhealth system and theforces -

- integrating all servicesneeded by the individual. Two types, of such centers areenVisioned, (a) comprehensive health care centers and(b) neighborhood service centerscontaining t morerudimentary services. Neighborhood Service Centers, wehope will in theforeseeable future, be located withinwalking distance of mostcitizens of low income areas in cities.These centers shouldprovide services rangingfrom information; guidance, andreferral to such basic services ashealth - screening examinations, treatmentfor uncomplicated illnessand minor injuries, family planning,Public assistance, employment service,legal advice, and opportunitiesfor learning .basic skills(e.g., how to read and writeapply for ajob, homemaking). Theseservices should be provided free -- or at appropriatecharges -- to all income groups. Such Centers could belocated in a variety ofplaces, including public housing projects, grouppractice units servinglow-income families, labor health centers,settlement houses, neighborhoodstores, and shopping centers. They would bepleasant places to come to, openweekends and some evenings, withcomfortable and convenientwaiting, space, a .4 rationally maintained appointmentsystem, and overridingcourtesy. 54 Neighborhood service centers necA to be closely affiliated with other cen';ers which provide continuing medical care -- particularly community hospitals or comprehensive health care centers. Comprehensiire Health Care Centers would provide tir broader and more :3ophisticated services -- inclu:ang preventive, diagnostic, curatiVe, restorative, rehabilitative, long-term institutional, nursing home care, and social services -- all services needed for complete care0 Ideally, these centers would also provide home health services by sending a physician, social worker, therapist, rrsc, home health aide to the homes of individuals who are too ill to receive care on an ambulatory basis but who do not re:iuire hospital or institutional care. ThroI_:gh their contacts in the center and in such home visits, these representatives of health and other social services would serve as focal points for channeling community health information and for providing access to related community services.These centers too would provide services free -- or at ap,ropriate charges -- to all income grollps.For an increasing aumber in the population we contemplate that services will be financed under provisions of Medicaid (Title XIX).

In some areas most of these services are availablbut in such a disorganized fashion that those who need them have difficulty in usinc:; them; in other areas there are gaps in service which need to be filled. 55

A high degree of consumerinvolvement would be buii.t into the system with neighborhoodaides to encourage the poor to seekhealth services as well as to enlist volunteersto man a play room or sitter service, a simple snack bar.Staffing would take account of language and cultural barriers whichinterfere with communicationsbetween consusner and providerof service. Community health information -- HEWshould initiate a major

_program to educatethe public about health; supportshould be made available to finance educationaldemonstrations aimed at communicating health information in selected metropolitan areasand rural areas of special need. If people of this country knew moreabout health -- about sanitation, about the causes of disease, aboutpreventive and early treatment techniques -- andthe availability of care, we :,:reconvinced that great progre6s could be made. The crucial needfor more effective education about healthis obvious.Fortunately, this need is more thanmatched by available opportunitie s. Educational science and technologyhave made a dramatic advance in recent years.This advance makes propitiousimaginative action to apply this new technology toincrease the public understanding ofsanitation, the causes of ill health, and waysand means of attaining better health. 56

The Public Health Service ha-scarried out a number of activities to facilitate State and local publiceducation programs, including field demonstrations, consultation,loan of health educators, trainingcourses and traineeships, thedevelopment of informationalliterature, visual aids, and the like.These efforts, howeve,r,have been allotted limited resources.

New opportunities for improvingpublic understandingare provided by recent legislation.The Partnership in Healthlegislation can stimulate, in connection with thenew emphasis on health planning,a broadened interest in and knowledge ofhealth programs. Similarly,the cooperative arrangments among the medicalcenters, research institutions,hospitals, health professionals, andState and voluntary healthagencies that are being induced by the regional medicalprograms for heart disease,cancer, and

Etroke can simultaneouslycontribute to the education ofthe lay publicas well as to the education ofhealth professionals.

Under the le,dership of the Officeof Education, publicschools throughout the nationcan contribute greatly to improvingthe health of all people.,Current schoolprograms should be improved to provide:

1. 1:tPttcr hPaith inst-ruction forstudents from kindergartenthrough twelfth grade;

2.Adult educationprograms to help individuals protecttheir own health and better understandand -atilize health servicesin the community; I

3.More remedial services tochildren, such as schoollunches , and breakfasts wherever needed;

4.Health services to all schoolchildren as part of the total community health provram; , for 50 Increased utilization ofschool facilities as centers community health programs toreach both youth and adults. Controlling costs -- If medical careis to be accessible to allthis colIntry's citizens, the increaseof costs as well as thegeographical locations and quality ofservice must be controlled.Spiraliwz medical and hospital costs canand do make preventive,diagnostic, treatment, and rehabilitativeserl,ices effectivelyinaccessible to gre:-;,t numbersof our population.This is especially truefor the vast majority of our population who are neitherwealthy nor very poor. The National Commission onCommunity Health Serviceshas recommended several actionsregarding hospital coStswhich warrant attention and investigation:development of extended carefacilities, home care programs,and othex appropriatealternative (to hospital)services; cost reduction studies,such as joint purchasingand management of laundries, laboratories, drugformularies, regional planningfor hospital facilities; reimbursement offull costs by insurance plansand government agencies. We endorse theserecommendations and suggest,in addition,

that voluntary 1::;roupmedical practice arrangementsoffer opportunities to provide a range of specializedservices with lower overheadcosts.

I 58 Stronger Local Health

Local health departments must be strengthened-- in attitude and in competence-- to provide' staff assistance, leadership, and stimulation for each Health Planning Council.

The interrelation of all-local health servicesin. a comprehensive health system-- in conception and in operation -- requires effective staff services which should be provided by therelevant local health agency. To assume this responsibility it is essential that in most instancesthe local health department must broaden its viewand enlarge its scope to match that of the health plan and of the representationincluded in the planning council.

In_assuming the responsibilityas staff agent of the planning cotmcil, the local health department shoullcollaborate with and obtain assistance from all related agencies in thecommunity bearing on healthproblems--

vocational, rehabilitation, mental health, welfare,education, and others. Local health departments have traditionally focusedtheir attention and their energies ona limited range of health services. They have been responsible for the control of conmunicable ,. diseases, for maternal and child health services, for vital statistics, and for 4 environmental sanitation.This latter responsibility has often been shared withlocal water, sewerage, housing,- and public works departments.Bold approaches to air and water pollution - 59

present control and total wastemanagement havebeen lacking, and pollution in our measures havegenerally failed tokeep pace with major cities. A narrowview of economicself-interest by industry - .. of the and local governmenthas contributed tothis deterioration

environment. preventive Local health serviceshave primarilybeen directed to suffering from medicine. Somelimited medical carefor individuals venereal disease andspecial programsfor maternal , tuberculosis and Local and infant careand crippledchildren offer majorexceptions. York and health departments,in a few majorcities (e.g., New indigent; but, San Francisco areable to providehealth care to the limited authority by and large, mostlocal healthdepartments have had Local to participatein the deliveryof health services toindividuals. boards of health,usually made upprimarily of privatephysicians, provision have ofte ndiscouraged these departmentsfrom undertaking the metropolitan of such services.Such discouragement,and the growth of centers, havelimited drastically theavailability of adequatehealth services, especially inthe core of our greatcities and in remote rural areas. for families Although the provisionof better personalhealth services that local health not now able toobtain them isemphasized, it is essential departments continue theirbasic public health programs.Preventive, 60 epidemiological, and immunizational activities, and the like,have contributed substantially to our improved health, local health departments cannot afford to curtail these functions. The local health department forms the logical agencyin the community to provide leadership and staff assistance for theCommunity Health Planning Council. However, the local health agency mustitself be provided the funds -- from local ,State, and Federal sources -- and qualified personnel it requires.Too frequently salaries have been too low to attract and retain such personnel.Moreover, the narrow and limited policy focus of many local.health agencies seems to frustrate and discourage those dedicated individuals that are attracted. Both of these conditions must be overcome if a vital leadership roleis to be exerted by local health agencies. Subsequently, we offer recommendations which will serve to increase the pool of qualified professional health manpower and will provide sup- plementary funds to pay personnel costs in local health departments.In addition we urge that HEW periodically survey and make public the levels of salaries prevalent in local health departments and emphasize thene'ed for the provision of salaries high enough to attract qualified individuals into, the se departments. 61

State Supplementationof Local Health Effort The State health agencyshould see to it that aneffeetive planning

i processexists for eacb local community,should aid local communities , in developing their plans,should develop minimumstandards for the organizaion and operation of local healthservices, and should require that local public healthservices become operative inall parts of the State. Federal and State, as well aslocal agencies, must support comprehensive community healthplanning.State health agencies should require the establishmentof a planning body in urban centersand a community health plan as acondition for the distributionof State and Federal 0 funds.It is essential, however, thatFederal and State agenciesadhere to the plan themselves onceit has been adopted.Thus, grants for local health services should bemade only in accordance withthe approved plan. At the present time, in anumber of States, local healthdepartments are to be foundonly in some parts of theState, with many countiesand other geographic areas completelywithout organizational arrangements and personnel for thedischarge of the public healthfunction.The Committee believes that health services,like welfare services, shouldbe operative and available in all politicalsubdivisions of the State and thatthe use of Federal and State funds for localhealth purposes be conditioned uponthis State-wide availability. 62 Additionally, in the past, many States have nottaken responsibility for health services in large cities.They have tended to concentrate their services in the rural areas. Some State agencieshave little to offer the large metropolitan areas where local health department personnel may be better qualified to solve their problemsthan are State health workers. It must be emphasized that merely to establish ahealth department in each major political subdivision or appropriategeographic area of the State by no means assures the availabilityof even a minimal 1.-.7el of public health services.The State must assume a strong leadership role in the development of standards for the operation of local healthservices and for insisting upon adherence to the standards as a conditionof State

financial supplementation of local health efforts. .. Where a State is unable or unwilling to assist in provicE.ng health services in urban areas, the urban governments should befree to deal directly with HEW. The State health agency should assume the responsibilityfor the character of the health services available throughout the entire State. Hence, it should play an appropriate role in the developmentof public health services in urban areas.Since the vast majority of the people live in cities, that is where the bulk of the State Iseffort should be directed. 63

