USVI Public Records

Document text

DOc ONERT 'REsoNE N. ED. 170 023 PS 010 464 - assessment Act and Increased Medicaid*, .;__Fnitding- for Puerto Rico. Rea/ring Before the Sullc,pmmittee on Health of the Committee on Finance United States -Senate, Ninety7Tifth Congress, Second Session- on H.R., 9434 and 'Si. -1392." INSTITUTION Coneess of the U.B.,,'Washington, Senate Cbfiittee on4inance- PUP DATE 14 Aug 78 ." 4NOTE' 272p.: lot availab3te in hard dopy dus to small type EDRS PRXCE *MF01- Plus. POstage. PC Not Available from EDRS. Children; Dental Health; ,Economic Disadvantagement.; Federal. Legislation; Financial Support; *Health 'Needs; Identification; I'Medicaj. Care Evaluatidn; *Medical Evaluation; *Medical Services; Mental. Health; *Policy t'ormation; 'Public Health; *Pdblic Health Legislation; Screening Tests IDENT/PIERk Medicaid . ABSTRACT. This Congressional hearing records the te4stimony of adthinisirration and public witnesses on H.-Rit 9434 and S. n92 and includes' the texts of the fegislation. -9434 is an act to amend the social 'security act to increase the della* limitation and federal medical assrstance per-centages applicable to the medicaid prbgrams of Puerto Rico, the '-yirgin..Islands, and Guam. S. 13927is the Child isse§sment Act, which provides for the .strengthening and improvement of' the, early and 'p'eriodic screening, diagnosis and treatment program 'a'nd broadens medicaid eligihility. DiScussion focus or the populations to be covered, in,terms- of age and condition ent-d cost efficiency of programs., The §5-page "final report of the American Association 'of. Psychiatric Services for ,Ckildren to HMV on developmental review in the early- and periodic es.er4bning, d4gnosis and treatment oprogram is .incinded in the pii,blication. In contrast to staple screening proc dures, periodi,rreview of the ways in Which IP ,development- is ocCurrng and the forms it takes it-advocated. Also included,is a Research Digest Series 'report titled ',Uncertainties of rdderal)thild Health Policies: Impact in Two States", which reviews two federtaly supported child health care programs from the original statement of' Congressional intent to its questionable delivery at the DESCRIPTORS A , iolt******.****.************;Ig********,*****************************31g******* * Reproductions supplied by ,EDRS; are the best that can ,13,e' 'made 1* *-, from the original document. -**********************************'*******"*******'*********************** U.S. DEPARTMENT OF HEALTH. EDUCATION & WELFARE NATIONAL INSTITUTE OF EDUCATION 'THIS DOCUMENT -HAS. BEEN REPRO- - DUCED EXACTLY AS RECEIVED FROM . ::..THE PERSON ORORGANIZATION ORIGIN- POINTS OF VIEW OR OPINIONS STATED' do .Nor NECESSARILY REPRE- SENT OFFICIAL NATIONAL INSTITUTE OF -EDUCATION POSITION OR POLICY- CHILD 11EAL'Til ASSESSMENT ACT AND INCREASED MEDICAIMUNDING FOR PUERTO RICO -HEA4ING . BEFORE" TEL131 SUBCOMMITTEE ON -HEALTH . - OF THE COMMITTEE. ON FINANCE UNITED' STATES SENATE. NINETY -FIFTH CONGRESS SECOND SESSION ON 9434 AN ACT TO AMEND THE SOCIAL SECURITY ACT TO INCRIPASE THE DOLLAR LIMITATION AN FEDERAL MEDICAL ASSIST- ANCE PERCENTAGES APPLICABLE. TO THE MEDICAID' PRO; GRAMS, OF PUERTO. RICO, THE VIRGIN ISLANDS, AND GUAM S. 1392 A BILL TO STRENGTHEN AND IgPROVE THE EARLY AP,ID PERIODIC SCREENING, DIAGNOSIS, AND FOR OTHER./ . PURPOSES AUGUST 14, 1978 Printed for the use of the Committee GOVERNMENT PRINTING WASHINGTON 001warITTEE-ONCE . . RIISBEL1,13. LONG, LowitijpipCiaairman , HARMAN E. TALRARBR Georg* v C ABRAHAM REBICOME Consmatimst ,C HARRY F. BYRD, As...:VIgghsts: aggeZORD NFLSOMIPlaccumbr B MNIERGRAVEL, Maim LID BENTSENAllsom illIEGGIAM D. HATKAIWAY. Hoare BO YD K. HeglermOrolionsth, 11111%.11K AL MATSUNARA,Bsussil L PATRICK IMMIKRIINK,.New NOR. IMINorammiellmsz, ° W Psermsar. r. currris, Nebraika NZ) P. HANSEN, Wyoming_ .`'DOLE, Kansas AuCKWOOD, Oregon AT. BOWL Is., Delaware Nevada DANFORTH, Missouri gip 4101111119MTH TAZERIMIGIL "A , Chairman DOLE, Kansas- , Nevada DANFORTH, Missouri. .lisseph Jr._ Secretary., of Health; Education, and isereenpApIert. Efealtir Care Financing. 4dministrdtion, Departimeat IlealtIVEducasion, And Welfare_ riff ,or critic' try; Joseph. 11 Noshpita,,. lif-D__ _ 66 1 of Pay . c ServiCes for Children, Joseph D. eYra, IIleatliameiratIon,Drlieodese.Leltas . 55 66 MsycheitridAssotiatiant. Jeseibi-D- NoebiAth, 3f-,D-ttr-_-7., 68 Asoudisiltilltorillogy, Joseph D. Nosapie-11.D__ 86 Barjaer,:iihr. Jima B.,' Msaiimal Weikel Assoclattoi,"'accom- penieslih, Dt-.11 NO- aibe:Hadional elsitiman_ NMAIDedis.tiles salmi Mr. siertrialieprojectifireetor, national 'swami- of the lalik....... r 52 / Willbleesee land, WendY AtiftatIllo health specialidt_ .' Z dai.18tia. Maltasar, BAaldeat ,:avesetasiemer from Puerto tea. wean- si pialeTliiy lik. jailk,Biveiti-Duesea.seeretary Of health, Puerto Biro_ / Mans, Marilim K., ettnaecticat.latimeigersiees; Inc - _,........ .2 117 . Lallarek Wendy, healtli :specialist el018111ten's Defense Fuad__.__ ___,_._ -29 6 Rialtos, Pr. Iliesiiice, on bat& of t airAinefilin Dental Assaelatim:_ l'55 Alfeatal-liealfh Amieriatton, Jo .1..liseahydaz, M.D -_,__,- .".___L_____ , 1" 416 14ZaahatssachatleabfPrivate c Hpapitals, Josepla p. Mishlilla, ; i atonal Assiclation, Bs Jena B. Barber,,:pfesident. anciar:', '' plaiedilby I:) Rifillbse Pay. ,nik31111ft isallanal chairmha, lchlAPlillaileal- .' ., ilacticog and Da. Glistrusle T..fiem roject director, nationallessomf- : soilonaaregrare OA* MU_ -' .: Nardwitiwpopik, MD.; 'prosiow of piyebiatry .i.Georite,Wai '52 13aivesalty; wat of the Amesie' an Atatletn9 of Child PyadilltrY, Associating- watiatual Aas atiOn :of Prfriselfey- n, drown, Mental iteidth Assodanask. aid AsseciatiOn fer.the. Boapatal American oArithatin of PsYchlatric. So f, -, Pearac Wrrair esas Page, 177 27 t tif Pisibology` *,1 - , ., ;. . PoimanYtoiamas - ; I . . Anode= .Acatimplt of Child Psychiatry Vialpnia 4Q Banitich exellhalive . dIttector ." ....._._. ,...,.. .209 t,.......4-....akia...1,1 Plealetrics, IllasildA.Alornelyechairnian, task ihree -lianeglesCal lham- of Obspetrielatis and Gyirecologists,t,Ervin V Nicippls, ..11131,,VAIZIWP- lifrectdri- -,..ace aetivitlea___, ..,.. Aiimileafr-MailualAssoda, "- ..,.' Inc ,..' :).: 255 ... -Ocerapoional Therap'y Asioatatham c., Ames: j ' Gairlbsike, -, , 7 r , , iwo ... 268 dbillitetZ ' ' . ; :Healthiamaelatien .s. , . . . . Irk bulk' hl.D.assielldent...-1:. Pt . '0.:. Asia .410e,r ,piellkria,. maternalariod child health, ynlveissifYOf. ' Nimik .01wrolina.:_!..,..,.._,_ 201 .../. ';,...,:. :ii, : ti..!/ 4 - 7 I: , %. : j. : t;. 1.. ' c. . 7 ,: Y. essociatioaof-State-and ,TerritOrial Maternal and Child Health and Crip- pled ChIldred'6-Directorsi 10totr Ebrc,e:.-af,D42 director, Crippled Chil- . dren7a-SerACeik.D.epertnie" -nt of Health and Mental .Hygene Bausch, Virginia -4--execiltiredi.taiktor,'.'Aineriean Academy of Child Psy- Page '193 Chavkiti;-DaVid;_seiller atalratfOiri4;-.Natiolial Health Law Program____ 206 C6mneft Donald 4r:, ciairOu.c.t:ask fgee:ctLEISDTAnd title V, Amercan Academy..Of,-......-.,.254 dt Lug); lsn:-Fiin-.. ----'' ": - -r` 1 Dental :Hygienists' Atsociatin:i = 260 Ellis, E. Frank, -M..D.,:Atiericati FAibUCTiegitli AssoCiatiolL.....---,- 201 Epilepsy Fotindationnf:Ameriea---- "-'.7''' '"7----7."