Public assessment of expiring Public health service act authorities : background report

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Public assessment of expiring Public health service act authorities : background report
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Mar. 1979.
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At head of title: 96th Congress, 1st session. Committee print. Committee print 96-IFC 10.
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prepared for the use of the Committee on Interstate and Foreign Commerce, House of Representatives, and its Subcommittee on Health and the Environment, Ninety-sixth Congress, first session.

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Full Text
!1ThnV P


96th Congress COMMITTEE PRINT COMMITTEE
1st Session I PRINT 96-IFC 10




PUBLIC ASSESSMENT OF EXPIRING
PUBLIC HEALTH SERVICE ACT
AUTHORITIES

BACKGROUND REPORT





PREPARED FOR THE USE OF THE

COMMITTEE ON INTERSTATE AND
FOREIGN COMMERCE
HOUSE OF REPRESENTATIVES

AND ITS

SUBCOMMITTEE ON
HEALTH AND THE ENVIRONMENT
NINETY-SIXTH CONGRESS
FIRST SESSION


MARCH 1979


42-731 0


U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 1979










COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE


HARLEY 0. STAGGERS: West Virginia, Chairman


JOHN D. DINGELL, Michigan
LIONEL VAN DEERLIN, California
JOHN M. MURPHY, New York
DAVID E. SATTERFIELD III, Virginia
BOB ECKHARDT, Texas
RICHARDSON PREYER, North Carolina
JAMES H. SCHEUER, New York
RICHARD L. OTTINGER, New York
HENRY A. WAXMAN, California
TIMOTHY E. WIRTH, Colorado
PHILIP R. SHARP, Indiana
JAMES J. FLORIO, New Jersey
ANTHONY TOBY MOFFET, Connecticut
JIM SANTINI, Nevada
ANDREW MAGUIRE, New Jersey
MARTY RUSSO, Illinois
EDWARD J. MARKEY, Massachusetts
THOMAS A. LUKEN, Ohio
DOUG WALGREN, Pennsylvania
ALBERT GORE, JR., Tennessee
BARBARA A. MIKULSKI, Maryland
RONALD M. MOTTL, Ohio
PHIL GRAMM, Texas
AL SWIFT, Washington
MICKEY LELAND, Texas
RICHARD C. SHELBY, Alabama


SAMUEL L. DEVINE, Ohio
JAMES T. BROYHILL, North Carolina
TIM LEE CARTER, Kentucky
CLARENCE J. BROWN, Ohio
JAMES M. COLLINS, Texas
NORMAN F. LENT, New York
EDWARD R. MADIGAN, Illinois
CARLOS J. MOORHEAD, California
MATTHEW J. RINALDO, New Jersey
DAVE STOCKMAN, Michigan
MARC L. MARKS, Pennsylvania
TOM CORCORAN, Illinois
GARY A. LEE, New York
TOM LOEFFLER, Texas
WILLIAM E. DANNEMEYER, California


W. E. WILLIAMSON, Chief Clerk and Staff Director
KENNETH J. PAINTER, First Assistant Clerk
KAREN NELSON, Professional Staff
ROBERT HENLEY LAMB, Associate Minority Counsel



SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT
HENRY A. WAXMAN, California, Chairman


DAVID E. SATTERFIELD III, Virginia
RICHARDSON PREYER, North Carolina
ANDREW MAGUIRE, New Jersey
THOMAS A. LUKEN, Ohio
DOUG WALGREN, Pennsylvania
BARBARA A. MIKULSKI, Maryland
PHIL GRAMM, Texas
MICKEY LELAND, Texas
RICHARD C. SHELBY, Alabama
JOHN M. MURPHY, New York
HARLEY 0. STAGGERS, West Virginia
(Ex Officio)


TIM LEE CARTER, Kentucky
EDWARD R. MADIGAN, Illinois
DAVE STOCKMAN, Michigan
WILLIAM E. DANNEMEYER, California
GARY A. LEE, New York
SAMUEL L. DEVINE, Ohio
(Ex Officio)


ELLIOT A. SEGAL, Staff Director


(II)








LETTER OF TRANSMITTAL


CONGRESS OF THE UNITED STATES,
HOUSE OF REPRESENTATIVES,
Committee on Interstate and Foreign Commerce,
Washington, D.C., March 21,1979.
Hon. HARLEY 0. STAGGERS,
Chairman, Committee on Interstate and Foreign Commerce,
U.S. House of Representatives,
Washington, D.C.
DEAR MR. CHAIRMAN: I am transmitting a background report on
Program Assessments of Expiring Public Health Service Act Au-
thorities. This background report is intended to provide a brief over-
view of the programs and the manner in which they have worked since
their inception. I believe this background report will be invaluable
to Members of the Committee as we consider the re-enactment of these
legislative authorities. I would like to point out to you that the Con-
gressional Research Service (CRS) provided these on short notice and
are not intended to serve as a comprehensive evaluation of these pro-
grams. We intend to carry out in conjunction with CRS, more exten-
sive program evaluations in the course of this Congress.
I would like to thank the Honorable Gilbert Gude, Director of Con-
gressional Research Service, and the Education and Public Welfare
Division of CRS for their assistance to us in the preparation of this
report.
Sincerely,
HENRY A. WAXMAN,
Chairman.
Enclosure.
(UI)













































































I.









CONTENTS

Page
Letter of transmittal------------------------------------------- III
Drug Abuse------------------------------------------------------ 1
A. National Institute on Drug Abuse----------------------- 1-------
B. Executive Office of the President------------------------------- 15
Emergency Medical Services Systems Act------------------------------ 19
Health Information and Health Promotion----------------------------- 28
Nurse Training------------------------------------------------ 33
Alcoholism ---------------------------------------------------- --- 44
National Health Planning and Resources Development; Titles XV and
XVI of Public Health Service Act----------------------------------- 53
(V)



















Digitized by the Internet Archive
in 2014













http://archive.org/detai Is/assessment00u nit










PUBLIC ASSESSMENT OF EXPIRING PUBLIC HEALTH SERVICE
ACT AUTHORITIES


DRUG ABUSE



A. National Institute on Drug Abuse


I. Program Description


The National Institute on Drug Abuse (NIDA) administers a number of pro-

grams designed to prevent abuse of dangerous drugs and to reduce drug depend-

ency. In addition to the traditional research efforts of a health institute,

these programs encompass the funding of prevention and treatment services,

training for the delivery of such services, provision of technical assistance

to appropriate State and local agencies, and the award of training fellowships

for research in areas related to drug abuse. Although some of these activities

are authorized by the general provisions of the Public Health Service Act, no-

tably in the research and program support areas, for the most part they are

mandated by the Drug Abuse Office and Treatment Act of 1972 (DAOT Act), as

amended. DAOT Act, which established NIDA as a separate entity, provides for

formula grants to States for various kinds of drug abuse prevention and treat-

ment efforts (sec. 409) and also provides for a program of project grants and

contracts for such purposes (sec. 410), continuing earlier programs authorized

by the Comunity Mental Health Centers Act and the Narcotic Addict Rehabilita-

tion Act. Other specific appropriation authorizations for NIDA (HEW) under the

DAOT Act relate to the establishment and maintenance of a National Drug Abuse

Training Center (sec. 412) and to the conduct of certain designated research

efforts (sec. 503).


(1)











II. Program Data






Research

Grants
Contracts


Clinical Training

Grants
Contracts


Research Training

Grants
Fellowships


Community Programs

A. Project Grants
and Contracts:


Treatment
Demonstration
Prevention


FY 1977


296
65


FY 1978


FY 1979 est


315
44


181
74
25


177
62
64


155
42
48


B. Formula Grants


SOURCE: NIDA appropriations justifications for FY 1980 and the NIDA
budget office.
























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IV. Administration Proposal

The presidential budget is based on the assumption that Congress will-

accept proposed legislation to consolidate the alcoholism and drug abuse

formula grant programs under existing law (sec. 301 of the Alcoholism Act

and sec. 409 of DAOTA), along with the mental health portion of the compre-

hensive health planning grants to States funded by the Health Services Ad-

ministration (under sec. 314(d), PHS Act). As outlined in the Budget Ap-

pendix (p. 491), the new program would provide a total authorization of $99

million for FY 1980. This figure was arrived at by adding the FY 1979 obliga-

tions for the alcoholism and drug abuse programs ($56.8 million and $40 mil-

lion, respectively) to $13.5 million for mental health planning, the total

being decreased by 10 percent. The principle behind the proposal is the pro-

vision of greater flexibility to the States in the allocation of resources.