The States should assistlocal agencies throughfinancial aid, technical consultation,laboratory services, and planningassistance. And, HEW should persistentlyencourage and aidthe States in measuring up to theseobligations. However, where a State isunable or unwilling to assistfinancially in providing services inurban areas, the urban governmentshould be free to deal directly with HEW,and the State should facilitatethe direct channeling of assistancefrom the Federal to the local level.In the case of large metropolitan areas,if State assistance is minimal,the great bulk of relationships shouldbe on a direct Federal-localbasis. Federal Supplementation of Local Health Effort HEW should seek statutoryauthority, adequate manpower,and funds that would enable it torespond to requests from State orlocal governments, when they areconfronted with emergencies growingout of critical unmet health careneeds. It is a well establishedFederal obligation to aid localcommunities when their populationssuffer from floods, hurricanes,and droughts to the full extent of its resources.SiMilarly, Federal aid is providedwhen lives are threatened by the onsetof epidemics. The need for aid tolocal communities can be almost as acutewhen their populations sufferbecause of a chronic lack of medical care.Such lacks of medical care wererevealed 64 by the catastrophic riots in Atlanta, in the Watts area of Los Angeles, and in San Francisco.In these instances health officials at national, regional, and State levels lacked the authority and funds to move quickly, in conjunction with the provision of other social services, to meet the need for medical care. It is the local health agency that must assure the availability of basic health care to all citizens in all sections of their jurisdiction if the goal of comprehensive health services is to be attained.However, the lack of such care is now evident in the core areas of some of our largest cities.There are increasing evidences that the citizens in many of these areas do not have access to needed health services and that the local health agencies in some such areas are unable to meet their responsibility for assuring the availability of essential health services. For those areas where the assurance of basic health care is beyond the capability of the local health agency, and where the State is unwilling oPunable to fill the gap, direct Federal aid should be provided.This aid should take the form either of the assignment of personnel for limited periods, or the provision of facilities, or both.Upon the request of State and local health agencies, or after consultation with each, we recommend that PHS professional personnel should be made available to assist in providing essential health services.In those neighborhoods where basic health care facilities are grossly inadequate, suchas the 65 Angeles, Bedford-Stuyvesant areaof Brooklyn and theWatts area of Los health Public Health Serviceshould acceptresponsibility for providing facilities should be clinics andfacilities for grouppractice; and these staffed by PublicHealth Servicepersonnel if privatephysicians and nurses cannotbe obtained. agencies In responding torequests from Stateand local health should assist to meet suchcritical needs, theRegional Health Director 1 developing their these agencies infinding solutions toproblems and in continuing basis. own capacity moreeffectively to meet needs on a Legislation should besought authorizingthe Public HealthService, their health Veterans Administration,and Departmentof Defense to make facilities available on areimbursable basis whenthey are hot otherwise fully utilized to meetState and communityneeds; and furtherauthorizing them to contract forthe use of localhealth services fortheir beneficiaries where these areavailable. Demonstrations should beundertaken in a fewcommunities where Federal health installations arelocated tomake manifest the feasibility of such reciprocalutilization of facilities. The reciprocal useof the healthfacilities of Federalagencies and

of local communitiesneeds to be encouraged sothat we may make maximum economic useof all existing, scarcehealth resources -- hospitals, clinics, and personnel.Several Federal agencies, 66 particularly the Public Health Service, Veterans Administration,and Department of Defense have health facilities and professional manpower in many communities throughout the Nation. Most of thesefacilities and their staffs operate in isolation from the health facilities and programs of the communities in whichthey are located.Yet, in most States and many communities the scarcity of physicians, nurses,and facilities dictates that Federal health installations within the area should be considered part of the total health facilifies to the extent that these facilities are not optimally utilized. Where local health facilities are inadequate and there is space in existing Federal hospitals, we recommend that the Federal facilities be made available and provision be made for reimbursement to the relevant appropriation account to meet the costs of care.Particularly,

ways should be developed to enable localcommunities to avail themselves of expensive services and facilities for kidney dialysis, cobalt treatment, poison control, rehabilitation, and mental health which cannot economically be duplicated. We recommend the exploration of laternative ways of establishing incentives to encourage Federal installations to participate in community health programs. On the other hand, this is a two-way street.Federal health programs should make use of community facilities and services for providing health care to beneficiaries.Thus, if a Veterans Administration hospital is 67 occupied with-veterans whocould better be cared forin their own homes or in nursinghomes in their communityand do not require hospitalization, this is notthe optimum u_se offacilities. A substantial start in this directionhas been made in recentlegislation authorizing the Veterans Administrationto purchase somehealth services for veterans1 and permitting Department ofDefense beneficiaries to secure health care from nongovernmentfacilities under certain circumstances.

Summary It is in each of theNation's communities that allFederal-State and local health effortshave their impact. Themaximization of this impact requires moreeffective and more comprehensivehealth planning than now obtains in mostcommunities to ensure thathealth services all.Such planning is a pre- .are availableand readily accessible to requisite to the mobilizationof all community health resources -- private physician, neighborhoodcenters, clinic, hospital,voluntary agency, nursinghome, medical school, health agency,and Federal facilities where needed -- intohealth care systems that willmake possible a total and coordinatedeffort to bring all resources tobear on improvingthe health of people.

1P.L. 89-785, "Veterans Hospitalization and MedicalServices Modernization Amendments of1966.II 68

Community health plans alone are not enough.They will bring better health services to people only when continually implementedby effective local health organizations.To be effective local health organizations must have a broader scope, encompassing the personal and environmental health of the whole community. And to be effective local health departments must accept responsibility for seeing to it that existing gaps in this broad scope of local health services are filled. A full range of personal and environmental health services should be available for all people, rich and poor alike.The fulfillment of this goal requires many implementary steps -- a system for coordinating and integrating health services, the geographic distribution of facilities, the establishment of neighborhood health centers, the conduct of health education programs, securing additional health manpower and holding down medical care costs. Proper utilization of existing health facilities and manpower could help meet many health needs now being neglected and could simplify

the task of planning.All health resources, from Federal health facilities to private physicians in solo practice, should supplement each other in meeting the community health needs. 69

The health services nowavailable to many Americansfalls short of what is clearlyattainable. Much canbe done within each community to ensure thefull utilization ofexisting facilities and resourcesto need -- and overcomeprevailing deficiencies.But there remairi%, the the opportunity --for both Federal andState governmehts toaid.In the chapter thatfollows the steps thatneed to be taken toimprove the capability of State healthagencies to play their partin the Federal- State-local partnership aredetailed. 71 PARTNER CHAPTER IV -STRENGTHENING THESTATE HEALTH

of health If the people ofeach State are toenjoy a full range health agencies services, the healthagencies in. manyStates, even as the deficiencies noted in many communities,must bestrengthened and the reqommendations in Chapter II mustbe corrected.This chapter contains to accomplishthat end. Goals of State Health Services well be to ensure: The minimum goalof a State healthdepartment might for I.The availabilityof comprehensivehealth services the people of everysection and everycommunity within the State. that will contribute 2.An increasinglyhealthful environment to humanwell-being. opportunities 3.A system of manpowerdevelopment, including education, that willproduce an increasing for continuing provide number ofprofessionally trained menand women to health se rvice s. knowledge on the causes 4.The continuingdevelopment of new and cures of illnessand on the meansof delivering health services to all thepeople. to 5.A health educationprogram tohelp all our citizens understand therudiments of personalhealth care and to learn how to useavailable health serviceseffectively. agencies -- public 6.The coordinatedeffort of all health and private --along with medicalschools, hospitals, and privatepractitioners, in providing alevel of health services not previouslyenvisioned. 72 Comprehensive State Health Planning Each State should formulate health objectives and carry out comprehensive planning for health services to meet the needs of all its people.The health objectives should be considered by the Governor and submitted to the Legislature for approval and enunciation as a declaration of State health policy. There has been some good planning in connection with health activities -- for example, hospital construction, mental health, and certain environmental health programs.In general, however, State health planning has been piecemeal and uncoordinated.Several types of resources within the State-- medical and professional schools, hospitals, voluntary agencies, and private institutions-- have not been effectively involved in the essential, continuing State health planning process. The Partnership in Health legislation offers an unprecedented opportunity for developing more comprehensive planning for health services than have been available heretofore.1It will enable the iSec. 314 (a) (1) ofPL 89-749 Grants to States for Comprehensive State Health Planning: "In order to assist the States in comprehensive and continuidg planning for their current and future health needs, the Surgeon General is authorized during the period beginning July 1, 1966, and ending June 30, 1968, to make grants to States which have submitted, and had approved by the Surgeon General, State plans for comprehensive State health planning.For the purposes of carrying out this subsection, there are hereby authorized to be appropriated $2,500,000 for the fiscal year ending June 30, 1967, and $5,000, 000 for the fiscalyear ending June 30, 1968." States through grants to set their own health goals,and help them to coordinate functions now fragmented by the multiplicityof grant programs and to correct deficiencies and imbalances in theservices now being provided. The Committee is hopeful that the States will takeadvantage of this opportunity and use it creatively to appraisehealth needs and resources throughout the State and toformulate comprehensive plans for health services that will:-

I.Set immediate and long-range health goals and establish priorities for meeting those goals.

2.Provide for the needs of all the people, including but not limited to such special target groups such as mothers, children,and the handicapped.

3.Extend to all the health proarams and resources -- private as well as public -- within the State.

4.Indicate how comprehensive local health services will be provided in all geographical areas of the State and describe how the plans are to be implemented.

5:Provide for the interrelation of health and related educational and social services.

6.Provide the means and methodology for Statewide data collection systems to assess and disseminate information on health needs within the State. Appraise physical facilities and ensure their maximum utilization. 74

8.Assess manpower requirements and develop methods of overcoming shortage including provision for the full use of allied health personnel.

9.Present a financial plan for State and local services, including Federal participation.

10. Initiate and integrate demonstration and pilot programs and research projects for the better delivery of health services into the total program.

11. Permit flexibility to meet the varying needs of different localities, changing needs over time, and to cope with human disasters as they arise.

12. Encourage local health planning and provide for its implementation.

13. Assess existing legislation to determine the extent to which it encourages or inhibits advance in health and the ability to carry out the plan.

14. Strengthen the planning evaluation and service capacities of the participants.

Federal Stimulus to State Health Planning The Congress has determined that the Federal government will provide assistance to States to develop better State health planning. To make such a proviso effective: The Department of Health, Education, and Welfare should develop national healith goals, and within the, limitations of these broad goals should allow the States maxityium flexibility to develop their health plans; once such health planis in effect, HEWshould requ.ire conformity' withthe established objectives and priorities as acondition to the receipt of both health services and facilitiesgrants. HEW should establish andincorporate within such guidelines a minimum workable programfor environmental and personalhealth services within a State.These guidelines should be revisedperiodically

so that healthservices will continue to beupgraded.The Childrents Bureau has used a similartechnique in the past and is tobe commended for the firm stand it hastaken on performance standardsand the improvement in the quality ofhealth services it has stimulatedin the States. Now with the new provisionof a block-type formula grantunder PL 89-749, the need for standards andtheir enforcement become all thegreater. Without requiring high standardsof performance, the resultcould be .. less effective servicesthan are currently available.

Health Planning Council A State health planningcouncil should be established in eachState to help set goals,plan programs, determinepriorities, and allocate resources, includinginterrelation of programs for hospitalconstruction; heart, cancer and stroke;mental health and retardation;and other relevant activities.

I. 76 -

The interest of many agencies and institutions, both public and private, must be considered in devising comprehensive plans of State health services.All the agencies and institutions involved in the health effort must be heard in the planning process. One of the better ways to ensure this involvement is through the establishment of a strong State health planning council which is broadly representative.The health planning council created under PL 89-749, must have broad enough scope to enable interrelationship of all health agencies and community forces.All other councils and commissions dealing with health matters (for example, regional medical programs and hospital construction) shall be expected to take into account and be guided by the judgments of the State health planning council, accom- modating as necessary to interstate and regional considerations.

_ The organizational location of the council should-remain flexible. Since the coilncil will comprehend such highly fragmented activities, it should be an advisory body to the Governor.The Governor should approve the plan formulated by the council and we hope will be guided by it in his allocation of' re sources.