------:- ---'--- -198 Foldte:Anne-Marie, 31.P.134 14:Phil: reSeltreli associate, Yale Uniersity, School of Medicine. ,... = -; ' ':;-- :_,_': ." , .212 .-. Force, Judson, M.D., director, Crippled" Children'a,'Seriices; Department Of Health and Mental .Hyglene,--bn behalf of the Association of State : and Territorial Maternal and -Child Health- and :Crippled: Chil- dren's Directors . 193: - Ga Id!, James J., 'executive direetar', Atherican Ocetipational Therapy lion, Inc_ Mille , liC. Arden, professor, maternal and child health; .University 201 niversity of North ' C -ne - , - Myer Beverlee A.,' director; State of., CaliforniaHealth and Welfare A cy;Depa.rtment of Health Services '2.12. Nati nal Association for Retarded Citigens__,_ , 196 Nati nil Health Law Program, David ChaVkin, senior staff attorney 206 Nati nal Society for Autistic Children_ ,e f=.- ' 198 Nichols; Ervin E., MAI,: RACOG, directorf practice activities; American - College orObstetrielans' and Gynecologists 003 United Cerebral Paley'Associations, Inc 196 Won pat, Hon. Antonio B., Memberof Congress -e 190, . ' APPENDIX HEW responses to questions of Senator Ribicoff Afaartorat.'Lcrcatatemox Committee press release Text of the hills H.R. 943-1,,S. 1 'Answera to questiotis stibmitted to Marilyn Katz, attorney with ( onnecti- r , cut Legal Services_ . 7.. GO Dgvelonmental Review in the .ERSDT Prograin 1 10 CHILD HEALTH ASSESSMENT ACT AND = MEDICAID FUNDING FOR PUERTO iliCtir ' 21,01TDAILY, A.13013221 14, 1978 CS- Sixes_ SuBcourrnauft* og, THE CaMAIFITEE 41.14,TANCE. The _subcommittee met, tsuant to hotline, at 9 wan. Dix. nath. Office Buil g, Hon. Abiataam Ribittiot .14 :Senators Ribicog and Dole: ress release annogincing this hemzung,ancl-th And S. follow :] (Press Release] ,II.S:' SENATE, .C.oinarprE.._ole . Stincost ME SPBCOMMITTPE ON .b4EALTi3t ANNOUNCES HEARINGS ON : S. ;Atm_ . AsSEsencERT ACT, AND. H.R. 9434 INcBzasED Alkorctuo I:Valet:am -Purim e Honorable Herman E..Talmadge (.1:0;,da..); diairaaaL the Alubconnoittei on Health of the Committee on Finance, aanounce&today ho.i I be amiditsmamittee will. hold 'a hearing' on the '.Child Health Assessment iir -I'M, S. introduced by' Senator Abraham Ribikoff (13.7Ct.), is:nivel:1de* to tiaprifiv .the' administration of and benefits under/the Medicaid, patecsam tnr ..sere.* and .treatment of children. , 46111 -Avoiding. ;1111134 ] "The Health Subcommittee of tliVnterstate and Foreign flow/mercer ll of,theouse Of Representatives n s completed' action Gm '..otapatmitsmi 13631). . . / The 'hearing on the Oiild Health 'Assessment Plan gt cp(4) ,Butioing. from the dim H.R. the Virgin ,4-.1ritng atichael ;`* ...4^`;y4Le OMCO 'itt'XIVesciay, 1.whttei. they V O 3PIrear at nein of the the S m- to con s date Common viesv.-- 8nbcontailtbee obtid.n. All to thur Monday, Autxust "14, 1978, in Adam 2221 of the Dirksen The Subcominittee will hear initiallt, beginning al A.dministmlion, mild the. Resident CoMmissioner Of "Peer-. 9434, a bill to increase Federal Medicaid funding for ..F.4 Islitnds and Guarn:, Requests to ..testify, atiMan Talthadge--.statOd thin testify during these earinga must make 'their reques Stern, Staff Di r, COMmittee on outface, Room 227 - Building, -Wasp on,./5.C. 20510; not liter than t ' .clope . August 8,1 , ' Witnes ea" will be notified as soon as possige after th&.= are scheduled to appear. If. for some reason 'the vritnes,N 'the time scheduled, he may Slew written statement for , personal appearance.. ," ,le` ' .. Consolidated' rearimone=--Clhairman 'Ziltiladke also st mittee strongly urges all *Itheases who have aiComm Xhelr testimony and designate a single spOltesman'to 'point orally to thtSubcommittee. This procedure will /..'to receive a wldei/expresition of.,,iriews than it nil . - witnesses were" farther ,7urged to 'exert 'a maximum statements. %' ' , . ,,- ., ,.,,.- AtidittanillY, because of the extensive hearing record established by .thiliOnse ' . Inter:Otte- anal Foreign Commerce Connulttee on the Child". Health Assessment act, lidtsensts areafiltednett to repeatthat tentimonyaince the Howe record wzillhe Moduli* neriewed by the Conn:l-tee on Fkaance. ° ' te.L. -- Legislative Rearganizatios. Acct. Legisilatiye Reorganization Act Of 1N6;-" i tequires ell witnesses' appeasing the Committees of Congress to "tile in advance *Otte; statementitred tit posed_ testimony and to limit their oral, -. presentaddirm-fo brietsumnneries their argument_" In light. of tibia statute, and the-nsenbtet,of witnesses lotto to.appear before the Subcommittee, and -----. the lintitet:Ilike available for -the-- rings,- all witnesses who are sehgduled to testify nrettskomplymi 1. imiggpy of the written the *Rees is scheduled us 2. Adi...-ditatesses Etat in their writti statements a summary oar. the prinal points taciadein.3matement. 3. Ther written* tee typed on, detter-size paper (not legal size) and tft least col**. m Atte su, it o,-4 before the beginning of the hearings,. ,.., . .., 4. are not read thiterrwei ents to the gubcommittee, but confine their 3.6411:11111Vit oral t ons .0.11 summary of the . 'paints included in the statement. . - , ., 5. No mere than 10 Minutes w..141 bg firm , r, the oral'summary. ,, "_, Witnesses who- fail to comply wittl:. then% 1!,ites -will .forfeli.their privilege to . testify. ,t . t ;must be 'filed by noon the day before, ' . . . Written ddstements.Persons not Settoirek ,to mate an oral presentation, and others who, grebe to present their-r-jewtt I- . .. unreotenittee,' are urged to pre- - Pare -a written statement for .stubmnssitt clninon in the printed record.Of .- .the hearings. 'These written statemsetn _-..... -I hi- mbffoitted to Michael, Stern, Staff Director. Senate Committee at. ?inattii-.. Rooitu 227 Ditksen Senate 'Office Building, Wasithingtot D.C. 205330, WI. ibleCT -31111 3i,,onbay, August 21, 4978.. / r , . /' rie 101 orn coma.' $0 3sueeewx DT-Mrs--S-ENATE-0-FAIIIE-LIBMMDS FIIIISUART 8 (legislattive day -FEU( At ird Wee and referred to the Conuo-- on Fintunce AN ACT To amend the Social Security Ait, to inereirme-tite collar limitir Lions and Federal medical assistance percentages:applicahic to the medicaid programs of Puertokiitieo, the Virgin Is- lands, and Guam. 1,; Be it enacted by toe Senate and riciuse of Repres&ta- times of thezUnited States.of anierica in Congress assentblea. 3. ADJUSTMENT OF DOLLS LIMITATION ON MEDICARDPAT y. 4 MENTS TO PUERTO RICO, TIIR rTIIGIN ISLANDS; AND 5 ottAisat 6 SECTION 1. (a) SubseCtian (c) of section 1100 of She 7 Social Security, Act (42 U.S-C. 1308 (c) ) is amendei- to 8 read as follows : t ON 2 1- .f` (c) The total. soma certified by the Secretary under 2 title XLX. with resp.et t to- 3 " (i ) the fiscait year ending. September 30, 1978, 4 for payment- 5 (A) t Puerto Rico shall riot exceed ", 6 .$50900,00t 7 03) 8 $1,600,0010, and 9 ".(C) Guam 'shall not exceed $1,475,000; " (2) r.11c ffs.vaif3c-rairbnding:74eptember 30, 1979, for Virgin.Islanda Alai"- not exceed ptayitient I S. ' . "-(_'.. , t. Puerto Rico shall not exceed,460,- t. 000,000, .14 " to Ilia a Virgin .Island - .shall not ,exceed . $2,000,00, and 16 "1.t') Jam shall not weed $1,800,000; 17 and _ 18 "(3) tt sr.ieqtaent fiscal year, for payment I 19 Puerto Ri(o. Ithe Virgin Islands, and Guam shaknot ao 6 - ) -4 20 exceed .the amoune, 1Taragraplis -0); 21 (B), and (q)., rApectively, of parkgr,aph (2) in- 22 created by a percenange equal to the percentage increase 23, 'in the "constuher Price Index (published monthly by 3 1 . the Bureau of Labor Statistics of ihe Department of 2 Labor) between October 1, 1979,. and the first day of 3 - such fiscal year.". 