V. Program Assessment

General

In its detailed and comprehensive report on the national drug abuse prob-

lem, issued in 1973, the Shafer Commission (National Commission on Marihuana

and Drug Abuse) was highly critical of Federal drug abuse efforts generally

and of treatment support activities particularly. Coining the phrase "drug

abuse industrial complex" to describe the build-up of grant and contract

programs during the previous five years, the Commission characterized the

governmental response as "reflexive", duplicative, uncontrolled, and ex-

ploited by professional service program administrators. Moreover, it was

found that the drug abuse efforts had suffered the same fate as other Govern-

ment initiatives involving financial support. The problem was being perpetu-

ated and inflated:

Emergrire of a dlni. aliiis iliLst riail oIIIplex e rnsiirrd perpet'lintion
of the crisis psychology snrrnunding tihe drui problem. Sirwe public
funding is in large measure a function of public coeiiern, na.eici.s niiid
programs had reason to maintain the eoint rCrs anxietyv nlmit dmlII-s,.
For example, to obtain funds, a nlocality must show it has i drugil prob-
lemn; chances of funding improve if the problem nlppears to l. g'rrvilig.
Once the money is ranited, staffs atre liri and (Ithe pigr.wiui goes into
operation, there develops an iiitiitinal .-iliitanre to e thelic problem
get smaller, for so too will the volume of fledera;il or state funds.
The funding mnechanismn is so stncvtuidwl li:,t it rtvipomnds ntili whein
"lx0 uhictini in the hody count. ivlil. it rew.;ink any inciirrC in incidvIce
fimgin-s and arr.t srlttisl iCs with I I oI iirt v. I'It I. ,. i ,',' i a i,. fn' .,
tlnhus linv. a vested interest ill ir it-'': Win or iiii:ii:iiliing I h n.ii,' urr'.
Tlie stiat isti s. i II urnmm. fi1 pllir ;icd ImnIM 1 iMer. ntinem ,r-,n. nnil I si I l
that he lil-lh-m e nminues to Ie derinri-.d ki'-rr, 'l 11%. There is no i11cen-
tive for local coliiinuiihes to 1i:1il.in111. a r.iaitioii-;. ,iiiinii-lino.n l
aplpimach to dnig uis.
Tni short, the prnofer ed g-mil nf ocianl ilh-y is rt rhuire or plimiiiit:t
d niru uII.. lut thile .overni.n-it's responi 'I,, '.,1] finn:m-sial iu,1enjtit's
to rn:l--ilify tlilt"- jIr)IeIII. Thi NY-..'i-'1 A '-sll to fi- 11" it' fiil r o or.,f / .
uo] r{ titi'r 'h li:an -iti'rf.. it nri iir;tlitre '- 1111 ii liti l i11n of -risis.


_/ U.S. National Commission on Marihuana and Drug Abuse. Drug use in America:
problem in perspective. Second report of the Commission. Washington,
U.S. Govt. Print. Off., March 1973. p. 282.










The Shafer Commission undoubtedly played a role in the evolution of the

bill that was enacted as the Drug Abuse Office and Treatment Act of 1972.

Four Members of Congress highly influential in the development of that legis-

lation were serving on the Commission at the time it was being considered.

A principal aim of the act was coordination of treatment and prevention efforts.

The provisions giving statutory basis and specific authority to the Special

Action Office for Drug Abuse Prevention (SAODAP), and establishing a "Strategy

Council" to fashion a national drug abuse "strategy", were measures aimed at

meeting some of the Shafer Commission's criticism.

Although such agencies as the Office of Economic Opportunity and the Law

Enforcement Assistance Administration were funding drug abuse projects at the

time the Shafer report was written, the principal assistance programs were

those being administered by the Division of Narcotics and Drug Abuse in the

National Institute of Mental Health, predecessor to NIDA.

While there may be those who view the Shafer Commission comments as

still timely, the NIDA programs are generally praised and defended by drug

abuse professionals, whose major complaint is that they should be funded at

higher levels.

The extent to which the programs are accomplishing their basic purpose

is difficult to judge. Significant treatment evaluations undertaken thus

far have produced fairly optimistic conclusions but raise many questions;

appropriate methodology for evaluating prevention is even more a matter of

debate. Drug user statistics, while undoubtedly more informative than in

the past, remain controversial.











In the 1979 State of the Union message, President Carter points to a re-

duction in the number of heroin addicts as evidence of the success of Federal

efforts generally.

In continuing our efforts to combat drug abuse, my
Administration will rely on those programs and initia-
tives which have proven successful in the past year and
which serve as building blocks for future programs.
Today, in the United States, there are 110,000 fewer
heroin addicts than there were in 1975; 1,000 fewer
Americans died of heroin overdoses in the twelve-month
period ending June 30, 1978 than in the previous twelve
months. .

The statistics cited were derived from NIDA's Drug Abuse Warning Network (DAWN),

and the following editorial, from a recent issue of the U.S. Journal of Drug

and Alcohol Dependence (January 1979), is a good example of the disagreements

such figures may generate:

HEROIN STATS MISLEADING

According to NIDA's most recent pronouncements,
the number of heroin addicts in the country has
dropped 20Z since 1975. That is based primarily
on data from the Drug Abuse Warning Network (DAWN)
and some information on drug price and purity.
It sounds encouraging, just the kind of thing
to set our minds at rest and confirm that the trends
are going our way.
But to take comfort from the NIDA report is to
live in a fool's paradise.
DAWN is not a reliable indicator of the national
incidence and prevalence of the use of any drug. It
is reasonably accurate only in its reports of hospi-
tal emergency room encounters and coroners' reports.
In effect, it tells us about some of the people who
had misadventures with certain drugs, many perhaps
victims of their own inexperience.
It gives no indication how many people are using a
drug, in this case heroin, without running into medi-
cal emergency. It does not tell us how many are chip-
ping, using it casually on weekends, and how many young
people are being introduced to its use.











All of these are groups are at high risk for ad-
diction at some point in the future.
We need to know if this pool of non-casualty heroin
users is growing. And if so, what happens to the in-
dividuals in that pool when the supply mechanisms crank
up again?

If we take too much encouragement from NIDA's latest
report, we are once again asking for a rude awakening.


On the other hand, it should be pointed out that whatever the nationwide level

of drug use is, it might be higher without the availability of such programs

as those administered by NIDA.


Treatment

The effect of treatment on drug users is difficult to gauge. All re-

searchers in the field point to the large number of variables involved. The

individual's personal history and community background, the age at which treat-

ment commences, the state of the general economy, the conditions in the com-

munity to which the patient returns after treatment, the presence or absence of

drug-using acquaintances in that community, the presence or absence-of stabil-

izing family or other relationships, the degree of the patient's former depen-

dence on drugs these and a number of other factors help determine the direc-

tion of a drug user's post-treatment behavior and thus make it difficult to

isolate the benefits of the treatment regimen itself.

2/
In a recent review of major evaluations of NIDA treatment programs, the

Congressional Research Service found that the studies which focused on treatment

U

2/ Community Treatment Programs of the National Institute on Drug Abuse:
Evaluations, 1973-1978. [by] Harry L. Hogan. March 2, 1978.
33 p. (78-123 EPW).











outcome generated guardedly optimistic conclusions. All showed that the popu-

lations sampled had reduced drug consumption after a period of treatment. Some

of the earlier reports, however, dealt only with patients still under care.

As for criminal behavior, the fact that one early study showed a reduction

while the clients were actually under treatment was perhaps to be expected. How-

ever, several follow-up studies also showed apparently substantial reductions in

arrests and incarcerations. Taking a different approach, another study (Public

Research Institute) further supported a positive relationship between availability

and use of drug treatment and a decrease in criminal activity.

On the question of the effect of treatment on employment status, the

studies reviewed were mixed. Early studies of the Institute of Behavioral Re-

search found gains in this respect to be "slight" and reflective of a failure

of the programs to "influence the vast majority of patients in the economic

domain." By contrast, the follow-up of one treatment cohort by the same research

group saw employment up "appreciably." The latter finding agreed with the re-

sults of a MACRO Systems study of the New York City treatment program and a Burt

Associates study of the Washington, D.C., program. In New York, 48 percent of

the follow-up group had paid jobs at the time of interview as opposed to 33 per-

cent prior to treatment. In the District, there was a 57 percent employment rate

at time of interview as opposed to 21 percent during pre-treatment months.

Despite the generally favorable outcomes of the studies reviewed, most

authorities are cautious in their reactions. Moreover, some results of the

MACRO and Burt studies raise fundamental questions for policy-makers and ad-

ministrators. Although both of these showed a "relatively high rate of pro-

social behavioral change," it was found that the change took place "virtually







10



irrespective of the type of treatment initiated and, to a considerable extent,

irrespective of whether or not clients remained in treatment for more than

brief periods." The latter finding, especially, might be taken to imply that

the determining factor is not the treatment itself but rather the presence of

motivation in the individual who becomes at all interested in treatment.