Strong Health Departments There should be a strong health department capable of giving leadership and direction to the total health effort in each State.Model legislation 77 should be prepared to guide States in developing such department s. The State health department is the organizationalentity around which a strong healtheffort should be built.Its mission is to achieve the highest attainable level of health and to ensurethat necessary health services are provided for all persons throughoutthe State. In effect, the State health agency should envision itsresponsibility as encompassing all theactivities that are related to health.While it certainly will not provide all the health servicesincluded in the plan, the health department should play a leadership rolein the total effort and should have responsibility for formulating plans toallocate resources among all tax-supported healthagencies for presentation to the State In order to do so, State health agencies must health planning council. 4 broaden their concept of "public health," especially to encompasstheir involvement in meeting the personal health problems of individuals,and, they must become a part of the mainstream of the political processin the State. The State health agency should be capable of working with and givinz leadership to all local agencies as well as areawideagencies where they have been established.It should move toward assumption of an active role in all direct Federal-local health relationships sothat these activities can be incorporated into the total State plan.

r. it We believe the American PublicHealth Association, in collaboration . with the Council of State Governments,could render a valuable service by studying the statutory frameworkin which State health departments operate and developing model legislation forState health organization. Such legislation should define therelationships among the Governor,

the State health officer, the Stateboard of health, and healthdepartment and define the functions andresponsibilities of each.

Planning Unit in Health Department

The growing demands of healthprograms make it essential that a permanent and well financed planning,development,and evaluation unit be an integral part of the Statehealth department. With the rapid changes comingin the diagnosis and treatment of disease, with the additional Federalfunds being made available for health services, and with theneed to improve the healthdelivery system, a special unit is necessary for improved planningand performance.

Along with health planning, itwould also engage in activitiesto assure:(a) that the effectiveness ofvarious health activities bemeasured,

(b) that alternateways of delivery services be tested, (c) thatnew approaches be conceived andevaluated, and (d) that the resultsof its studies and evaluations be appliedas widely and as soon as possible.

The Federal government shouldparticipate in the financing of suchunits. 79

Responsible Health Officer There should be aresponsible Statehealth officerappointed by in each State. and serving atthe pleasureof the Governor the State level, In order todevelop a strongfocus for leadership at State health officer. authority andresponsibility shouldbe vested in the advisor to theGovernor, This officialshould be theprincipal health matters to thelegislature. and the Governor'srepresentative on health Otherwise, the healthdepartment runs therisk of becominginsulated effective in from public opinionand concern, andthereby being less marshalling politicaland financial supportfor vital programs. State boards This insulationhas often existed,most notably where and the Governor of health have beeninterposed betweenthe health officer The board and have had theresponsibility for settinghealth policy. It should advise should have noadministrative orpolicy-making functions. in presently the State healthofficer as to healthneeds and as to gaps for health available healthservices; it shouldmarshall public support programs; andit should reviewall proposed healthregulations. emerging needs for If the State health agencyis to be responsive to and is to exploit health services,particularly inmetropolitan centers it the increased popularsupport forgovernmental health programs, ".. 80 must be effectively related to all groups in the coynmunity.This dictates the reorganization of those State boards of health that are made up largely or solely of private practitioners.The majority of the members of State boards of health should be from the general public A Broader Partner s hip State health agencies should broaden their partnership with all the health resources in the State, incluc!ing medical and other professional

s schools; a wide variety of groups shoild be involved in State health planning and in developing a comprehensive system of personal and environmental health services. The changing nature of the national causes of death and disability, new sources of funds (public and private) to pay for personal health services, the continuing growth of medical specialization, automation, population increases, rapid growth of scientific knowledge, and an increasing public interest in health are all putting pressure on existing systems for delivery of medical care.There is a general awareness of the great increase in medical knowledge.There is much less awareness, however, that modern fechnology and sophisticated methoc!s 'of diagnosis and treatment make our existing systems of health care anachronistic.These systems are ill-adapted to make adequate use of available methods and techniques. A revolution in health delivery systems is called for; the situation demands innovation, wider use of 81 allied health personnel, newchannels of cooperative effort, and new partnerships. The State health departmentshould be the focal point for these changes. The development of comprehensiveState health planning depends on the participationof many agencies and institutions.It is necessary for State health departments to work moreclosely than ever before with medical schools, hospitals, andprivate practitioners in developing an adequate systemof personal health services.Likewise they must work more closely with natural resources,pollution control, public works,and agriculture agencies in developing anadequate system of environmental health services.The State health department should widen and deepen its partnership with allthese agencies.The probleYns of involving these diverse groups are many.Asking for comments from them serves not only to elicit support butguides their thinking to seek new horizons. Private physicians, as part of the totalhealth care system, need to learn more of the many problemsinvolved and participate in planning. Medical schools too seem destined to becomeincreasingly involved in the delivery of community health services.They are already beginning to do so through the regional programsfor heart disease, cancer, and stroke.This is a desirable trend for it can lead to morerapid and widespread application of new knowledgeand to improved quality of care. 82 To ensure a closer liaison between health departments and medical schools, State health plans should bear the comments of the Deanof the medical school (s) or other organization operating the heart, cancer, and stroke program within the State and similar proposals submitted to the Federal government for regional medical programs for heart, canc.er and stroke should bear the co:nmentsof the State health officer (s).

The Health-Welfare Team HEW should seek amendment to the Medicaid program (Title XIX)

to make the State health agency responsible for the health aspectsof this program (health goals, scope of medical benefits, standards, relationships with providers of health care, utilization control, and

evaluation). The health aspects of the Title XIX program should be the responsibility of a strengthened State health agency. By "health aspects," we mean the:

1.Determination of specific health goals (e.g., reducing the infant mortality rate among the assisted population to the level of the general population). 2. Establishment of the scope of medical benefits (diagnostic services, drugs, etc.) to be provided. Setting of standards for services, including hospital and nursing home care. 83

doctors, dentists, 4.Conduct ofrelationships with nurses,hospitals, nursinghomes, insurance companies, andother providersof health services. facilities andservices. 5.Utilization controlof health 4 of the health carebeing provided, 6.Continual evaluation planning and periodicreporting to theState health council and theState welfare agency. should beresponsible for: Simultaneously theState welfare agency of the program. 1. Formulation of thesocial goals

2.Determination ofeligibility. services. 3.Determination ofneeded social

4.Conduct of fiaancialrelationships. significant new In recent years,government hasassumed a health care for asizeable responsibility --the financingof personal of thisresponsibility portion of thepopulation. Anoutstanding example between Statehealth is the TitleXIX Medicaid program.The struggle this programhas created and welfareagencies forresponsibilities under be complementaryaction friction andcompetition wherethere should

and unity ofpurpose. accepted clear Conflict can beminimized if thereis mutually welfare agenciesin medical understanding ofthe roles ofhealth and worthwhile to examinethe care.In thisconnection,it may be California where astrong healthdepartment operates 1 structure in i

i 84 within the organiational framework of a combined health and welfare agency. Single State Agency Concept The "single State agency" requirement shauld be modified in order to allow States to combine the skills and resources of several agencies into a coordinated State effort, subject to the approval of the alternate arrangement by the Secretary of HEW. The scope of public health is infinitely broader than it was a quarter of a century ago.It is inextricably intermingled with social, rehabilitative, and educational services in the provision of preventive anc: therapeutic care; and with sanitation, public works, and community planning in the provision of environmental health services.It is essential that State health departments work with and share with other SVate agencies in the achievement of what are not only health but community goals.It must not be denied the opportunity to develop imaginative and unprecedented collaborative approaches. At present, however, its hands are often tie'i by the require-nent that a single State ,-..gency be responsible for the administration of a particular program. 85

The concept of asole, or single,State agency wasdeveloped treatment on a in the 1930'sin an. attempt toprovide for equitable responsibility in the State-wide basisand to provide afixed point of funds were State for theadministration of a programfor which Federal of being madeavailable.This was necessaryin the formative years State grant programs.The concept sometimespresents barriers to efforts to meet theneeds of individualsthrough joint projectsand agencies ventures.Under this requirement,for example, State fo find it difficult to pooltheir resources,funds, and staffs, and result is share responsibilityin the decision-makingprocess. The which dilute fragmented servicesand artificalbureaucratic decisions States from attaining the quantity andquality of servicesand prevent the State the objectives they aretrying to reach underthe comprehensive

health plan. mounting The changingcharacteristics of thepopulation and the pressuresfor integrated servicesat the communitylevel emphasize provide services the problems ofcoordination andprogramming so as to and in the rnanner where thepeople are, whenthey first need them, in which they willbe most effective. 86

Although administration bya single State agency will most often still be the metliod of first choice,a more liberalized interpretation is needed to allow sufficient administrativeflexibility to cut across program lines.State agencies should be free to deal withspecial needs and emergencies througha variety of organizational arrangements

Interstate Arrangements and Federal Support Thereof

The Governors and their health agenciesshould initiate and negotiate interstate compacts andother cooperative arrangements with neighboring States in order thateffective actionmay be brought to bear upon health problems affecting interstateareas. HEW should encourage such interstate cooperation and renderfinancial support to the health programs of interstateagencies.Legislation should be sought from the Congress grantinadvanced consent to interstate compacts for the purpose of public healthplanning and health education. Previously it has been pointed out thatmany health problems can not be contained within local jurisdictionalboundaries and require regional solution.Often the region involvedencompasses all or portions of two or more States.This is particularly thecase in many of our metropolitan areas and inmost major river basins. Thus interstate compact agencies (such as the Ohio RiverSanitation Commission) and 87 other cooperative arrangements(such as the Metropolitan Washington Council of Governments) haveevolved to fill the need. Such interstate cooperationshould be fully extended to thehealth field and encouraged by HEW throughfinancial support.

SUMMARY A strong State partner is a vitallink in the Federal-State-local system of health services.The State partner must be strengthened in order to improve the relationshipsbetween the Department of Health, Education, and Welfare and Statehealth agencies.There should be a comprehensiveState plan for health services, organizedaround a strengthened health agency. A Statehealth planning council is essential in order to involve otherofficial agencies, medical schools, private and voluntary resources in thecomprehensive plan.The State health program should be directedby a State health officer who is responsible to the Governor.There should be an effective health and welfare partnership with clearlydelineated responsibilities. The Federal Government should stimulateand support all of these actions designed to strengthenState health agencies, to promote a coordinated andcompi-ehensive State plan for health servicesand to support interstate cooperation.How the Federal partner can improve its own organizational and administrativemechanism, and provide national health leadership is thesubject of the next chapter. 89

CHAPTER V -STRENGTHENING THEFEDERAL HEALTHPARTNER

The bulk of healthservices for the people areprovided locally. State agencies supportand supplement theseservices and plan comprehensive State-wideefforts.The Federal partnershould play a role of nationalleadership in all ofthese activities, primarily through the Departmentof Health, Education,and Welfare.This Department should: consideration 1. Formulate nationalhealth goals for the of the President andthe Congress.

2. Provide nationalleadership to reach thosegoals, including the planningof health programs,the development and allocationof resources and the evaluation of accomplishments.

3. Assist in carrying outplans through thedesign and financial supportof programs for thedelivery of personal andenvironmental healthservices.

4. Realign itsinternal organization tominimize confusion, conflict, and competition amongprograms and agencies for which itis responsible.

