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PROJECTIONS OF THE HEALTH CARE SYSTEM OF THE FUTURE AND
IMPLICATIONS FOR THE ADMINISTRATOR OF THE NURSING CARE SYSTEM











BY

SUSAN SHERMAN BANDER ACKER


A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY



UNIVERSITY OF FLORIDA


1978




























This dissertation is dedicated to Arthur I. Acker, whose
patience and resources were tested but whose confidence
and love prevailed.













ACKNOWLEDGMENTS


I am grateful to many individuals for their assistance in the prepara-

tion of this study. I am indebted to Professor Phillip A. Clark,

University of Florida (Educational Administration), for his supervision

of the research and his unwaivering understanding. In addition, I am

extremely appreciative for the professional expertise and valuable sug-

gestions offered by Dean Blanche I. Urey, University of Florida (Nursing).

Professor Ralph B. Kimbrough, University of Florida (Educational

Administration), was a constant source of inspiration and optimism for

which I am grateful. My gratitude also goes to Professor Patricia A.

Clunn, University of Florida (Nursing), and Professor John M. Champion,

University of Florida (Health and Hospital Administration).

I am indebted to Ms. Paula Massie, who reviewed the preliminary

drafts of the text and provided constant support throughout the period

of its preparation. Special thanks go to Ms. Karen Charles for her

typing of certain sections of the draft. The manuscript was typed by

Ms. Jo Ann Salter, whose skills and confidence were a source of encourage-

ment. Also I would like to acknowledge those countless librarians and

secretaries at the University of Florida who smoothed the way for me.

An immeasurable debt of gratitude is owed to Ms. Theresa Vernetson

and Ms. Sandi Scaggs for their unsurpassed mastery of the University of

Florida system and their abiding friendship. Finally, I would like to

acknowledge the special role that my parents, Rita and Irv Bander,

played in precipitating the completion of this effort.














TABLE OF CONTENTS

Page
ACKNOWLEDGMENTS . . . . . .... . . . . . iii

LIST OF FIGURES . . . . . .. .. . . . . vi

ABSTRACT . . . . . . . . . . . . vii

CHAPTER

I. INTRODUCTION AND OVERVIEW OF THE STUDY . . . . 1
Purposes of the Study . . . . . . . . 5
Justification for the Study . . . . . . 6
Delimitations and Limitations . . . . . . 7
Procedures . . . . . . . . . . . 8
Definition of Terms . . . . . . . . . 9
Overview of the Remaining Chapters . . . . .. 11

II. SELECTED HEALTH CARE LEGISLATION . . . . .. 12
Introduction . . . . . . . . . . 12
Most-favored Disease Legislation . . . . .. 13
Mental Health Legislation . . . . . . . 27
Health Manpower Education Legislation . . . .. 32
Nursing Manpower Education Legislation . . . .. 42
Statutes Developing Research Facilities and Libraries 49
Hospital Survey and Construction Legislation . .. 54
Health Services Legislation . . . . .... 61
Social Security Legislation . . . . . . . 62
Health Planning Legislation . . . . . . . 72
Summary . . . . . . . . .. . . 76

III. PREDICTIONS OF THE HEALTH CARE SYSTEM OF THE FUTURE 88
Introduction . . . . . . ... .88
Predictions Regarding the Role of Government . . 89
General Predictions About the Health
Care System of the Future . . . .... 91
Predictions Regarding Health Care Financing . . .. 94
Predictions of the Hospital of the Future . . .. 95
Predicted Changes in the Practice of Medicine . .. 97
Predictions for the Practice of Nursing . . .. 98
Summary . . . . . . . . . . 100









Page


IV. THE DEVELOPMENTAL MODEL OF THE HEALTH
CARE SYSTEM OF THE FUTURE . . . . . . .. 101
Introduction . . . . . . . . . . 101
Theory of the Developmental Model . . . . .. 101
Classification of Health Care Legislation . . .. 103
Constructing the Model . . . . . . ... .118
Summary . . . . . . . . .. .. . .132

V. CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS . 134
Introduction . . . . . . . .... . 134
Conclusions . . . . . . . . ... . 134
Recommendations . . . . . . . . . 139
Implications for the Administrator of
the Nursing Care Delivery System . . . ... 141
Summary . . . . . . . . .. .. . .145

REFERENCE NOTES . . . . . . . . ... .. . .146

REFERENCES . . . . . . . . .. . . . . 147

BIOGRAPHICAL SKETCH . . . . . . . ... . 156














LIST OF FIGURES


Figure

1. Most-Favored Diseases Legislation . . . .

2. Health Care Funding Legislation . . . .

3. Health Manpower Legislation . . . . .

4. Health Care Facilities Construction Legislation .

5. Biomedical Research Legislation . . . . .

6. National Health Posture Legislation . . . .

7. Developmental Model: Most-Favored Disease Legisli

8. Developmental Model: Health Care Funding Segment

9. Developmental Model: Health Manpower Segment .

10. Developmental Model: Health Care Facilities
Construction Segment . . . . . .

11. Developmental Model: Biomedical Research Segment

12. Developmental Model: National Health Posture
Segment . . . . . . . . .

13. Developmental Model: Construction and Prediction


Page
. . 106

. . 107

. 112

. . 114

. . 117

S. 119

ition. 122

. . 125

. . 127


. 129

. . 131


. 133

. 137









Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the Requirements
for the Degree of Doctor of Philosophy


PROJECTIONS OF THE HEALTH CARE SYSTEM OF THE FUTURE AND
IMPLICATIONS FOR THE ADMINISTRATION OF
THE NURSING CARE SYSTEM

By

Susan Sherman Bander Acker

December 1978

Chairman: Phillip A. Clark
Major Department: Educational Administration


In order for nurses to be prepared for roles in the health care

system of the future they must have an awareness of its characteristics.

Many of these characteristics will be shaped by federal legislation and

the resultant national health care policy. A knowledge of the health

care system of the future as determined by the study of Congressional

enactments will provide the administrator of the nursing care system

with guidelines for future strategy planning and decision making.

The purpose of this study was to construct a developmental model

of the health care system, including projections for the future. Once

constructed, the developmental model served to illustrate those future

trends of importance to the administrator of the nursing care system.

An assessment of the implications of the trends was the second research

objective.

The identification and analysis of selected pieces of health care

legislation served as the theoretical basis for the construction of the

Developmental Model of the Health Care System. The statutes enacted









from 1946 until 1976 were reviewed and summarized chronologically by

category. Timelines were included to depict the legislative programs.

In addition, predictions of the future of the health care system by

health care deliverers were reviewed to determine the state of the art.

The Developmental Model of the Health Care System was constructed in

six sections, each representing a segment of the health care system.

The sections were: most favored diseases, funding of health care, health

manpower, construction of health care facilities, biomedical research, and

national health posture. Diagrams of the links between pieces of legisla-

tion formed the graphic depicts of the Model. From the trends pictured

in the Model, predictions regarding the future of each of the six seg-

ments of the health care system were developed and reviewed in depth.

In addition, four general conclusions were drawn from the research:

(a) a health care program that is embodied in legislation and continues

to receive a broad base of Congressional support for an extended period

of time is tantamount to a national health care policy. (b) The

legislation enacted by Congress in response to a particular health problem

often reflects its significance at a given point in time. (c) Concurrent

expiration of various pieces of health care legislation often leads to

an amalgamation of the authorizations for the individual programs in the

future. (d) Federal health care programs are more likely to be expanded

than cancelled by subsequent legislation.

Implications meaningful to the administrators of the nursing care

system were drawn from the research. The shift to comprehensive com-

munity-based health care, the emphasis on disease prevention and the

effects of the environment, and the importance of governmental policy


viii









regarding the health manpower shortage and health planning were among

those implications reviewed. The implications for the future of

nursing education, nursing practice, and nursing leadership were presented

in light of the trends depicted in the Developmental Model of the Health

Care System. The Model and the related conclusions of the study offer

the administrator of the nursing care system the foundations of a better

understanding of the health care system.






































ix













CHAPTER I

INTRODUCTION AND OVERVIEW OF THE STUDY


An exact description of the health care system eludes both health care

professionals and consumers. Often commentators on the contemporary

American health care system have had great difficulty defining it as a

system. Somers (1971) characterized the health care system as having

the following essential elements: physicians, patients, hospitals, and

finances. Mechanic (1972) broadened his list to include: manpower,

facilities, and technology. Abdellah (1976) pictured the health care

system as having: (a) a full range of medical and health services; (b)

geographical and enrollment populations; (c) a family oriented recovery

system; (d) organizations and systems of accountability; (e) 24 hour

accessibility to service; (g) transportation and linkage with an

emergency health care system (p. 237). Other individuals willingly

described the lack of a cohesive national health care policy (Bosomworth,

1975; Falkson, 1977). Krause (1977) countered with the profundity

"To those who say we have a nonsystem of health care, a response is

easy: try to change it" (p. 154).

The activities and institutions which comprise the health care

system are quite numerous. Rogers and Hyde (1976) defined health care

as "all the activities undertaken for the conscious purpose of improving

people's health, including public health activities, medical care,

and activities affecting whole communities as well as those serving

individuals within the community" (p. 109). The function of the American





2


medical system as determined by B. Ehrenreich and J. Ehrenreich (1970)

were: (a) patient care; (b) profit making; (c) research; and (d)

medical education. They characterized the health care system of the

1970's as highly organized, institutionalized, and centralized with

major interlocks to health financing institutions, government, and the

health commodities and equipment industry. The complex, diverse, and

all-pervasive nature of the health care system only serves to magnify

its enormity.

The health care system is and will be influenced by the federal

government. The statutes, regulations, and guidelines implemented

during the period since World War II are illustrative of increased

federal government involvement in the health care system at every level.

Falkson (1977) maintained that "the federal government promotes a broad

range of health programs in a highly inefficient manner," and he

characterized the federal government's intervention into the health

care system as "episodic and piecemeal" (p. 310). But this criticism

only serves to highlight the growing trend of governmental influence.

Historically the federal government's role in the delivery of health care

has expanded since the late 1940's. The expansion of the health bureaus

in the 1960's was evidence of governmental involvement in two new ways:

(a) financing (and administering) health care in the private sector;

(b) large scale funding of medical research (Krause,1977). Greenberg

(1975) warned of an increased federal influence on the health care

system because of the government's bill paying role. Bordman (1974)

concurred noting governmental involvement at all levels of the health

care system including the construction of medical facilities, and









subsidies for training health care personnel. In addition, he noted

the direct involvement of the government in the cost of the health

care system by present and proposed health insurance legislation.

Direct public expenditures in 1976 equaled 42% of the total monies

spent for health in that year, 28% of which was spent by the federal

government. Governmental expenditures reached $53.3 billion during

the Fiscal Year 1975 with 60% of the total spent for Medicare and

Medicaid and 13% of the total spent for programs sponsored by Indian

Health Service and the U.S. Public Health Service. In addition, federal

expenditures for research and development in medical and health related

activities equaled $2.8 billion (U.S. DHEW, 1977).

The active supply of registered nurses numbered 723,000 (U.S.

DHEW, 1974, p. 13). Registered nurses were and continue to be the

largest group of health professionals. In 1976, 682,300 registered

nurses were practicing full-time in the United States (ANA, 1977) of

which 29,752 practiced in administrative positions, 3.8% of the total.

Directors and assistants of organized nursing services in the hospitals

numbered 3,953; 6,816 served as administrators in nursing homes; 2,667

worked in public health agencies (Arnold, 1972).

There has been increased awareness within the nursing profession

of the need for qualified nurse administrators. Roundtable discussions

have focused on the pressing nursing issues including those of nursing

administration and the health care system. One such panel met in

February, 1975, at the request of the officers of the American Nurses

Association (ANA) to discuss the "issues and challenges facing organized

delivery of nursing services" (Flaherty, 1975, p. 1). This group

recommended that nursing administrators have planning skills, political









sophistication, a knowledge of relationships within the health care

field, and an increasing awareness of the community and consumer needs

(Flaherty, 1975). Another group of nursing leaders was invited by the

staff of the American Journal of Nursing (AJN) on the occasion of its

75th anniversary (October, 1975) to discuss the current issues in nursing.

Opinions were expressed on the influence of the nursing profession on the

delivery of health care, the lack of academic preparation of students

for administration, and the crisis in nursing leadership (Nurses and

Nursing, 1975). As these groups suggested, the nurse administrator must

have an awareness of the health care system and of the potential strength

of the nursing profession in order to respond appropriately in the health

care system of the future.

A model of the health care system will project implications for

the system of the future. Elements of significance can be selected from

the model by any health care professional and utilized to determine

actions and policies which will effect a particular discipline in the

health care system. The implications drawn from the model of the health

care system of the future most pertinent to the nurse administrator will

prove to be of indisputable value to those who hope to influence and

implement elements of that system.


Purposes of the Study

This study had two purposes. One purpose of this study was to

identify and analyze selected federal statutes related to the health

care delivery system in the United States. The goal of this analysis

was to construct a developmental model of the health care system including

projections for the health care system of the future. The second purpose

of this study was to identify and assess those elements of the model








of unique consequence to the nursing care system. By assessing the

impact of such ele:;ents, this study determined the implications the

health care system of the future has for the nurse administrator.


Justification for the Study

The role of the federal government in the health care system had

been emphasized by several authorities. Rushmer (1975) stated that "no

recognizable national health policy has been established, and the criteria

of current national priorities must be interpreted from diverse and

disparate legislative and administrative action" (p. 68). The effects

of the legislative process began to become apparent. Millis (1975)

listed the internal and the external forces on the health care system

including the scientific, the technical, the economic, the social, the

moral, and the political (p. 160). Mechanic (1972) maintained that major

health care decisions in the United States are determined through the

political process by the ability to influence enactments and forms of

administration mandates.