The studies reviewed also found (1) that the community programs had failed

to provide a "sufficiently wide range of treatments to enable adequate testing

of alternative approaches for certain population groups;" (2) that ratios of

the benefits of all forms of treatment to their costs were in every case greater

than one, over a multi-year period reviewed, and that the adjusted ratio was

as high as 12.82 for outpatient drug-free treatment; and (3) that the two most

cost-effective treatment modalities for opiate users, in terms of reduced drug

use, are detoxification-outpatient and methadone maintenance.'

NIDA and other interested parties hope that a new evaluation project

sponsored by the agency will provide more definitive answers than those con-

ducted in the past. Known as the Treatment Outcome Prospective Study (TOPS),

the project is being carried out under contract by the Research Triangle In-

stitute in Chapel Hill, North Carolina. Long-range follow-up will be emphasized.

Finally, a General Accounting Office report on NIDA's treatment programs

is now being written. Testifying on March 2, 1979, before the Senate Subcommit-
3/
tee on Alcoholism and Drug Abuse, a GAO official provided a brief summary of



3/ Gregory J. Ahart, Director, Human Resources Division.








11



tentative findings. Pointing out that NIDA had been aware of many of the prob-

lems addressed by the GAO investigation and that the agency had initiated cor-

rective actions, he mentioned the following as matters for continuing concern:

--NIDA's method of funding drug abuse treatment programs

contributes to problems such as (I) unused capacity in

treatment programs, (2) inflation of- reported treatment

utilization rates, (3) low levels of treatment provided

to some abusers, and (4) funding levels that do not re-

flect actual costs of treatment.

--NIDA's standards for controlling the design and operation

of treatment programs should be clarified and upgraded.

--NIDA's plans for States to establish standards that are

equivalent to or more stringent than the Federal funding

criteria have moved very slowly.


Worth especial note was the finding that the reported rate of clients completing

treatment is about 20 percent. The GAO investigators speculate as to whether

"the low level of treatment provided to the abusers may well be one of the causal

factors of the low success rate."


Research

In 1976, the President's Biomedical Research Panel issued its detailed

review and assessment of the conduct, support, policies, and management of

biomedical and behavioral research by the National Institutes of Health and

the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). The Panel








12



made a large number of recommendations but stressed that the United States

"can take pride in a remarkably productive biomedical and behavioral research

effort" and noted that 160 of "the most distinguished scientists in the U.S."

had reported that the successes of the last three decades "portend an accelera-

tion in the pace of discovery in the immediate and the distant future."

Among the Panel's more specific recommendations applying to ADAMHA were

the following:

Budget items of the National Institute on Drug Abuse and
the National Institute on Alcohol Abuse and Alcoholism
identified for research must grow sufficiently to support
an augmented research effort.

Each institute of the NIH and the ADAMHA should organize
a formal structure for knowledge application and dissemi-
nation activities.

An Alcohol, Drug Abuse, and Mental Health Administration
Advisory Board should be established to advise the Ad-
ministrator, ADAMHA.

The National Advisory Councils of the NIH and the ADAMHA
should be brought to full strength with members appointed
solely on the basis of their qualifications and commitment
to excellence.

The peer review system must be maintained and strengthened
in both the NIH and the ADAMHA.

The initial review for scientific merit of applications for
all grants reviewed within an Institute, including program-
project, center, and other large grants, should be managed
by a separate unit that is totally independent of the units
that administer grants.

The Review Committees of the ADAMHA should be brought together
to form a central, program-independent "division of research
grants" within the ADAMHA.









13


In most instances, these and other Panel recommendations appear to have

been implemented by NIDA. Withrespect to knowledge application and dissemina-

tion activities, the Institute has sponsored the Research Analysis and Utiliza-

tion System (RAUS), produced and distributed research monographs (mailing list
/
of approximately 4,000), and contracted for production of compilations of ab-

stracts connected with major research issues. A number of internal, inter-agency

groups (Scientific Research Advisory Groups) have been formed to advise the

ADAMHA Administrator in specific areas, such as treatment research, epidemiology

research, etc. Although there are presently vacancies, for the most part the

National Advisory Council on Drug Abuse has been at full strength since its es-

tablishment. Initial review inception has been removed from the grant management

unit; initial review itself, by the outside reviewers, is now conducted,

not at the ADANHA level as recommended, but at the level of the Institute Director's

office.


Management Integrity

During January 1978, syndicated columnist Jack Anderson wrote a series of

articles alleging improper conduct by the staff, management, grantees, and con-

tractors of NIDA. The allegations fell into three general categories: (1) that

there had been a pattern of improper relationships between NIDA staff and the

recipients of NIDA funds; (2) that NIDA had funded a series of projects of

questionable value; and (3) that senior NIDA staff members had traveled exten-
4/
sively to "exotic locales." In consequence of the charges, HEW Secretary

Joseph Califano requested an audit by the department's inspector General.

The Inspector General's audit team summarized the conclusions of its

investigation as follows:


4/ Memorandum from the Inspector General to Secretary Califano; May 26, 1978;
p.1.








14


The Anderson allegations are, in large measure, based
on fact. It does not follow, however, that actionable
improprieties were committed. With the few exceptions.
noted, our review has disclosed a substantial appearance
of impropriety but no provable violations of law.

The principal area in which the Inspector General found questionable pro-

cedures was the process of contract award:

It is crucial that NIDA implement a competitive pro-
curement system in which no single individual can un-
duly influence an award. The system used by NIDA to
award research grants appears to meet this requirement,
but the contract award process does not. The NIDA
division that sponsors the procurement selects the
review committee and usually has at least two members
on it. It is theoretically possible, therefore, that
a Division Director could influence the committee's
selection. 5/

The Oversight Subcommittpe held hearings on the Anderson allegations

during the last session and plans to continue its investigations of NIDA

activities during the current Congress.


5/ Ibid., p. 18.









B. Executive Office of the President


I. Program Description

In June of 1971, former President Richard Nixon issued an Executive

order establishing a new agency in the Executive Office of the President

(EOP). Designated the Special Action Office for Drug Abuse Prevention

(SAODAP), its purpose was to provide White House-level coordination and

direction of all activities of the Federal government aimed at the pre-

vention or control of drug abuse, except for those having to do with en-

forcement of the dangerous drug regulatory scheme or the curtailment of il-

legal international traffic. Later given statutory basis and funding author-

ity by the Drug Abuse Office and Treatment Act of 1972 (DAOT Act), SAODAP

was originally conceived as a temporary entity to provide leadership during

an emergency period; the Presidential message to Congress requesting the

formal legislation described the step as "an emergency response to a national

problem." As the 1972 law was written, SAODAP was scheduled to go out of

existence at the end of a three-year period unless the President were to find

its continuation necessary. The same legislation established, as of January

1, 1974, a new agency in the Public Health Service, the National Institute

on Drug Abuse (NIDA), essentially an elevation of the Old Division on Narcotics

and Drug Abuse in the National Institute on Mental Health. Upon expiration

of SAODAP, the statute contemplated that the agency's role would be assumed

by NIDA.

One of SAODAP's most important tools for achieving its coordinating and

policy-guiding goals was budget review. All agencies involved in drug abuse

efforts of a non-law enforcement character were obliged to submit their annual

and supplementary requests to SAODAP, which then had the opportunity to make

changes before sending them on to the Office of Management and Budget.





16


In the 1976 amendments to the DAOT Act, over administration opposition,

Congress provided for creation of a replacement for SAODAP, the Office of

Drug Abuse Policy (ODAP), also in the EOP. Charged with making reconenda-

tions to the President regarding priorities, goals, and policies for Federal

drug abuse programs and to coordinate all Federal drug abuse activities,

ODAP was given a three-year authorization. However, the Ford Administration

declined to implement the legislation, maintaining that a White House-level

agency was no longer needed and that interagency committee mechanisms were

more appropriate.

President Carter reversed the Ford Administration decision and estab-

lished ODAP, a director taking office in June 1977. However, an Executive

Office of the President reorganization plan submitted in July 1977 called

for the agency's abolition. Since the plan was not disapproved by Congress,

ODAP was disbanded as of April 1978. In its place, a small unit of the Domestic

Policy Staff, the Drug Policy Office, has been charged with similar functions.