4- , 4 ,(b) The amendment made. by subsection Tit) shall 5, apfily to fiscal years .beginning after September 30, 1977. 6 ELIMINATION OF .SPECIAL LIMITATION ON THE FEDERAL 7 MEDICAL ASSISTANCE PERCENT_GE FOR PUERTO RICO, 8- THE. VIIIGDT ISLANDS, AN-tr.GUSI 9 S. 2. (a) The first sentence of section 19'05 (b) of the 10 Social Security Act (42 .1.7.S.C. 1396d (b) ) is amended 11 (1) by striking out " (1) ", and 12 (2) by sulking out ", and (2) ". and all that 13 follows through "shall,fie 160 percentum". 14 (b) (1) Except as provided' in paragraph (2), the 15 amendments made by subsection (a.) shall apply with re- 16 spect to care and services provided, under a State plan . 17 approved' under title XIX of the Social Security Act, in a . 18 calendar quarter beginning "after September 30, 1978. 19 p,) Each of the agencies administering er supervis- . 20 ing administration of the State An, approved under .21 .vide. XIX of the Social Security Act, for Puerto Rico, the N. . Virgin Islands; or Guam may elect not to have the amend- . 23 ments tirade by subsection (a) apply to any care or ( f 4 1 services provided' in its *jurisdiction to atfildividual over a 2- period of time beginning before October 1, 1b8, and ending ,3 after Octoheill, 1978. Passed the House of Representatives February 6, 19782 Attest : EDIAIIIND L. HENSHAW, JR.; Clerk, V. r - 95Tir CONGRESS &sum S. 1392' omr IN,THE ArNATE'OF TILE UNITED- STATES Aniu, 26 (legislative day, FF.BRVARY in), 197f .% Mr. RIBICOPF (for hirsself, Mr. HATLIAWAY, and Mr. K.K.viccor) introduced the following bill; which was read twice and referred to the 'Committee on Finance . - .4.. A -13ILL 11 To strengthen and improve chi' early and 1)criodicsereening, - diagnosis, and treatment program, and. for other purposes, . . 1 Be it enacted by the Senate and House of Vepre,senta- . 2 lives of the United States of America in Congress assembled, 3 That-this At may be known as the "Child Itealtit Assess:. 4 ment Act". - 5 4 DECLARATiON OF PVRPOAE 6 SEC. 2. The purpose of this Ac.t Is 4o xriodifF the Early . Enid perriodic Screening, diagnosis, and treatment prbgram and 8 hroadgn medicaid. eligibility-- (1) to continue and expand the availahility! 10 health care to children iliase families do not have ade- 11. ./ (late resources to cover the cost of such care and to . , ti .2 3 strengthen effbrtg to assure ,adrquate .eluld health assess_: ments, diagnosis, treatment, and-periodic' reassessment g 2 of all eligiPle children; 1 4 (2') to 'increase the number of children eligible for .7 8 *- sich cue ; (3), to assure, the continuitrof care for a period after a child Would on account of income become ineligible for medical care under title XIX of the Social Seciirit , 9 Act; 10 (4) to increase immunization levels of children; . . - ell.: and 11, (5' to provide further incentives to States to 14 arrange for and encourage :guality, health 15 REQUIREMENT. FOR .ASSESOIENT AND TVEATMEN*OF ALL 16 INCOME ELIGIBLE CHILDREN *dot* 17 SEC. 3, Section 19,02 (a) (13) of thec- -Social Security 18 Act is amended, by, inserting "and" at the end of subpara-r 49 graph (R), and by inserting after subparagraph (E) 20 th6 following new snbparagraph , (F) effective October 1, 1977, in the case of 22. 23: 24 and resources, be eligibldfor aid under the State plan 25 approved under part. -A of title.' IV of this Act, but any individual under the age of six who, is a mem- ber of a family who would, on the basis of income who is mot a ,dependent child. ;as that term is defined in section 406 (a ), of tills fist, for the litchi- .... sion of the acre and services, specified in section 4 1905.(a) (4) (B) ; and 5 ":(G) effective October 1, 1977, in the case oh, - any Individual under the age of twenty-one who "has received his periodic assessment purstiAnt to section 1912 (b) (1); for the inclusion of -all care and services appropflate.for indiv.duals under age ;10 twenty-one (but nottx ces, .including (1) those. 11 for le treatinent of mental illness, niental ,yetarda- ,stion,y develo tat disabilities,, an (ii) dental *13 -.care When not for :the treatmen of 'condiqons dis- 14 ; . covered-fitiring an -assessmerit ) for which payment is 15 * 404 available underthis title, whether or not tinder the 16. State plan for the:State _.such care and services are 17 Provided to individals who have not been periodi- i8 Bally assessed pursuarit to seion 1912 (b) (1) ;". 19 MEDICAIDIELIGIBILITY OF CERTAIN CHILDREN TINDER SIX .20 SEC. 4. (a) Sectipn 1902 (a). (10) of thG.Aet is nmendei I 21 by striking out "and" .atssthe .end of subparagraph (B).,: 22 by redesignting subparagraph (C). .§ubparagraph 23:0vnd by adding after subparagraph, (B), the fpllowing new . 24 'subparagraph: " (0) for making, medical assistance .available 44, ry 10 4 t to any 'individual. under the age.' of six who is a .-member of a family who would, on the basis, of in- , coMe'kurd resources, be eligible, for aid under the State plan approved under part A of title IV 9f this 6 but Who is not a-dependent-child as that term is 6 Vned in section 496 (a). of this Act; and". (b) (1) section 1902.(a) (10) of the Act is amended 8 laihsertin"C`fer-itarse (C)" afte; "clause (A)" each place. 9 it appears in that section. 10 (2) Section 1902 la) (10) (I) of the Act is amended '11 by inserting "or pursmint to clause (C) of this paragraph, 12 clause' (F) or (0) of paragraph :(13), or section 1912" salter "section 1905 (a) ". 14 ''' CHILD HEALTH ASSESSMENT PROGRAM. 15 SEC. 5. Title XIX.of the Act is, amendecthy inserting at 16 the end thereof the following new sectiOn: 17. "CHILD:. HEALTH. ASSESSMENT PROGRAM 18 "SEC. 1912. (a) Effective October 1 1977, each State 19 with it plan approved by the Secretary under section 1902 20 . (b) must include the provision of child health assessments 21 andrprimary care pursuant to this section to any individual 22 under the ageof twenty-one and eligible for such services 23 pursuant to seetion'19og (a) (13). (p) ,any individual under 24 the age of six and eligible for such service, pursuant to _pc- - 25 tion 1902 (a) (13) (F) , and any other individual under the . , . 11 /r 1 age wenty-one ho is eligible for such tervrees under the 2 S approv d under th's title. 3 d health' ass sments under this title may be 4 rovide i lily y a lealt care provider whio enters into an ,agreement wi i the State agency responsible for administer- . ing or supery sing the administration af-the State plan under this title t a ) provide. to individuals specified in subsection eriodie health assessments, as required by reittla- oi the Secretary; " (2) provide to individuals assessed a minimum nge of diagnostic and treatment services (including lin-, munization against childhood diseases) as required by gulations of the Secretary, except that in lieu thereof (A) during the period beginning October 1, 1977, and 16 ending September 30, 19787.a State may enter into an 17 agreement with any health care provider who agrees / 18 to 'refer such individuals for such diagnostic' and treat - 19 services; (B) during the period beginning Oc- 20 tober 1, 1978, and ending September 30, 1980, a State 21 may enter into an agreement vith any health care pro- 22 vider who has written arrangements for the referral 23 of such individuals to appropriate providers for) such 24 diagnostic and treatment services; and (C) after Sep- 25 tember 30, 1980, the Secretary may, with respect to any 2 3 4. . 