Krause (1977) predicted that "new laws passed by Congress, or new

programs initiated by federal bureaucrats themselves, may eventually

result in new requirements and rearrangements in the patterns of services

delivered in the community" (p. 133). Schaefer (1973) and Burns (1973)

concurred that there would be a different kind of health care system in

the future by public mandate. The implications offered by these

authorities was that the future of the health care system is subject to

both the direct and indirect influence of the branches and agencies of

the United States government. Consequently, construction of a model of

the health care system from the analysis of the statutes directing








federal government activity advanced knowledge and enhanced under-

standing of this complex phenomenon

In addition to developing a model of the health care system, the

study has specific implications for nurse administrators. There will

be changes in the roles of the nurse in the health care system of the

future (Isler, 1976). Ford (Note 2) listed as one of her assumptions:

The political arena will be used increasingly by consumers,
women, and particularly professional nurses to demedicalize
the health care delivery systems) because, although
organized medicine has the opportunity and power (albeit)
dwindling) to adopt new and creative relationships with other
health professionals and consumers, medicine has neither the
interest nor the commitment equal to the problem of inter-
disciplinarity before us. (p. 174)

The changes in the roles of nurses will reflect changes in the

health care system of the future and will most certainly have implica-

tions for the nurse administrator. Therefore, a study of the implica-

tions that the health care system of the future holds for the nurse

administrator may be useful to the decision making process.


Delimitations and Limitations

This study is delimited to the construction of a developmental model

of the health care system based upon theoretical elements derived only

from existing federal statutes which directly impact on the health care

system of the United States. Legislation enacted that indirectly ef-

fected the health care system by altering the social, educational, and/or

economic climate of the country was excluded. The study is further de-

limited to an analysis of selected federal statutes enacted during the

period from January, 1946, until December, 1975. Projections from the

study will be confined to those of the immediate future except as long-

range predictions are included with those more relevant to the study.









Procedures

Public laws with reference to components of the health care system

and enacted during the period from January, 1946, until December, 1975,

were identified through the use of primary and secondary sources. The

collections of the Depository Library and the Law Library at the

University of Florida served as the foundation for the research. Resources

such as Title 42 of the United States Code, compilations of selected

acts, and reviews of legislative enactments were utilized. Selected

federal statutes which significantly influenced the future of the health

care system were analyzed and the historic and current trends in the

health care system as reflected by legislation were compiled.

Predictions of the characteristics of the health care system of

the future by health care professionals were identified. The future pre-

dictions were selected from those published in the health care periodicals

listed in the International Nursing Index, Hospital Index, Index Medicus,

and in the collection of the Medical Center Library at the University

of Florida. The MEDLARS and MEDLINE computerized literature search

services of the National Library of Medicine were used to cite highly

relevant publications and articles. An analysis of the predictions of

the health care system of the future by the health care professionals

was completed, and the most probable future trends based upon those

predictions in the health care system were listed.

The historic and current trends determined from selected health

care legislation in light of the future predictions were used to con-

struct the Developmental Model of the American Health Care System.

The Model consisted of six segments. They pertained to most-favored









diseases, funding of health care, health manpower, construction of

health care facilities, biomedical research, and the national health

posture. The Model included past, present, and future stages of the

health care system. Three decades of health care legislation

representing the past and present health care system were analyzed,

and the analysis formed the basis of predictions regarding the fourth

decade or future of the health care system. The research of Robert

Chin (1961) was the prototype for the Developmental Model of the Health

Care System. Elements of the Model with strong implications for the

administrator of the nursing care system were determined by inductive

logic and based upon the criteria recommended by Chin (1961)

regarding the utility of a developmental model for the practitioner.


Definition of Terms

Biomedical research. Biomedical research is investigation and/or

experimentation in the area of clinical medicine based on the principles

of physiology and biochemistry.

Future. The future is the decade of the 1980's.

Government expenditure. Government expenditure is the total

national expenditure for health services and support less the expenses

for research and health facility construction.

Health care system. The health care system in America as defined

by Charles C. Edwards (1975) is:

The private sector as well as the public sector, voluntary
institutions, industry, the academic community, professional
societies--in short, all elements of the health system and
the people it serves. (p. 247)










Health maintenance organization. A health maintenance organiza-

tion is a legal entity which provides basic and supplementary health

services to its members with payment at a fixed rate on a periodic

basis, regardless of the dates service is provided (Pub. L. No.

93-222).

Inpatient care. Inpatient care is health care which is provided

to patients admitted to health care facilities for periods of

residence.

Model. A model is "a symbolic depiction in logical terms of

an idealized relatively simple situation showing the structure of the

original system" (Hazzard and Kergin, 1971, p. 392).

Nurse administrator. A nurse administrator is an individual who

has basic preparation in the practice of nursing and in addition

advanced education and experience in the management skills necessary

to direct the affairs of the nursing care segment of the health care

system. This individual possesses the legal authority and responsibility

for the appropriate functioning of that segment.

Nursing care system. The nursing care system in America includes

all elements of the provision of patient/client care through nursing

practice as well as organized nursing service.

Outpatient care. Outpatient care is health care which is provided

at health care facilities for patients on the basis of non-residence.

Public expenditures. Public expenditures are those paid by

federal, state, and local governments.











Technogenic disease. A technogenic disease is an illness or

malady which is environmentally induced or associated (Steinfeld,

1976).

Third party payment. Third party payment is all payment for

health care which is not directly paid by the consumer.


Overview of the Remaining Chapters


The succeeding chapters in the dissertation examine the following

topics:

Chapter II: Selected Health Care Legislation. An analysis

of the selected federal statutes is presented and the resultant

historical trends in the health care system are highlighted.

Chapter III: Predictions of the Health Care System of the Future.

Statements and predictions describing the health care system of the

future, as perceived by health care professionals, are presented.

Chapter IV: The Developmental Model of the Health Care System of

the Future. The techniques and applications of the developmental

model are explored. A developmental model of the health care system

is constructed.

Chapter V: Conclusions, Implications, and Recommendations.

Conclusions, implications, and recommendations are offered concerning

the health care system of the future and the implications for the

administrator of the nursing care system.






11


Graphic representations of the Model of the Health Care System

are included in the text where pertinent. A flow chart depicting the

predictive process described therein is also included.













CHAPTER II

SELECTED HEALTH CARE LEGISLATION

Introduction

The involvement of the Federal government in all aspects of the

delivery of health care has increased markedly. In each succeeding year

Congress has passed an increasing number of laws pertaining to the health

care system. Table 1 (DHEW, 1976) illustrates that increase. It should

be noted that the pieces of legislation included in Table 1 are not

necessarily presented individually in the following chapter.

Table 1
Health Legislation Passed, 1935-1975
(Selected Laws, by 4-Year Intervals)

Congresses Year Number of Laws

74-75 1935-1938 5
76-77 1939-1942 3
78-79 1943-1946 8
80-81 1947-1950 9
82-83 1951-1954 3
84-85 1955-1958 13
86-87 1959-1962 9
88-89 1963-1966 21
90-91 1967-1970 26
92-93-94a 1971-1975 32

TOTAL 129


aFirst Session

Each piece of health care

purpose is illustrative of the

Table 2 (DHEW, 1976) shows the

presented above in Table 1.


legislation has a primary purpose. This

direction of national health care policy.

range of health care legislation









Table 2

Purposes of 129 Federal Health Laws, 1935-1975


Purposes of Legislation Number of Laws Passed

Health Protection
Disease Prevention and Control 8
Food, Drug and Consumer Safety 19
Occupational and Public Safety 4
Environmental Protection 17

Health Care and Financing 34

Health Resources
Manpower 13
Facilities, Planning and Information 12

Biomedical Research 22

TOTAL 129


The following chapter examines nine categories of health care

legislation. Laws pertaining to research facilities, health planning,

health services, diseases, hospital construction, mental health, health

manpower education, and related social security legislation are summarized.


Most-favored Disease Legislation


The National Dental Research Act, Pub. L. No. 80-755, was enacted

on June 24, 1948. The purpose of the act was to improve the dental

health of the population of the United States through research, investiga-

tion, experiments, and studies relating to the cause, diagnosis, and

treatment of dental diseases and conditions. It was to provide training

in matters related to dental disease, to promote the coordination of

research and activities, and to promote the most effe-tive methods of

prevention, diagnosis, and treatment of dental diseases and conditions.









Appropriations were authorized for the erection and equipment of suitable

and adequate buildings for the National Institute of Dental Research. The

aim of the institute was to foster research related to the causes, pre-

vention, and methods of diagnosing and treatment of dental diseases and

conditions. The Institute was to promote the coordination of research

and to secure expert advice and services as needed. The legislation

provided and established clinical traineeships in the Institute and else-

where. It also established the National Advisory Dental Research Council,

composed of 12 members. The Council was authorized to review research

problems, collect and disseminate information, review applications for

grants-in-aid for research and traineeships, make recommendations on

the acceptance of gifts, and make recommendations on the administration

of the law.

Pub. L. No. 81-692: National Research Institutes Act was enacted

on August 15, 1950. The purpose was to promote the conduct of research,

investigations, experiments, and demonstrations, relating to the cause,

prevention, and methods of diagnosing and treatment of arthritis,

rheumatism, multiple sclerosis, cerebral palsy, epilepsy, poliomyelitis,

blindness, leprosy, and other diseases. The legislation was to foster

research by agencies and promote the application of such research. In

addition, it offered help to states to develop programs of prevention,

diagnosis, and treatment of such diseases. The Institute for Research

on Arthritis, Rheumatism, and Metabolic Diseases was established as

was the Institute for Research on Neurological Diseases and Blindness.

A national advisory council was established for each, composed of 12

appointed members each. The legislation established within the Public









Health Service institutes to conduct and support the scientific research

and professional training relating to the cause, method of diagnosis

and treatment of the particular disease mentioned above.

The National Institutes of Child Health and Human Development and

General Medical Sciences Act, Pub. L. No. 87-838, was enacted October

17, 1962. It amended the Public Health Service Act to establish an

Institute of Child Health and Human Development and to extend for three

additional years the authorizations for grants for the construction of

facilities for research in the sciences related to health. The Institute

of Child Health and Human Development was for the conduct and support of

research and training relating to maternal health, child health, and

human development, including the special health problems of mothers and

children and in the basic sciences relating to human growth and develop-

ment during the prenatal period. The Institute of General Medical

Sciences was established for the conduct and support of research and

training in general and basic medical sciences and related natural and

behavioral sciences. Advisory councils were established for both institutes.

Traineeships and fellowships were authorized in the institutes in matters

relating to diagnosis, prevention, and treatment of diseases and other

aspects of maternal health, child health, and human development. Grants

to public and nonprofit institutions were also authorized for trainee-

ships and fellowships in the areas of study.

Pub. L. No. 87-868: Vaccination Assistance Act of 1962 was

enacted on October 23, 1962. It authorized grants to states and political

subdivisions to assist in meeting the costs of communicable and other

disease control programs. It mandated the development of a plan to









utilize personnel, equipment, supplies, etc., to meet epidemics or

other health emergencies. The statute required the presentation of an

annual report regarding the effectiveness of disease control, problems,

and plans for the following year.

August 5, 1965 was the date of enactment of Pub. L. No. 89-109:

Community Health Services Extension Amendments of 1965. The purpose of

the legislation was to extend expiring provisions of the Public Health

Service Act. Grants were authorized to pay the costs of immunization

programs against infectious diseases susceptible to elimination through

immunization. It also increased the appropriations for the next two

years of the migratory workers health services.

Pub. L. No. 92-449: Communicable Disease Control Amendments Act

of 1972 was enacted on September 30, 1972. Grants were authorized for

the costs of communicable disease programs including vaccination programs.

Communicable diseases were defined as tuberculosis, rubella, measles,

Rh disease, poliomyelitis, diptheria, tetanus, whooping cough, and

others except venereal disease. Title II of Pub. L. No. 92-449 was

cited as the National Venereal Disease Prevention and Control Act.

Grants were authorized for projects and programs for the prevention and

control of venereal disease. States were required to develop a state

plan for eligibility for funds. Title III authorized grants for projects

for family planning services. The statute authorized funds for disease

control programs. For the fiscal year ending June 30, 1973, $11,000,000

was authorized for the control of tuberculosis. The authorization was

to remain the same for fiscal years 1974 and 1975. The programs for the

control of measles received an authorization of $6,000,000 for the fiscal









years from 1973 to 1975. The programs for the control of other com-

municable diseases such as rubella, poliomyelitis, diptheria, tetanus,

whooping cough, and others, excluding venereal disease, were awarded

authorizations totaling $23,000,000 for the fiscal years 1973, 1974,

and 1975. The authorization for the development of an emergency plan

for the management of epidemics for the fiscal years 1973 through 1975

equaled $5,000,000. Authorizations for research into the causes of

venereal disease for the same period of time were $7,500,000. For fiscal

years 1973, 1974, 1975, aid to states for diagnosis and treatment of

venereal disease was authorized at $25,000,000. Grants were authorized

for fiscal years 1973 through 1974 for epidemiological programs to

control venereal disease at the $30,000,000 level.

Pub. L. No. 80-655: National Heart Act was enacted on June 16,

1948. It made provisions for the establishment of the National Advisory

Heart Council. The statute changed the name of the National Institutes

of Health to the National Institute of Health. It made the general

research and investigation clauses of the Public Health Service Act

applicable to the National Advisory Heart Council.

The Heart Disease, Cancer, and Stroke Amendments of 1965, Pub. L.

No. 89-239, wereenacted October 6, 1965, to amend the Public Health

Service Act to assist in combating heart disease, cancer, stroke, and

related diseases. Grants were authorized to encourage regional coopera-

tion agreements among medical schools, research institutions, and

hospitals for research, training including continuing education, and

demonstrations in patient care in the field of heart disease, cancer,

stroke, and related diseases. The National Advisory Council on Regional









Medical Programs was established to recommend grants to universities,

medical schools, research institutions, and other agencies to assist

in planning and development of regional medical programs including the

construction and equipment of facilities. The Council was to have 12

members. The statute mandated the establishment and maintenance of a

list(s) of facilities in the United States able to provide the most

advanced care in the treatment of heart disease, cancer, and stroke.

The list was to be available to licensed practitioners and other persons.