17



II. Program Data, ODAP FY 1978



(a) Personnel and Related Costs ....... .......... .. ... .. 781,000
Resources to fund ten (10) permanent positions are requested for the Office in
PY 1978. Additionally, resources are required for private expertise on an as needed
basis for travel, and for other related coats to fulfil the mandate of the Office.
(b) Operations and Facilities . . . . . . . . . . .... .$ 204,000
To continue the Office of Drug Abuse Policy and sustain ita operation for
Fiscal Year 1978, a total of $204,000 is required. This amount includes such
items as rent, communications, printing, reproduction, office furniture, equipment
and supplies. These items are necessary to support the Congressionally mandated
requlrementa such as the development and distribution of an annual drug abuse strategy,
as well as initial procurement and maintenance of space, equipment, supplies and
services to support the full-time staff and other government and non-government experts.
(c) Contractual and Other Services . . ...................... $ 335,000
In addition to continuing the initiatives begun in Fiscal Year 1977, there are
several major areas requiring policy and program evaluation. The areas include
such specific projects as: evaluate the elimination of the Department of Defense's
mandatory urinalysis program and its relationship to abuse levels in the uniformed
services evaluate the effectiveness of the government's Regulatory and Compliance
program at the Federal, State and local levels: and an assessment of the viability
of crop substitution and economic development in foreign drug producing regions.






































SOURCE: U.S. Congress. House. Committee on Appropriations. Treasury,
Postal Service, and General Government Appropriations for Fiscal
Year 1978. Hearings...95th Cong., 1st sess. p. 381. (Part 3:
Executive Office of the President)





18



III. Budget History


AUTHORIZATIONS/APPROPRIATIONS
(millions of dollars)


Authorizations


1975


Appropriations


$82.0


1976

1977

1978


$10.1


2.0

2.0


1.2


Domestic Policy Staff,
Drug Policy Office:


1979


1980 (request)


Indef.

Indef.


1/ TQ authorization was $.5 million.


Source of Appropriations Data: Drug Policy Office, Domestic Policy Staff.


SAODAP:


ODAP:










Emergency Medical Services Systems Act


I. Program Description

The Emergency Medical Services Systems program, authorized in 1973

by P.L. 93-154 and extended in 1976 by P.L. 94-573, is a program of grants

and contracts to support the development of a nationwide network of self-

supporting regional emergency medical services systems. Grants and con-

tracts are awarded to eligible entities, such as States, local governments,

regional consortia, and non-profit organizations, for a succession of three

types of activities in the development of emergency medical services systems:

(1) the conduct of feasibility studies and planning; (2) establishment and

initial operations and (3) expansion and improvement. The program also in-

cludes authority for grants for research in the special techniques, methods,

and devices, in the delivery of emergency medical services, and also, since

the 1976 amendments, authority for a National Burn Injury Program.


(19)







20


II. Program Data

At the completion of FY 1979 program activities, 291 of the 304

designated EMS regions will have received grant assistance under the pro-

gram. Eighty-five regions will have completed the planning phase and will

be ready to move to the operational phase. One hundred and forty regions

will be in some phase of operational development. Sixty-six regions will

have completed their eligibility under the program and will be moving to

self-sufficiency.

Program funds have been awarded to projects in all 50 States and in

the District of Columbia, Puerto Rico, Virgin Islands, Guam, Northern Mariana

Islands, and the Trust Territory of the Pacific Islands. Almost 50 percent

of available funds have been used to serve rural areas.

The research program, under the direction of the National Center for

Health Services Research, awarded 20 grants and contracts in 1979.

In 1979, the six Burn Demonstration Centers under the Burn Injury pro-

gram entered the final phase of the program.



Source: Conversation with Mr. John Reardon, Assistant Director of the
Division of Emergency Medical Services, Health Services Adminis-
tration, Department of Health, Education, and Welfare.




























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22


IV. Program Assessment

The original intent of the 1973 Emergency Medical Services Systems

Act, P.L. 93-154, was, as stated in H. Rept. 93-149, to respond to the

need for:

"1. Substantially increasing planning and coor-
dination of emergency medical services by local
communities, States, and the Federal Government;
2. Expanded resources for the establishment,
initial operation, expansion and improvement of
emergency medical services systems;
3. Increased public awareness and understand-
ing of the nature and use of emergency medical
services;
4. Improved communications facilities for emer-
gency medical services for both the general public
and those providing the services;
5. Expanded research and training in the nature,
techniques, and delivery of emergency medical ser-
vices;
6. Coordination and rationalization of the
presently fragmented and duplicative Federal pro-
grams for emergency medical services; and
7. Removal of existing legal barriers to the
effective delivery of emergency medical care." 1/

The legislation was developed as an attempt to deal with certain

deficiencies in emergency medical services in this country unnecessary

mortality and disability from medical emergencies; inadequacies in ambu-

lance services in both urban and rural areas, inability of hospital emer-

gency rooms to deal with the increasingly critical situation, and the lack

of trained personnel at all levels of emergency medical care.



1I/ House Report 93-149, "Emergency Medical Services Act of 1973,' report
by the Committee on Interstate and Foreign Commerce to accompany
H.R. 6485, April 18, 1973: p4.






23


The program began operation in FY 1974 vith the obligation of $17 mil-

lion for the three types of grants: feasibility studies and planning, es-

tablishment and initial operation, and expansion and improvement. Authori-

zation for the program was due to expire at the end of FY 1976. At that

time, the General Accounting Office made a study of the program and reported

to the Congress on its findings on July 13, 1976. 2/

The GAO, in its report, noted points of progress in improving emaer-

gency medical services in the U.S., specifically that communities, with

Federal funding, had obtained better equipped ambulances, improved coamuni-

cations capabilities, and up-to-date equipment for hospital emergency depart-

ments and other treatment centers. The GAO also found increased awareness

amnig local government and com-unities of the need for better emergency

medical services and of their responsibility to provide such services.

The GAO also cited certain problems in the program. For instance, it

found the development of emergency medical systems with strong central

management one system for several counties to be spotty. It found

regional management organizations receiving grants to be having difficulty

finding permanent financing for administrative and operating costs to replace

Federal grants funds. With little control over the financial support made

available by local governments and other providers, such as hospitals, the

management organizations could not assure continuation of regional systems

services when Federal funding stopped. The GAO also found that regional



2/ Report to the Congress by the Comptroller General of the United States.
"Progress, But Problems In Developing Emergency Medical Services
Systems", July 13, 1976.






24


management organizations were sometimes unable to obtain commitment from

local governments and local providers to the regional system concept.

The GAO found deficiencies in certain respects of the Department of

Health, Education, and Uelfare's management of the program that, in its opin-

ion, adversely affected the development of ENS systems. The GAO recommended

that the health Services Administration could improve its administration of the

program by: (I) improving its guidelines for evaluating grantee progress and

for assessing the readings of grantees to proceed with system development;

(2) increasing grant monitoring and technical assistance; and (3) improving

coordination with other Federal agencies whose programs relate to EXS.

The GAO included in its report proposed legislative changes in the EMS

Act to deal with some of the afore-mentioned problems. These recommendations

were to: (I) require local commitment to regional system development; (2) re-

duce the scope of mandatory system components; (3) improve HEW program admin-

istration; and (4) improve coordination among Federal programs related to EMS.

The 1976 EKS Amendments, P.L. 94-573, contained several provisions

designed to meet some of the GAO recommendations. It required grantees to

provide assurances of support for and participation in the program by public,

private, and volunteer organizations and other entities involved in and essential

to the effective provision of emergency medical services in the region. Also,

grantees would have to show support and cooperation from local legislative and

executive governmental bodies and show guarantees of local government financial

support for the program after the last year of Federal government support.

Another provision was designed to improve HEW administration by expanding

the specificity of assigned administrative duties. The 1976 law also required







25



the existing Interagency Committee on Emergency Medical Services to develop

and publish a plan for coordinated and comprehensive Federal emergency medical

services funding and resource-sharing. The plan would also include a descrip-

tion of sources of other Federal support for the purchase of vehicles and commu-

nications equipment and for training activities related to emergency medical

services.

A provision of the 1976 amendments directed the Division of Emergency

Medical Services in HEW to carry out through the Interagency Committee on

ELS a study of Federal programs and activities relating to emergency medical

services. As a part of that study, the study project team interviewed a num-

ber of Federal program officials or State EMS coordinators for their percep-

tions of the strengths and weaknesses of the Federal program. The following

points received strong agreement from those interviewed during 1977 and 1978

(as reported in a draft report from the Health Services Administration):

(1) Federal and State officials consider Federal funding of EMS
activities to be inadequate.

(2) State E1S coordinators expressed concern with technical assis-
tance from Division of Emergency Medical Services personnel,
calling it less than adequate, crisis-oriented, and dependent
on personal relationships with Federal officials.

(3) Some State EMIS coordinators expressed criticisms about Division
of EMS application procedures, specifically arbitrary criteria
in some regards and unattainable criteria in others, unclear
instructions, requirements for excessive numbers of application
copies, and extensive and repetitious application procedures. 3/



3/ Draft of Annual Report for FY 1977 and FY 1978, "Roles, Resources and
Responsibilities of Federal Programs and Activities Relating to
Emergency Medical Services." Health Services Administration, Public
Health Service, U.S. Department of Health, Education and Welfare.
pp. 10-13.