5. Encourage innovativeapproaches andadministrative flexibility in meeting needs.

6. Expand and ensurethe effectivenessof efforts to meet the increasingmanpower needsof the Nation. This chapter outlines-the actions needed tostrengthen the , Department of Health,Education, and Welfare tomeet theseexpectations. '`o Setting National Health Goals The Department of Health, Education, and Welfare mustdevelop . its capability for formulating national health goals specific in nature, clear in statement, and including a plan of sequential stepsand a schedule to guide implementation; these goals should be considered by the President and submitted to the Congress for approval and , enunciation as a declaration of National health policy. Such health goals for the Nation as are now stated from time to

, time by various Federal officials are piecemeal in nature, vague in statement, uneconomic in their failure to allocate scarce resources among competing demands for services, and ineffective inproviding guidance to the total national health effort. 1 Within the Department, the Public Health Service should be equipped to develop (with the aid of State and local governments) a coherent set of such goals and plans for improving the. health of eVery person in our society.This formulation should serve as the basis for the President's submission to the Congress of proposed national health goals and policies and for subsequent action by the Congress to set forth a national health policy in statutory form.The legislative program and budget for health should provide the Department with authority and resources to achieve the stated goals. An amendment to the "Partnership 91

would have . in Health" bill which wasdeleted before final passage, called upon the SurgeonGeneral to developNational health goals. The final "Partnershipin Health" legislationdoes serve, however, as a first steptoward the establishmentof a continuing health planning process. Andit surely providesthe opportunity for local, State, and Federalagencies to strengthentheir health partnership. We urge that it beutilized to establish trulycomprehensive health planning in each Stateand locality.

Planning to Attain Goals National health planningis the responsibilityof HEW. To be effective such national healthplanning must becoordinated with planning for housing,education, welfare,employment, and recreation

and with planningfor the overall social,economic, and physical development of each community,each State, and theNation as a whole. To ensure that the needsof people in every sectionof the country are meteffectively, State and localgovernments must playappropriate roles. HEW shnuldorovide the initiative andthe leadership that will manifest itself in nationalguidelines and should makeavailable to the States essentialtechnical knowledge andskills.In addition, HEW, through thePublic Health Service,should develop a greater 92 capability for helping the State and localgovernments to do health planning and to coordinate their effortswith the private sector. One illustrative opportunity isafforded by the regional medical programs for heart, cancer, and strokenow being established. The areawide planning efforts ofthe regional heart,cancer, and stroke programs to improve quality of health servicesthrough actions by medical schools, universities,research institutes, trainingcenters, and laboratories complementthe planning provisions ofthe Partnership in Health Act and should becoordinated.

Similarly, planning for thevocational rehabilitation,maternal and child health, mentalhealth, and other healthactivities of the Department of Health, Education,and Welfare shouLd beencompassed in the planning by eachState and locality.Such coordinated planning would then be supplementedby the provisions in theAct for interagency and intergovernmentalcollaboration and for the exchangeof personnel; such collaboration shouldimprove health planning byintegrating the contributions of the mentalhealth, mental retardation,vocational rehabilitation, recreation, housing,physical planning, and otheragencies. Applying the New Health Knowledge

HEW should provide ampleresources for research and stimulate demonstrations to devisenew systems and methods for the deliveryof health services to people. 93

The Federal Government hasmade a large investment in basic health research over the postWorld War II years.This research has produced valuable new knowledge.It has materially advanced our ability to prevent and to treatdisease.It has expanded our understanding of the effect of environment on healthand has increased our ability to control environmental hazards.This investment in basic health research has paid large dividends and mustbe continued. The translation of researchfindings into action programs that improve the health of people, however,has lagged. The need now is for greater effort to find ways to applythese findings to disease protection, environmental control, and the delivery ofhealth services.This will require discovery of better and moreeffective means for the delivery of comprehensive health services to peopleand the communication of research findings to professionals who can putthem into practical use. It will also involve massive and imaginativeefforts to educate the populace on health matters, particularly withregard to maintaining personal health. Focusing Health Leadership A stronger and better integrated organizationalfocus for health activities of the Federal Government must becreated; this should take the form of a subsidiary "Department ofHealth" within the Department of Health, Education, and Welfare. 94 : The effectiveness of collaborativeFederal-State-local efforts

4 I t in health can be increased through better organization and practices i at the State and local levels.But achievement, in each community of the level of health services-- personal and environmental-- that is now attainable will require better coordinated leadershipat the Federal level.

Planning for efficient use of healthresources for the focusing of national health efforts andto strengthen and guide State and local health agencies requires realignmentof health ageLcies and health programs now located within the Department of Health,Education, and Welfare. A greater integrationthan now obtains must be effected if critical needsare to be met with respect to personal health and environmental health services. By betterarticulating the several health programs, relative healthneeds and prioritiescan be appraised and balanced, legislation andbudgets can be better developedto meet our health goals, and relationships with State andlocal health agencies can be greatly clarified.

What organizational form shouldsuch a national organizational focus for health activities take?Health programs are intimately involved at the family level with othersocial factors-- education, economic opportunity, and welfare.We have recommended that such activities be associated at the communitylevel.This is an association that should be continued andamplified at the Federal level. 95

There is need within the Federal Governmentfor the association of such activities under a cabinetofficer who will, for the President, weigh competing demands andmaintain a balanced effort among health, education, and welfare programs(e.g., services for selective service rejectees, compared with servicesfor school "dropouts, " compared with income for retired aged)in terms of all that is currently known of the needs of American families.Hence, creation of a separate "Department of Health" reporting tothe President, is we believe unwise, and indeed runs counter tothe evolving recognition of the need for greater interrelation of health andother social services. What is needed is the creation of a subsidiarydepartment or 1 1 administration" of health within a Department of Health, Education, and Welfare that relates all healthactivities in a better integrated effort to marshall available economic andtechnical resources with equally available political and socialsupport to cope with the pressing problems of today -- how to provideimproved personal health services and environmental health servicesfor all citizens. The need will best be met by the establishmentof a separate subsidiary "Department of Health"headed by a subcabinet secretary reporting directly to the Secretary of Health,Education, and Welfare. Recognizing that many factors mustinfluence the assignment of functions within HEW and among its subsidiarydepartments, the Committee believes, 96

from the standpoint of intergovernmentalrelations in the field of health, that the following activities should be broughttogether in the Department of Health: (I) The Public Health Service

.. (2) Maternal and Child Health and CrippledChildren's Programs of the Children's Bureau

(3) Health aspects of Title XVIII (Medicare)and Title XIX (Medicaid) of the Social Security Act s,

(4) The Vocational RehabilitationAdministration (5) School healthprograms of the Office of Education

1 (6) Environmental health functions ofthe Food and Drug Administration. Research should be intimately associated withprograms for service in a mission-oriented organization.

4 Increased Emphasis on 1 Environmental Health Within the proposed subsidiary Department ofHealth, greater provision should be made for leadershipand for funding in the field of environmental health than isnow apparent.

While there are many important nationalhealth needs to be met, we are particularly concerned about the increasingenvironmental problems.Until recently, environmental health activitiesseem to ). have been largely submerged withinthe HEW organization.. Weare

; 96

from the standpoint of intergovernmental relations in the field of

health, that the following activities should be brought togetherin the Department of Health:- (1) The Public Health Service (2) Maternal and Child Health and Crippled Children's Programs of the Children's Bureau

(3) Health aspects of Title XVIII (Medicare)and Title XIX (Medicaid) of the Social Security Act (4) The Vocational Rehabilitation Administration (5) School health programs of the Office of Education

(6) Environmental health functions of theFood and Drug Administration. Research should be intimately associated withprograms for service in a mission-oriented organization. Increased Emphasis on Environmental Health Within the proposed subsidiary Department of Health,greater provision should be made for leadership and forfunding in the field of environmental health than isnow apparent. While there are many important national healthneeds to be met, we are particularly concerned about the increasing environmental problems.Until recently, environmental health activitiesseem to have been largely submerged within the HEWorganization.. We are 97 much encouraged by the stepsthat have been taken in the reorganization of the Public Health Service togive greater organizational stature and status to environmentalhealth activities.The creation of a center for urban and industrialhealth seems a forward moving stepwhich, with adequate funding, can serve toextend environmental health knowledge down to State and local levels. Until recent years, environmentalhealth activities (except for support for occupational healthfor a short period of time) at State and local levels have not shared in thecategorical funding accorded many diseases (tuberculosis, venereal disease,mental illness) and special populations (children, mothers). Overthe last ten years, actual expenditures for environmental health(excluding water pollution) were on the order of only10 percent or less of the PHS assistance toState programs. The end resultin a period of industrial and urbanexpansion has been that environmental hazardshave multiplied faster than they have been contained. More coordination is needed at the Federallevel.At the State level, environmental health activities aregenerally coordinated by and focused in the State health department.But, when the State agency looks toward the Federal Government forguidance and leadership in environmental health, it finds this activityfragmented, diffused, and submerged among disparate Federaldepartments and their subordinate agencies. 98

Within HEW, responsibilities in theareas of food, drugs, and pesticides are shared between PHS and FDA. Studies are now underway to resolve the areas of overlap.With regard to environmental activities located in other departments, HEW should be responsible forhealth aspects o.t environmental problems (e.g., housing,water pollution, transportation, land use) and should provide guidance and leadershipto other Federal

e agencies that are responsible for the administration ofthese programs. Coordinating Federal Health Activities

A Federal Interagency Health Council should beestablisned to better coordinate health activitiesamong Federal agencies; the Council should r:onsist of the head (or deputy head) ofeach of the agencies with sizable health programs and shouldmeet regularly under the chairmanship of the proposednew Secretary of Health.

It was noted earlier that additional medicaland health related programs are scattered throughout the Federal establishment ina score of agencies, including the Department ofDefense, Interior, State, Agriculture, Housing and Urban Development,Labor, Commerce, and Justice; the Veterans Administration; AtomicEnergy Commission;

National Aeronautics and Space Administration;Office of Economic Opportunity; National Science Foundation;Civil Service Commission;

Canal Zone Government; Federal AviationAgency; and the United States Information Agency. 99

agencies shouldbe included in The activitiesof these various and theiroperationscoordinated the formulationof nationalhealth goals Bureau of theBudget can under Departmentof Healthleadership. The allocation ofFederal resources. assist in thiscoordinationthrough the wise of these Federalactivities But the morepositive andcontinued coordination communities shouldbe performedby in theirimpact onfamilies and on In the long run,the economic the proposedDepartment ofHealth. benefit for utilization of resourcesand the attainmentof a maximum should be more,frequent the Americansociety dictatesthat there collaboration in the use interchange amongthe agenciesand greater of resourcesand in copingwith keyproblems. consolidation Although theCommittee believesthat considerable be feasiblycarried of health activitiesconducted outsideof HEW could role of theOffice of Economic out, it hasonly had time tostudy the health present arecommendation. I Opportunity insufficient detail to 0E0 Health DemonstrationProjects transferred to HEW 0E0 healthdemonstrationprojects should be their worth bythree to five years administrationafter they have proven of successfuloperation. the provisionof an In absorbing0E0 projects,HEW must assure providing supportwill organizational settingand a freedomwhich while demonstrated. retain theinnovative qualitiesthat they have 1

I Uninhibited by traditionand dedicated toinnovation and action, the 0E0 has madea significant, though limited,contribution to the total offering of public health services inthe United States.It now provides health servicesthrough the establishmentof "neighborhood health centers," through "OperationHeadstart, " and otherhealth programs. However, 0E0was created to actas a catalyst, to stimulate

experimentation andinnovation by local,public, and privateagencies (and by 0E0 itself) in developingnew ways of attacking thecomplex problems of poverty. It will continueto serve this centralpurpose only if it does not become weighted downin the administrationof

programs which wereonce new and innovative buthave become

established and accepted.It is importanttoo that thesenew health projects andprograms becomean integral part of the comprehensive health care system.