Authorizations were included for planning grants and funds for the

establishment of regional medical programs. Fifty million dollars

were authorized for the fiscal year ending June 30, 1966; $90,000,000

were authorized for the fiscal year ending June 30, 1967; $200,000,000

were authorized for the fiscal year ending June 30, 1968; $65,000,000

were authorized for the fiscal year ending June 30, 1969; $120,000,000

were authorized for the fiscal year ending June 30, 1970; $125,000,000

were authorized for the fiscal year ending June 30, 1971; $150,000,000

were authorized for the fiscal year ending June 30, 1972; $250,000,000

were authorized for the fiscal year ending June 30, 1973; and $159,000,000

were authorized for the fiscal year ending June 30, 1974.

Pub. L. No. 91-515: Heart Disease, Cancer, Stroke, and Kidney

Disease Amendments of 1970 was enacted on October 30, 1970. Grants

were authorized to encourage and establish regional cooperative arrange-

ments among medical schools, research institutions, and hospitals for

medical data exchange and demonstrations in the fields of heart disease,

cancer, stroke, and kidney disease. This exchange was to make available

to patients the latest in prevention and rehabilitation. Appropriations









were authorized for feasibility studies and pilot projects for the

establishment of regional medical research, training, and demonstrations.

Grants were authorized for the planning and development of regional

medical programs. The legislation mandated the establishment of

advisory groups to advise applicants participating in resulting regional

medical programs. Group membership should include practicing physicians,

medical center officials, hospital administrators, representatives of

the appropriate medical societies, representatives of voluntary or

official health agencies or health planning agencies, and representatives

of other organizations concerned with the activities of the program.

The legislation mandated the appointment of the 20 member National Advisory

Council on Regional Medical Programs. Lists were to be compiled of

facilities in the United States equipped and staffed for the most

advanced methods and techniques of diagnosis and treatment of heart

disease, cancer, stroke, or kidney disease. Grants and contracts were

authorized for (a) programs of use to two or more regional medical

programs, (b) trial methods for the control of heart disease, cancer,

stroke, or kidney disease (c) collection of epidemiological data related

to the above diseases, (d) development of training related to the

diagnosis, treatment, or rehabilitation of persons suffering from

heart disease, cancer, stroke, or kidney disease, (e) conduct of co-

operative field trials.

The National Cancer Act of 1971, Pub. L. No. 92-218, was enacted

on December 23, 1971. It amended the Public Health Service Act to

strengthen the National Cancer Institute and the National Institute of

Health in order to deal more effectively to carry out the national effort

against cancer. The legislation established the three member President's









Cancer Panel. Provisions were enacted for 15 new centers for clinical

research, training, and demonstrations of advanced diagnostic and

treatment methods relating to cancer. Cancer Control Programs were

established with health agencies involved with the diagnosis, treatment,

and prevention of cancer. The statute mandated annual scientific peer

review of cancer programs. It established the National Cancer Advisory

Board, to be composed of 18 members. According to the legislation the

directors of the National Institute of Health and the National Cancer

Institute were to be appointed by the President of the United States.

Pub. L. No. 92-218 established the National Institute on Aging. The

appropriations authorized by the statute were $400,000,000 for the

fiscal year ending June 30, 1972; $500,000,000 for the fiscal year

ending June 30, 1973; $600,000,000 for the fiscal year ending June 30,

1974; $750,000,000 for the fiscal year ending June 30, 1975; $830,000,000

for the fiscal year ending June 30, 1976; $985,000,000 for the fiscal

year ending June 30, 1977.

Pub. L. No. 92-423: National Heart, Blood Vessel, Lung, and Blood

Act of 1972 was enacted on September 19, 1972. The act changed the name

of the National Heart Institute to the National Heart and Lung Institute

and the name of the National Heart Advisory council to the National Heart

and Lung Advisory Council. The Institute was to foster and assist in

research relating to the cause, prevention, and methods of diagnosis

and treatment of heart, blood vessel, lung, and blood disease. Research

facilities were to be made available to public authorities, health

officials, and other scientists. Grants-in-aid were authorized to

universities, hospitals, laboratories, and other institutions and









individuals for research projects relating to heart, blood vessel,

lung, and blood disease, including grants for construction, acquisitions,

leasing equipment, and the maintenance of hospitals, laboratories, and

related facilities, and for the care of patients. The statute established

information centers on research, prevention, diagnosis, and treatment of

heart, blood vessel, lung, and blood disease. Pub. L. No. 92-423

provided for clinical training and the maintenance of traineeships in

the Institute and elsewhere in matters relating to diagnosis, treatment,

and prevention of heart, blood vessel, lung, and blood disease. The

legislation mandated the establishment of programs with the cooperation

of federal health agencies, public health agencies, and private health

agencies in the diagnosis, prevention, and treatment of heart, blood

vessel, lung, and blood disease, emphasizing those dealing with children.

Fifteen new centers were to be established for basic and clinical research

into advanced diagnosis, prevention, and treatment methods for heart,

blood vessel, lung, and blood disease. The Interagency was established

to coordinate all aspects of related federal health programs. The act

established the Institute of National Heart and Lung Advisory Council,

composed of 23 members. The Council was to review research programs,

review applications for grants-in-aid for research and traineeships,

collect and disseminate information, recommend acceptance of gifts,

participate in Congressional hearings, and submit annual reports. The

authorization for appropriations within the statute were: $375,000,000

for the fiscal year ending June 30, 1973; $425,000,000 for the fiscal

year ending June 30, 1974; and, $475,000,000 for the fiscal year ending

June 30, 1975.









Pub. L. No. 93-352: National Cancer Amendments of 1974 was enacted

on July 23, 1974. It established the president's Biomedical Research

Panel, a seven member panel charged to review, assess, and identify

policy issues and make recommendations. It also established the National

Cancer Program to (a) develop and plan an expanded, intensified, and

coordinated cancer research program; (b) utilize existing research

facilities; (c) encourage research by industrial concerns; (c) collect,

analyze, and disseminate information regarding prevention, diagnosis,

and treatment of cancer including the establishment of an international

cancer research data bank; (e) establish or support large-scale produc-

tion of specialized biological materials and other therapeutic substances;

(f) support research in cancer outside the United States; (g) support

manpower training programs to expand the manpower base of the health

professions; (h) call meetings of the National Cancer Advisory Board

as needed; (i) prepare and submit annual budget estimates and receive

appropriate funds directly for expenditure by the National Cancer

Institute. The provisions of the statute included the following authoriza-

tions: $400,000,000 for the fiscal year ending June 30, 1972; $500,000,000

for the fiscal year ending June 30, 1973; $600,000,000 for the fiscal

year ending June 30, 1974; $750,000,000 for the fiscal year ending June

30, 1975; $830,000,000 for the fiscal year ending June 30, 1976; and

$985,000,000 for the fiscal year ending June 30, 1977.

Pub. L. No. 90-489, enacted August 16, 1968, amended the Public

Health Service Act to provide for the establishment of the National Eye

Institute in the National Institute of Health. The National Eye Institute

was established for the conduct and support of research for treatment,

cures, and training related to blinding eye disease and visual disorders,









including research on the special problems of the blind, mechanisms of

visual function, and the preservation of sight. An advisory council

was also established. Traineeships and fellowships were authorized in

the National Eye Institute and elsewhere in matters relating to diagnosis,

prevention, and treatment of blinding eye disorders and visual disorders.

The statute changed the name of the Institute for Neurological Diseases

and Blindness to the Institute for Neurological Diseases.

The Family Planning Services and Population Research Act of 1970,

Pub. L. No. 91-572, was enacted on December 24, 1970. Grants were

authorized to entities to establish voluntary family planning projects.

Grants to states were authorized to assist in the planning, establishing,

maintaining, coordinating, and evaluating of family planning services.

Grants or contracts were authorized with entities or individuals for

training personnel to carry on family planning programs. Authorization

were also enacted for grants and contracts to promote biomedical, contra-

ceptive, developmental, behavioral, and program implementations related

to family planning and population. Grants and contracts to assist in

developing family planning and population growth information were also

authorized. The legislation strongly noted that participation in family

planning activities was not a prerequisite for eligibility or receipt

of any other federal aid or service, nor were any federally funded

projects to use abortion as a family planning method. Authorizations

were included for the fiscal years ending June 30, 1971, through the

one ending June 30, 1974. Funds authorized for project grants for

family planning services were $30,000,000, $60,000,000, $111,500,000,

and $111,500,000, respectively. Two million dollars were authorized

for training personnel in family planning services for the fiscal year









ending June 30, 1971; $3,000,000 was authorized for the fiscal year

ending June 30, 1972; $4,000,000 was authorized for the fiscal year

ending June 30, 1973; $3,000,000 was authorized for the fiscal year

ending June 30, 1974. The authorizations for the same time period for

the research effort were: $30,000,000; $50,000,000; $65,000,000; and

$2,615,000, respectively.

Pub. L. No. 93-45: Health Programs Extension Act of 1973 was

enacted June 18, 1973. It extended the appropriations under the Family

Planning Services and Population Research Act. It authorized increased

appropriations and extended the termination dates of a broad range of

public health legislation. Its primary purpose was to authorize grants

to agencies for developing specialized training programs, training

personnel, conducting surveys and field trials, and projects of special

significance in relation to narcotic addiction, drug abuse, and drug

dependency. The authorizations under the provisions of the statute for

appropriations for health services research and health statistics were

$42,617,000 for the fiscal year ending 1974.

December 31, 1970 was the date of enactment of Pub. L. No. 91-616:

Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and

Rehabilitation Act of 1970. The act established the 12 member National

Advisory Council on Alcohol Abuse and Alcoholism as well as the National

Institute on Alcohol Abuse and Alcoholism. The Institute was to develop

and conduct comprehensive health, education, training, research, and

planning programs for the prevention and treatment of alcohol abuse and

the rehabilitation of alcohol abusers and alcoholics.

Pub. L. No. 93-282: Comprehensive Alcohol Abuse and Alcoholism

Prevension, Treatment, and Rehabilitation Act Amendments of 1974 was









enacted on May 14, 1974. Congress declared the utilization of programs

under other federal laws in the fields of health and social services to

help eradicate alcohol abuse and alcoholism. The legislation established

an Interagency Committee on Federal Activities for Alcohol Abuse and

Alcoholism to evaluate all federal programs and activities related to

alcoholism and alcohol abuse and to seek a coordinated effort. The

members were to include representatives from the appropriate federal

departments and five members of the general public.

The National Sickle Cell Anemia Control Act, Pub. L. No. 92-294,

was enacted on May 16, 1972. It authorized grants for screening and

counseling programs, primarily through other existing health programs.

Grants were authorized for programs to develop information and educa-

tional materials. Authorization was also included for grants in (a)

research and training in diagnosis, treatment, and control of sickle

cell anemia; (b) educational programs as to the nature and inheritance

of the trait and the disease; (c) counseling, testing, and other related

programs. Participation was only to occur on a voluntary basis. The

authorizations for screening programs, counseling programs, and educa-

tional programs were $20,000, $30,000, and $35,000, for the fiscal years

1973, 1974, and 1975. For the same period of time, $5,000,000, $10,000,000,

and $15,000,000 were authorized for research, public education, diagnosis,

and control programs.

Pub. L. No. 92-414: National Cooley's Anemia Control Act was

enacted August 29, 1972. It authorized grants and contracts with

entities for health projects of screening, treatment, and counseling

for patients with Cooley's anemia. Grants and contracts were also









authorized with entities for research into the diagnosis, treatment,

and prevention of Cooley's anemia including the development of an

inexpensive and effective test identifying those with the disease and

the carriers of the trait. Grants for the development of information

and educational materials and their dissemination were authorized.

Authorizations for screening, treatment, counseling, research, informa-

tion, and education programs were $1,000,000 for the fiscal year ending

June 30, 1973; $1,000,000 for the fiscal year ending June 30, 1974;

and $1,000,000 for the fiscal year ending June 30, 1975.

April 22, 1974 was the date of enactment of Pub. L. No. 93-270:

Sudden Infant Death Syndrome Act of 1974. It mandated the development

of public information and professional educational materials relating

to sudden infant death syndrome and the dissemination of such materials

to health care providers, public safety officials, and the general

public. Grants and contracts were authorized with entities for projects

to collect and analyze information relating to the causes of sudden

infant death syndrome and the provision of information and counseling

to families affected by sudden infant death syndrome. The statute

authorized $2,000,000 for the fiscal year ending June 30, 1975; $3,000,000

for the fiscal year ending June 30, 1976; and $4,000,000 for the fiscal

year ending June 30, 1977.

Pub. L. No. 93-354: National Diabetes Mellitus Research and

Education Act of 1974 was enacted on July 23, 1974. It established

the position of Associate Director for Diabetes in the National Institute

of Arthritis, Metabolic, and Digestive Diseases with responsibility for

programs related to diabetes. The legislation mandated the development









or expansion of centers for research and training in diabetes mellitus

or related endocrine and metabolic disorders. The centers would conduct

research, train physicians and allied health personnel, and provide

information for primary health care deliverers. The act established

the National Commission on Diabetes, composed of 17 members. The

Diabetes Mellitus Coordinating Commission was created to coordinate all

aspects of the federal health program relating to diabetes, to provide

for communication and the exchange of information, and to coordinate

programs and activities.


Mental Health Legislation

On July 3, 1946, Pub. L. No. 79-487: National Mental Health Act

was enacted to improve the mental health of the population of the United

States through the conducting of research, investigating, experimenting,

and demonstrations relating to the cause, diagnosis, and treatment of

psychiatric disorders. Additional purposes were the promotion and

coordination of such research; the training of personnel in matters related

to mental health; helping states use the most effective methods of pre-

vention, diagnosis, and treatment of psychiatric disorders. The

National Advisory Mental Health Council was established. It was composed

of 12 members, six members had to be medical or scientific authorities

on mental health. The purpose of the council was to offer advice

related to mental health, and the acceptance of gifts on behalf of the

National Institute of Mental Health. Pub. L. No. 79-487 authorized

appropriations for the erection and equipment of hospital buildings and

facilities including living quarters for personnel and adequate labora-

tory buildings to be known as the National Institute of Mental Health.









