HEALTH PLANNING AMENDMENTS OF 1978 MONDAY, FEBRUARY 6, 1978 U.S. SENATE, SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH Washington, D.C. The subcommittee met, pursuant to notice, at 9:55 a.m., in room 4232, Dirksen Senate Office Building, Senator John H. Chafee, presiding pro tempore. Present: Senators Kennedy, Chafee, and Javits. Also present: Stuart Shapiro, M.D., professional staff member, Robert Wenger, J.D. counsel, David Winston, professional staff member and Polly Gault, professional staff member. Senator CHAFEE. Good morning, ladies and gentlemen. First of all, I would like to apologize for the lateness in starting. I like to start these things on time, but through Allegheny Airlines and intemperate weather, I have been circling overhead. I can report for anybody who is planning to go to the Northeast, that all airports are closed north of Baltimore, and everything seems to be running pretty late. I have a statement here from Senator Kennedy, dealing with the Health Planning Act and the amendments, which I will insert in the record at this point. [The following was received for the record:] OPENING STATEMENT OF SENATOR EDWARD M. KENNEDY Senator KENNEDY. I am pleased to open the last day in this series of hearings on S. 2410, "The Health Planning Amendments of 1978" which I introduced along with Senators Schweiker, Javits, Randolph, Pell, and Chafee. These amendments build on and strengthen the "National Health Planning and Resources Development Act of 1974," and should help us achieve a rational system of health planning so that every American will be able to receive quality health care at a reasonable cost. In draftng the bill, I adhered to a basic belief that the planning process can work and thus have attempted to strengthen this processnot disrupt it. The past three years have been full of turmoil for those involved in planning for health care. It has taken more time than we anticipated for the Health Systems Agencies, the State Health Planning and Development Agencies, and the State Health Coordinating Councils to get themselves fully organized and functioning. Some of the working relationships between local and State agencies are still nuclear. The bill that was introduced has purposely not mandated changes in board composition of the HSA's or the SHCC's for fear of slowing down the process further. Unless there are very compelling reasons to tamper with those boards, I'm not inclined to disrupt what have become, in most instances, stable relationships. The bill contains a number of provisions that will strengthen the role of the consumers. The requirements of the State Health Plan have been significantly strengthened and once approved by the consumer dominated SHCC, this plan will be the foundation on which certificate of need decisions are based. This will foster closer coordination in the planning and review process and should help reduce the past arbitrariness of many certificate of need decisions. This plan includes a special requirement that should strengthen HMO's. Nationwide it has been estimated that we have as many as 100,000 unneeded hospital beds costing well over $2 billion a year. In order to equitably address this concern, the bill establishes a program that encourages hospitals to merge, close or convert unnecessary facilities and services. This would be an entirely voluntary program and includes incentive payments to encourage planning, development, and delivery of long-term care services, and other alternatives to hospital care. Any such program must also address the impact of such programs on the employees of hospitals. At this hearing, I also hope to hear suggestions on ways to modify Title XVI of the Planning Law in order to provide funds to insure that there are adequate private care centers, out-patient departments and inpatient services in urban and rural poverty areas. There is no question in my mind that if planning is to work it must be generously funded. Without an adequate financial base, the local and state agencies will not be able to carry out their already extensive responsibilities. The bill provides this financial base. I would like to hear from the witnesses today their thoughts on the HSA's receiving financial support from insurance companies and other entities. I am hopeful that the witnesses today will discuss improvements in the planning process. The hearing record will remain open for written testimony through Feruary 28, 1978. Senator CHAFEE. Of course, we are delighted to have Senator Clark here, and again, I apologize to you, Senator, for holding you up. We will start right in with your testimony. STATEMENT OF HON. DICK CLARK, A U.S. SENATOR FROM THE STATE OF IOWA Senator CLARK. Thank you very much. I just drove in near the airport, and I am amazed that you would even land here. Senator CHAFEE. Well, they are stacked up, and I am not sure they are going to be landing very long. Senator CLARK. I thank you for this opportunity to speak about a particular aspect of health planning and resources development, most specifically the rural aspects. The issue of health planning is, of course, of great concern to our State, as it is to yours and others all across the country. In the past 2 years, the Senate Rural Development Subcommitteewhich I chair, as part of the Senate Agriculture Committee, of course has held extensive hearings on rural health care. And we have done this in various parts of the country. These hearings have led me to the conclusion that health planning can and should have a very critical impact on the medically underserved. Equal access to health care is, of course, the top priority of the Health Planning Act. It is essential, then, that we structure the planning process to accomplish that goal-especially as it relates to the unique health needs of rural people. Because I have a deep sense that the process is not working adequately to meet these needs, I come before you today with various proposals that we believe would strengthen the Health Planning Act. S. 2410 corrects many of the existing inequities in the Health Planning Act. It represents an important first step toward promoting adequate representation within the planning process, consumer education, and more efficient use of underutilized facilities. But there is more that we can do to fulfill the promise of the Act, in our judgment. The recent controversy over the national health planning guidelines demonstrates that the Act is not operating as it should. The rural community perceived them to be a direct threat to the existence of their hospitals. These guidelines were seen as a lack of good faith on the part of the Federal Government, because rural Americans felt that their needs and desires had been neglected. And I might add that I think much of it was misunderstanding, but I think there were also some very valid arguments, that were presented against those specific guidelines, and I think HEW became very much aware of that and made needed changes. Well, this kind of situation should not occur again. Until we restore the faith of rural Americans in the health planning process, the process itself cannot succeed. Now is the time to make the Planning Act more relevant and more responsive. The health planning process must recognize the distinct differences between urban and rural communities. The