6 7. wlitr are eligible pursuant to this paragraph for such . e. '8 serviceS 0 `` (3). refer such indiVidualit. to appropriate providers services; 10 for any .cCbrective treatment the need for which is dis- closed by an assessment but which is not available.direct- 712 ' ly from the provider who has the agreement....wtli the 13 and follow-uk t assure the provision of such .q 14. -;treatmet . 15 " (4) take responSibility for the management. of the , , 16 medical case of each individual assessed to assure that all 17 Merril 'services which are offered tinder the State plan 18 (pursuant to section 1902 (a) (13) (0) ); and which are' 19 found to be necessary pursuant to an assessment are' , 20' made: available in a timely manner and that reassess- . 21 ments..are performed as' required in regulations of the . 22 Secretary; 23 " (5) be reasonably accessible on an ongoing basis 24 to individuals who have been assessed to assure the cod= 6. ,geogralihie area in a State, continue to allow agreements pursuant to clause Of) if he determines that a State 1 ' ., has nlade reason4ble efforts to assure provider partieipa- .- tion,,bilt the number of providers.who have agreed with thelS4te to proVide directly diagnostic and treatment s: 7.. , ervices' is. insufficient to serve ..the number of children 25 tinning availability of medical care; and 4,4 "(6) m d reports which (he State or the Secratiry may replireito assure compliance with the retitfitements , ot this section. 4 ".(c) Any individual Under the age of tweuty-bue who 5 has received an.assessnient pursuantto this seetion,aball, not- 6 withstanding any other proisi of this section or the tate 7 plan approved Ander this, itle, remain eligible for all, care 8 and services provided rindet tte State plan to innividuals-who .9 ' have been iissesaed for a period of six months following thr 16. date on whict the income and esouices of his family first 11.: exceeded the eligibility limits specified in the State plan for 42 finch care and services,- orN the individual was "dligible-fof 13 aidto,famills with dependent clilltIfeh under part A. of title' j4 IV of this.4ct, for a pelitn1 of sik months fojlowing the date 15 on which he becaniifflteligible for such aid, except that 'p {rio 16 case shall an (nclividualbe eligible for'such care-and services 17 by reason of the application of this ;subsection (1) who lets. 18 attained the age of ttventy-one or, with -ha4 not been:. 19 reassessed-in a timely manner.". 20 ADDITIONAL STATE PLAN REQUIREMENTS 21 I SEC. 6. Section 1902 (a) of the Act is'amended by strik- ing out "and" after paragraph (35) , by striking out the 23 period after paragraph (36) and inserting insteld '"; and" 24 and by adding after paragrap (36) the following new 25 paragraph 34-484 0 - 79 2 6 ,.f 7 '137) provide that the State' will encourage par- ticipation by physicians' and health cute ce ters in the proisratn described in section, 1912 of this AL: ; ,will as- Sure coordination between State and localxianies ticipating in that program and communiey'haalth centers funded under seciidn-330' of the Public Health SerSice , j.. Act.,-and assure theavailability of appropriate sup= $ port services Including tracking and outreach), in 9 accirdance with regulations of theSecretary, tindivid- . . 10 :dale and health care( providers participating in the pro- . 11 / sgram described in section 19121. 12 FEDERAL REIMBURSEMENT 13 r SEC. . (a) Section 1903.(a) of the Act is amended by 14 s redes,ignating-paragraph, (6) 'as paragraph (7) and by 'add- / 15. ingafter paragraph (5) the following new paragraph ,. s 16 a (6) an amount equal to a per minim of so much of then sults oexpended during such quarter as are at- - 18 tributableto child health assessments performed pursuant , 19 to section 1912 (b) (1 alld to diagnosisetreatment 20 (other than dental 'and inpatient care), referral, follow- - up, and medical case -management of individuals who have been assessed pursua nt to that section and regula- 23 i tionv of the Secretary pomulgated thereunder; which 24 yer centum shall be equal to one-hall of the sum of the 25 40. Federal,medical assistance percentage (as calculated for J .: 15 .1 ..y,purposes 0( paragraph (1) of this subsection) and 90 - . 2 pet,. centum or 75 per cen'tum, whichever is greater; 3 plus". .4 (h) Section 1903,9f the Act is amended by iidding at 5 \the end sthereof the following new subsections:- 6' " (1) .Notwi4Istancling any other provision of this title, 7 beginning Octobei 1,.97741/h.enever 4e Secretary deter- 8 ,mines; that a -State dctes.not have a program, -which meets 1 9' such stanclards it',;4iie shall spe.4fy in regulations, for the 10-r purposes of 4 11 "(1)- inforthingtfamilies of Sildren eligible .pursuant .. ., , .. . 12 ' to subiaragraph ai) Or-(F) of,,section 1902 (a) (13)",' 13 for services under the'State plan pursuant to section 1912 14 of the availability of suclpservices;. 15 "(2) assuring _the, provision of child leanth 16, , meets in a timely manner m cases where it is requested . 17 and required under the State plan; 18 " (3) assuring- the proVision, in a timely manner, 19 of any medical care or service the nd for which is dig- . 20 closed by an assessment; or 21 " (4) assuring compliance with the terms; of the 22 , agreements it has with providers of .services under sec- 23 tion 1912; . 24 the Secretary shall notify the State of such failure and that 25 the amount otherwise required till be paid to sue z'zt.ftt- 1 2 ,3 .4 5, - 7 , .''10 10 withaespect to each. succeeding fisdal quarter'io,llowingdel/ dotificaiton pursuant to parag'"phs ,(2) , (3) , (4), afid, (7) of this'seeticfn for the a be .reduied by 20 Per State" slaws to the sati failure witli respect to iv Coleited. Until the Secretary any reduction referred to in the preceding sentence, except of the 'State planishall that amount until the the Secretary that the duetion apps has been satisfied he shall make tlifit if the SedretarY is satisfied that the State intends to cor- feet sash/ fctiluret. the Secretary 'May withhold 'the iznposi- . 11 tion of the 'reduction referred to in the preceding sentence: for 12 a period of tithe, not exceeding six months, to allow the 13: Staie, to fully comply with the requirements of this substo, A tion, and where, at the end of uny such period he determines 15 that the failure with respect to which thd reduction would 16 apply has been corrected, lie may waive the impositiOn of the 17 reduction- entirely. Nothing in this or any other section of 18 this title shall be construed to require the Secretory to review 19- a. Eitate'F activities to assure compliance:with this subsec-; 20 don more. frequently than he determines is necessary based' 21 upon. the State's previous performance in meeting the re- . 22 quirementS of this subsection. gaairState shall cooperate with 23 the Secretary by prCviding appropriate docuinentation of its 24 itiorniance pursuant to this subsection. 4. 