The National Advisory Mental Health Council was to make recommenda-

tions to the Surgeon General regarding awards of grants-in-aid for

research programs with respect to mental health. Such grants could be

awarded to universities, hospitals, laboratories, or other institutions

or individuals. The grants were to provide clinical training and establish

clinical traineeships with respect to mental health. Additional grants

were to be awarded to state or local agencies, laboratories, institutions,

or individuals for investigations, experiments, demonstrations, and

research proposals with respect to improving methods of diagnosing,

care, treatment, and rehabilitation of the mentally ill. The statute

required the maintenance of confidentiality and authorized increased

appropriation of funds.

The primary purpose of Pub. L. No. 84-182: Mental Health Study

Act of 1955, enacted July 28, 1955, was to alleviate the critical need

for analysis and reevaluation of human and economic problems of mental

illness and of the resources, methods, and practices utilized in the

diagnosis, treatment, care and rehabilitation of the mentally ill.

The legislation encouraged non-governmental, multidisciplinary research

into and reevaluation of all aspects of resources, methodology, and

practices for diagnosing, treatment, care, and rehabilitation of the

mentally ill, including research aimed at prevention.

Assistance in combating mental retardation through grants for the

construction of research centers and grants for facilities for the

mentally retarded, as well as assistance in improving mental health

through grants for the construction of community mental health centers

were provided by Pub. L. No. 88-164: Mental Retardation Facilities and

Community Mental Health Centers Construction Act of 1963, enacted on









October 31, 1963. Title I of the act, referred to as the Mental

Retardation Facilities Construction Act, authorized appropriations for

grants for the construction of facilities for mental health research or

research relating to human development which attempted to find the causes,

means of prevention of mental retardation or the means of ameliorating

the effects of mental retardation. Grants for clinical facilities for

mental retardation and facilities with service in diagnosis, treatment,

education, training, and care of the mentally retarded or the clinical

training of physicians and other specialized personnel were also

authorized. Project grants were authorized for the construction of

facilities for the mentally retarded which are associated with colleges

or universities. States receiving such funds must have a state plan.

Title II, referred to as the Community Mental Health Centers Act,

authorized appropriations for grants for the construction of public and

nonprofit community mental health centers. Such awards required that

the state have a plan for community mental health care provision.

Pub. L. No. 89-105 enacted on August 4, 1965, authorized assistance

in meeting the initial costs of professional and technical personnel

for comprehensive community mental health centers. It assisted in the

establishment of community mental health centers providing comprehensive

programs. Grants were authorized for portions of the costs of profes-

sional and technical personnel as well as for initial operations.

Recipients of the grants were to keep records subject to audit by the

Comptroller General of the United States. The statute also included

authorization for grants to institutions of higher education for the

construction, equipping, and operation of facilities for research to be

awarded by the Commissioner of Education.









The Mental Health Amendments of 1967, Pub. L. No. 90-31, were

enacted on June 24, 1967. They amended the public health laws relating

to mental health to extend, expand, and improve them. Grants for the

construction of community mental health centers were authorized. In

addition, grants were authorized for the initial staffing of community

mental health centers.

The extension, expansion, and improvement of the public health

laws relating to mental retardation were amended by Pub. L. No. 90-170:

Mental Retardation Amendments of 1967, enacted on December 4, 1967.

Grants were authorized for the construction of university-affiliated

mental retardation clinical facilities, as were grants for the construc-

tion of community mental retardation facilities, and grants for the

costs of professional and technical personnel for community mental

retardation facilities. In addition grants were authorized for institu-

tions of higher education for programs involved in the training of

physical educators and recreation personnel for the mentally retarded

and other handicapped children, as well as programs in supervision,

research, and teaching. Appropriations were allocated for grants for

research and demonstration projects in physical education and recrea-

tion for the mentally retarded and other handicapped individuals. The

Secretary of Health, Education, and Welfare was required to appoint an

advisory committee of seven members: three members from the field of

physical education, two members from the field of recreation, and two

members with special experience in the education of mentally retarded

or handicapped children. The statute authorized $20,000,000 for the

fiscal years 1969 through 1973 for construction of facilities. Authoriza-

tions for training programs were $15,000,000 for the fiscal year ending









June 30, 1971; $17,000,000 for the fiscal year ending June 30, 1972;

$20,000,000 for the fiscal year ending June 30, 1973; and $9,250,000

for the fiscal year ending June 30, 1974. For the same period of time

the authorizations for programs for the developmentally disabled were

$60,000,000; $105,000,000; $130,000,000; and $32,500,000, respectively.

Pub. L. No. 91-211: Community Mental Health Centers Amendments of

1970, enacted on March 13, 1970, extended the appropriations of Pub. L.

No. 88-164: Mental Retardation Facilities Act. In addition to increasing

the duration and amount of funding, Pub. L. No. 91-211 authorized the

leasing of specialized facilities including those for emergency medical

services, intermediate care services, or outpatient services. It ex-

tended the appropriations for projects referring to the treatment and

prevention of drug abuse and drug dependence. Grants were also authorized

to agencies to: (a) develop special training regarding the provision

of mental health services for children; (b) train personnel to operate,

supervise, and administer such services; (c) conduct surveys and field

trials to evaluate the adequacy of programs of mental health for children

in the several states. It included the criteria for the determination

of a poverty area. The statute authorized funds for the construction

of facilities for the prevention and treatment of alcohol abuse. The

authorizations for fiscal years 1969 through 1974 were $15,000,000;

$40,000,000; $60,000,000; $80,000,000; and $36,774,000 respectively.

Authorizations for grants for the construction of facilities for the

prevention and treatment of drug abuse for the same time period were

$60,000,000; $70,000,000; $80,000,000; $90,000,000; $100,000,000; and

$20,000,0000. Fiscal years 1973, 1974, and 1975 had authorizations of









$60,000,000 for programs to combat drug abuse. Authorizations for

alcohol abuse programs were $30,000,000 for the fiscal year ending

June 30, 1971.

On October 30, 1970, Pub. L. No. 91-517: Developmental Disabilities

Services and Facilities Construction Amendments was enacted. It

expanded Pub. L. No. 90-170: Mental Retardation Amendments of 1967 to

include interdisciplinary training. The major change expanded the

program beneficiaries from the mentally retarded to those persons with

all types of developmental disabilities.


Health Manpower Education Legislation


Pub. L. No. 84-911: Health Amendments Act of 1956 was enacted

on August 2, 1956. The purpose of the act was to improve the health

of the people by assisting in increasing the number of adequately trained

professional and practical nurses and professional public health personnel.

Its purpose was also to assist in the development of improved methods

of care and treatment in the field of mental health.

Title I authorized funds for traineeships for graduate or specialized

training in public health for physicians, engineers, nurses, and other

professional health personnel. Grants could be awarded to either

individuals or institutions. Title II provided funds for traineeships

for training professional nurses to teach in various fields of nurse's

training (including that of practical nursing) or to serve in an

administrative or supervisory capacity. Such grants were to be awarded

to institutions with the consent of an advisory committee formed for

that purpose.









Title III amended the Vocational Education Act of 1946, providing

funds for grants to the states to extend and improve practical nurse

training. The states were required to have a state plan as well as an

advisory committee to review the requests for funds. Title IV extended

the Hospital Survey and Construction Act for two more years.

Title V provided for training and instruction by establishing

traineeships in the field of mental health. Grants were authorized

to state or local agencies, laboratories, other public or non-profit

agencies or institutions, and individuals for investigations, experiments,

demonstrations, studies, and research programs with respect to the

development of improved methods of diagnosing mental illness. Funds

were provided for grants to state agencies for improving methods of

operation and administration of state institutions of care.

Appropriations for the construction of facilities were authorized

by Pub. L. No. 88-129: Health Professions Educational Assistance Act

of 1963, enacted on September 24, 1963. Funds were included for the

construction of research facilities and the construction of teaching

facilities for the training of physicians, dentists, pharmacists,

optometrists, podiatrists, veterinarians, and professional public health

persons. The statute established the National Advisory Council on

Health Professionals Education. Originally the council had 17 members;

legislation has since increased the membership to 20 individuals. Pub.

L. No. 88-129 allowed for the establishment and operation of a student

loan fund with any public or non-profit private school of medicine,

osteopathy, dentistry, pharmacy, podiatry, optometry, or veterinary

medicine. Loan limitations, terms, and conditions were outlined.

The legislation included the authorization of appropriations.









The Health Professions Educational Assistance Amendments of 1965,

Pub. L. No. 89-290, were enacted on October 22, 1965. The statute

amended the Public Health Service Act to improve the educational quality

of schools of medicine, dentistry, and osteopathy. The statute

authorized grants to such schools for the awarding of scholarships to

needy students and to extend the provisions for student loans. Grants-

in-aid were authorized for the construction of teaching facilities for

students in such schools and schools for other health professionals.

Grants of $12,500 plus the product of $250 multiplied by the number

of full-time students were allowed for schools of medicine, dentistry,

osteopathy, and podiatry to improve the quality of the educational

program. Special improvement grants were to be awarded to such schools

upon the recommendation of the National Advisory Council on Medical,

Dental, Optometric, and Podiatric Education. The grants were to be

used to maintain the accreditations of the professional schools or to

provide for special functions and school services. The National Advisory

Council on Medical, Dental, Optometric, and Podiatric Education was to

be appointed with 12 members.

Funds were authorized for the award of scholarships to students in

the health professional schools listed above that were from low income

families. The scholarships could be applied to a portion of tuition,

fees, the cost of books and equipment, and living expenses with the total

not to exceed $2,500. In addition appropriations were included for the

construction of new teaching facilities at professional schools and for

the replacement and/or rehabilitation of existing facilities.









For the fiscal years 1967, 1968, and 1969, $480,000,000 were

authorized for grants for the construction of teaching facilities.

These grants were extended by Pub. L. No. 90-490 to equal $170,000,000

for the fiscal year ending June 30, 1970 and $225,000,000 for the fiscal

year ending June 30, 1971. Pub. L. No. 92-157 extended the authorization

from 1972 through 1974 at $225,000,000; $250,000,000; and $275,000,000,

respectively. The authorizations for student loans under the provisions

of this statute were $25,000,000 for the years 1967, 1968, and 1969.

Authorizations under the provisions of Pub. L. No. 90-490 were $35,000,000

for the fiscal years ending June 30, 1970, and June 30, 1971. Pub. L. No.

92-157 extended the authorizations for 1972 through 1974 at the following

levels: $50,000,000; $55,000,000; and $60,000,000. Fiscal years 1975

through 1977 were authorized $60,000,000 each under the statute.

Pub. L. No. 89-751: Allied Health Professions Personnel Training

Act of 1966, enacted on November 3, 1966, amended the Public Health

Services Act to increase the opportunities for training medical

technologists and personnel in other allied health professions. The

statute sought to improve the educational quality of the schools training

such allied health professions personnel, and to strengthen and improve

existing student loan programs for medical, osteopathic, dental,

podiatric, pharmacy, optometric, and nursing students.

Grants were authorized for the construction of facilities for

training allied health professionals or to replace and/or rehabilitate

existing facilities. Funds were authorized for grants to assist training

centers for allied health professionals to promote the development of

new or improved curriculums for training allied health professionals and

increase the quality of the educational programs. Special improvement









grants were to be awarded to training centers having special functions.

Appropriations were authorized for traineeships for allied health profes-

sion personnel requiring advanced training, or pursuing training in the

fields of teaching, administration, or supervision. The statute allowed

for grants for centers to develop, demonstrate, or evaluate curriculum

for new types of health technologists. Recipients of any of the grants

listed above were required to keep records readily accessible for audit.

Authorizations for grants for the construction of teaching facilities

for the fiscal years 1967 through 1973 equaled $3,000,000; $9,000,000;

$13,500,000; $10,000,000; $20,000,000; $30,000,000; and $40,000,000.

Authorizations for the granting of traineeships for advanced study in

the related areas for the same period of time equaled $1,500,000; $2,500,000;

$3,500,000; $5,000,000; $8,000,000; $10,000,000; $12,000,000; and $6,000,000.

Funds were authorized for special project grants at the level of $10,000,000

for the fiscal year ending June 30, 1971; $20,000,000 for the fiscal year

ending June 30, 1973; $30,000,000 for the fiscal year ending June 30,

1973; and $18,245,000 for the fiscal year ending June 30, 1974. Special

grants for the improvement of the quality of educational programs were

authorized at the following levels for the years 1971 through 1974:

$15,000,000; $20,000,000; $30,000,000; and $20,000,000.

The Allied Health Professions Personnel Training Act of 1966 also

provided for the cancellation of up to 50% of the amount of a student

loan awarded to a physician, dentist, or optometrist establishing a

practice in a rural area or one characterized by low family income.

The statute established a revolving fund from which schools might

obtain loans to capitalize health care professions student loan funds









under Title VII-C of the Public Health Service Act. Grants were

authorized to schools of nursing for undergraduate students of nursing

with exceptional financial need. Such grants became known as nursing

educational opportunity grants.

The Health Manpower Act of 1968, Pub. L. No. 90-490, was enacted

on August 16, 1968 to amend the Public Health Service Act. The purpose

of the statute was to extend and improve the programs relating to the

training of nurses and other health professionals and allied health

professions personnel. Improvement was also sought for programs relating

to student aid for such personnel and programs relating to the upgrading

of health research facilities.

Title I of Pub. L. No. 90-490 dealt with health professions

training. It extended construction authorizations. In addition, grants

were authorized for the construction of multipurpose facilities, and

for continuing and advanced education facilities. Schools of medicine,

dentistry, osteopathy, pharmacy, optometry, veterinary medicine, and

podiatry were eligible for grants to be used for training and to be

used to increase enrollment. Grants to the above types of schools were

authorized to allow the schools to meet the costs of special projects

to plan, develop, or establish new programs, or to improve the curriculums,

or assist those schools in financial straits to meet the costs of opera-

tion, or to help meet accreditation requirements.

The Health Manpower Act of 1968 changed the name of the advisory

committee to the National Advisory Council on Health Professions

Educational Assistance. It extended the student loan program. It

required the submission of reports appraising school aid and student aid









programs in light of their adequacy to meet the long-term needs for

health professionals.