26


The EMS program has had a number of significant accomplishments in the

form of decreases in certain types of deaths and improvements in recovery

rates from certain disease and injury conditions, as reported by the Division

of EMS, primarily during appropriation hearings.

For instance, during hearings on the DHEW FY 1979 appropriations bill,

the division cited:

50 percent decrease in vehicular deaths in seven of eight downstate

Illinois regions;

In projects with pre-hospital cardiac care, in Seattle, San Diego,

Chicago, Norfolk, Charlottesville, Toledo, Boise, and Kansas City, an initial

decrease of 25 percent in cardiac deaths with 80 percent long-term survivors

(longer than one-year). 4/

Other accomplishments had been cited during FY 1978 appropriations

hearings.

In Massachusetts, a decrease of over 50 percent in number of deaths en-

route by ambulance to hospital;

Examples of regionalization and community support are also cited:

The Norfolk region, involving 10 counties and cities has established

a fully operational basic EMS communications system with mobile radios and

and hospitals.



4/ Departments of Labor, and Health, Education, and Welfare Appropriations
for 1979, hearings before a subcommittee of the Committee on Appro-
priations, House of Representatives, 95th Congress, 2nd Session,
Part 4, p. 87)







27


The citizens of Lu:as County in Northwest Ohio have passed .8 mill

levy to establish a- advanced life support County EMS system composed of

nine life squad inits supported by volunteer and paid rescue units and

commercial ami.iance companies.

The Amarillo, Texas, region has completed a Communications Center in a

25 county rural region, connecting hospitals, ambulances, and regions. 5/



5/ Departments of Labor and Health, Education, and Welfare Appropriations
for 1978, Hearings before a Subcommittee of the Committee on
Appropriation, House of Representatives, 95th Congress, First
session, p. 160).


42-731 0 79 5










Health Information and Health Promotion


I. Program Description

The National Consumer Health Information and Health Promotion Act of

1976, P.L. 94-317, authorized a program whose principal activities are: (1)

participation in policy development, oversight and coordination of Public

Health Service and Departmental activities in disease prevention and health

promotion, (2) identification of unmet needs and development of resources

to meet such needs, (3) recommendation of necessary changes in current

Federal policies with respect to governmental and non-governmental programs,

(4) development of a National Health Promotion program, and (5) dissemination

of health information to the public through the operation of a National

Health Information Clearinghouse. The authorizing legislation, besides

creating the general authority in this area, also authorized research pro-

grams, community programs, and information programs in health information

and health promotion.


(28)






29



II. Program Data

The Health Information and Health Promotion program is not viewed by

the Department as a grant or contract program: rather as a central office to

encourage others in the PHS and the rest of the Department and in the public

and private sectors to- fund more prevention, preventive health services,

health promotion, and health education and information activities.

In the coming year, the Department expects the National Health Infor-

mation Clearinghouse to become fully operational. Also anticipated is the

release of the Surgeon General's Report on Prevention.



Source: Department of Health, Education, and Welfare. FY 1980 Justification
of Appropriation Estimates for Committee on Appropriations.







III. Budget History


FY 1977
Author./Appi


AUTHORIZATIONS/APPROPRIATIONS
(in millions of dollars)

FY 1978
rop. Author./Approp. A,


FT 1979
uthor./Approp.


FY 1980
Budget Request


Program
Activities
Sec. 1701


$1.5


$14


$1.4


Sources: 1. Telephone conversation with Ms. Martha Petkas, Office of Disease
Prevention, Department of Health, Education, and Welfare.
2. Department of Health, Education, and Welfare. FY 1979 and FY 1980
Justification of Appropriation Estimates for Comittee on Appropriations.






30


IV. Program Assessment

Title I of P.L. 94-317, the Rational Consumer Health Information anad

Health Promotion Act of 1976, requires the Secretary of Health, Education,

and Welfare to: (1) Develop national goals and strategies concerning health

information and promotion, preventive health services, and education in the

appropriate use of health care ... (2) Analyze necessary and available re-

sources for implementing the goals and recommend educational and quality as-

surance policies for needed manpower resources identified by this analysis ...

(3) Undertake and support necessary activities and programs to: Incorporate

appropriate health education components into our society, especially into all

aspects of education and health care ... increase use of health knowledge,

skills, and practices by the general population ... establish systematic ex-

ploration, development, demonstration and evaluation oi innovative health

promotion concepts...

(4) Conduct and support research and demonstration concerning health infor-

mation and promotion, preventive health services, and education in the

appropriate use of health care ... (5) Undertake and support appropriate

training in the operation of programs concerned with health information and

promotion, etc. ... (6) Undertake and support effective and efficient pro-

grams of health information and promotion, etc. ... (7) Foster information

exchange and cooperation in conducting research, demonstration and training

programs respecting health information and promotion, etc. ...

(8) Provide technical assistance for such programs ... (9) Use other avail-

able authorities for programs concerned with health information and promotion,







31



preventive health services, and education in the appropriate use of health

care.

The Act also authorized the Secretary to carry out research programs,

community programs, and information programs in the area.

During hearings on the FY 1978 HEW appropriations bill, the Department

of HEW in responding to submitted questions indicated that it had established

an Office of Health Information and Health Promotion which was primarily en-

gaged in formation of plans for implementing the Act.

The Department stated that it did not envision the new office conducting

a major grant or contract program, but rather encouraging others in the Public

Health Service, the Department, and the public and private sectors to fund

more prevention, preventive health services, health promotion, and health

education and information activities. The Office, according to this testimony,

expected to develop initial goals and strategies in the areas of: childhood

immunization, selected aspects of nutrition (e.g., obesity, salt intake), school

health, new directions in smoking prevention and cessation, and impact of the

media on health. I/

In Senate hearings on the FY 1979 HEW Appropriations bill, the Depart-

ment responded to submitted questions concerning the work of the Office of

Health Information and Health Promotion. It said that efforts were begun in

FY 1977 to identify effective programs to prevent and control disease, to en-

courage more appropriate use of the health care system and to promote wellness.



1/ Departments of Labor and Health, Education, and Welfare Appropriations
for 1978, Hearings before a Subcommittee of the Comittee on
Appropriations, House of Representatives, 95th Congress, first
session, pp. 745-746.







32



The Office was said to be reviewing several important areas of research

on behavior change to try to identify common threads which may exist which

cut across several areas of prevention and health promotion. This effort

was undertaken because existing efforts to change bad health habits in such

areas as smoking, obesity, and physical inactivity, rarely show much success

for more than a year. 2/

The Office of Health Information and Health Promotion will become

fully operational during FY 1980, so it is still early to assess the effec-

tiveness of the program in implementing the legislative goals of the legis-

lation.



2/ Departments of Labor and Health, Education, and Welfare and related agen-
cies appropriations, FY 1979, Hearings before the Senate Committee
on Appropriations, pp. 947-948.










Nurse Training


I. Program Description

Since the 1930's, the Federal Government has been involved in assist-

ing nursing programs. The first comprehensive Federal legislation to pro-

vide funds for nursing education, the Nurse Training Act of 1964, consolidated

and expanded those programs which had been underway for 30 years. Currently,

Federal funds are provided to nursing schools for the construction of teach-

ing facilities, capitation assistance to aid education programs, and finan-

cial distress grants to help schools maintain programs or meet special needs.

Special projects to improve nurse training are also funded. In addition,

Federal funds also authorize grants to nursing schools for advanced nurse

training programs and nurse practitioner programs. Student assistance is

also available in the form of loans, scholarships, and advanced nurse

traineeships.


(33)






34


II. Program Data

A. Construction

Since 1975, there has been a general moratorium on new construction

awards with the exception of a single award of $3,500,000 in FY 1978 to assist

in the construction of an intercollegiate nursing education center at Spokane,

Washington.


Capitation Assistance

Type of Educational Program

1976
Diploma
Associate Degree
Baccalaureate

1977
Diploma
Associate Degree
Baccalaureate

1978
Diploma
Associate Degree
Baccalaureate


Number of Schools Assisted
1/
1,012
176
505
331
2/
1,055
168
522
365

1,100
190
,550
360


1/ Two awards cancelled
2/ Four awards cancelled


2. Effect on enrollment From 1964 to 1970, prior to the inception

of the capitation grant program, nursing school enrollment increased by less

than 18,000 students. From 1970 to 1976, the increase in enrollment has

nearly doubled to 34,000 students.

C. Special Projects

FY 1976 211 projects funded
FY 1977 171 projects funded
FY 1978 150 projects funded








35


D. Advanced Nurse Training


1976
1977
1978


E. Nurse


1976
1977
1978


projects
projects
projects


funded
funded
funded


Practitioner Training


projects
projects
projects


funded
funded
funded


F. Advanced Traineeships


109 schools received
135 schools received
109 schools received


funds
funds
funds


to distribute to students.
to distribute to students.
to distribute to students.