The transfer oftested andproven 0E0 health projectsto HEW contributes strength to these projects,assures their acceptanceinto the health care system, places operatingresponsibility inan experienced health services organization and shouldhave a stimulatingeffect upon that organization. Strengthening Regional Offices

HEW should takesteps to developstronger Regional Offices. Substantially greaterauthority for coordinationand decision making 101 should be delegated to the HEWRegional Directors; each Regional Director in turn should be able to depend uponspecialists for assistance in the direction and coordinationof activities within each region. Previous attempts to revamp and tostrengthen the regional offices of this and of other departmentshave not been marked by notable success. Yet we believe this objective -- strongerregional offices to relate HEW more effectively toState and local governments -- is sound. The Surgeon General has indicatedhis intent to delegate to the Regional Health Director responsibilityfor grants management and authority to approve State plans under the"Partnership in Health Act, " and his intent to assign personnel toregional offices to carry out these delegations.This is an encouraging development, and onewhich should materially aid in coordinating Federal andState efforts to meet health needs. The Regional Director, however,needs to be intimately involved in all HEW relations with States in ordereffectively to relate health, education, and social welfare services toeach other and to the total needs of the States (especially to meet problemsrequiring concerted action). The Regional Director, in arriving atdecisions, will of course be expected to counsel with and utilize thetechnical staff available to him in each field within the regional office. Hence, we recommend that thefollowing steps be taken: 102

(I) Authority for theapproval or disapprovalof comprehensive State health plans, andamendments to such plans,be delegated to the Regional Directors, withthe proviso that Stategovernments can appeal adverse decisions to theSecretary of HEW.

(2) Greater authorityto effect coordinationamong related programs at the regional level,including authority toemploy and reassignper- sonnel within the region,be delegated toRegional Directors.

(3) A firm practicebe initiated by theSecretary of HEW thatneither he nor the commissionersof HEW agencieswill act on requestsfrom State or local governmentalofficials withoutconsulting with the Regional Director.

(4) The RegionalDirector be directedto plan and make regular visits with the Governorsand with themayors of major cities to discuEs relevant HEW activities,including health matters,so that the Governors and mayorsmay develop fuller confidencein the RegionalDirectors, and may be expected to c!eal withthem first more oftenthan in the past. (5) Contingency fundsbe provided so thateach Regional Director (without approval ofspecific actions atheadquarters)may assist States in emergencies andmay stimulate innovative projects. (6) The FDA districtsbe realigned to relatebetter to other health activities and to functionunder the HEW RegionalDirector, insofaras that is practicable. 103 Simplifying Grants Administration Prevailing practices for the administration of grants to the States must be simplified and made more flexible to reduce in the future the confusion and distortion of programs caused by the wide variations in these ratios. An opportunity to correct some of the deficiencies in grants administration is provided by the new "Partnership in Health Act" which addresses itself in part to the problem of categorical financing and program fragmentation.Under this legislation most PHS categorical grants are eliminated and consolidated into one block grant for health services. However, certain categorical grants of the Public Health Service and alt of the grant programs administered by the Children's Bureau, Vocational Rehabilitation. Administration, and the Office of Education 'are unaffected.Until the new concept is further extended, many of the problems cited earlier can be expected to persist. If financial grants are to stimulate and aid the States to provide a wider range and quality of he=tIth servicf-.s, formulas must take into account State variations in per capita income, in population, and in the intensity of problems.It is also appropriate to maintain additional flexibility so as to allow greater emphasis for newly developing programs, innovative approaches, and critical problem areas. However, grant 104

inducements should not beallowed tocause or force the State governments to distributetheir resourcesto maximize Federal funds they obtain rather than to distributetheir resourcesconsistent with the urgency of the needs forservices within theState. The haphazardly varying ratiosamong programs /MO sotne time s 1:1, 2:1, 3:1, andeven 9:1 -- have tended to prod-ace distortionin the , distribution of State resources. A typical examplewhich shotild be eliminated is the disparity in the ratiosat which expendituresfor the compensation of professionalmedical personnelis matched under Medicaid. When medical activitiesare carried on by the "singleState agency," usually the State welfaredepartment, Stateexpenditures for the compensation or training of professionalmedical personnelengaged in the administration of the planare matched 3 for 1.If the State welfare department contracts with the State healthdepartment to providemedical services, the expenditures are matched ata ratio of I to 1.The total expenditures for this purpose are small, but thelimiting effectupon how the State government shall conductits affairs isapparent. The newest experimental anddemonstration grantprograms and those established to aid in resolvingespecially criticalproblems should be at the higher end of the matchingscale.But it will be desirableto have the matching revert to a lower ratioafter the first fewstimulatory years. 105

Specifically, we recommend the following implementing steps: (1) The principle of a broad health service formula grant, established under the Partnership in Health Act, should be extended to include the consolidation of other appropriate categorical health grants.1If the health services tormula grant cannot be so extended, then the States shou'd be authorized to transfer a portion of the funds available for any one category of health services to meet other needs up to an amount approved by the Secretary. (2) Where project grants are made, up to 20 percent of the total should be made broadly available to improve the administration and provision of basic support services required effectively to undertake the special program, such as laboratories, generalized public health nursing, overall planning and evaluation, and comprehensive health centers. (3) Greater uniformity should be established in Federal-State matching ratios to reduce in the future the confusion and distortion of programs caused by1-ie wide variations in these ratios. (4) Using the precedent already set in welfare grants, under which $202 million are made available annually for the administration of welfare activities by State and local governments, HEW should make provision for

1See Section 314(d) "Grants for Comprehensive Public Health Services," PL 89-749. 106 sharing, on a 1:1 matching basis, theadministrativecosts of State and local health agencies.IHEW should requireas a condition to the receipt of such grants for administrativecosts, conformanceto the objectives and standards of thecomprehensive Statehealth plan. (5) A mechanism should be establishedto facilitate projectgrants for developing and providingdemonstrations of improvedsystems of organizing and providing health service-: (e.g.,group practice,contracts with private groups for public services),and for developingof environmental controlprograms on a "problemshed" basis (inclu:Ung interstate andregional projects). (6) Finally, we suggest (2) thatgrants should be usedto induce States to 'establish performance standards,and (b) in evaluatingState and local performance such standards beincreasingly usedas yardsticks of accomplishment (rather than financialaccountability alone). Increasing Health Manpower A major effort is needed toincrease the nationalpool of skilled health manpower -- doctors, dentists, engineers,nurses, and all types of paramedical personnel. A significantstep forward hasbeen taken in the creation. within the PublicHealth Service ofa new Bureau of Health Manpower. It shouldsoon play a key role inassessing requirements and encouraging and assisting inthe developmentand utilization 1Estimated Federal share foradministrative costsfor FY 1967. of health manpower. Theproposed establishment of a "Health Service of the United States"is another basic step forward. We recommend that HEWtake the following steps: (1) Devise for use in healthagencies throughout the country, new approaches to the better utilizationof the existing limited su?ply of trained health manpowerunder the leadership of the new*PHSBureau of Health Manpower. Suchapproaches would include the use of paramedical personnel in placeof physicians; the use of automated techniques to minimize the numberof nurses, technicians, and others required; the extension of grouppractice; and the use of contract relationships to utilize the servicesof non-governmental professional health personnel in meeting especiallyurgent needs. (2) Expand the proposed "HealthService of the United States" (or the Commissioned Corps ofthe Public Health Service if it is not succeeded by the Health Service) sothat qualified officers may be deployed as needed to assignmentsin any Federal, State, or local

agency.This expansion should permitqualified officers of the Health Service to provide needed healthservices in areas lacking essential health facilities and personnel, even asthe National Teacher Corns provides qualified services where childrenotherwise would be deprived

of adequate education. (3) Make full use of thenew Personnel Interchange provisions of PL 89-749 to createa vigorous cadre of health planners and administrators at Federal-State-local levels.IThe Act broadens the Secretary's authority to detail Federalhealth workers to State and local governments; it enables the transfer ofcompetent personnel in one community to.another in need of assistance; andfinally it enhances Federal health planning and administrationby bringing in hybrid vigor from those experiencedon the firing line.

(4) Encourage Stategovernments to mA.ke careers in the public health services more attractive; thiswill require the provision of competitive salaries, the promotion ofoccupational and interdisciplinary mobility through planned staff development,and the facilitation of the movement of personnel between Federal, State,and local agencies. The Department's Division of StateMerit Systems should extend technical services to local jurisdictions,as well as to States, for improvement of personnel administration and for thedevelopment of practicalmeasures to meet these objectives.

(5) Establisha loan program to induce more of this Nation'sablest young people to enter the health professions. Sucha loan program should be designed to induce highschool, college, and graduate students to undertake training for the healthprofessions, including preparation

I See Section 314(f) "Interchangeof Personnel with States, "PL 89-749. 109 to becomephysicians, engineers,and nurses.The loans made to young peopleaccepting this aid shouldbe forgiven after aservice period (five to sevenyears) in a designatedFederal, State, or local health agency. (6) Expand the vocationaland higher education programsto train technicalsupporting personnel forthe health serviceswhich are carried onby the Office ofEducation.In addition, thereshould be a general expansionof career guidance,student aid, and teacher education programs supportedby the Office ofEducation with appropriate emphasis onthe health fields.

(7) Expand the PHS"COSTEP" summerinternship program to provide early student exposureand valuable workexperience for engineers, physicians,and other professionalswho may manifest interest in a career inhealth work. (8) Establish a HealthService Education Institutewithin the Department of Health toprovide specialized training(e.g.,health planning and administration)not available elsewherefor all members

of the National HealthCareer Service and amongState E-Lnd local health personnel. The training programof the CommunicableDisease Center's Epidemic IntelligenceService has done morethan any similareffort, within or without the government,to attract youngphysicians -- and future leaders -- to the healthfield.This kind of programshould be established in other healthfields. 110 (9) Develop and expand theinstruction and research in preventive and community health servicesnow offered in many medical schools. The development of such servicesdeserves the same kind of support and emphasis currently givento clinical services. (10) Establish additional graduateschools of public health. A major part of the need formore trained public health personnel is in the major metropolises; it will bedesirable that the additional schools

be established in these centers.The existing system of grantsupport should be revised to keep the presentschools at their high level of performance while developingadditional schools in majorareas where none now exist.

SUMMARY

A number of significantsteps need to be taken at the Federal level to strengthen the local-State-Federalhealth partnership.In particular, there is need for better coordination ofFederal health activitie:4, through a Federal Health Agency Council, and for the creationof a new focal point for health, througha subsidiary Department of Health within HEW. These actions will provide bettermachinery for the exercise of national leadership in health, for the formulationof national health goals, andfor the planning necessary to reachthese goals. Federal grants administration needsto be overhauled and simplified.