Title II of Pub. L. No. 90-490 dealt with nurses' training. It

too extended construction authorizations. Grants were authorized for

special projects to plan, develop, or establish new programs or modify

existing programs of nursing education, or to improve the curriculums

of such programs, or to research nursing education, or to assist schools

in financial straits, or to meet the costs of any other special project

to help increase the supply of nursing personnel. Grants were authorized

to schools of nursing to increase enrollment of students.

The statute increased and extended the student loan program and

authorized scholarship grants. Pub. L. No. 90-490 mandated a study of

school and student aid programs, appraising them in light of their

ability to meet the long-term need for nurses.

Title III of Pub. L. No. 90-490 dealt with the training of allied

health professionals and those engaged in the study of public health.

Funds were authorized for the extension and the improvement of allied

health professions educational programs. It mandated the study of the

adequacy of such programs to meet the future needs for allied health

professions personnel. The legislation also mandated the extension and

improvement of such programs in public health. Title V of Pub. L. No.

90-490 extended the authorizations for the construction of health

research facilities.

Title VII of the Public Health Service Act was amended to provide

increased manpower for the health professions by Pub. L. No. 92-157:









Comprehensive Health Manpower Training Act of 1971, was enacted November

18, 1971. Title I of Pub. L. No. 92-157 extended the grants and loan

guaranties for the construction of teaching facilities for medical,

dental, and other health professional schools, as well as loan guaranties

for construction projects for teaching facilities. The legislation

allowed for the provision of technical assistance to applicants in

designing or planning the construction of any educational facility.

Capitation grants were authorized to schools of medicine, osteo-

pathy, dentistry, veterinary medicine, optometry, pharmacy, and podiatry.

Such grants were to be based on the number of students enrolled and

their year in school. Capitation grants were also authorized for students

enrolled in programs training physicians assistants and dental therapists.

The continuation of all grants was contingent upon increasing student

enrollment. Grants were also authorized for the construction of new

schools.

The Comprehensive Health Manpower Training Act of 1971 permitted

the awarding of special project grants to improve professional education

curriculums, including shortening the length of time requiring for

training, as well as for the establishment of programs in family medicine.

The development of interdisciplinary programs emphasizing a team approach

to health care and the development of training programs for new roles

such as that of the physicians assistant were mandated by the legislation.

New educational programs, research into health education, and programs

improving the geographical distribution of health care providers were

also authorized.









Funds were authorized for programs emphasizing the study of pre-

vention, diagnosis, treatment, and rehabilitation of individuals suf-

fering from alcoholism and drug dependence, as well as for those empha-

sizing human nutrition and health. Special projects were authorized

to assist individuals who will practice in rural areas or other areas

of severe shortages of health personnel. In addition Pub. L. No. 92-157

mandated programs for the enrollment of minorities and low income

persons in professional education programs. It provided for trainee-

ships for the study of family practice, pediatrics, internal medicine,

or health care in rural areas. Programs for the utilization of health

care professionals through the application of computer technology were

also eligible for funds.

Grants were authorized to assist health professions schools which

were in financial distress. Funds were furnished to improve the distri-

bution, supply, quality, utilization, and efficiency of health personnel

and the health care delivery system. Guidelines were present in the

legislation for student loan programs and for waivers of repayment for

individuals practicing in areas of health personnel shortage. Grants

were funded for the training of, as well as traineeships and fellowships

in, family medicine. Support was offered for postgraduate programs for

physicians and dentists.

Other grants were made available for the training, traineeships,

and fellowships for teachers of medicine, dentistry, osteopathy,

podiatry, optometry, pharmacy, and veterinary medicine. Demonstration

projects in the applications of computer technology in the field of

health care were also eligible for funds under the Comprehensive Health









Manpower Training Act of 1971. It established a Public Health Service

and National Advisory Council on Health Profession Education, consisting

of 20 members including four from the general public and two full-time

students enrolled in health professions schools. All provisions of the

legislation prohibited discrimination in admission to programs on the

basis of sex.

Title II of Pub. L. No. 92-157 contained miscellaneous provisions

relating to health manpower programs. It established the National Health

Manpower Clearinghouse. The purposes of the clearinghouse were to compile

a list of communities and areas with health professionals needs and

maintain perspectives on health workers interested in such opportunities.

In addition it allowed for the assignment of Public Health Services

physicians to certain medically underserved counties.

Pub. L. No. 92-157 mandated a study and report by the Comptroller

General of Health facilities construction costs. It also mandated a

study and report of the programs of educating students in various health

professions, a study and report of the uniformity of educational standards

for determining the costs of education, and a study estimating the future

of professional education. The legislation required the submission of a

report on the effects of the act on the number of persons entering health

professions and the number of practitioners in relation to public need.

Authorizations under the provisions of the statute equaled $225,000,000

for the fiscal year ending June 30, 1973; $275,000,000 for the fiscal

year ending June 30, 1974.

Improvement of the programs of medical assistance to areas with

health manpower shortages was the purpose of Pub. L. No. 92-585:








Emergency Health Personnel Act Amendments of 1972, enacted on October

27, 1972. It established the Regular and Reserve Public Health Services

Corps. Under the legislation the Secretary of Health, Education and

Welfare was permitted to determine areas of critical health manpower

shortage and assign Public Health Service personnel to that locale.

The practitioners were to utilize the most appropriate facilities for

the area. Care was to be given regardless of an individual's ability

to pay, although individuals were to be charged on a fee-for-service

basis. An individual's inability to pay might result in either a reduced

fee or no charge.

The statute authorized a recruiting program for the Public Health

Service Corps. It established Public Health Service Corps and

National Health Service Corps scholarships, requiring a recipient to

exchange one year of service for each year of academic training received.

The statute authorized the following appropriations: $10,000,000 for the

fiscal year ending June 30, 1971; $20,000,000 for the fiscal year ending

June 30, 1972; $30,000,000 for the fiscal year ending June 30, 1973;

and $25,000,000 for the fiscal year ending June 30, 1974.


Nursing Manpower Education Legislation


Pub. L. No. 88-581: Nurse Training Act of 1964 was enacted on

September 4, 1964, to mend the Public Health Service Act to increase the

opportunities for training professional nursing personnel. Grants were

authorized for the construction of collegiate schools of nursing or for

the replacement and/or rehabilitation of existing facilities. To prevent

further attrition and to promote the development of public and non-profit









diploma schools of nursing, the statute authorized grants to defray

the costs of training students in such nursing programs. Students

enrolled in diploma nursing education programs were eligible for

federally sponsored loans.

Appropriations were authorized for traineeships for the education

of professional nurses to teach in various fields of nursing education

including practical nursing, to serve in administrative or supervisory

capacities, or to serve in other professional nursing specialties.

Grants for the above efforts were to go to institutions of nursing

education. The authorizations for grants for the construction of col-

legiate schools of nursing equaled $5,000,000 for the fiscal year ending

June 30, 1966, and $10,000,000 for the next three years. The authoriza-

tions for grants for the construction of facilities for associate

degree and diploma schools of nursing equaled $10,000,000 for the fiscal

year ending June 30, 1966 and $15,000,000 for the next three years.

Additional grants were authorized to prevent further attrition of

diploma programs. These were equal to $4,000,000 for the fiscal year

ending June 30, 1965; $7,000,000 for the fiscal year ending June 30,

1966; and $10,000,000 for the next three years.

A federal student loan fund was established by Pub. L. No. 88-581.

Loans were to go to schools of nursing to establish loan funds. The

National Advisory Council on Nurse Training was established, to be com-

posed of 16 members.

The purpose of Pub. L. No. 92-158: Nurse Training Act of 1971

enacted on November 18, 1971 was to amend the Public Health Service






44


Act to increase the numbers of nurses trained in nursing education

programs. The levels of appropriations for grants for the construction

of schools of nursing were increased. Loan guaranties and interest

subsidies for nonprofit private schools of nursing were approved.

Special project grants and contracts were authorized for the fol-

lowing: (a) to alleviate financial distress; (b) to aid mergers between

hospital training programs and academic institutions; (c) to develop

programs for the training of the pediatric nurse practitioner and other

nurse practitioners; (d) to develop interdisciplinary nursing education

programs; (e) to increase the supply or improve the distribution of

nurses; (f) to improve nursing education curriculums; (g) to foster

research in nursing education; (h) to provide programs for continuing

education and in professional retraining; (i) to increase the availability

of personnel in health services and preventive health care. Capitation

grants were authorized for nursing schools based upon the number of

students enrolled and the number of years the students had spent in

the program. Start-up grants were allowed for new nurse training programs.

Traineeships were made available for individuals pursuing advanced

training in professional nursing.

Loan repayments were cancelled for individuals employed full-time

in areas of health manpower shortage and having a need for nurses.

Grants for scholarships were authorized. Contracts and grants were

authorized to identify individuals with a potential for education in

the nursing profession. Such grants and contracts were to be used to

assist those individuals to enroll and to help in post secondary educa-

tion so as to be qualified to enroll. Special publicity was to be









prepared aimed at recruiting the licensed vocational nurse. All

provisions of the statute included a prohibition of discrimination on

the basis of sex. A report was mandated assessing the effectiveness of

the act in meeting the long-term national need for nurses.

The statute contained authorizations for the fiscal years 1972,

1973, and 1974. For that period the authorizations for capitation

grants equaled $78,000,000; $82,000,000; and $88,000,000. For that

period the authorizations for start-up grants equaled $4,000,000;

$8,000,000; and $12,000,000. Authorizations for traineeships for

advanced study equaled $20,000,000; $22,000,000; and $24,000,000 for

that time period. For that period authorizations for grants for the

rehabilitation of facilities equaled $35,000,000; $40,000,000; and

$45,000,000. Authorizations for special project grants equaled

$20,000,000; $28,000,000; and $35,000,000 for that time period. Authoriza-

tions for financial distress grants equaled $15,000,000; $10,000,000;

and $5,000,000 for that time period.

The Health Revenue Sharing and Nurse Training Act, Pub. L. No. 94-63,

was enacted on July 29, 1975. It prohibited any officer or employee of

the United States or of any state receiving federal funds from coercing

any person to undergo an abortion or sterilization. The statute

established a temporary commission, the Commission for the Control of

Epilepsy and Its Consequences, with the following duties: (a) to study

the medical and social management of epilepsy; (b) to examine the role

of government in research, prevention, identification, treatment, and

rehabilitation of persons with epilepsy; (c) to develop a comprehensive

national plan for the control of spilepsy; (d) to transmit the report

to Congress within one year. The commission was to have nine members.









In addition, the legislation impaneled a temporary Commission for

the Control of Huntington's Disease and Its Consequences. The focus

of the study of the Commission for the Control of Huntington's Disease

was to be the same as that for epilepsy: (a) the medical and social

management of the disease; (b) the government's role in efforts related

to Huntington's disease; (c) the development of a national plan; (d)

transmission of a report to Congress. The commission was to be composed

of nine members.

The statute mandated a study of the future mental health needs of

the elderly and the Committee on the Mental Health and Illness of the

Elderly was established for that purpose. The committee was also to

study the appropriate level of care for those elderly in mental institu-

tions and those discharged,as well as to offer proposals for implementing

the recommendations of the 1971 White House Conference on Aging. The

committee was allowed one year for its study and was to be composed of

nine members.

Pub. L. No. 94-63 established the National Center for the Prevention

and Control of Rape within the National Institute of Mental Health. The

Rape Center was to study: (a) the effectiveness of laws dealing with

rape; (b) the relationship between the legal and social sexual role

attitudes, the act of rape, and the formulation of laws dealing with

rape; (c) the treatment of rape victims; (d) the causes of rape; (e)

the impact of rape on the victim and her family; (f) the sexual assaults

in correctional institutions; (g) the actual incidence of rape as

compared with the reported incidence of rape and the reasons for any

difference; (h) the effectiveness of educational, counseling, and other









programs designed to prevent and control rape. The Rape Center was to

compile, analyze, and publish summaries of the studies. It was also to

develop and maintain an information clearinghouse on the prevention

and control of rape, the treatment and counseling of victims and

families, and the rehabilitation of offenders. The Rape Center was to

conduct the compilation and publication of training materials for

personnel engaged in programs to prevent and control rape. It was to

assist community mental health centers and other agencies with the

conducting of research on the subject of rape, and to assist community

mental health centers in meeting the costs of consultation and education

services regarding rape. The legislation mandated the appointment of an

advisory council with a majority of female membership.

The Health Revenue Sharing and Nurse Training Act empowered the

Secretary of Health, Education, and Welfare to make grants to assist

schools of nursing in serious financial straits to meet operating costs

or to meet accreditation requirements. Grants were authorized to meet

the costs of special programs such as: (a) mergers between hospital

training programs, or between hospital training programs and academic

institutions; (b) planning, development, or establishment of new nurses

training programs or programs of research in nursing education; (c)

improvement of curriculum; (d) increasing the nursing education op-

portunity for individuals from disadvantaged backgrounds; (e) provision

of continuing education for nurses; (f) providing retraining opportunities

for previously inactive nurses; (g) increase the supply or improve the

distribution by geographical area or specialty of adequately trained

nursing personnel; (h) provision of education to upgrade licensed









vocational or practical nurses; (i) assist in meeting the costs of

developing short-term in-service programs for nurses aides and orderlies

for nursing homes.

The legislation encouraged and assisted in the utilization of

medical facilities by federal departments and agencies for nurses

training programs. Grants and contracts were authorized for advanced

nurse training programs for those interested in serving as teacher

or administrators or supervisors. Grants and contracts were authorized

for nurse practitioner training programs with special consideration for

training programs of nurse practitioners who would practice in health

manpower shortage areas or with emphasis on geriatric patients.