conditions of rural America are very special. For example, metropolitan areas have 150 patient care physicians per 100,000; nonmetropolitan areas have only 70. Almost 50 percent of our Nation's poor people are rural residents; 4 of every 10 older Americans live outside of metropolitan areas. Senator CHAFEE. I must say that these statistics amaze me. I was not aware that certainly regarding the poor, nor the older population Senator CLARK. It is amazing. And it is striking, when one remembers the population of people who live in metropolitan areas, compared to rural areas overall. These, I think, are examples and underscore how rural communities differ in terms of the availability of physician care, access to health services, and the level of care required. Thirty million Americans live in rural, medically underserved areas. We must no longer allow the health planning process to ignore these people. Even with the proposed changes contained in S. 2410, representation of rural interests at all levels of that process would still not be assured, in our judgment. Neither would there be adequate financial support for the health care systems agencies to allow them to plan, develop, and coordinate health services in rural areas at least, that is our judgment. To deal with these lingering problems, I am introducing today, with Senators Leahy and Anderson as cosponsors a package of six rural amendments to the Health Planning Act, and I will attach a copy to my statement. These are intended to build upon the efforts that you have begun, and of course, I ask this committee to consider them carefully, as I know you will, and to support those that you feel are worthy of support. The amendments focus upon national health planning guidelines, adequate representation of rural interests, and financial support for health planning in medically underserved areas. Let me speak about each one, just a sentence or two. First, national health planning guidelines must deal with issues unique to rural areas. Our amendment mandates special attention within the overall guidelines to the needs and concerns of rural people. These are not separate guidelines, obviously, but they are a consideration within the guidelines. Now, this amendment precludes the imposition of inflexible national standards on rural and medically underserved communities. In fact, in my judgment, if this amendment had been law, I am convinced that we could have completely avoided the recent small hospital controversy. Second, rural consumers of health care should be assured of representation on the National Council on Health Planning and Development-the body that advises and consults with the Secretary of HEW. Our amendment requires broader representation of population groups, including residents of nonmetropolitan areas, on the National Council, much as is required of the health systems agencies. Since the Department of Agriculture has major responsibility for rural development, this amendment also adds the Department's Assistant Secretary for Rural Development as an ex officio member of the National Council. I might say, in talking with the Assistant Secretary from time to time, they are very interested in the health area. Obviously, they have no jurisdiction over it. But they realize that rural development is quite incomplete without the health component. Our third amendment would assure adequate representation of the same groups on statewide health coordinating councils-in other words, representation on statewide, as well as the National Council. Fourth, the amendment that I consider most significant requires the development of subarea councils, which are smaller divisions of HSA's. The Secretary of HEW would be authorized to make grants to health system agencies for the development and operation of subarea councils. The size of the grant would be related to both the square mileage and geographical barriers within a particular health services area. This amendment would make sure that geographic isolation and barriers do not restrict active citizen participation in the health planning process. Subarea councils especially promote the involvement of rural people who have, up until now, sometimes been discouraged from participation. This amendment also requires health system agencies to consider subarea views in the planning process. It insures that interests at the local level will not be lost. And fifth, the funding mechanism for health system agency grants should include extra assistance for those areas with medically underserved populations. While S. 2410 increases the overall level of health system agency grants, we feel another increase is needed to accommodate the special planning requirements of medically underserved populations. And here, of course, we are not speaking just of rural areas, but of medically underserved urban and rural areas. Specifically, the amount of any grant should be increased by 10 cents per medically underserved person in the health service area. Needless to say, there is nothing automatic about that figure, but it seemed a reasonable one to us. And finally, our sixth amendment strengthens the S. 2410 provision requiring centers for health planning to develop consumer education packages. We think that is an excellent idea, but under this amendment, these centers would emphasize the needs again of the medically underserved. These six amendments embody the views of several organizations that are active in the cause of rural health care. I have received valuable input from a number of agencies-for example, the Appalachian Regional Commission, the Health Planning Council of the Midlands, the Iowa Health Systems Agency, Inc., the National Farmers Union, the National Rural Center, the National Rural Electric Cooperatives Association, Rural America, Inc., and the Department of Agriculture. All of these people, I know, are interested in these particular amendments. Finally, Mr. Chairman, like you, I look forward to the day when access to high quality health care is a fact for all Americans, rural and urban alike, rather than just a promise. And, I believe the adoption of these amendments will help to bring that day closer. Senator CHAFEE. Thank you very much, Senator, for that excellent statement, and certainly, we will look forward with the greatest of interest in reviewing the six amendments which you have submitted. We appreciate your input, and we will be working with you personally you and Senator Leahy-as we continue with the consideration of these. Senator Javits, do you have any questions? Senator JAVITS. Yes. Senator Clark, before you leave, I just have one thing I would like to ask you. We have two big problems in the cities, and I wonder whether they are shared in the rural areas. One is the use of the emergency room for outpatient services because of the paucity of doctors. And the other is the breakdown in our public hospitals, which in many cases cannot even meet health standards, accreditation standards. Do you have either of those problems in the rural areas? Senator CLARK. Well, I think the problem in the rural area is somewhat different. You see that problem occasionally, depending upon the local situation. But it is harder to generalize in the rural areas, because they are so different-even from one part of our State to another, for example. |