And the Federal Governmentmust develop new approaches toaugment the present supply of professionalhealth manpower.The new 1.11. not onlyfor Partnership inHealth legislationoffers an opportunity health planning atFederal, the establishmentof neededcomprehensive for reform of State, and locallevels, but also abeginning stimulus wen as a starttoward better Federal grant-in-aidmechanisms, as utilization ofhealth manpower. depends on strong,viable health The deliveryof health services The actionsrecommended in this agencies atState and locallevels. chapter wiIIhelp towardthis end. _ Committee aredesigned to clarrfy Therecommendationsof this health agenciesand to simplify the rolesof local, State,and Federal them.The health of thepeople and improvethe relationshipsamong creative, andresponsive to depends on astructure thatis flexible, is tolwIp buildsuch a human needs.The purposeof thIS-Jleport opportunities are tobe met, structure.If today'schallenges and of purpose,expand the total healthstructure mustdevelop a unity leadership. its horizons,and bringforth .vigorous new 113 CONCLUSIONS AND RECOMMENDATIONS Sirengthening the Local Health Partner Page

1. Local governmental units, to cope with today's health problems, must be consolidated or effectively interrelated in a joint effort, that establishes a governmental service area coterminous with the health problem area. 43 2. A health planning council should be established to assess local needs, to hear citizens' views, and to formulate plans in all local areas sufficiently large to cope effectively with health problems.

3. A community health plan should provide a full range of personal health services for all people and such environmental health services as are susceptible to solution on a community-wide basis; this plan should include:a system for coordinating and integrating health services, the optimum geographic distribution of facilities, the establishment of neighborhood service and comprehensive health care centers, the conduct of health education programs and experimental projects, and the application of improved methods for controlling medical costs.

4. HEW should initiate a major program to educate the public about health; support should be made available to finance educational demonstrations aimed at communicating health information 'in selected metropolitan areas and rural areas of -special ne ed.

5. Local health departments must be strengthened- in attitude and in competence - to provide staff assistance, leadership, and stimulation for each Health Planning Council.

6. The State health agency should see to it that an effective planning process exists for each local community, should aid local communities in developing their plans, should develop minimum standards for the organization and operation of local health services, and should require that local public health services become operative in all parts of the State. 114

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7.Where a State is unable or unwilling to assist in providing health services in urban areas, the urban governments should be free to deal directly with HEW. 62 8. HEW should seek statutory authority, adequate manpower, and funds that would enable it to respond to requests from State or local governments, when they are confronted with emergencies growing out of critical unmet health care needs.63

9.For those areas where the assurance of basic health care is beyond the capability of the local health agency, and where the State is unwilling or unable to fill the gap, direct Federal aid should be provided.This aid should take-the form either of the as-s-i-gnment of- pe-rsonne-1 for- limited periods, or the provision of facilities, or both. 64

10.Legislation should be sought authorizing the Public Health Service, Veterans Administration, and Department of Defense to make their health facilities available on a reimbursable basis when they are not otherwise fully utilized to meet State and community needs; and further authorizing them to contract for the use of local health services for their beneficiaries where these are available. Demonstrations should be undertaken in a few communities where Federal health installations are located to make manifest the feasibility of such reciprocal utilization of facilities. 65 Strengthening the State Health Partner

11. Each State should formulate health objectives anct carry out comprehensive planning for health services to meet the needs of all its people.The health objectives should be considered by the Governor and submitted to the Legislature for approval and enunciation as a declaration of State health policy. 72

12.The Department of Health, Education, and Welfare should develop national health goals, and within the limitations of these broad goals should allow the States maximum flexibility 115

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to developtheir health plans; oncesuch health plan is in effect, HEW shouldrequire conformitywith the established objectives and priorities as acondition to the receiptof both health servicesand facilities grants. 74

13.A State healthplanningcouncil:should be established in each State to help setgoals, plan programs,determine priorities, and allocate resources,including interrelation of programs forhospital construction;heart, cancer, and stroke; mental healthand retardation; andother relevant activities. 75 capable of 14.There should be astrong health department giving le-ade-r-ship_and_dixectionto the total healtheffort in each State.Model legislationshou1d be prepared to guide States indeveloping such departments. 76 make it essential 15.The growing demandsof health programs that a pertrianent andwell financed planning,development, and evaluation unitbe an integral partof the State health department. -78 responsible State healthofficer appointed 16.There should be a 79 by and serving atthe pleasure of theGovernor in each State. partnership with 17.State health agenciesshould broaden their all the health resourcesin thr State, includingmedical and other professionalschools; a wide varietyof groups should be involved in Statehealth planning andin developing a comprehensive system ofpersonal and environmental health services. 80 18. HEW should seekamendment to the Medicaidprogram (Title X[X) to makespecific the State health agency responsible for the1-iealth aspects of this program (health goals, scopeof medical benefits,standards, relationships with providersof health care,utilization control, and evaluation). EC 116

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19.The "single State agency" requirement should be modified in order to allow States to combine the skills andresources . of several agencies'into a coordinated State effort, subject to the approval of the alternate arrangement by the Secretary of HEW. 84 20. The Governors and their health agencies should initiate and negotiate interstate compacts and other cooperative arrangements with neighboring States in order that effective action may be brought to bearupon health problems affecting interstate areas. HEW should encourage such interstate cooperation and render fin-a-nei-a-l-s-uppo-rt-t-o-t-h-e-h-e-a-Ith-p-rog-ra=-0f-inte-rsrate agencies.Legislation should be sought from the Congress granting advanced consent to interstate compacts for the purpose of public health planning and health education. 86 Strengthening the Federal Health Partner

21.The Department of Health, Education, and Welfare must develop its capability for formulating national health goals specific in nature, clear in statement, and includinga plan of sequential steps and a schedule to guide implementation; these goals should be considered by the President and submitted to the Congress for approval and enunciation as a declaration of National health policy. 90 22. HEW should provide ample resources for research and stimulate demonstrations to devise new systems and methods for the delivery of health services to people. 92 23.A strOnger and better integrated organizational focus for health activities of the Federal Governmentmust - be created; this should take the form ofa subsidiary "Department of Health" within the Department of Heallh, Education, and Welfare. 93 24. Within the proposed subsidiary Department of Health, greater provision should be made for leadership and for funding in the field of environtywntal health than is now apparent 96 MW.....`,

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25. A Federal Interagency HealthCouncil should be established to better coordinatehealth activities among Federal agencies; the Council should consist of thehead (or deputy head) of each of the agencies with sizable health programsand should meet regularly under the chairmanshipof the proposed new .. 'Secretary of Health. 98 26. 0E0 health demonstration projects should betransferred to HEW administrationafter they have proven their worth by three to five years of successful operation. 99 27. HEW should take steps to develop strongerRegional Offices._Substantially greate.r authority for coordination .._. and decision making should be delegated tothe HEW Regional Directors; each Regional Directorin turn should be able to depend upon specialistsfor assistance in the direction and coordination of activitieswithin each region. 100 The following steps should be taken: (1) Authority for the approval or disapprovalof comprehensive State health plans, and amendments to such plans, be delegated tothe Regional Directors, with the proviso that State governments can appeal adversedecisions to the Secretary of HEW. (2) Greater authority to effect coordination among related programs at the regional level,including authority to employ and reassign personnelwithin the region, be delegated to Regional Directors. (3) A firm practice be initiated by theSecretary of HEW that neither he northe commissioners of HEW agencies will act on requests from State orlocal governmental officials without consulting with the Regional. Director. (4) The Regional Director be directed to plan andmake regular visits with Governors and with the mayorsof major cities to discuss relevant HEW activities, 118

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including health matters, so that theGovernors and mayors may develop fullerconfidence in the Regional Directors, and may be expected todeal with them first more often than in thepast.

(5) Contingency funds be provided sothat each Regional Director (without approvalof specific actions at headquarters) may assistStates in emergencies and may stimulateinnovative projects. (6) The FDA districts be realigned to relatebetter to other health activitiesand to function under the HEW Regional Director,insofar as that is practicable.

28.Prevailing practices for the administrationof grants to the States must be simplified and made moreflexible to reduce in the future the confusionand distortion of programs caused bythe wide variations in these ratios. 103 The following steps should betaken:

(1)The principle of a broad healthservice formula grant, established under thePartnership in Health Act, should be extended to includethe consolidation of other appropriate categorical health grants.If the health service formula grant cannotbe so extended, then the States should beauthorized to transfer a portion of the funds availablefor any one category of healthservices to meet other needs, up to an amount approved by theSecretary. (2) Where project grants are made, up to20 percent of the total should be made broadlyavailable to improve the administration and pi:ovisionof basic support services requiredeffectively to undertake the special program, such aslaboratories, generalized public health nursing, overallplanning and evaluation, and comprehensivehealth centers. -

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(3) Greater uniformity should be establishedin Federal- State matching ratios to reduce inthe future the _ confusion and distortion of programs caused bythe wide variations in these ratios. (4) Using the precedent already set in welfare grants, under which $202 million are made availableannually for the administration of welfare activitiesby State and local governments, HEW shouldmake provision for also sharing, on a 1:1 matching basis,the administrative costs of State and local healthagencies.I HEW should require as a condition to thereceipt of such grants for administrative costs,conformance -to the objectives and-standards-ofthe comprehensive State health plan. (5) A mechanism should be established tofacilitate project grants for developing and providingdemonstrations of improved systems of organizing and providinghealth services (e.g., group practice, contracts withprivate groups for publicservice), and for development of environmental control programs on a "problemshed" basis (including interstate and regionalprojects). (6) Finally, we suggest (a) that grants be used toinduce States to establish performance standards,and (b)in evaluating State and local performance,such standards be increasingly used as yardsticks ofaccomplishment (rather than financial accountability alone). 29. A major effort is needed to increasethe national pool of skilled health manpower -- doctors, dentists,engineers, nurses, and all types ofparamedical personnel. 106 The following steps should be taken: (1) Devise for use in health agencies throughout the country, new approaches to the betterutilization of the existing limited supply of trained health

IEstimated Federal share for administrative costsfor FY 1967. -

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Page manpower, under the leadership of the new PHS Bureau of Health Manpower. Such approaches would include the use of paramedical personnel in place of physicians; the use of automated techniques to minimize the number of nurses, technicians, and others required; the extension of group practice; and theuse of contract relationships to utilize the services ofnon- governmental professional health personnel in meeting especially urgent needs. (2) Expand the proposed "Health Service of the United States" (or the Commissioned Corps of the Public Health Service if it is not succeeded by the He alth- Service) so that qualified officers may be deployed as needed to assignments in any Federal, State, or local agency.This expansion should permit qualified officers of the Health Service to provide needed health services in areas lacking essential health facilities and personnel,even as the National Teacher Corps provides qualified services where children otherwise would be deprived of adequate education.