G. Scholarships


Participating


Number of Students
Assisted (est.)


FY 1976
FY 1977
1977-1978 1/



1I/ Academic Year

H. Student Loans


Number of Participating
Schools


Number of Students
Assisted (est.)


FY 1976
1976-1977 1/
1977-1978 1/



1/ Academic Year


1,190
1,193
1,205


26,250
28,096
28,125


Sources: 1. H. Rept. 95-1189, "Nurse Training Amendments of 1978", Report of
the Committee on Interstate and Foreign Commerce.
2. Telephone conversation with Mr. Groner, Bureau of Health Manpower,
Department of Health, Education, and Welfare.
3. House Committee on Appropriations, Hearings Departments of
Labor and Health, Education, and Welfare Appropriations for FY
1979.


FY 1976
FY 1977
FY 1978


Number of
Schools


1,252
1,296
1,350


6,000
6,000
9,000












36






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38


IV. Program Assessment

The Nurse Training Act of 1964, P.L. 88-151, established the first com-

prehensive program of Federal support for nursing education. The legislation

consolidated and expanded nearly three decades of Federal support for nurse

training programs. Enactment of the legislation represented Congressional

response to the increasing concern over existing and potential shortages in

the nursing profession.

The 1964 legislation authorized a balanced program of Federal assistance

to students and schools of professional nursing including grants for the con-

struction of nursing education facilities contingent upon expansion of enroll-

ment; special project grants to improve nurse training; formula grants to diplo-

ma schools which agreed to increase enrollment; low interest, partially cancel-

lable loans for students and traineeships. New program authorities were added

in 1966, 1968, and 1971. They included contracts to encourage the recruit-

ment of individuals from disadvantaged backgrounds, capitation grants to

schools agreeing to increase enrollments, financial distress grants, and

start-up grants. Legislation in 1975 further extended the program. Current-

ly, Federal support of nursing education programs exists in the form of insti-

tutional assistance such as capitation, construction, financial distress spe-

cial projects, advanced nurse training, and nurse practitioner grants as well

as student assistance such as traineeships, loans, and scholarships.

Congressional support for nurse training programs has remained relative-

ly high over the years. This is exemplified by Congress' steady refusal,

despite administration demands, to drastically reduce program support. It

has been the contention of several administration's that a nursing shortage





39


no longer exists in this country, eliminating the need for so much Federal

support. The most recent administration attempts to reduce Federal nursing

support include President Carter's pocket-veto of the 1978 nurse training

reauthorizing legislation as well as his efforts to drastically cut the

FY 1979 and 1980 nurse training program budgets. In its report on the 1978

legislation, the Senate Human Resources Committee cited their belief that

the administration's conclusions with respect to funding were "premature

and unsubstantiated by available data". Congress has called for a study

to determine the need to continue a specific program of Federal financial

support for nursing education. In the meantime, many members of Congress

have expressed concern that nursing shortages continue to exist within

various parts of the country. They fear an abrupt termination of the program

might seriously affect the quality of nurse training programs as well as the

opportunity for disadvantaged individuals to enter the nursing field. Such

concern has led to the re-introduction of nurse training legislation in the

96th Congress as well as Congressional refusal to agree to all of the President's

budget cuts.

One of the best indicators of the effectiveness of the nurse training

program has been the steadily increasing number of nurses. Since 1957, the

number of active nurses has more than doubled to over one million. Eleven

years ago, in 1968, there were 300 active nurses per 100,000 population in the

U.S. By the beginning of 1977, this ratio had risen to 395 per 100,000 popu-

lation. Such increases can be directly attributable to Federal aid. Capita-

tion assistance, for example, has been a successful tool to increase enroll-

ment. According to the House Interstate and Foreign Commerce Committee





40



report on the 1978 legislation, from 1964 to 1970, prior to the inception

of that grant program, nursing school enrollment increased by less than

18,000 students, from 1970 to 1976, the increase in enrollment nearly

doubled to 34,000.

The House Interstate and Foreign Commerce Committee further cited the

impact capitation assistance had made on the national health goals of primary

care, manpower production and distribution, and manpower quality and competency.

The committee noted that 23 of the collegiate nursing schools had chosen to

operate programs for nurse practitioner training in such primary care fields

as pediatrics, geriatrics, family health, nurse midwifery, community health

and emergency care. The committee added that almost 200 schools planned pro-

grams of remote site training; 161 schools provided continuing education courses

in which approximately 40,000 professional nurses participated, and more than

150 schools submitted plans to enroll and retain students from disadvantaged

backgrounds.

Construction assistance has also influenced the quality of education and

expanded nursing enrollment. A total of 225 awards were made to 219 schools

for construction of education facilities between December 1965 and June 1974.

Such support provided for more than 11,000 new first year places in nursing

schools as well as the maintenance of approximately 34,000 student places.

Since 1975, there has been a general moratorium on new construction awards

with one exception. A single award was made in FT 1978 to assist in the con-

struction of an intercollegiate nursing education center.

Special projects assistance was labeled "the most significant of all

nurse training provisions in terms of effectiveness in improving nursing





41



education nationwide" by the Senate Labor and Public Welfare Committee re-

port on 1975 nurse training legislation. Over the past several years, spe-

cial projects have usually averaged over 150 awards per year.

Progress has also been made in the area of advanced training for nurses

including nurse practitioners. Between 1971 and 1974, over 600 nurses com-

pleted preparation to become nurse practitioners. Currently almost 50 per-

cent of the 198 nurse practitioner training programs are supported under Federal

authority. Approximately 1,000 practitioners currently graduate annually from

these programs; almost 50 percent of them are employed in ambulatory care

settings in inner cities and rural areas. In the past three years, advanced

nurse training awards have assisted a variety of special educational pro-

grams with the enrollments totalling 2000 students.

Student assistance has also made an impact on increasing the supply of

nurses in the country. More than 70,000 nurses received traineeships for

long-term full-time study and/or short-term intensive courses between 1956

and 1974. In the past several years, over 109 schools have received funds

to distribute to students each year. Schools participating in the loan pro-

gram rose from 426 in 1975 to 1,151 in 1974. In the 1977-1978 school year,

the number of schools participating in the program rose to 1,205. Approxi-

mately 28,125 students were aided that year by the program. Schools parti-

cipating in the scholarship program increased from 667 in 1970 to 1,227 in

1974. In the 1977-1978 school year, 1,350 schools participated in the pro-

gram. Approximately 9,000 students received scholarship assistance that year.

A 1978 Congressional Budget Office report also indicated the achieve-

ments made in the field of nursing due to Federal support. For example, CBO





42


noted that annual additions to the aggregate RN supply are higher than ever.

CBO also claimed that the quality of nursing schools had improved as evidenced

by the increase in the national accreditation of nursing schools. In 1964,

the following percentage of schools were accredited: diploma-67 percent,

associate-5 percent, baccalaureate-70 percent. Those figures increased to

90, 40 and 80 percent respectively in 1977. In addition, CBO cited the in-

crease in nurse practitioner supply and the number of graduate degree

trained nurses.

'Vhile citing these demonstrable gains in the nurse training program over

the years, CBO also determined that several problems remain. For example,

while the existing aggregate supply is apparently adequate, CBO claimed that

the problem of geographic maldistribution still exists. In addition, CBO

cited the uncertainty of an adequate supply of graduate degree nurses.

Further, while minority enrollment in nursing schools expanded rapidly between

1965 and 1972, CBO noted that recent data indicate such enrollment has stabi-

lized.

In their 1975 and 1978 reports on nurse training legislation, the Inter-

state and Foreign Commerce Committee also noted the serious geographic mal-

distribution of nurses. To underline that concern, the committee, in 1978,

proposed limiting loan cancellation opportunity for all education loans

obtained after the date of its enactment to the shortage area program.








43



Sources: 1. H. Rept. 95-1189, "Nurse Training Amendments of 1978", Report
of the Committee on Interstate and Foreign Commerce, May 1978.

2. S. Rept. 95-859, "Nurse Training Amendments of 1978", Report
of the Committee on Human Resources, May 1978.

3. Congressional Budget Office, Nursing Education and Training:
Alternative Federal Approaches", May 1978.

4. H. Rept. 94-143, "Nurse Training Act of 1975", Report of the
Committee on Interstate and Foreign Commerce, April 1975.

5. S. Rept. 94-29, "Nurse Training and Health Revenue Sharing and
Health Services Act of 1975", Report of Committee on the Labor
and Public Welfare, March 1975.










