All of the same reasons that prevent farm people from participating in other programs and in acquiring other services apply in this instance as well. Farm people are scattered over large distances and their energies and attention are so thinly spread that it is difficult for them to have an impact on something as complicated as areawide health planning. Also, they are almost always outnumbered and often are, as a result, powerless to compete for the attention of health planners, health care providers or government agencies.

The National Farmers Union, therefore, urges that the requirement that members of HSA boards be broadly representative be enlarged to say that HSA boards must include approximately the same proportion of rural people as in the population in the planning areas. We believe this requirement of rural representation should apply to providers as well as to consumers, as far as possible, because providers in rural areas are often ignored in the same way that rural health consumers are ignored.

We also urge you to accept a change that would provide that only consumers shall vote for consumer members of HSA boards and that providers vote for providers. This change would insure that board members truly represent the views of those they are elected to represent.

The requirement that over half of the members of HSA boards be consumers should be retained and the minimum increased to 60 percent. The proper role for providers is as advisers, and consumers should play the dominant role in deciding what services they want and what they have to pay for those services.

We do not believe that elected officials should be included on HSA boards at the expense of consumers. In many cases, elected officials are also providers. Also, both providers and elected officials are usually located in the urban areas. If the number of consumers is reduced, there will be less possibility for rural people to be represented and heard.

We also propose that the manner in which members of HSA boards are selected should be uniform and should be included in the law or in regulations.

We have found that differences in the way HSA board members are selected to be confusing to consumers wishing to participate and a hindrance to public education. The Farmers Union in some states has been carrying on an effort to encourage its members to take part in the health planning process. One of the states where Farmers Union has taken this active role is North Dakota. There are three HSAs in that state, two of them including part of the state of Minnesota. The selection process in each of these three HSAs is different and the North Dakota Farmers Union finds it very difficult to inform their members because of these quite major differences.

In one HSA, anyone that comes to the annual meeting may vote. In another, local governmental officials select representatives to attend the annual meeting and to vote. The third HSA in that state has a third method for selecting HSA board members. Neither the Farmers Union nor state health officials can have much success in educating citizens on how to participate because no channels of communication exist that do not cross the boundaries of the HSA areas. This variation also makes it difficult to monitor the HSAS or the press to report their activities.

Only thirteen states have a single HSA within their boundaries and all others have a similar confusion as to the operation of their various HSAs.

Our state Farmers Union organizations find that retired nurses and doctors or other providers have been elected as consumer members of HSA boards and that they consistently represent the views of providers rather than consumers. We believe they should be elected as

providers or in some classification within the provider group.

One of the serious problems of planning rural health services is the large geographic areas included in some Health Service Areas and the geographic barriers that isolate many rural areas. Although there may be no need for sub-area planning and sub-area councils in urban or metropolitan areas, it could be an important element in planning for large rural HSAs or in areas of geographic isolation. We believe these sub-area planning units should be encouraged in appropriate HSAs.

We are very pleased that your committee has proposed to provide more funds to HSAs in rural areas by increasing the per capita funding as the population goes down in numbers. We would also encourage you to provide additional funds to HSAs with functioning sub-area units.

Whether that additional funding goes to HSAs which have large geographic areas or barriers, as the Clark-Leahy amendments propose, or to HSAs with functioning sub-area units, it would be a motivation for increased use of smaller planning units where they are needed.

We do not, however, propose to transfer decision-making authority to the sub-area councils, but only to bring local rural people into the planning process.

Rural people were alarmed last year when National Guidelines for Health Planning were issued under the planning act and were fearful that it would mean the closing of many small rural hospitals. Future guidelines should take into account the different needs of rural areas and there should be an effort to seek information and comments before they are issued.

There are excess facilities in many areas and it is to be hoped that the planning process will in time give rural people the support

they need in determining what facilities they actually need and what services they can rightfully expect. We think the health planning law should direct the Secretary to give rural areas this kind of support.

We also urge that rural interest be more fairly represented on the National Council on Health Planning and Development and on the Statewide Health Coordinating Council. We think the Statewide Councils should have rural members in proportion to their population in the state. We support the Clark-Leahy amendment that would make the Assistant Secretary of Agriculture for Rural Development an exofficio member of the National Council.