11 1 " (m) Notwithstanding any. other, provisions of thl title, 2 with respect to any quarter beginning after September 30, 3 1977, for which. the. Secretary deterinines thal a State has 4 met the cliteria for pod performance applicable to the pro - 5 gram :required by Section 1912 which he shall specify in 6 regulations lursuent.to this in bieetiOn, he shall7pay,.in ad- to any other payments he is required to make to the 8 State. pursuant to this section, an amount equal to 25 per -9 centam of the- remainder tpecified. in-section 1903n) (7).. 1Q The standards the SecietarY :shall -specify for determining good performance under this subsection may include criteria 12 such as the percent of children eligible for "assessment under . 13. the State plan who are assessed; the percent of condition& 14 identified daring an assessment which are treated; and the 15 percent of children eligible for assessment who are fully im- 16 munized following assessment.". 17 ,CONFORMING AMENDMENTS . 18 SEC. 8. (a) (1) Section 403 (g) of the Act is repealed. 19 (2) The amendment made by paragraph (1) of this ,g(rf subsection shall be effective with respect to quarters begin- . 21 ning after September 30, 1977. 22 (b) (1) Section 1905(a) (4) (B) ,)f the Social Se- , 23 curity Act is amended to read as follows: (B) child health- 24 assessments, diagnosis. treattnetkileferral. and medical case -ti 4. 12 1. management of individuals. under the age of twenty-one who. 2 are eligible.for such services under the State plan' in accord- s UM with the requirementain secdoni912;". ..4 (2) The amendment made by 'paragraph (1) of this 6 subsection shall_ be effective 'beginning. Octobeiv'1, 1977. 6 (c) Any individual who had been screened pursuant to 7 section 4905 (a) (4) (B) , as in effect prior to. October' 1, 8 1977, and who meets the criteria pertaining to age and date' .9 of _previous. screening which, the Secretary shall specify in - . 10 ingulations, shall, for purposes o1 the amendments made by' n this ACt, be -deemed to have been assessed according to see- n ,\tion 1905 (a) 14) (B), as amended by subsection (b) of e( 13 this section, on the date when he was screened. I . 19 Senator itTBICOPT: The commatesewill be, in order: The first matter before. us,_is H.R. ,9434. The Honorable Billasar Corrada and Robert Derzon. - You may proceed, sir. I understand you !lye suminaryi, but your entire statement will go into the-record as ifetTad. STATEMENT OF HON. BALTASAB, CORRADA, RESIDENT "COMMIS- SIONER FROM PUERTO RICO ; ACCOMPANIED BY DR, JAIME ^RivER-DUF.110, SECRETARY OF ITRAT427, PUERTO. RICO Mr. CORRADA Good morning, Mr. Chairman and members of the committee. I am accompanied by Dr. Jaime Rivera-Dueno, Secretary of Health for the Commonwealth of -Puerto ico, and it is a pleasure for me to appear before you today. .. This bill provides for an increase in the ceiling Federal expendi- tures for the medicaid program in Puerto Rico, Guam, and the Virgin' Islands. 'It is a very simple and I believe noncontroversial piece of legislation. z.A.utou 'probably know, this bill passed the House Under" suspension of.,the rules, -which meansidtlat a two-third majority was required for its'pmage. Mr. Chairman, one of the priorities of Governor Romero's adminis- tration is to provide the lest possible health care to the people. of, Puerto Rico, but unless we are, afforded a better treatment under the medicaid program, mast of our efforts will be 'seriously-hampered. The medicaid program was designed to provide medical care .to those in our society who are Medically indigent. By placing ceilings and re- strictions on the applicability of the program .in Puerto Rico, we have been seriously. constrained in carrying outAthe spirit of the law. The public health care system in Puerto Rico is a very extensive one . and it provides_services to approximately 1.3 million persons whO are eligible for medicaid and an additional 400,000 persons who receive services at 100 - percent. State cost. To keep this expensive system oper-. ating at adequate standards and servicing this large clientele, the Government of Puerto Rico spends around 10 percent of its- total budget for health care. For example, in die 10-year period- from 1965 to .1975, the Govern- men of Puerto Rico's appropriations for health care were increased from $37.8 'Million to $109 milliOn or by 188.4 percent. For fiscal yea; /977-78, this figure was increased to $141.2 million. 'During this same period, the municipalities of Puerto Rico increased the health care costfrom $24:2 million to $538 million hit an increase of 122 percent. Governor Romero Marcelo in his testimony before the m House SubCommittee on Health assured the members of that subcom- mittee-that the dollar commitment to the improvement of health care in Puerto Rico will continue to increase and that no reductions will be made in the health budget if' we receive additional Federal lunds under the meditaid program. I would like to make that same pledge to this subcommittee. Attached to my testimony, you will find table-A, which I make part of this testimony, and I request that it be made part .of, the record,- showing the constant increase in' the local appropriations. Puerto Rico has also invested heavily in physical facilities. Approxi- mately $210.5 million have been spent during the last 6 years from 20 ' loeal.functs for the construction of diagnostic and treatment centers to . provide services to the medically indigent. WhenCongress established in.1965 the Medical assistance program through title XIX of -the Social' Security Act, Puerto Rico was included in the same inanner as the States except that the matching formula applied' to the-island was 55 percent. But in 1968, Congress established .-an annual ceiling or $20 million for the program and reduced the Federal share to 50 percent. In 1972, the ceiling was raised to $30 million-, which is still the applicable ceiling for medicaid ex: t penditures in Puerto Rico. , Title XIX of the Social Security 'Ad, as it applies .to Puerto Rico, does not entirely 'fulfill the intent of Congress of helping hiw-income families in the Nation to availtheroelves of-high- quality medictil care on an equal basis witk those who can afford to pay for it. The con- straints imposed by the ipfle4ibili1y of the statutory limitation of $60 milliorrand the requirements that the island comply with virtually the fulhange of legislative And'administrative conditions for the,Keceipt of those funds, as they apply to,the States, are the key factors that limit thd full implementation of the program in Puerto Rico. The medicaid progfainrin Nerto Rico has to provide the same serv- ices to welfare and haalth clients and to engage in various administra- tive actions asiequIred from the states, despite the statutory financial limitation to the island. The range of required services includes medical and hospital serv- ices; early and periodic screenings; diagnosis and treatment for chil- dren; home health services; nursing home services; faMily planning services; and reimbursement for certain emergency and other health services provided in other States-to participants while traveling in the mainland. These 'service requirements alone imply costs far in exces of the available State and Federy financing. To aggravate the problem, we find that the :government of Puerto Rico has been