(3) Make full use of thenew Personnel Interchange provisions of PL 89-749 to createa vigorous cadre of health planners and administrators at Federal-State-local levels.The Act broadens the Secretary's authority to detail Federal health workers to State and local governments; it enables the transfer of competent personnel in one community to another in need of assistance; and finally it enhances Fedeial health planning and administration by bringing in hybrid vigor from those experiencedon the firing line. 121

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in (4) EncourageState governmentsto make careers health services moreattractive; this the public salaries, will requirethe provisionof competitive the promotionof occupationaland interdisciplinary mobility throughplanned staffdevelopment, and the facilitationof the movementof personnel between Federal,State, and localagencies. The Division of StateMerit Systemsshould Department's jurisdictions, as extend technicalservices to local well as toStates, forimprovement ofpersonnel administration andfor thedevelopment ofpractical measures tomeet theseobjectives. mor-e-OrallS---- (5) Establish aloan program toinduce NationTs ablest youngpeople to enterthe health professions. Such aloan programshould be designed gracluate students to inducehigh school,college, and to undertaketraining for thehealth professions, to becomephysicians,engineers, including preparation people accepting and nurses.The loans madeto young be forgivenafter a serviceperiod this aid should State, (five to sevenyears) in adesignated Federal, or localhealth agency. vocational andhigher educationprograms (6) Expand the personnel for thehealth to traintechnical supporting services which arecarried on by theOffice of Education. there shouldbe a generalexpansion of career In addition, programs guidance, studentaid, andteacher education supported by theOffice of Educationwith appropriate emphasis on thehealth fields. PHS "COSTEP"summerinternship program (7) Expand the and valuable work to provideearly studefit exposure engineers,physicians, andother vro- experience for in fessionals who maymanifest interestin a career health wo rk . -

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(8) Establish a Health ServiceEducation Institute within the Department ofHealth to provide specialized training (e.g.,health planning and administration) not available elsewherefor all members of the National HealthCareer Service and among State and localhealth personnel.The training program of theCommunicable Disease Center's Epidemic IntelligenceService has done more than anysimilar effort, within or without the government, to attract youngphysicians -- and future leaders -- tothe health field.This kind of program should beestablished in other health fields. (9) Develop and expand theinstruction and research iri preventive and communityhealth services now offered in many medical schools.The development of such services deserves the samekind of support and emphasis currently given toclinical services.

(10) Establish additional graduateschools of public health. A major part of theneed for more trained public health personnel is in the majormetropolises; it will be desirable that theadditional schools be established in these centers.The existing system of grant support should be revisedto keep the present schools at thdirhigh level of performance while developing additional schoolsin major areas where none now exist.

.. 123 Appendix A Secretary's Advisory Committee onHEW Relationships with State HealthAgencies

Chairman Dr. John J. Corson,Consultant

Members Dr. Leona Baumgartner,Visiting Professor, Schoolof Medicine, Harvard University, Boston,Massachusetts

; Director ;Institute 43f-Lawand_Covernment,___ UnivPrsity of Georgia, Athens,Georgia Mr. William G. Colman,Executive Director, AdvisoryCommission on Intergovernmental Relations,Washington, D. C. Dr. William J. Peeples,Commissioner of Public Health,Maryland Department of Health,Baltimore, Maryland Mr. Edmund F. Ricketts,Lecturer in Government,Miami University, Oxford, Ohio Dr. Harold M. Visotsky,Director, State Departmentof Mental Health, Chicago, Illinois Mr. Paul D. Ward,Health and WelfareAdministrator, State of C9.1ifornia, Sac rame nto, California Dr. Alonzo S. Yerby,Professor and Head, Departmentof Health Services Administration, Harvard Schoolof Public Health, Boston,Massachusetts Staff and Task Force Members

Staff Director Dr. P. Walton Purdom,Director of Graduate Programin Environmental Engineering and Science, DrexelInstitute of Technology,Philadelphia, -Pennsylvania 124 Staff Associate Dr. Frederick Nevins, Sanitary Engineer Director, Office of the Chief, Division of Environmental Engineering and Food Protection, Public Health Service .. v Task Force Members

.. Food and Drug Administration . - c, Mr. J. K. Kirk, Assistant Commissioner for Operations 0 Mr. Bill V. McFarland, Deputy Director, Office of Federal-State Relations Office of Economic Opportunity Mrs. Ruth Hanft, Program Analyst, Health Division, Community Action Program Office of Education Mr. John R. Ludington, Deputy Associate Commissioner, Bureau of Adult and Vocational Education Miss Helen K. Powers, Chief, Health Occupations Unit, Division of Vocational and Technical Education, Bureau of Adult and Vocational Education Public Health Service Dr. Eugene H. Guthrie, Assistant Surgeon General for Operations Mr. William M. Hiscock, Deputy Chief, Division of Public Health Methods, Office of the Surgeon General

Social Security Administration - Mr. Karl W. Bredenberg, Deputy Assistant Commissioner, Field Mr. Roger J. Cumming, Deputy Director, Community Services Staff, Office of the Commissioner ape

125

Vocational RehabilitationAdministration

. Mr. Joseph Hunt,Assistant Commissioner for Program Services

., WelfareAdminikratiOn Mr. John J.Hurley, DeputyDirector, Bureau ofFamily'Services 1 Dr. Arthur J.Lesser, DeputyChief, Children's Bureau

. I 127 . Appendix B

Agencies and Profess'unalOrganizations Contacted

t American Academy ofGeneral Practice American Associationfor Hospital Planning American Associationfor Maternal and Child Health American Associationfor Rehabilitation Therapy American Association ofHomes for the Aging American Association ofMedical Clinics American Association ofPoison Control Centers American Cancer Society American College HealthAssociation American College ofApothecaries American College ofHospital Administrators American Dental Association American Diabetes Association American Dietetic Association American Geriatrics Society American Heart Association American Hospital Association American Industrial HygieneAssociation American Institute ofArchitects American Medical A.ssociation American Nurses' Association American Nursing HomeAssociation American PharmaceuticalAssociation American PsychiatricAssociation American Psychological Associa-tion American Public HealthAssociation American Public WelfareAssociation American School HealthAssociation American Society for PublicAdministration American Society ofPlanning Officials American Standards Association American VeterinaryMedical Association American Water WorksAssociation Association for Physical andMental Rehabilitation Association for the Aid ofCrippled Children Association of AmericanMedical Colleges Association of Food and DrugOfficials of the U.S. 128

Association of Rehabilitation Centers Association of State and Territorial Health Officers Blue Cross Association Conference of State and Territorial Hospital and Medical Facilities and Survey Construction Authorities Conference of State and Territorial Mental Health Authorities Council of Social Work Education Council .of State Administrators of Vocational Rehabilitation Council of State Governments Federation of State Medical Boards of the United States Group Health Association of America Joint Council to Improve the Health Care of the Aging National Academy of Sciences--National Research Council National Association for Mental Health National Association of Blue Shield Plans National Ascociation of Boards of Pharmacy National Association of Sanitarians National Association of Social Workers National Association of State Departments of Agriculture National Conference on Social Welfare National Council of State- Public Welfare Administrators National Council on Aging National Education Association National Health Council National Health Education Committee National League for Nursing National Medical Association National Rehabilitation Association National Safety Council National Social Welfare Assembly National Society for Crippled Children and Adults National Tuberculosis Association The National Foundation United Community Funds and Councils of America 129

AssociationContacts

Mr. Noble J.:Swearingen Director,Washington Office American PublicHealth Association

Committee On November4, 1966, membersof the Advisory following Directorsof the AmericanPublic met with the of State and Health Associationand the Association Territorial Flea1th Officers: Dr. Ernest L.Stebbins Dr. LesterBreslow Dr. BernardBucove Dr. JohnHanlon Dr. GeorgeJames Dr. BerwynF. Mattison Dr. CecilSheps Dr. MiltonTerris Dr. Myron E.Wegman 131 Appendix C Officials of the Federal Government Consulted by the Advisory Committee or Its Representatives

Department of Health, Education, and Welfare Mr. Dean W. Coston, Deputy Under Secretary Dr. Philip R. Lee, Assistant Secretary for Health and Scientific Affairs Dr. George A. Silver, DePuty Assistant Secretary for Health and Scientific Affairs Mr. Donald F. Simpson, Assistant Secretary for Administration-. Mr. John D. R. Cole, Deputy Assistant Secretary for Administration Mr. Edmund Baxter, Director, Office of Field Coordination Mr. James C. CaEison, Field Administration Representative, Office of Field Coordination Mr. Albert Henry Aronson, Director, Division of State Merit Systems Public Health Service Dr. William H. Stewart, Surgeon General Dr. Leo J. Gehrig, Deputy Surgeon General Dr. Eugene H. Guthrie, Assistant Surgeon General for Operations Mr. M. Allen Pond, Assistant Surgeon General for Plans Mr. Albert H. Stevenson, Chief Sanitary Engineering Officer k: Mr. J. Robert Painter, Representative for PHS Regional Activities Dr. William L. Kissick, Chief, Division of Public Healp Methods t, I Mr. William M. Hiscock, Deputy Chief, Division of Public Health Methods Bureau of Medical services Dr. Carruth J. Wagner, Chief Dro Andrew P. Sackett, Deputy Chief p. Mr. Jerrold Mo Michael, A ssoci at e Chief for Prog-cam Mr. Saul R. Rosoff, Executive Officer Dr. Kazumi Kasuga, Deputy Chief, Division of Indian Health 132

Bureau of State Services. .. Dr. Richard A. Prindle, Chief

Dr. Paul 0. Peterson, Acting Deputy Chief . Dr. Philip Broughton, Consultant, Office of the Bureau Chief Mr. Hershel Engler, Special Assistant to the Bureau Chief for Regional Office Liaison Miss Evelyn Flook, Chief, Research Grants Branch, Division of Community Health Services t Dr. Joseph A. Gallagher, Deputy Chief, Division of Hospital, and Medical Facilities Mr. Wesley Gilbertson, Chief, Office of Solid Wastes Mr. Malcolm C. Hope, Acting Chief, Division of Environmental Engineering and Food Protection Mr. Vernon G. MacKenzie, Chief, Division of Air Pollution Dr. James D. Wharton, Chief, Division of Community Health Services Mr. Earl 0. Wright, Chief, Office of Grants Management Division of Regional Medical Programs, National Institutes of Healt h Dr. Robert Q. Marston, Chief Mr. Stephen J. Ackerman, Chief, Planning and Evaluation Branc h National Institute of Mental Health Dr. Stanley F. Yolles, Director Dr. Phillip L. Sirotkin, Deputy Director Mr. George M. Kingman, Assistant Executive Officer Food and Drug Administration Dr. James L. Goddard, Commissioner Mr. Winston B. Rankin, Deputy Commissioner Mr. James C. Pearson, Director, Office of Federal-State Relations Mr. Bill V. McFarland, Deputy Director, Office of Federal-State Relations Mr. Glenn W. Kilpatrick, Office of Federal-State Relations Mr, Frank D. Clark, Deputy Director, Bureau of Education and Voluntary Compliance 133

Social.Security Administration Mr. Robert M.Ball, Commissioner Miss Neota Larson,*Director, CommunityServices Staff, Office of theCommissioner Mr. Roger J.Cumming, Deputy Director,Community Services Staff, Officeof the Commissioner Mr. Arthur E.Hess, Director,Bureau of HealthInsurance Mr. BernardPopick, Director,Bureau of DisabilityInsurance Vocational RehabilitationAdministration Miss Mary E.Switzer, Commissioner Mr. Joseph Hunt,Assistant Commissionerfor Program Services Mr. James F. Garrett,Assistant Commissionerfor Research and Training Mr. Thomas J.Skelley, Chief, Divisionof Disability Services Welfare Administration Dr. Ellen Winston,Commissioner