Alcoholism


I. Program Description

The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment,

and Rehabilitation Act of 1970, P.L. 91-616, authorized formula and project

grants to support alcoholism prevention, treatment and rehabilitation ser-

vices in local communities. The 1970 legislation also created the National

Institute on Alcohol Abuse and Alcoholism. NIAAA develops and supports pro-

grams to (1) improve treatment services for alcoholic persons in States and

communities; (2) treat and rehabilitate employees with drinking problems in

Government and private industry; (3) modify public attitudes toward alcohol

and alcohol-related problems by developing a program of education and pub-

lic information; (4) train professional and non-professional personnel; and

(5) determine through research the causes and prevention of alcoholism and

alcohol abuse. Since 1970, additional legislation has broadened the Federal

alcoholism program. For example, the most recent amendments, P.L. 94-371,

placed special emphasis on treatment for underserved populations, women and

youth, and mandated a new interest on research.

(44)








45



II. Program Data

A. Grants and Contracts


1977 1978 1979 eat.
Research
Grants 139 171 158
Contracts 40 9 9


Training
Grants 92 89 95
Contracts 3 6


Community Programs
Prevention
Grants 22 32 22
Contracts 1 4 2

Treatment
Grants 486 516 433
Contracts 4 10 9


State Volunteer
Resource Development
Grants 30 30

Uniform Act
Grants 25 29 34

Formula Grants 56 57 57


Other Contracts


5








46


B. Estimate of NIAAA Program Beneficiaries


Occupational .......................
Women...............................
Youth ...............................
Indian..............................
Domestic Violence...................
Other Target Populations:
Staffing ..........................
Poverty ...........................
Cross Population..................
Drinking Driver...................
Public Inebriate..................
Criminal Justice..................
Spanish-Speaking..................
Black.............................
Aged ..............................
Non-categorial....................

Total....................


1979
Estimate

16,000
7,000
2,000
18,000


51,000
55,000
33,000
18,000
26,000
3,000
11,000
7,000
2,000
2,000

251,000


Sources: I. Telephone conversation with Ms. Betty Turner, Office of
Financial Management, National Institute on Alcohol Abuse
and Alcoholism, Department of Health, Education, and Welfare.
2. Telephone conversation with Ms. Rhoda Christenson, Grants
Management Branch, NIAAA, DHEW.
3. Department of Health, Education and Welfare, F 1980 Justi-
fication of Appropriation Estimates for Committee on Appro-
priations.







47


III. Administration Proposals

In the FY 1980 budget, the President has proposed a $99 million program

which would consolidate State formula grants administered by the Alcohol,

Drug Abuse, and Mental Health Administration, and grant programs for mental

health services administered by the Health Services Administration. Currently,

15 percent of the HSA program of comprehensive health grants to States is

allocated to each State's mental health authority. Some State mental health

authorities use such funds only for mental health services, but others use

them for alcoholism and drug abuse services as well. Under the President's

proposal, grant money would not be earmarked for a specific program such as

alcoholism. States would be permitted to allocate funds for all three pro-

grams as they deem appropriate.

Although not initiated by the Administration, S. 440, a bill to reautho-

rize the alcoholism program was introduced by Senator Riegle in the 96th Con-

gress. The Senate Human Resources Subcommittee on Alcoholism and Drug Abuse

held hearings on the legislation which would revise and extend the 1970 Act.












48










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49



V. Program Assessment

The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment

and Rehabilitation Act of 1970, P.L. 91-616, represented the first major

Federal effort to deal with problems associated with alcohol abuse and

alcoholism. At that time, Congressional opinion was generally unified that

action was needed in this area. For example, the report by the House Inter-

state and Foreign Commerce Committee reflected concern that "an across-the-

board, locally oriented attack on the massive alcohol abuse and alcoholism

problem" was needed in the country. On the Senate side, the Labor and

Public Welfare Health Subcommittee expressed its view that an effective

program could be maintained only with the assistance of "significant finan-

cial support" from the Federal government.

The passage of the 1970 Act initiated a major Federal effort in alcohol-

ism research, training, treatment, and prevention. Two components of the

legislation were the formula grant and project grant programs. The formula

grant program was intended to launch a nationwide effort to alleviate the

alcoholism abuse problem by making it possible for each State to stimulate

and encourage the establishment of alcohol abuse programs and provide assis-

tance for programs based on the particular needs of a State. Since 1970,

every State has established programs under this authority. The second com-

ponent, project grants were authorized to provide financial assistance to

local community programs designed to meet the needs of special target popu-

lations. Over the years, these grants have aided the operation of more than

600 community alcoholism programs.







50



The 1970 legislation also created the National Institute of Alcohol

Abuse and Alcoholism. Congress intended NIAAA to be the focal point for

Federal activities in the area of alcoholism. Approximately $1 billion has

been committed over a seven-year period by the Institute for its alcohol

abuse programs. According to February 1979 testimony by Alcohol, Drug Abuse,

and Mental Health Administration Director Dr. Gerald L. Klerman before the

Senate Human Resources Alcohol and Drug Abuse Subcommittee, such funds have

supported a number of achievements. Among other things, Klerman cited his

belief that such support has provided a national visibility to alcoholism

problems. It has also encouraged State governments to increase their bud-

get allocations for alcoholism programs. Currently, State expenditures for

these purposes total four times the NIAAA formula grant appropriation. In

addition, NIAAA research capacity has been increased. For example, in FY

1979, significant findings were made in the area of fetal alcoholism syndrome.

Advancements were also made in identifying the role of inheritable factors in

the transmission of alcoholism. Further, NIAAA efforts have sought to take

the "public inebriate" out of the criminal justice system, and provide him

or her with the alternatives of treatment and rehabilitation services.

According to Klerman's testimony, the death rate from cirrhosis of

the liver, nationwide, has declined over the past three years for the first

time in half a century. Furthermore, Klerman maintained total per capital

consumption of alcohol has stabilized. In addition, he indicated that pub-

lic awareness of alcoholism has increased and the stigma of alcoholism was

being reduced.







51



Federal efforts regarding alcohol abuse problems were evaluated by a 1977

General Accounting Office report, "Progress and Problems in Treating Alcohol

Abusers". In that report, GAO noted difficulty in determining the overall

impact of the Institute's program on alcohol abusers. However, GAO indicated

that certain progress had been made including the funding of alcoholism treat-

ment programs which benefited thousands of people. In addition, GAO found

that Federal involvement had stimulated greater State and local involvement in

alcoholism treatment programs. However, the GAO report also revealed certain

problems limiting NIAAA's attack on alcoholism. For example, NIAAA's plan-

ning efforts for treatment programs were criticized. GAO also criticized

what it termed a slow Federal approach by NIAAA against the alcoholism pro-

blem. GAO maintained that NIAAA had been unable to develop a coordination

mechanism to insure that all Federal alcohol related activities are inte-

grated into a single coordinated Federal approach to the alcohol abuse pro-

blem. Although HEW indicated agreement with the thrust of the GAO recommen-

dations, the department objected to the "passage of time since GAO has col-

lected its information" (three years). During that time, HEW noted that new

legislation passed, NIAAA leadership changed, staff increased, and progress

on many of the problems has been made.

The House Interstate and Foreign Commerce Committee, in its report on

alcoholism legislation in 1976, also noted that progress had been made in

the fight against alcoholism. The Committee indicated difficulties in deter-

mining whether an actual reduction in the number of alcohol abusers had

occurred since it had received no information which would indicate a reduc-

tion in alcoholism abuse. In fact, the Committee found existing evidence







52



showed that the incidence of alcohol abuse had been increasing at an alarm-

ing rate for two specific segments of the nation's population youth and

women. The legislation which was enacted that year, P.L. 94-371, even placed

special emphasis on women and youth as well as other underserved populations.

In the past, the House Appropriations Committee had also noted this increase.

As a result, the Committee issued a directive to NIAAA requesting expansion

of outreach and service programs for women. As an indication of progress in

this area, NIAAA reported that beginning in FY 1976, their agency began an

extensive campaign directed toward providing services to certain target popu-

lations including women and youth. In FY 1977, NIAAA complied with a Senate

Appropriation Committee directive that the Institute develop a comprehensive

public education and information disemination program dealing specifically

with teenage alcoholism programs. In FY 1978, the Institute continued to fund

alcoholism treatment projects targeted to high risk, poverty and minority

populations including women and youth. Approximately 217,000 people were

served by such projects during that year.










National Health Planning and Resources Development;
Titles XV and XVI of Public Health Service Act



I. Program Description

The National Health Planning and Resources Development Act of 1974

(P.L. 93-641) provided authority for creation of a nationwide network of

State and areawide health planning agencies responsible for developing local

and Statewide health plans to be used as the basis for health resources

allocation within specified health service areas. The health planning

agencies are to ensure that needed services are provided while duplica-

tive services are eliminated and the development of less expensive, equally

effective alternatives to inpatient medical care is encouraged.