Finally, we believe there is a great need for public education about the health planning process and the responsibilities and authority of the health systems agencies. We recommend that a part of the budget of each HSA should be devoted to general public information. There seems to be little or no effort in that direction today, but the system will not work effectively, we believe, without public awareness and support.

On February 2, 1978, the Senate Subcommittee on Health and Scientific Research heard testimony on behalf of Legal Services Clients regarding the Health Planning Ammendments of 1978 (S. 2410). The testimony was presented by the Atlanta Legal Aid Society, Georgia Legal Services Program, New Orleans Legal Assistance Corporation, and the National Health Law Program. Attached to the testimony were statements from three individuals who made references to this agency. Since these statements contained numerous errors of fact and assorted inaccuracies, misstatements, distortions, and fabrications, the intent of this letter is merely to correct the record of the hearings by providing examples to the committee of some of these factual inaccuracies. Additional inaccuracies in the testimony can be documented if the committee would like to have it.

Page 1 of the combined statement of Biskind, Brown, Ellin, Chavkin, Schneider, and Stolier, in the third paragraph concludes that Willie Mitchell "has seen the consequences of decisions made by improperly constituted HSA boards... (emphasis added). This statement is made as an unsubstantiated conclusion of fact and has not and cannot be proven.

In the same paragraph in the following sentence, again the statement is made as fact that in Mr. Mitchell's hometown, "unrepresentative boards (emphasis added) have approved expansion of private institutions which offer little or no service to the surrounding poor and minority communities. Again, the term "unrepresentative" is an unsubstantiated conclusion. A more serious error, however, is the reference to approval of expansion of private institutions. Apparently, this refers to Newnan Hospital in Newnan, Georgia. Indeed, this institution did submit a capital expenditure

The Honorable Edward Kennedy
February 22, 1978
Page 2

application for expansion to this agency which was withdrawn
by the proponent prior to any final action by this agency's
Executive Committee. Therefore, this statement is factually
untrue. There are other unsubstantiated conclusions in this
first section of the testimony, but will not be mentioned
in the interest of brevity.

Page 34 of the testimony contains a statement by Dr. Daniel S. Blumenthal. In the last paragraph of page 35, Dr. Blumenthal fails to mention that the consumers who were nominated to this agency's Board of Directors in addition to being nominated by provider groups, also were nominated by such diverse groups as Community Action Agencies, County Commissioners, Area Planning and Development Commissions, Mayors, Chambers of Commerce, State Legislators, and other community groups.

At the top of page 37, Dr. Blumenthal discusses projects reviewed and rejected by this agency. It is difficult to understand why he chose the period April, 1977 to the present when this agency began conducting reviews in November of 1976, or four months after it began operations as a new HSA. Had

Dr. Blumenthal chose, he could have easily obtained the attached Project Review Report, dated January 5, 1978 which was distributed to the Board prior to its January 25, 1978 Board meeting. This report was available to Dr. Blumenthal had he made the effort to contact our offices for the latest project review data.

It should also be noted both in Dr. Blumenthal's statement and Mr. Presel's statement regarding references to CHAMP, that at CHAMP's organizational meeting, which was advertised as an open meeting, in fact was a closed meeting in which HSA staff members were called and told they would not be allowed to attend.

Mr. Mitchell's statement on page 44 again omits reference to the fact that Newnan Hospital withdrew its project prior to final action by this agency's Executive Committee. As a matter of fact, the Newnan Times-Herald article attached to Mr. Mitchell's statement quotes Mr. Robert Youngerman, this agency's Executive Director as saying that, "Newnan Hospital cannot exist forever serving a select clientele."

Mr. Pressel's statement begins on page 56 of the testimony. He was primary attorney for the plaintiff's in the Rakestraw litigation against the Georgia HSAs.* On page 57, Mr. Pressel

*Additional correspondence concerning the status of the Rakestraw suit will be forthcoming from the attorney's representing the Georgia HSAS, the Atlanta firm of Kilpatrick, Cody, Rogers, McClatchey, and Regenstein.