Guidelines for programs training nurse practitioners were listed

in Pub. L. No. 94-63. They stated that practitioner programs must:

(a) be for registered nurses irrespective of the school of nursing

where they received their training; (b) upon the completion of their

study be able to provide primary health care in homes, ambulatory care

facilities, long-term care facilities, and other facilities; (c)

programs must be at least one academic year long with at least four

months of classroom instruction. Grants and contracts were authorized

with entities to operate traineeship programs for nurse practitioners

who were residents of health manpower shortage areas including payment

for tuition, living and moving expenses, books, fees, etc. Individuals

receiving such aid would promise to practice in health manpower shortage

areas.

The authorizations for construction of facilities under the

provisions of the statute were $20,000,000 for the years 1976 through
j









1978. Capitation grant authorizations equaled $50,000,000 for 1976

and $55,000,000 for 1977 and 1978. Authorizations for special project

grants equaled $45,000,000 for the years 1976 through 1978. Advanced

traineeship authorizations increased from $15,000,000 to $20,000,00 to

$25,000,000 for that time period. Authorizations for student loans

were set at $25,000,000 for the fiscal year ending June 30, 1976;

$30,000,000 for the fiscal year ending June 30, 1977; and $35,000,000

for the fiscal year ending June 30, 1978.


Statutes Developing Research Facilities and Libraries

The National Library of Medicine was established in the United

States Public Health Service by Pub. L. No. 84-941: National Library

of Medicine Act on August 3, 1956. The functions of the Library were to

be (a) the acquisition and preservation of learning material and media,

(b) the organization of materials, (c) the publication of catalogs,

indexes, etc., (d) the availability of Library materials through loans,

(e) the provision for reference and research assistance, (f) the

provision for other related activities. The Board of Regents of the

National Library of Medicine was established by Pub. L. No. 84-941.

In addition to the ex officio members representing the federal health

care bureaucracy, 10 members were to be appointed to the Board of Regents

by the President of the United States. These members were to represent

leaders in the health care field, leaders in medical library work, and

leaders in public affairs. The legislation also made provisions for

regulations governing the acceptance and the administration of gifts

and the establishment of memorials. The National Library of Medicine Act









mandated the transfer of the holdings of the Armed Forces Medical

Library, personnel, equipment, collections, unexpended appropriations,

etc. to the newly established National Library of Medicine. The legisla-

tion authorized the establishment of branches of the National Library of

Medicine in geographical areas previously without adequate regional

medical libraries or no medical libraries.

Pub. L. No. 89-291: Medical Library Assistance Act enacted on

October 22, 1965,amended the Public Health Service Act to provide a

program of grants to assist in meeting the need for adequate medical

library services and facilities. The role of the Board of Regents of

the National Library of Medicine was expanded by Pub. L. No. 89-291 to

include that of a National Medical Library Assistance Advisory Board.

Grants were authorized to agencies or institutions to be used toward the

cost of construction of medical library facilities. Also grants to

individuals were authorized allowing such persons to accept fellowships

and traineeships in post baccalaureate academic programs awarding

degrees in medical library sciences or in the field of communication of

information. The legislation authorized grants to individual librarians

or specialists in information on science related to health to undergo

training or retraining. Grants to assist institutions in developing,

expanding, and/or improving training programs in library science relating

to health were authorized. The establishment of internship programs in

medical libraries was provided for in the statute. The Medical Library

Assistance Act allowed the award of special fellowships to physicians

and other practitioners in science related to health for compilations

or other original works relating to the advancement of science related

to health.









Authorizations for grants to assist biomedical publications were

$1,000,000 for the years 1966 through 1973. The statute authorized

the same amount for grants for training in medical library science.

The authorizations for grants for research in medical library science

equaled $3,000,000 for that time period and authorizations for grants

for advanced research in health equaled $500,000.

Grants-in-aid on a matching basis to public or nonprofit private

institutions to assist in the construction of facilities for the conduct

of research in the sciences related to health were authorized by Pub. L.

No. 84-835: Health Research Facilities Act of July 30, 1956. The

legislation established in the United States Public Health Service the

National Advisory Council on Health Research Facilities. Membership

on the Council was to consist of a chairman and 12 members--four members

from the general public, eight members from medical, dental, or

scientific authorities skilled in health sciences. Regulations regarding

the time of application, the maximum amounts of the grants, and the

recapture of payment were included. The Act had a clause stating the

federal government's policy of noninterference with the administration

of institutions receiving such grants and allowing for the provision

of technical assistance to institutions in designing and planning con-

struction. The original authorizations under the provisions of the

statute equaled $50,000,000 for the years 1957 through 1967. Pub. L.

No. 90-490 added authorizations for 1968 and 1969 at $280,000,000;

$20,000,000 for 1970; and $30,000,000 for 1971.

On September 15, 1960, Pub. L. No. 86-798 was enacted to amend

the Public Health Services Act to authorize grants-in-aid to universities,








hospitals, laboratories, and other public or nonprofit private institu-

tions to strengthen their programs of research and research training

in sciences related to health. Such grants would be awarded on the recom-

mendation of the National Advisory Health Council. Grants-in-aid to

public and nonprofit private universities, hospitals, laboratories,

and other institutions were to be used for the general support of research

and research training programs. Not more than 15% of the National

Institutes of Health appropriation for research could be transferred

to the new program.

Pub. L. No. 93-348: National Research Service Award Act was

enacted on July 12, 1974. The statute provided National Research Service

Awards for (a) biomedical and behavioral research at the National

Institutes of Health and the Alcohol, Drug Abuse, and Mental Health

Administration; (b) training at the Institutes and Administrations of

individuals to undertake research; (c) biomedical and behavioral research

at non-Federal public and nonprofit private institutions; (d) pre- and

postdoctoral training at these institutions of individuals to undertake

such research. Grants were authorized to institutions to enable the

institutions to make National Research Service Awards. Such monies

were not to be used to support residencies. The grant periods were not

to exceed three years without good cause. Individuals receiving National

Research Service Awards were to engage in hospital research or teaching,

or continue practice as a physician, dentist, nurse or other individual

trained to provide health care in private practice, a health maintenance

organization, or as a member of the National Health Service Corps. The

authorization for the awards was established as $207,947,000 for the

fiscal year ending June 30, 1975.









Pub. L. No. 93-348 established the National Commission for the

Protection of Human Subjects of Biomedical and Behavioral Research.

The eleven members of the Commission were to be individuals distinguished

in the fields of medicine, law, ethics, theology, biological, physical,

behavioral, and social sciences, philosophy, humanities, health

administration, government and public affairs. Not more than five

members shall have been engaged in research with human subjects. The

duties of the commission were outlined as follows: (a) to develop guide-

lines for research involving human subjects after a study of the

issues; (b) to identify and define consent requirements; (c) to study

the protection mechanisms of human subjects; (d) to study living fetus

research; (e) to study and define the use of psychosurgery; (f) to make

recommendations to Congress; (g) to undertake special comprehensive

studies of the ethical, social, and legal implications of the advances

in biomedical and behavioral research and technology. The statute

prohibited the identification of individual subjects and/or the disclosure

of trade secrets.

The National Center for Health Statistics was established under

Pub. L. No. 93-353: Health Services Research, Health Statistics, and

Medical Libraries Act of 1974 of July 23, 1974. The duties of the

center included (a) the collection of statistics, and (b) the support

of research responding to the need for new or improved methodology for

obtaining current data. Congressional requests for special statistical

compilations and surveys were to be honored by the center. In addition,

it was to provide technical aid to states and localities. Pub. L. No.

93-353 mandated federal, state, and local cooperation in establishing

a health statistics system, with annual collection in the registration









areas. The legislation attempted to secure uniformity in the

registration and collection of statistics. It established the United

States National Committee on Vital Statistics, a 15 member panel of

individuals distinguished in the field of health statistics, epidemiology,

and the provision of health care. The Committee on Vital Statistics

was to submit annual reports on health care costs and financing, health

resources, health resources utilization, and the health of the nation's

people. The committee was to publish and disseminate the results of

such studies for the public, and to provide services leading to more

effective and timely dissemination of information on health service

research (including indexing, abstracting, translating, and publishing).

The statute authorized appropriations and mandated annual conferences

on topics of health for health authorities from several states. The

committee was responsible for the publication of weekly reports of health

conditions in the United States and other countries and other pertinent

health information for the use of persons and institutions concerned

with health services. The authorizations for health research, evaluation,

and demonstrations equaled $65,200,000 for the fiscal year ending June

30, 1975 and $80,000,000 for the fiscal year ending June 30, 1976.

Authorizations for the assembly of health statistics were $30,000,000

for both years.


Hospital Survey and Construction Legislation


Pub. L. No. 79-725: Hospital Survey and Construction Act was

enacted on August 13, 1946 to amend Title VI of the Public Health Service

Act. The primary purposes of the Pub. L. No. 79-725 were to mandate an









inventory by the states of existing hospital facilities and survey

the need for construction of additional facilities, and to assist in

the construction of public and nonprofit private hospitals. In order

to be eligible for federal assistance the states were to have a state

plan, a single agency charged with related responsibilities, and an

advisory council.

The statute included appropriations for the construction of beds

in general hospitals for tuberculosis patients, psychiatric patients,

and patients with chronic diseases. It authorized the construction of

public health centers--one for every 30,000 population or one for every

20,000 population in rural areas. Priority was given for the construc-

tion of hospitals in rural areas with small financial resources. The

statute authorized an appropriation of $75,000,000 for the fiscal year

ending June 30, 1947 and for each of the four succeeding years.

The Hospital Survey and Construction Act prohibited discrimination

on the basis of race, creed, color, or ability to pay except where

separate hospital facilities of like quality were available for each

group. All hospitals built with federal funds from this program had to

have beds and services for those unable to pay except if such beds were

not feasible from a financial standpoint. The federal government could

withhold certification for funds until there was compliance, or get re-

payment of federal monies from the state.

The legislation mandated the appointment of the Federal Hospital

Council. The membership of the council was to include the Surgeon

General, four experts in hospital and health administration, and four

representatives of consumers. The council was to promote the purposes

of the act by state conferences and to maintain the control of the states

of the operations of the hospitals.


I








Pub. L. No. 80-830, enacted on June 29, 1949, amended the Public

Health Service Act so as to provide a minimum allotment of $100,000 to

each state for the construction of hospitals. Each state had to have

an approved state plan to be eligible for funds. The sum of the allot-

ment was to be based upon the population of the state, but not less

than $100,000. The appropriations were for a total of four years.

The Hospital Survey and Construction Amendments of 1949, Pub. L.

No. 81-380, were enacted on October 25, 1949. The legislation amended

the Hospital Survey and Construction Act to extend its duration and

provide greater financial assistance in the construction of hospitals.

Appropriations were authorized for 1950 and the succeeding five years

for the construction of public and other non-profit hospitals. A

requirement for standards in the individual state plans for the percentage

of the federal share was included in the statute. The Amendments of

1949 authorized research, experiments, and demonstrations related to

effective development and utilization of hospital services, facilities,

and resources. Funds could be awarded as grants-in-aid to states,

political subdivisions, universities, and hospitals for such studies.

The statute authorized appropriations for the fiscal year ending June

30, 1950 and each of the five succeeding years of $150,000,000 for the

construction of public and other nonprofit hospitals.

The primary purpose of Pub. L. No. 82-139: Defense Housing and

Community Facilities and Service Act, enacted September 1, 1951, was

the provision of housing and community facilities and services required

in connection with the national defense. However, provisions were

included authorizing grants and loans for the construction of hospitals.









Pub. L. No. 93-151, enacted July 27, 1953, extended the duration of

the Hospital Survey and Construction Act two more years.

The Medical Facilities Survey and Construction Act of 1954 was

enacted on July 12, 1954. The purpose of the act was to amend the

hospital survey and construction provisions of the Public Health

Service Act to provide assistance to the states for a survey of the

need for diagnostic and treatment centers, for hospitals for the

chronically ill and impaired, for rehabilitation facilities, and for

nursing homes. Another purpose of the act was to provide assistance

in the construction of such facilities through grants to public and

private nonprofit agencies. An inventory of the existing diagnostic

and treatment centers, hospitals for the chronically ill and imparied,

rehabilitation facilities, and nursing homes was mandated, as was a

survey of the need for construction. Appropriations were authorized for

catagorical awards. To be eligible each state was required to have a

state plan, but was to retain control of operations. The statute

authorized appropriations for the inventory of diagnostic and treatment

centers ($20,000,000), hospitals for the chronically ill ($20,000,000),

rehabilitation facilities ($10,000,000), and nursing homes ($10,000,000).

Pub. L. No. 85-589, enacted August 1, 1958, authorized loans for

the construction of hospitals and other facilities under Title VI of

the Public Health Service Act. Pub. L. No. 85-664, enacted August 14,

1958, extended the Hospital Survey and Construction Act for an additional

three year period. Although the primary purpose of Pub. L. No. 86-372:

Housing Act of 1961, enacted on June 30, 1961, was the provision of housing

for moderate and low income families, it added two more years to provisions

of the Hospital Survey and Construction Act.









The Community Health Services and Facilities Act of 1961,

Pub. L. No. 87-395, was enacted on October 5, 1961, to assist in

expanding and improving community facilities and services for the

health care of the aged and other persons. It increased appropriations.

Grants were authorized for states and other public and nonprofit agencies

to conduct studies, experiments, and demonstrations toward improving the

health services outside the hospital for the chronically ill and aged.

The legislation increased the funds for grants for construction of

nonprofit nursing homes. Grants for research, experiments, and demonstra-

tions in the utilization of other medical facilities, agencies, and

institutions were authorized, as were programs for the construction of

facilities and projects for the acquisition of experimental or demonstra-

tional equipment.

Pub. L. No. 87-395 included a more precise definition of a

rehabilitation facility. Such a facility must be capable of providing

medical evaluation and service, psychological evaluation and service,

social evaluation and service, and vocational evaluation and service.

The major portion of the evaluation and service must occur within the

facility under auspices of a hospital or a physician. The statute

increased the authorizations from $30,000,000 per year to $50,000,000

for the five fiscal years succeeding 1961.

Pub. L. No. 88-443: Hospital and Medical Facilities Amendments

of 1964 was enacted on August 18, 1964. The purpose of the statute was

to improve the public health through revising, consolidating, and improving

the hospital and other medical facilities. Appropriations were authorized

for grants to state agencies for projects developing and assisting in









the implementation of comprehensive regional, metropolitan, area or

other local area plans for coordination of existing and planned health

facilities.