sued in court by the Puerto Rico. Legal Services, Inc., which is funded, by the Federat,Governinent, because we are not able tOcomply with Federal regulations under the medicaid program. Clip ofrthe main reasons, Mr. Chairman, that makes it difficult for us -*to comply With these regulations is that we do not, receive adequate fund- ing from the Federal Government. Certainly we are anxious to provide more and better services. Mr. Chairman, as I mentioned before, the public health caore system in Puerto. Rico is quite extensive, Due to the severe limitations of fujs we are providing only in a very limited scale nursing home services .and w are Antible to reimburse other States for emergency and other 'services provided to the residents of Puerto Rico. During the 'last few years, most of the Federal legislation related to the delivery of'health services to the medically indigent population has been based on the third-party reimbursement concept. In, the United States the 'main source of third-party reimbursement for these programs is medicaid. This is obviously not true in the case of Puerto Rico and, therefore, any progiAm depending on third-party reimburse- ment is doomed to failure. This is so because, most of these programs provide only for "seed money" with a phaseout schedule providing. the projects enough time to become self-sufficient"through third arty funds. In Puerto Rico, wte cannot foresee that this will ever be, feasible because of the absence a , c-- 4. x.1 of third-party payors, especially medicaid. If this trend continues, the ° medically indigent in Puerto Rico would not be able to benefit from any of the new legislation their counterparts it the United States are benefiting from.. .Although Puerto Rico, has made efforts of its own to expand the health budget it has been unable to effectively upgrade the quality and expand the services to our indigent population. Most of the increases in funding have been offset by the annual. increase population-,-the high cost of living, and inflation in health care oos '\ AsI h e stated before, approximately 1'4 million persons in Puerto. Rico are onsidered to be medically indigent,,57 percent of these, or 975,000, a children. This low-aged group places increasing demands an tinantiale resources of the Gdvernment of Puerto-Rico if we are to provide them all the health care services they need. Tith cost of living in Puerto Rico is highe'r than in most areas of the United States. As a matter of fact, the U.S. Civil Service Commission has established a 12.5-Percent cost-of-living allowance for Federal employees working in the Sim Jimn metropolitan area, and 5 percent for those working outside the metropolitan area. A, recent report hit. the Puerto Rico Department of Labor shows that, there has been a 67- percent increase in the cost of living in Puerto Rico over the past 8 years. This same report' indicates a cost-A,living'index for ,medical care of 190,7 percent. . As an example, Mr% CFI-airman, t average annual medicaid pay- ment per eligible recipient in 1972 We $21.21. In 1975, that was equal to $12.85; an effective drop of $8.40 due to the decrease in the purchas- ing power of the dollar.. ' As you can see, the $30 million ceiling, unfair as it is, becomes more - burdensome because of inflation,and the high cost of living, in inedical dercare. In conclusion, Mr. Chairman, it is unfortunate that after 9 years, in spite of a considerable State effort, Puerto" Rio has not been able to reach the commendable goals set by medicaid legislation clue to insuf- ficient.funding: In order to prevent further deterioration of the serv- yips and to treat as equal the medically indigent U.S. citiZens residing in Puerto Rico, we urge this committee to recommend the lifting of the WO million ceiling for medicaid expenditures in our island..I believe that the House-passed bill takes a sensible approach and I hope that this committee will concur with the House on this, matter. Mr, Chairman, I have provided the subcommittee. with a series of tables containing data relative to my testimony and I would appreciate it if they could be made part of the record. Senator RIBICOFF. Without objection. [The material referred to follows :] TABLE A.STATE AND LOCAL APPROPRIATIONS FOR HEALTH IN SELECTED FISCAL YEARS Appropriations (millions) Sources Fiscal year 1965 Fiscal year 1975 Ptiertci Rico '(State) 8 9. 0. Municipal S37. 2C 2 $10 53. g Total le t .62.0 162.8 01/41: 'Mu Aniiiiirkel. runt) Arravrniffilum ,140L11EALDb,SERtES . ,...7.11E;:;COMMONVIEALTR OF PyER .196777, 112,141)11 *468 .68-69 69'070 ,10!.,71 7107 '7317474-75 75-76 t6;77 . . _g Fiscal ears 1971"1976 (U,S; A,.) .1 .1 I t 1972 1973 19 74 1975, 1976 MPIMIWAN6 i; yzlas sz.itrta, rnal,tru 1111 xricat or . grzuttio ritct r UNEIPMENT-RAfiVILEFOCO-,. YEARS. 468-11977 I I I 201 67.68 68.69.69'7 /1-72 y2.73, 73.71'474475 1576 ; 76e77./. 1 PUERTO NCO OttIFIN OF 141011, 6 t 5; d;0804 ior 'IR;°6 ars F 'I'Mgqr3s po , 01 A ith totle le ',., wiln.:31000 .0.1t0IA ; 10 13 040 No *12 lom 4 0 z .... I.V. a'' (0 E ccw,: a Ha (0 CR' 01 o 0 NI' 0 0 2" 4 , A toot p1 6 0 pi fo ii m NiM It m VN k0 411V 41 MM, O gli 000.0 11 r m A a eh 12 4 m p D lei P4 i O2, .47; boa . 40 v0 M 0 .' ol 1 fti 13 prOds b o tt ; a limi' 5 0 5 01 os r ,...1 .4 0 MI V 0 11' , 1 M M ig 1 1 i 2 V : °2 Ms M 0 NC a Al o0 I, 0 g 1 . azErs,;0 0 Is VA 11 5Z2..., ..0e1.0., .,.. 0 , to a 0,0 FA ill 91 2.44 4 orb so 0 0;0'0, PI 0.4t Pi* I II4 sl I 0 M 14 r °5 MI 4 I Mi 210 00 015' 200- - rt . P 190 o 1 ?1 1 8 0 - 1 7 0 2 . 'a 0160 r fp ei fra 150 aa , i40 130 Pi \ 110 - 71 ht 120 GENERAL CONSUERS PRICEANDEX't;"1'iir'' 'AND. MEDICAL CARE INDEX r. . , Puertoi Rico 197277 . I 1972 1973 1974 1976 197.7 1 1 GENERAL INDEX MEDICAL CARE 1figX. 1011, NOT INCLA A411.441 .F0/1 TNT OW it mat to at $21142jriPTUATON's. 0triAist07 Of WOW or uvui.0 1114,1P 26 PERCENT OF ELIGIBLE MEDICAID PATIENTS BY TOWN Town Population Percent eligiblei Adjantas.- 20, 240 61.9 Aro* - 60, 800 67.6 33, 300 78.4 . 660 59. 5 A/O Buenas 23, 200 71.4 Agasca . 24, 060 53.1 Areclbo_ 86, 690 65.3 Barceloneta MOP 761 78 Florida -,- . 69. 0 . Bamsnquitas4_ A. 24,840 42.0 CaguasL 183, 590 29,740 Bayamon - , 60.2 57.8 Canovanu k 1291: 437100 71.6 Com, . Winona - 12 53040 :. F050 ..- 51L. 8 36. 7 74-. 0 , 42, 296 74.2 stra. 40.2 Males-- -.- Cidra .' 211526,, 5594270g 88. 3 66. 5 82. 2 Coaroo ' 30, 26, 320 . 68. Corozal 1 21, 250 4 Cando 310 6. 7 . Culebra 870 50.3 Dorado 23, 570 27 7770 Fajardo Conks 16, 7 62.8 43, 600 63. 4 Guayama 2. 2 7 Guayanilla 19, 970 12, 500. 44.9 02. Guaynabo 76,810 Gurabo ,, . . 20,760 . 23, 620 Hatillo , Honeiguern f 58.6 Humacao 41, 550 14, 120 67.0 79. Isabela 35, 390. *UP 43,950 68. a Juana Diaz Juncos 24,060 70.5 Lila,___ 18, 980 51.7 Lams . , 29;080 10, 890 '70.) Las Marla: 20, 340 - 51. 60 . , Las Piedras Mans ti 3, 420 ----til LuquMo_ 11, 230 6, 650 59. 6 Marlow :. N. 7 Mannabo 10, 690 43. 6 . Mop kiMmiiiez 4... 99, 010 29,870 68.3 48, 530 83 . 5 4 20, 320 -,1, 23, 300 7 89. 9 20.460 76. 1 194, 300770 63.0 175, 690 56.1 60. 5 17 370 70. 9 10, , 70 5 10 5 0 . 36326, 6, 060 21. 2, 8 18, 470 64.0 Salinas ' ,-, . i. ... A 31, 23, 73. 8 62. 8 66.2 1147, San bah' - . , , 34, 390 78. 2 'Silva -,-.v5-'.;'--41-,-7- . 37,470 67.1 ..i'l .:10 , . . .. 63.3 r%--7,.,7-,t,y-., , . _4!..;... ,'''''.,--r.- ,__. 17, 670 66. 