F's Bureau of FamilyServices Mr. Fred H.Steininger, Director Mr. John J. Hurley,Deputy Director Mr. Carel E. H.Mulder, AssistantChief, Division of Medical Services Childrenls Bureau Mrs. Katherine B.Oettinger, Chief Dr. Arthur J.Lesser, Deputy Chief Dr. Louis Spekter,Director, Division ofHealth Services Mr. Ralph Pardee,Assistant Chief,Administrative Methods Branch

*Deceased - 1 134 e 4 DHEW Region 1, Boston, Massachusetts Mr. Walter W. Mode, Regional Director Dr. Mabel Ross, Regional Health Director Dr. Harriet Felton, Ch,ildrenIs Bureau Representative Mr'. Frank Tetzlaff, Associate Regional HealthDirector DHEW Region IV, Atlanta, Georgia Mr. William J. Page, Jr., Regional Director Dr. Hugh Cottrell, Regional Health Director Dr. John Thomas Leslie, Regional MedicalDirector, Children's Bureau DHEW Region IX, San Francisco, California Dr. R. Leslie Smith, Regional Health Director

Communicable Disease Center, PHS, Atlanta,Georgia Dr. David J. Sencer, Chief Dr. John R. Bagby, Deputy Chief Mr. Bill Watson, Executive Officer

'S.',...... , 135

Bureau of the Budget Mr. Irving Lewis, Chief, Divisionof Health and Welfare Mr. Mark Alger, Division of Healthand Welfare , Mr. Walter Smith, Division ofHealth and Welfare Mr. Milton Turen, Division ofHealth and Welfare t . Department of Housing and UrbanDevelopment Mr. Ralph Taylor,Assistant-Secretary for Intergovernmental Relations Mr. Richard Gerson, ActingDirector, Urban Policy Coordination Office of Economic Opportunity Miss Lisbeth Bamberger, Assistant Director,Health Division, Community Action Program Mrs. Ruth Hanft, Program Analyst,Health Division, Community Action Program Rogers' Subcommittee onInvestigationof the Department of Health, Education, and Welfare, Committee onInterstate and Foreign Commerce, U. S. House of Representatives Mr. Jonathan W. Sloat, Chief Counsel Mr. Norman E. Holly, Chief Economist Mr. Daniel J. Manelli, Attorney 137 Appendix.D

Officials of StateGovernments Consultedby Members . orRepresentatives of theAdvisory Committee

s Arkansas E. Faubus,Governor Honorable Orval Governor Mr. ClarenceC. Thornborough,Secretary to the State HealthOfficer Dr. J. T. Herron, Officer and : Dr. Edgar J.Easley, AssistantState Health Director, Bureauof Local HealthSr.irvices Mr. Marvin L.Wood, Director,State WaterPollution Control Commission Mrs. LucyUterbock, Secretaryand Director,State Cancer Commission Mr. A. W.Ford, Commissionerof Education Mr. E. RussellBaxter, Director,Arkansas Rehabilitation Service Mr. A. J. Moss,Commissioner ofWelfare

California Honorable EdmundG. Brown,Governor Mr. Paul D.Ward, Healthand WelfareAdministration. Dr. LesterBreslow, Directorof Public Health Mr. Frank M.Stead, Chief,Division ofEnvironmental Sanitation Mr. James W.Bell, Chief,Bureau of Foodand Drug of EnvironmentalSanitation Inspections, Division Sanitation, Division Mr. John A.Maga, Chief,Bureau of Air Sanitation of Environmental Health, Division Dr. John M.Heslep, Bureauof Radiological Sanitation of Environmental of Dr. Saylor,Waste ManagementProject, Division Sanitation Environmental of Dr. TheodoreMontgomery, AssistantChief, Division Services Preventive Medical Division Mr. John R.Derry, Chief,Bureau of Hospitals, / of PreventiveMedical Services t. Dr. Robert R.Johnson, ActingChief, Bureau ofOccupational- of PreventiveMedical Services Health, Division Children Dr. Charles R.Gardipee, Chief,Bureau of Crippled Services, Divisionof PreventiveMedical Services Mr. Barnes,Division ofPreventive MedicalServices 138 California Mr. Kirkpatrick, Division of Preventive Medical Services Dr. William A. Longshore, Jr., Chief, Division of Community Health Services Dr. James T. Harrison, Assistant Chief, Division of Community Health Services Dr. C. Henry Murphy, Regional Medical Coordinator, Division of Community Health Services Mr. Robert G. Webster, Chief, Division---- of Administration Dr. James V. Lowry, Director, State DepartMent of Mental Hygi.ene Mr. Warren Thompson, Director, State Department of Rehabilitation Mr. J. M. Wedemeyer, Director, State Department of Social Welfare Mr. Fernando Torgeson, Health and Medical Care Dr. Harry Brickman, Director, Los Angeles County Department of Mental Health Dr. Donald Schwartz, Deputy Director, Los Angeles County Department of Mental Health Mr. William A. Barr, Superintendent of Charities, Los Angeles County Dr. John E. Affeldt, Medical Director, Department of Charities, Los Angeles County Dr. Harold D. Chope, Director of Public Health and Welfare, San Mateo County Dr. Henrik Blum, Health Officer, Contra Costa County Connecticut Honorable John Dempsey, Governor Dr. Franklin M. Foote, Commissioner of Health Dr. Harold S. Barrett, Deputy Commissioner of Health Dr. Wilfred Bloomberg, Commissioner, State Department of Mental Health Mr. John F. Harder, Deputy Commissioner, Department of Welfare Dr. Ryan, Medical Division, Department of Welfare Dr. James S. Peters, Director, Division of Vocational Rehabilitation Mr. Attilio R. Frassinelli, Commissioner, State Department of Consumer Protection 1.39

Connecticut Mr. Herbert P. Plank, Chief, Drug Division, State Department of Consumer Protection Mr. Raymond L. Dunn, Director, Pharmacy Division, State Department of Consumer Protection Mr. George J. Conk ling, Commissioner, State Department of Finance and Control Georgia Honorable Carl E. Sanders, Governor Mr. Frank C. Smith, Director, Office of Administration Mr. Rufus F. Davis, Budget Officer Dr. John H. Venable, Director, Department of PublicHealth Dr. Elton S. Osborne, Deputy Director, Department ofPublic Health Dr. Addison M. Duval, Director, Division of Mental Health Miss Diane C. Stephenson, Project Officer Mr. James M. Sitten, Director, Medical Facilities Branch Dr. Oscar F. Whitman, Director, Office of Local Health Mr. Raymund Summer lin, Director, Food Division, State Department of Agriculture Mr. Frank Stancil, State Department of Agriculture Mr. McCullorn, State Department of Education Dr. T. 0. Vinson, Health Officer, DeKalbcand Rockdale Counties, Decatur, Georgia Mr. A. P. Jarrell, Office of Rehabilitation, Milledgeville,Georgia Mr. John Prickett, Office of Rehabilitation, Milledgeville,Georgia Mr. J. L. Hise, Office of Rehabilitation, Milledgeville,Georgia Mr. Wallace Petty, Office of Rehabilitation, Milledgeville,Georgia Mr. W. A. Crump, Office of. Rehabilitation, Millecigeville,Ge orgia Idaho Honorable Robert E. Smylie, Governor Mr. Robert McCall, Assistant to the Governor Dr. Terrell 0. Carver, Administrator of Health Dr. F. 0. Graeber, Deputy Administrator of Health Mr. Richard Adams, Director, Hospital Facilities Division Mr. Jack Steneck, Director, Community Mental HealthDivision Mr. Vaughn Anderson, Director, Engineering andSanitation Division Dr. John Marks, Chief, Maternal and Child Health Sectionand Superintendent, Idaho State Scho,ol and Hospital 140 Idaho

Mr. Lloyd Young, Director, Vocational RehabilitationService Mr. William Child, Commissioner, Department of Public ssistance

Iowa Honorable Harold E. Hughes, Governor Dr. Arthur P. Long, Commissioner of Public Health Mr. Paul H. Crews, S'ecretary, Pharmacy and Narcotics Board Mr. Arthur Downing, Chairman, Social Welfare Mr. Ross Wilbur, Director, Division of Family and Children Services Dr. John C. MacQueen, Director, State Services for Crippled Children Dr. Sidney S. Kripke, Assistant Director, State Services for Crippled Children Mr. Jerry Starkweather, Director, Vocational Rehabilitation Dr. James Cromwell, Mental Health Board of Control Mr. Verne Kelley, Mental Health Authority Maryland Honorable J. Millard Tawes, Governor Mr. Henry G. Bosz, State Department of Budget andProcurement Dr. William J. Peeples, Commissioner, State Department ofHealth Mr. Clemens W. Gaines, Assistant Commissioner forAdministration Mr. Francis S. Balassone, Chief, Division of Drug Control,State Department of Health Dr. Isadore Tuerk, Commissioner, State Department ofMental Hygiene Mr. Raleigh C. Hobspn, Director, State Department of Public Welfare Mr. Dennis A. Alessi, Staff Specialist, MarylandState Planning Board Mr. R. Kenneth Barnes, Assistant State Superintendent,State Department of Education, Division of Vocational Rehabilitation Mr. Merl D. Myers, Division of Vocational Rehabilitation Mr. J. Leo Delaney, Division of VoCational Rehabilitation Mr. Robert L. Burton, Division of VocationalRehabilitation 141

Michigan Honorable George Romney, Governor Mr. Herb DeJonge, Administrative Assistant to Governor Romney Dr. Albert E. Heustis, State Health Commissioner Dr. John L. Isbister, Chief, Bureau of CommunityHealth Dr. G. D. Cummings, Director of Laboratories Mr. Bernard Bloomfield, Occupational HealthDivision Mr. Edwin Rice, Consultant, Health, PhysicalEducation, and Recreation, Department of Education Dr, R. Gerald Rice, Director, Michigan StateCrippled Children's Commission Mi% Bernard Houston, Director, Departmentof Social Services Dr. Robert A. Kimmich, Director, Departmentof Mental Health Mr. Ralf A. Peckham, Assistant Superintendent,Vocational Rehabilitation, Department of Education

Pennsylvania Honorable William W. Scranton, Governor Mr. Mc,Jugh Brackbill, Budget Secretary Dr. Charles L. Wilbar, Secretary of Health Mr. Charles L. Eby, Director ofVocational Rehabilitation IvIr. Max Rosenn, Secretary of PublicWelfare Mr. L. H. Bull, Secretary of Agriculture Dr. Joseph Wunsch, Regional MedicalDirector, Region VI, West Reading, Pennsylvania Dr, Norman R. Ingraham, Health Commissioner,City of Philadelphia Dr, Lear, Health Department, Cityof Philadelphia Dr. Polk, Health Department, City ofPhiladelphia 4).- Mro Jackson, Health Department, Cityof Philadelphia Mr. Randolph E. Wise, Directorof Public Welfare, City of Philadelphia

* U. S. GOVERNMENT PRINTING OFFICE : 1967 0 - 246-122 s