Title VI of Pub. L. No. 88-443 provided for assistance for the

construction of hospitals and other medical facilities. This included

grants for long-term care facilities, diagnostic and treatment centers,

rehabilitation facilities, and the construction or modernization of

public and nonprofit hospitals and public health centers. Eligibility

for funds required a state plan. Loans for construction or moderniza-

tion of hospitals or other medical facilities were also authorized.

Membership on the Federal Hospital Council was expanded to 12 members.

Grants-in-aid were authorized to states and other nonprofit entities

or institutions for projects relating to the development, utilization,

and coordination of facilities and resources of hospitals and other

medical facilities, including experimental architectural design or

functional layout, and experimental or demonstration equipment. The

authorizations for appropriations for grants for the construction of

hospitals and public health centers were as follows: $150,000,000 for

1965; $160,000,000 for 1966; $170,000,000 for 1967; $180,000,000 for

1968 and 1969; $195,000,000 for 1970; $147,000,000 for 1971; $152,000,000

for 1972; $157,500,000 for 1973; and $41,400,000 for 1974.

The Hospital and Medical Facilities Construction and Modernization

Assistance Amendments of 1968, Pub. L. No. 90-574, were enacted on

October 15, 1968. The legislation amended the Public Health Service

Act to extend and improve the provisions relating to regional medical

programs. It extended the authorization for grants for the health of









migratory agricultural workers. The statute provided for specialized

facilities for alcoholics and narcotic addicts.

Pub. L. No. 91-296: Medical Facilities Construction and Moderniza-

tion Amendments of 1970 was enacted on June 30, 1970. Title I allows

grants for the construction and modernization of hospitals and other

medical facilities. The legislation mandated a study of the effects

of the funding formula for construction of health facilities with recom-

mendations for possible changes. The name of "diagnostic and treatment

centers" was changed in all subsequent legislation to "outpatient center."

Facilities receiving grants or loans under the provisions of this act

were required to file an annual financial statement showing the financial

operations of the facility, the costs of providing services, and the

charges made by the facility for health services.

The statute mandated provision for extended care services to patients

of general hospitals as a structure part or in immediate proximity to

the hospital. Title II authorized loans and loan guaranties for

modernization and construction of hospitals and other medical facilities,

with cost limitations, and with the consent of the Department of Housing

and Urban Development.

Title III authorized grants for the construction or modernization

of emergency rooms in general hospitals. Title IV mandated the evalua-

tion of the programs initiated under grants from this act, the Mental

Retardation Facilities Construction Act, the Community Mental Health

Centers Act, Pub. L. No. 83-568, and Pub. L. No. 85-151. Title V

mandated a study of the health consequences of using marijuana with

recommendations for legislation by January 31, 1971.









Health Services Legislation

Pub. L. No. 93-154: Emergency Medical Services Systems Act of

1973 was enacted on November 16, 1973. It mandated a study to deter-

mine the legal barriers to effective delivery of medical care under

emergency conditions. Grants and contracts were authorized to entities

for a feasibility study of establishing and operating an emergency

medical services system and planning the establishment and operation of

such a system. Grants and contracts were authorized for the establish-

ment and operation of an emergency medical services system within a

geographical area. Special consideration was to be given to requests

for grants for systems to coordinate a statewide emergency medical

service system, as well as to those in rural areas. Grants were

authorized for the modernization of existing facilities, and for the

expansion and improvement of emergency medical service systems including

the acquisition of facilities and equipment, the modernization of

facilities, etc. Authorization was made for grants to entities for the

support of research into emergency medical techniques, methods, devices,

and delivery with special consideration for rural areas. The act

established the Interagency Commission on Emergency Medical Services

to evaluate all federal programs relating to emergency medical services.

The authorizations for grants for feasibility studies, planning, establish-

ment and initial operation, and expansion and improvement equaled

$30,000,000 for the fiscal year ending June 30, 1974; $60,000,000 for

the fiscal year ending June 30, 1975; and $70,000,000 for the fiscal

year ending June 30, 1976. For the same period of time authorizations

for research in emergency medical techniques equaled $5,000,000 per year.









Pub. L. No. 93-222: Health Maintenance Organization Act of 1973

was enacted on December 29, 1973. It defined a health maintenance

organization as a legal entity which provides basic and supplemental

health services to its members and is organized and operates in a pre-

scribed manner. The legislation described the general qualifications

of a health maintenance organization, as well as the responsibilities

and health services required. Grants and contracts were authorized

with entities for feasibility surveys for developing and operating, or

expanding a health maintenance organization. Funds for planning projects

and loan guaranties were also authorized. The authorizations for the

establishment of a loan fund equaled $75,000,000 for the years 1974

and 1975. Authorizations for grants for feasibility surveys, planning,

and initial development costs were $25,000,000 for 1974; $55,000,000

for 1975; and $85,000,000 for 1976 and 1977.


Social Security Legislation

As background information, consider the Social Security Act,

Pub. L. No. 74-271, enacted on August 14, 1935. The major purposes of

the legislation were to provide for the general welfare by establishing

a system of federal old-age benefits and by enabling the several states

to make more adequate provisions for aged persons, blind persons, dependent

and crippled children, maternal and child welfare, and the public health.

The act allowed for the administration of unemployment compensation

laws, established the Social Security Board, and provided the mechanisms

to raise revenue.

Title V of the Social Security Act Authorized grants to states for

maternal and child welfare. It authorized appropriations for services

promoting the health of mothers and children, especially in rural and









economically depressed areas. Appropriations were authorized to extend

and improve services for the locating, providing care, and facilities

for the diagnosis, hospitalization, and aftercare for crippled children

or children with diseases which lead to crippling, especially those

located in rural or economically depressed areas.

Title VI authorized appropriations to assist states, counties,

health districts, etc. to establish and maintain adequate health services.

Title X permitted the award of grants to states for aid to the blind.

Appropriations were authorized to enable states to furnish assistance

to needy individuals who were blind.

Pub. L. No. 81-734: Social Security Act Amendments of 1950 was

enacted August 28, 1950. The legislation's purpose was to extend and

improve the Federal Old-Age and Survivors Insurance System and to amend

the public assistance and child welfare provisions of the Social Security

Act. Title III increased the appropriations for maternal and child

welfare. It also included a clear definition of "blind" and mandated

a state plan for aid to the blind. Title XIV authorized grants to the

states for aid to the permanently and totally disabled. Financial

assistance was to be available to those needy individuals. A state plan

for aid was required.

The Social Security Amendments of 1956, Pub. L. No. 84-880, was

enacted on August 1, 1956. The purposes of the amendments were to provide

disability insurance benefits for certain disabled individuals who had

attained age 50, to reduce to age 62 the age on the basis of which

benefits are payable to certain women, to provide for child's insurance

benefits for children who are disabled before attaining the age of 18,









and to extend other coverage. Title III, the Public Assistance

Amendments, authorized assistance for the states in providing for the

costs of medical care for persons eligible for public assistance. That

included the costs of medical care for old-age assistance recipients,

for recipients of aid to dependent children, for recipients of aid to

the blind as well as the permanently and totally disabled.

Pub. L. No. 86-778: Social Security Amendments of 1960 was enacted

September 13, 1960. It extended and improved the coverage under the

Federal Old-Age Survivors and Disability Insurance System in an attempt

to remove the hardships and inequities. Efforts were made to improve

the financing of the trust funds. Grants were authorized to the states

for medical care for aged individuals of low income. Amendments were

included to alter the public assistance and maternal and child provisions

of the Social Security Act, as well as to improve the unemployment

compensation provisions of the act.

Title VI authorized grants to the states for old age assistance

and medical assistance for the aged, enabling each state to furnish

medical assistance for aged individuals who were not recipients of old

age assistance but whose income and resources were insufficient to

meet the costs of necessary medical services. The legislation mandated

a state plan for old age assistance, medical assistance, and old age and

medical assistance. Recipients of such assistance were to be 65 years

old or older.

Pub. L. No. 88-156: Maternal and Child Health and Mental Retardation

Planning Amendments of 1963 was enacted on October 24, 1963. The legisla-

tion was to amend the Social Security Act to assist states and communities









in preventing and combating mental retardation through the expansion

and improvement of maternal and child and crippled children programs,

as well as through provision of prenatal maternity and infant care for

individuals with conditions associated with childbearing which may

lead to mental retardation. Provisions for planning for comprehensive

action to combat mental retardation were also included in the statute.

Increases in services for both crippled children and maternal and child

health were in the amendments. Grants were authorized for projects

for the provision of necessary health care to prospective mothers having

or likely to have conditions which increase the hazards of health to

mothers or infants (physical and emotional). Authorizations for

maternal and child health programs were $25,000,000 for 1963; $30,000,000

for 1964; $35,000,000 for 1965; $45,000,000 for 1966; $50,000,000 for

1967; and $55,000,000 for 1968.

Title XVII of Pub. L. No. 88-156 authorized appropriations to

assist the states to plan and take other steps leading to comprehensive

community action to combat mental retardation. Grants were to be

awarded to states to determine the action needed, to assist in developing

public awareness, to help coordinate state and local activities, and

to plan for comprehensive action.

Pub. L. No. 89-97: Social Security Act Amendments of 1965, enacted

July 30, 1965, was a landmark in federal health care legislation.

The primary purpose of the legislation was to provide a hospital

insurance program for the aged under the Social Security Act with a

supplementary medical benefits program of medical assistance. It

mandated an increase of benefits under the Old-Age Survivors and Disability









Insurance Systems and sought to improve the federal-state public

assistance programs.

Title I of Pub. L. No. 89-97 was cited as the Health Insurance

for the Aged Act. For individuals who had attained the age of 65, the

legislation granted them entitlement to hospital insurance benefits

for payment of inpatient hospital services, post-hospitalization extended

care services, post-hospitalization home health service, and outpatient

hospital diagnostic services. Title XVIII included a prohibition against

any federal interference in the practice of medicine or the provision

of medical services. The free choice of health services by individuals

entitled to benefits were guaranteed. Individuals retained the right

to obtain other health insurance protection.

Part A contained the description of the hospital insurance bene-

fits for the aged. The scope of payment, deductibles, and coverage

were explained. Payment to providers was to occur only after certifica-

tion of the need for inpatient care was made available. The amount paid

was subject to the definition of "reasonable cost of service." The

legislation allowed for the use of public agencies or private corpora-

tions to facilitate payment to the providers of service. The establish-

ment of the Federal Hospital Insurance Trust Fund with a board of

trustees was mandated by the act. The statute authorized appropriations

to the Federal Hospital Insurance Trust Fund in sums the Secretary of

Health, Education, and Welfare deems necessary.

Part B described the supplementary medical insurance benefits

for the aged. A voluntary insurance program was to be established to

provide medical insurance to individuals over 65 entitled to medical

and other health benefits. The statute allowed for the creation of

the Federal Supplementary Medical Insurance Trust Fund with a Board of









Directors. Commercial carriers were allowed to administer the benefits.

The agreements with the states were for coverage of eligible individuals

who were receiving money payments under public assistance programs. A

utilization review plan was in the legislation and included the evalua-

tion of the admission to the institution, the duration of stay, the

professional services rendered (including drugs) with respect to the

medical necessity and promoting the most efficient use of hospital

facilities and services. Utilization review boards were to be impaneled

either as an internal or external committee composed of two or more

physicians and with or without other professional personnel. Agreements

between hospitals and extended care facilities were mandated to allow

for easy transfer of patients from one facility to another. Medical

services were to include: physician's services, services and supplies

including drugs, hospital services, diagnostic x-rays, laboratory tests,

radioactive isotope therapy, surgical dressings, splints, casts,

rental of durable medical equipment, prosthetic devices, braces, and

ambulance services.

The statute provided for consultations of federal agencies with

state agencies and other organizations to develop the conditions of

participation for the providers of service. It allowed for the use of

state agencies to determine compliance by the providers of services

with the condition of participation. Accreditation by the Joint

Commission on Accreditation of Hospital was established as a require-

ment for participation. The legislation created the Hospital Insurance

Benefits Advisory Council to be composed of 16 members. In addition it









created the National Medical Review Committee with a total of nine

members, one member of the public and the majority to be physicians.

Title XIX of Pub. L. No. 89-97 authorized grants to the states

for medical assistance programs. Medical assistance was to be awarded

on behalf of families with dependent children, aged, blind, or

permanently or totally disabled, or those whose income and resources

were insufficient to meet the costs of necessary medical services,

and rehabilitation services for such families. State plans for the

uses of such medical assistance were required for eligibility. The

legislation also included the authorization for grants for the higher

learning for training professional personnel for health and related

care of crippled children particularly the mentally retarded and children

with multiple handicaps. Special project grants were authorized to

promote the health of school and preschool age children particularly

in areas with a high concentration of low income families. Grants were

authorized for research programs to study the resources, methods, and

practices for diagnosing or preventing emotional disease in children;

and the treatment, care, and rehabilitation of children with emotional

disease.

Pub. L. No. 90-248: Social Security Amendments of 1967 was enacted

on January 2, 1968. The purpose was to amend the Social Security Act

to provide an increase in benefits under the Old-age Survivors and

Disability Insurance, to provide benefits for an additional category of

individuals, and to improve the public assistance program and the programs

relating to the welfare and health of children. The legislation allowed

a method of payment to physicians under the supplementary medical

insurance program on the basis of an itemized bill under the terms of a









reasonable charge for services. The services of podiatrists were

included under the provisions of the supplementary medical insurance

program. The supplementary medical insurance plan was to cover pay-

ments for all outpatient hospital services. Payments for reasonable

charges for radiological and pathological services furnished by certain

physicians to hospitalized patients was to be included. In addition

payments were authorized for the purchase of durable medical equipment,

physical therapy services furnished to outpatients, and certain portable

x-ray services in the patient's home or place of residence.