At the local or areawide level, entities called health systems agen-

cies or HSAs (which are usually private nonprofit corporations) are the

basic component in the structure. At the State level, entities referred

to as State health planning and development agencies or State agencies (in

all cases a unit of State government) compose the next tier in the health

planning system. State agencies are in turn advised by Statewide health

and coordinating councils or SHCCS, composed of State officials and HSA

representatives. At the national level, there is a National Council on

Health Planning and Development, set up to advise the Secretary of HEW

on implementation of the program.

The Act also authorized the Secretary of HEW to issue national guide-

lines for health planning, including standards for the appropriate supply,

distribution, and organization of health resources. Funds were also made

available for contracts to establish regional centers for health planning,


(53)






54



designed to offer technical assistance to the various health planning

bodies. Authority was also provided for a program of demonstration grants

to be awarded to State agencies for purposes of hospital rate regulation.

In addition, the law authorized a program of Federal assistance for

health resources development (title XVI of the Public Health Service Act)

through grants, loans, and loan guarantees for construction and moderniza-

tion of medical facilities, for special projects for the elimination or

prevention of safety hazards or to assure compliance with licensure or

accreditation standards, and for area health systems development.







55



II. Program Data

Health planning agencies have been established in 205 geographic re-

gions and 57 States, including eight so-called "section 1536 States" which

carry out both the HSA and State agency functions. These planning agencies

include 205 health systems agencies (HSAs), 57 State health planning and

development agencies (SHPDAs), and 51 Statewide health coordinating councils

(SHCCs). In addition, ten centers for health planning and a National Health

Planning Information Center, both authorized under the Act, have been estab-

lished to provide technical assistance and information to the planning agen-

cies.

By the end of 1978, 168 HSAs (80 percent) had achieved full designa-

tion status, thus having developed satisfactory health systems plans and

annual implementation plans, as well as having demonstrated a capacity to

perform all functions required of them under statute. Eight State agen-

cies were fully designated during 1978, each of them having developed a

satisfactory certificate of need program which provides for the review of

proposals for new construction, replacement, and modernization of health

facilities and the elimination of duplicative health services.

The Department of HEW estimates that, by the end of 1979, approxi-

mately 191 HSAs and 41 State agencies will be fully designated and will

be performing all functions required of them under statute, including the

review of new institutional health services, review of the appropriateness

of existing health services, and review and approval of the proposed use

of certain Federal health funds in their respective areas. In many of the
/33 additional State agencies projected to be fully designated in 1979, full
33 additional State agencies projected to be fully designated in 1979, full







56


designation is contingent on the enactment of State legislation which will

allow the development of acceptable certificate of need programs.

While no funds have been obligated for State allotment grants for

construction or modernization of medical facilities (under section 1602 of

the statute), grants have been made under section 1625 of the Act to fund

projects designed to prevent or eliminate safety hazards and to assure com-

pliance with State or voluntary licensure or accreditation standards. In

1978, $11.4 million was awarded to fund four section 1625 projects from an

approved list of 48 potential recipients. The Department estimates that

during 1979 approximately 40 of the remaining approved projects will be

funded.



Source: Department of Health, Education, and Welfare. FY 1980 Justification
of Appropriation Estimates for Committee on Appropriations.













57


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58


IV. Program Assessment

The original intent of P.L. 93-641 was to create throughout the Nation

a new, strengthened and improved Federal, State and areawide system of

health planning and resources development. The various health planning

entities set up under the terms of the Act were directed to address their

efforts to increase the accessibility, acceptability, continuity, and quality

of health services; restrain increases in the cost of providing health ser-

vices; preventing unneccessary duplication of health resources; and ulti-

mately to improve'the health of the residents of each health service area.

Reflecting concern that earlier health planning efforts had been plagued

by a number of interrelated problems, the Committee in its original design

for P.L. 93-641 sought to embody the following principles:

(1) Planning should be done by organizations which re-
present and incorporate the interests of consumers of
health services, providers of the services, and con-
cerned public and private agencies and organizations.
(2) In order to be effective, health planning must be
adequately financed.
(3) Effective planning requires a strong emphasis on
the implementation of plans and implementation requires
that planning agencies have authority with which to
implement the plans.
(4) The generation of new health resources should be
closely tied to health planning.
(5) If health planning is to be done, it must be good
health planning.
(6) Effective Federal, State and areawide health plan-
ning will be possible only if the Federal government
itself engages in health planning.







59


(7) If health planning is actually to improve people's
health, it must not be limited just to planning for
medical needs. 1/

The law emphasized an important, indeed dominant role for consumers in

formulation of health planning policy and decisions. It detailed an intri-

cate series of interrelationships among Federal, State, and local interests

to improve coordination of planning activities and, to the extent possible,

to avoid jurisdictional conflicts and fragmentation. It required agencies

to formulate concrete health systems plans (HSPs) and annual implementation

plans (AlPs) which would act as the basis for decisions regarding which

specific projects and programs would be given priority and encouragement with-

in their respective areas. National guidelines were drawn up to provide

standardized criteria (adjusted to local needs and circumstances) for deter-

mining and evaluating the supply, distribution and organization of health

resources.

State agencies were mandated to establish State certificate of need

(CON) programs which would review all proposals for new institutional health

services proposed to be offered or developed within the State. The CON pro-

grams were to contain certain sanctions so that only those services, facili-

ties, and organizations found to be needed would actually be offered or

developed in the State. HSAs were expected to participate in the certifi-

cate of need review process as well as conduct reviews of the appropriateness

of existing health services, priorities for modernization, construction, and



I/ House Report 93-1382, "National health policy, planning and resources
development act of 1974," report by the Comittee on Interstate
and Foreign Commerce to accompany H.R. 16204, September 26, 1974:
pgs. 32-35







60



conversion of medical facilities, and applications for Federal funds for

various health programs within their respective health service areas.

State agencies were further required to develop State health plans (SHPs)

representing a Statewide composite of needs and priorities addressed in

the plans submitted by each State's HSAs.

Since enactment of the program much time has been spent in establish-

ing the various component parts of the health planning network. While con-

cern exists about the overall, long-term effectiveness of the health plan-

ning system in accomplishing the basic intent of the law, there is also

recognition that the initial development of such a large complex system is

a time-consuming, contentious, and often difficult process. Some believe,

it may still be too soon to measure the effect of planning entities which

in most cases have been fully operative for only slightly more than two

years and in many cases are not yet even fully designated in accordance

with the terms of the Act and its subsequent regulations.

One of the key measures used to evaluate effectiveness of health plan-

ning is the degree to which health planning activities have resulted in

documented cost savings for the health care system. A survey released

February 1979 by the American Health Planning Association reports that health

systems agencies and State health planning and development agencies disap-

proved $2.3 billion of a proposed $10.6 billion in capital investments be-

tween August 1976 and August 1978. The survey covers 166, or 81 percent,

of the country's 205 HSAs and 27, or 52 percent, of its 57 SHPDSs.

The report shows that planning agencies have saved money not only

through certificate of need review and reviews required under section 1122







61



of the Social Security Act, but also through technical assistance to

health care facilities and the influences of their health systems plans

and State health plans. For example, the health planning review process

has in some cases acted to discourage institutional providers from submit-

ting proposals known to be inconsistent with the health systems plan of

the local HSA. In other cases, unofficial contacts between providers and

the HSA may elicit negative responses to part or all of a capital expendi-

ture proposal, resulting in withdrawal or modification of certain proposals

prior to official submission.

The report notes that if unofficial data -- referred to as documentable

pre-application "reviews" are considered, the figure for total cost sav-

ings by HSAs and SHPDAs would total $3.4 billion. The report notes that

16,000 hospital beds were unofficially proposed, and 11,500 were requested in

official applications. Planning agencies disapproved 3,700 beds officially,

and 7,900 beds if unofficial reviews are included. Some 49,000 skilled nur-

sing home or intermediate care facilities were also unofficially disapproved

-- 20,000 officially -- out of an unofficially proposed 114,000 beds, or

85,000 officially requested. It was estimated that such capital investment

denials will save about $10 billion in operating costs in the 1980s.

While cost savings attributable to effective health planning may be a

measurable output, it is perhaps far more difficult to assess the effective-

ness of health planning activities in dealing with other key health issues,

such as accessibility and quality of health services, improvements in health

status, etc. Some have pointed to the actual limitations of health planning

to deal with problems generally regarded as outside its control, e.g. the




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basic structure and orientation of the medical profession with its emphasis
on specialization, hospital as opposed to ambulatory care, high technology,
and surgery. In addition there are problems presented by the fundamental
nature of the medical marketplace with the capacity of supply to generate
demand unchecked by a relatively open reimbursement system.
I