3 .v Santa Ise .4. ...., ' ''''.1.--.z.:-A-,,4.:-.. . : . ...... ... ,:i.f.-----4--.. . 25, 150 60, 910 rut t'. ttea ...,-...:_,...i.....__ , ° 40,280 57. 9 35.1 .rts 4 ;,'...;;'L :".*.i.--.:.:,,;a..- ,..3V,-.- -_' --,,..--,---7- 7 . 33, 470 -,' 4 fr.!, st --- r -* ... , . : '', .,* 27,780 64.4 55.9 **:;* 37, 600 72.6 is.e. ,.1 ..-t...*-?.:- -,..- ;,i6-- .-L, .. . , .-.7 . ..4.. ..t., 9, 040 . . 82. 3 4;'.."'''i47744 , V 36: 210. 19, 320 56. 7 ?';'"2!. !'0' -,-:. .... 37,610 69.0 , : r %... .',. 18, 370 45.0 . . Morovs . . Naguaibo Dr N aaranwls lito -S, Venueles . Quebradillas. Rincon__ . Rio Grams Rio Piedras Sirbanagde 3,120, 900 56.1 Comma.- These tables and charts show the Site and local ap- propriations for health in selected fiscal years, hospitalization, indi, vi dual. costs. They also shott State and municipal funds, appropriatiol for health services in Puerto Rico for fiscal year 1967 through 1977; total vendor payinent under title XIX for fiscal years 1971 thiough 1976; unem- ployment rates in Puerto Riesz through the years 1968 through 1977; and leneral consumer price index and medical care index, Plierto Rico, 1972 through 1977; Puerto Ricio estimated annual expenditure for a family of five members; anda summary table i percene d eligible medicaid patients by island municipalities. All this information will be of help to the suipommittee Further, Dr. Rifera and I will be glad to answer any questions you may have a Senator Emmen% Thank you very much. .Mr. Derzon si STATEMENT OF ROBERT . DERZON, ADMINISTRATOR, HEALTH CARE FINANCING ADMINISTRATION, , DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Mr. DERZON. Thank you very much, Mr. Chairman. I),,am Robert Derzo4, Administrator of the Health CareFinancing Adirunistiation; and to my . right is Mr. Richard Heim, Director of the Medicaid Bu- reau. We are pleased to be here today to strongly support the objectives of H.R. 9434, increasing Federal aid tohe territories. I think it is self-evident from the testimony you have already heard that [an] extraordinary increase in inflation and health care costs is taking place in Puerto Rico, Guam, and the Virgin.Islanas it has throughout ceilings the rest of the United States. The ilings oFederal assistance have not been adjusted since 1972, and we strongly concur that adjustments need to be made so that; in fact we can have a fair progra or all citizens of the United States, wherever they might be. I sim want to strongly urge the committee's support -of the thrust of .R. 9434. We would like the effective date to be-after Octo- ber 1 of t 's year so that we can make proper provisions within the budget of the President, and we would like future increasesin the ceil- ing to be tied, as they are in the proposed bill, to:the Consumer Price Index so that there can be adjustments each year, without going through an additional legislative process. The administration's proposal transmitted. to Congress: June 7, would increase the proportion of Federal matching from 50 to approxi- mateily 75 percent. This seems more reasonable for these territories, where the per capita incomes are very low, than the approach proposed in H.R. 9434. ° I think that summarizes pretty fully our statement. We would .be.. pleased to answer any questions. t Senator RIBICOFF. Does the administration supOrt adding the Mari- anastethis bill Mr. DERZON: Our draft bill would also extend the medicaidFrogram to the northern Marianas, and would permitTederal.financia partici- pation in medicaid costs of up to $1,500,000 per fiscal year. As is pro- posed for Puerto Rico, Guam, and the Virgin Islands, the match.rate would be .established at 75 percent. Senator RIBIC017. Thank you very much, gentlemen. [ThOrpreimirea statement and letter Mr. Derzon follow . STRTRMENT OF ROBERT A. Mme* ADMINIBTRATOR, HEALTH CARE FINANCING ArnarturrusnoN Mr. Chairinan, I am pleased to share with yeti and the committee the ])epart-,. meat's views on H.R. 9434; which would increase Federal Medicaid funding for Puerto Rico, Guam, and the Virgin Islands. The Department is sympathetic to the prOblems which this legislation seeks to alleviate. Medicaid was enacted to help all low-income U.S. citizens-to have access to quality medical,eaire, and these territories, which have a -high poverty' level 4pd substantial unemployment, rely on that commitment. The la established; by the Congress on Federal medical assistance to Puerto Rico, Guam ..ahli_the 'Virgin Islands have not been adltisted since 1970. I . geed not remind this committee of the change in health care costs since that time. The price tag of- the Medfcaid program alone has nearly tripled ill six. years. Although this, legislation could be viewed as contributing to this trend, we do not believe thatiOw-ineome recipients of medical care should be penalized because of widespread inflation in the health care field, intolerable as that inflation is.. In this connection, I am. pleased to note. that Governor Romero-Unreel° of,- 'Puerto RIO has stated that the public health care system serving. the indigent'. population of Puerto Rico has built -in controls on expenditures to keep coats down. He can be proud of a system Which is predominantly- anibulatorg, and which has shifted its focus from acute care to a preventive approach to assuring good health. I believe it is also appropriate this morning to note that the Commonwealth has invested heavily in maternal and child health cure. The Department supports. the objectives.of H.R. 9434. The fiscal 1979 budget included a proposal to provide fiscal relief to these jurisdictions along theines or H.R. 9434. The DepartMent formally transmitted this proposed legislation. to Congress on June 7,.1978.' Because -funds are. not included in* the fiscal year 1978 budget, however, we would urge you to ensure that the changes.mnde by this legislation do not take effect until after October 1. H.R...9434 provides for increased expedi tures begin- ning in this fiscal year, which could result in unbudgeted- increases of $21 . million. .Our recommendation to double the ceiling in fiscal year 1979 conforms to the House bill. In future years we propose, as does 11.It. 9434; to tie the increases in the ceiling to thg Consumer Price Index. Accordingly, the impact of the bill on budget outlays ill within the amounts projected In 'the President's budget' for the next five years. We also propose increasing the Federal match rate from 50 to 75 percent.. We view this as equitable and preferable to the provision in-H.R. 9434 which' would set the Federal'. share in the stune manner as is determined for the.5q Slates. These jurisdictions are, exempt from Federal income taxes; they 'e exempt from the usual Medicaid requirement that recipients be given their. ree choice of qualified providers, and they are exempt from the ceiling on income levels for the medically needy. These arrangements reflect the special status of these juris- dictions and the silecial nature of ,their health care systems. We believe a flat percentage Federal share, as well as the ceiling on funding, is consistent with our 'recognition of this unique system and the need to 'preserve a certain amount of flexibility.' With the changes mentioned above, we would be pleased' to support ,the bill. yon.. DEPARTMENT OF HEALTH, ..tDUCATION, AND WEi.FARE,, 14, 4 August J4; 1978: Hon. Ituesri.j.. B. LONG. . Chairman,' Committee on Finance, Senate Washington, D.C. Imo Ma. Caarameav : This is to follow up on and provide a formal response to Senator Ribicoirs question during this morning's hearing o .IL 9434. The Senator asked for the Department's views on extending the leg slation to the Northern Marianas. . , -As you are aware, th Trust Territory of the Northern Mari Islands has not previously participated in the Medicaid program. The Department's draft bill to' provide increased funding to Puerto Rico, Guam, and the Virgin Islands, which 29 ., . . the Secretary transmitted to the Congress on June 7, 1978, would also extend the Medicaid progiam to the NorthMarianas. This amendment is required by section . 