Title II placed limitations on federal participation in medical

assistance programs to families within the income limits. It created

the Medical Assistance Advisory Council, with 21 members representing

state and local agencies. Free choice was guaranteed for individuals

eligible for medical assistance. Standards for skilled nursing homes

furnishing service under state plans were approved under Title XIX.

Title V authorized appropriations for services for reducing infant

mortality and promoting the health of mothers and children. Appropria-

tions were also authorized for locating and providing service for

crippled children and those suffering from crippling diseases. Allot-

ments were made to the states for maternal and child health services,

and for crippled children' services. Special project grants were

authorized for study of the health of school and preschool age children,

especially those from low income families. Special project grants

were authorized for projects related to dental health in those groups.

Grants were authorized for training health care personnel for service

relating to mothers and children. Grants for research projects relating









to maternal and child health services and crippled children services

were authorized. The general provisions of Title VI authorized the

Secretary of Health, Education, and Welfare to develop and engage

in experiments under which physicians and institutions who would other-

wise be entitled to receive payment on the basis of reasonable charge

would be reimbursed under a plan of incentive factors. Demonstrations

were to show increased efficiency and economy through the creation of

incentives without adversly effecting the quality of care. Authoriza-

tions for maternal and child health programs were $250,000,000 for

1969; $275,000,000 for 1970; $300,000,000 for 1971; $325,000,000 for

1972; and $350,000,000 for 1973.

Pub. L. No. 92-603: Social Security Amendments of 1972 was

enacted on October 20, 1972. It added supplementary medical insurance

benefits for the aged and disabled. It authorized incentives for

states to establish effective utilization review procedures under

Medicaid including physician certification of need of medical assistance

and inpatient services. Optometrists services were included under

Medicaid. Grants were authorized for experiments and demonstration

projects to determine alternative methods of making payments to

service providers including financial incentives to use facilities and

personnel more effectively and thereby reduce the total costs without

adversely affecting quality. A study was mandated to assess the re-

imbursement for physicians' services under Medicare to evaluate (a)

physicians' fees generally, (b) extent of assignments accepted by

physicians, (c) the share of total physician-fee costs Medicare does not

pay and beneficiary must assume. The study was to be undertaken by the

Health Insurance Benefits Advisory Council.








Pub. L. No. 92-603 authorized payments to health maintenance

organizations with an interim per capital rate paid for each individual

enrolled. A definition of a health maintenance organization was also

included. Payment for services of a physician rendered in a teaching

hospital were authorized. Institutional planning was mandated under

Medicare including annual operating budgets, and capital expenditure

plans for three years with provisions for review. Payments of the

states under Medicaid were authorized for the installation and opera-

tion of claims processing and information retrieval systems. State

health agencies were to be used to perform certain functions under

Medicaid and under maternal and child health programs including

regulations for establishing and maintaining health standards.

The statute established the Provider Reimbursement Review Board

and included conditions for appeal, and rules and regulations. In

addition it listed uniform standards for skilled nursing facilities

under Medicare and Medicaid including the level of care required for

skilled nursing home services. Reimbursement rates for skilled

nursing and intermediate care facilities were listed. Payments to

states were authorized under Medicaid for compensation of inspectors

responsible for inspecting public or private institutions providing

long-term care for residents. The legislation mandated the disclosure

of information concerning the eprformance of carriers, intermediaries,

state agencies, and providers of service under Medicare and Medicaid.

The general provisions of Title XI established Professional

Standards Review Organizations in areas throughout the country. To

qualify as such an organization one must be a nonprofit professional

association composed of licensed medical doctors or doctors of osteopathy,









with membership including a substantial proportion of physicians in

the area with professional competence to review health care services

and with open and voluntary membership. The duties and functions of

the Professional Standards Review Organization were specified.

The legislation authorized physical therapy service under Medicare,

as well as hospital admissions for dental services. Prosthetic lenses

furnished by optometrists and chiropractic service were also authorized,

as was outpatient speech pathology service. Intermediate care in

mental and tuberculosis institutions was allowed under Medicaid as

were family planning services.


Health Planning Legislation

Pub. L. No. 84-652: National Health Survey Act was enacted on

July 3, 1956. It established the National Center for Health Service

Research. The purpose of the Center was to conduct national health

surveys, develop and test methods for obtaining current data, develop

a uniform system of health information and statistics, and publish

the results of all efforts.

November 3, 1966 was the enactment date of Pub. L. No. 89-749:

Comprehensive Health Planning and Public Health Service Amendments

of 1966. Grants were authorized to the states for comprehensive health

plans. Project grants were authorized to agencies or organizations

developing comprehensive, regional, metropolitan area, or local area

plans for coordination of existing or planned health services.

Authorization was given for grants to private agencies or institutions

to cover the costs of programs for training, studies, or demonstrations









toward the development of improved comprehensive health planning through-

out the nation. State health or mental health authorities were authorized

funds for establishing and maintaining public health services including

the personnel for state and local health work. Grants to schools of

public health were continued.

The statute authorized grants to states for comprehensive and

continuing planning at the following levels: $2,500,000 for 1967;

$7,000,000 for 1968; $10,000,000 for 1969; $15,000,000 for 1970 and 1971;

$17,000,000 for 1972; $20,000,000 for 1973; and $10,000,000 for 1974.

Project grants for areawide health planning were $5,000,000 for 1967;

$7,500,000 for 1968; $10,000,000 for 1969; $15,000,000 for 1970; $20,000,000

for 1971; $30,000,000 for 1972; $40,000,000 for 1973; and $25,100,000

for 1974. For the same period of time, grants were authorized for

comprehensive public health programs at $70,000,000; $90,000,000;

$100,000,000; $130,000,000; $145,000,000; $165,000,000; and $90,000,000

for the respective years. Project grants were authorized for health

service programs for 1968 at a level of $90,000,000; for 1969--$95,000,000;

for 1970--$80,000,000; for 1971--$109,000,000; for 1972--$135,000,000;

for 1973--$157,000,000; and for 1974--$230,700,000.

Pub. L. No. 90-174: Partnership for Health Amendments of 1967

was enacted on December 5, 1967. It amended the Public Health Service

Act to extend the authorizations of grants for comprehensive health

planning and services, to broaden and improve the authorizations for

research and demonstrations relating to the delivery of health services,

to authorize the performance of clinical abortions, and to authorize

cooperation between the Public Health Service hospitals and community









facilities. Grants were authorized for community health planning

services and public health services. Appropriations were authorized

for state health planning grants. Each health facility in the state

plan was to assist in developing a program for replacement, moderniza-

tion, and expansion based on the state plan for facilities, equipment,

and services without duplication and in the most efficient and economical

manner. Grants were authorized for projects relating to the development,

utilization, quality, organization, and financing of services, research,

and facilities including the testing of new equipment and systems, new

careers in health manpower, and new ways of education and utilizing

health personnel. The statute mandated federal licensure for clinical

laboratories and included the standards for qualification. A survey of

the incidence and location of severe hunger and malnutrition and related

health problems was mandated.

January 4, 1975, was the date of enactment of Pub. L. No. 93-641:

National Health Planning and Resources Development Act of 1974. It

mandated the issuance of guidelines concerning a national health planning

policy including guidelines for standards regarding the supply, distri-

bution, and organization of health resources; and a statement of health

planning goals. The act established the National Council on Health

Planning and Development to make related recommendations. Health

service areas were defined as geographical regions with at least one

center for the provision of highly specialized health care and a popula-

tion of from 500,000 to 3,000,000. Each health service area was to

have a health systems agency which was to be nonprofit, private corpora-

tion; a public regional planning body; or a single unit of general








local government. The health systems agency was to have a staff

to provide expertise and a governing body for advice in health planning.

The functions of the health systems agency were listed in the statute.

Grants were authorized for health planning and development, for regulating

the rates for provision of health care, and to plan and develop new

centers for multidisciplinary health planning development and assistance.

The Secretary of Health, Education, and Welfare was to prescribe general

standards for programs of providing medical facilities. Criteria were

to be developed for determining the need for medical facilities in each

state. Each state was required to develop a state medical facilities

plan to provide adequate medical facilities for the residents and for

persons unable to pay. The legislation prescribed means for entities

receiving funds to demonstrate compliance. The statute included authori-

zations for comprehensive health service agency personnel, the collec-

tion of data, planning and the functions of the agency. For the fiscal

year ending June 30, 1975,the authorization equaled $60,000,000; for

the fiscal year ending June 30, 1976,the authorization equaled $90,000,000;

and for the fiscal year ending June 30, 1977, the authorization equaled

$125,000,000. The authorizations for years 1975 through 1978 for grants

for state planning and development equaled $25,000,000; $30,000,000;

$35,000,000; and $35,000,000. For the same period of time authorizations

for efforts to initiate rate regulation were $4,000,000; $5,000,000;

$6,000,000; and $6,000,000. Authorizations for the establishment of

centers for health planning were $5,000,000; $8,000,000; $10,000,000;

and $10,000,000 for those years. Authorizations for state medical

facilities projects for that time period equaled $125,000,000; $130,000,000;

$135,000,000; and $135,000,000.









Summary

During the period from 1944 until 975, Congress has shown an

increased interest in the development, expansion, and improvement of

the health care system in America. Laws have provided financial

assistance for health related research, the education of health care

providers, and construction of health care facilities (see Table 3).

Other health legislation has allowed the Federal and State governments

to assume the burden of payment for health care to the elderly and

those individuals of low income. The trends toward more government

involvement through financing, regulations, and sponsorship are evident

and help to shape the health care system of the future.























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CHAPTER III
PREDICTIONS OF THE HEALTH CARE SYSTEM OF THE FUTURE


Introduction

The art and science of predicting the future faces no stronger

test than when applied to forecasting the health care system of the

future. Experts and authorities in related fields from law to consumerism

have developed descriptions of the future and recommendations for its

alteration. Health practitioners and those directly involved in the

administration and analysis of the health care system are not only privy

to more indepth data, but they share a unique knowledge of the pressures

and problems of this complex institution. The predictions of those

individuals most closely associated with the health care system and

its immediate future are reviewed in the following chapter.

Before examining the future of the health care system it is

important to note its current status. B. Ehrenreich and J. Ehrenreich

(1970) characterized the health care system of the 1970's as highly

organized, institutionalized, and centralized. They noted major

interlocks of the health care system to health financing institutions,

government, and the health commodities and equipment industry. The

physicians office was seen as linked with the hospital to form a medical

empire. The functions of the American health care system were the pro-

vision of patient care, the making of profit, the conduct of research,








and the conduct of health professional education. With this perspective

in mind, we will examine the predictions of the health care system of

the future.

Predictions Regarding the Role of Government

The continued growth of scientific knowledge and technology were

predicted by Rogers (1972). He forecasted the separation of issues of

health from those of education and welfare, and the establishment of a

Cabinet level Department of Health. He believed there would be little

Congressional support for the financing of long-term scientific projects.

Support would be provided for those with immediate application to the

health of mankind. He foresaw the proliferation of health maintenance

organizations, as well as an increased quality and accessibility of

health care.

Quality assurance was linked to a national health insurance plan

by Kennedy (1973). He forecasted continued federal government assurance

of a stable level of financial support of academic medical centers,

including school construction and modernization, as well as a change in

emphasis of medical education to meet the true needs of the people.

Other predictions included the supervision of internship and residency

programs by medical schools, and the development of a definite role for

consumers of health care services.

Lee and Franks (1977) listed the major responsibilities of the

Federal government during the past 30 years as (a) supplementation of

biomedical research, education, and training of health manpower, construc-

tion of hospitals and related facilities, and creation of a national health

planning capacity; (b) provision for or payment of hospital and medical









services; (c) prevention or control of disease or accidents. They

predicted the future would bring increased government involvement in

health education, child health, nutrition, environmental health, and

the reduction of alcohol and drug abuse, mental illness, infectious

disease, and dental disease. Programs providing family planning services,

pollution control, nutrition, and physical fitness were seen as having

priority in the future. The role of government was assessed by Cooper

(1977) to include support, stimulation, and coordination. His predic-

tions of programs which will receive the greatest Federal assistance

agreed with those listed by Lee and Franks.

The challenge of better health and health care for older people

was offered by Lawrence (1976) as the major one for the future. Other

issues of future import were thought to be prenatal care, the causes

of childhood death, nutrition, dental health, the increase in the

number of deaths by violence, chronic disease, mental health, and the

expanding nursing home population. Steinfeld (1976) anticipated that

chronic diseases and those environmentally induced or associated, the

"technogenic diseases," would replace infectious and nutritional diseases

on the list of health priorities in the future. He concurred with

Rogers (1972) in the belief that a separate Department of Health should

and would be established. Such a department would be concerned with

health research, food and drug regulation, organization and development

of public health service and personal health care, and modifying and

improving the environment.

The Department of Health Education and Welfare issued two studies

of the future in 1975 and 1976. The first listed a number of themes for









the health care system of the future. The future development of knowledge

was presented as being a matter of research support, research priorities,

and the allocation of resources. Health education, child health, and

nutrition were shown to be components of health promotion. The lists of

preventable health problems cited including smoking, alcohol consumption,

inadequate or excess food intake, motor vehicle accidents, environmental

pollution, physical inactivity, disease and injury in the workplace,

infectious disease, product safety, genetic factors, and social-psycho-

logical factors. Elements included as essential to the future improve-

ment of the health care system were cost containment, the improvement

of the health planning system, improvement of service distribution and

of service delivery. The study predicted the importance of the assurance

of quality of care and the eventuality of a national health insurance

was seen as a means of guaranteeing that quality. The 1976 plan for

the future forecast the following strategies: (a) improving the health

policymaking apparatus; (b) containing the cost of health care; (c)

implementing an aggressive preventive strategy; (d) improving the

quality of health care; and (e) strengthening the essential resources.


General Predictions About the Health Care System of the Future


The existence of three types of health care facilities were

predicted by Carlson (1975): (a) neighborhood hospitals and learning

centers with emergency and outpatient service; (b) regional health centers

which provide costly and sophisticated treatment; (c) residential

complexes for the elderly. Health care professionals will become

hospital-based according to Carlson's prediction and there will no longer

be independent office practice of medicine. Physicians will be trained




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