502(a) (1) of Public Law 94-241, the Joint Resolution to approve the' covenant to establish a Commonwealth, of the Northern Mariana- Islands in political union "..,with the United States. The Department's draft bill would permit - Federal financial participation in Medicaid costs of up to $1,500,000 per fiscal year and, as is proposed.tor Puerto Bab, Guam, and the Virgin Islauls, the Federal match- ing rate would be established at 75 percent. . SincerelY, e . a RoaErr A. DERZON, Administrator, Health Care Financing Administration. Senator Rnrxc,orr. We will now to S. 1392, the Child Health . e, Assessment Act. The first witness will be Ms. Wendy Lazarus. Without objection, youi opening statement will go into the record, as if read. . - STATEMENT OF WEAJYY LAZARUS, HEALTH SPECIALIST, CHIL- DREN'S DEFENSE .FU.dil . Ms: LAzAntrs. ank you, Mr. Chairman. My name is Wendy Lazarus, and I .am' presenting the Children's Defense Fund. I di- rected CDS nationwide study of the EPSDT program. I am grate fill to have the opportunity to comment on 1392, .the CHAP bill. , ...To proposal currently being acted on by Congress has greater sig- nificance for the health of children in ,this couritty.. We appreciate the willingness of the subcommittee, and the leadership exhibited by you, 31j. Ribicoff and Chairman Talrnadge,-to schedule these hearings at when Congress is confronted with u. full agenda of pressing issues. .We are joined by a number of.. other organizations who are committed to passage of a strong CHAP bill this year, and we are pleased the Senate is taking action. The Children's Defense Fund is a national, nonprofit, child ad- vocacy organization created. in 1973 to gather evidence about the conditions.of American children and to address their needs systemati- cally'. We seek to correct problems uncovered by our research through: Federal and State policy changes, public.information, and a variety' of other means. S. 1392 contains many good and extremely important provisions. Although, we will not use limited time this morning to' discuss them. I do Want to underscore our support for the administration's efforts to Make legislative improvements in EPSDT. We are, submitting today extensive written testimony on the bill that sets forth the value Of CHAP, the provisions we support in '1392, the amendment we . believe are essential 'to Make CHAP, effective and the rationale for each. We request that this 'be submitted into the record. Senator Rraicorr. Without objeCtion, the entire statentebt,a.nd ex- hibits will go into the record as if read. Ms. .LAzAnus. I will summarize briefly here why a strong CHAP bill should passed now-, and which changes in S. 1392 we consider imexpendable. For'2 years, between 1975 and 1977, we studied the operation of EPSDT.. In addition to reviewing statistics and reports of the pro-. gram nationally, eve went out and looked at programs'in a number of localities. Unfortunately, we- saw far too many instances where chil- 34-$64-7S-3 30 dren were simply not getting EPSDT services, The consequences are extremely severe. _. . Arc* le Douglas is now 8 years old and has already failed the first grade twice. His problem is a hearing loss which developed as a result. of an ear. infection he suffered when he was 2 years old. Archie would have been spared much of his suffering had.he received EPSDT serv- ices within a year after he had his infection. The hearing hiss could have been identified -..much earlier, before it seriously affected'his language skills. Once his problem was identified, Archie could have gotten a hearing,- aid and services-in sehOol suited to his special needs. 17'7- -Millions of poor children like Archie, cannot do without health- services. For every three screenings- done through the EPSDT pro grarti nationally, two health problems.requiring followup care are found. vast majority of these problems- have never been found or treated, yet, they are the kind of troubles that interfere with a child's ability to learn in school, eat, properly, and lead a productive- life. For instance, vision and hearing disorders. serious-dental needs. .ftn(I a lot 'of ftnentia are found: All von have to do is see firsthand what ,...EPSDT can do for children to Become convinced that if it can be - made. to work better, that it must be done. To make this happen reqUires relatiely simple legislative and administrative changes. I would like to emphasize that CHAP is not major new program. It is an attempt to fare Squarely and resolve ytbe deficiencies in a program which has been-in existence more than vezrs. CITAP's goals. while absolittely crucial. are modest. No. 1, to modify EPSDT so. it will enroll all needy lo-income children in a system of health care which assures them complete preventive services and b.neeessarvsubsequent care: \o. 2. to correct the most serious inequitjes in eligibility and benefits policies for children and youth:x*1(1er medicaid. Certain modifications in S. 1392 are necessary to accomplish these Iwo purposes. Most of them are administrative changes which are doable no which cost no money at all. The reitin index do require. funds, but: only a modest increase. particularly given the .evidence that pre- ventive care actually brings costs savings when properly provided.ta children. . - ,Let me begin discussing' he changes tlot would require no. or mini mal,'new funds. These amendments are intended to deaf with the sad fact 'that only it small portion of medicaid children now receive EPSDT services. , . . We.fo,un.d, for instance, m 19Tfl only- one-quarter of the number.of ..Sereenings needed: by. Eligiblelchililreit wer4.,provided. Three of the,, major reasons forthis Inadequate:record aPe not addressedsliffieientiv by S. 1392. and we urge that. theN be corrected. . First, few Statet. have set up the kind of public education or (tilt reach program, which, properly informs eligible faini.lies about ' EPSDT and how to secure services. Obviously, this is the first ern- cial step in the program,' and if it is not. done effectively, no children will benent from. CHAP,. regardless of how good the rest of the- pr Liogrm is. kea EPSDT, S.1392'fails to promote the methods of outreach that have been shown -ko work best by every serious study of -this .pro--- ° 31 gram. To be effective CHAP mustshift outreach activities in a state away from ,heavy reliance on welfare agencies. it should promote community organizations. that employ trained paraprofessionals who arelmown.andt rusted bY medicaid families. Second, few States.have invo ved the full raaige of providers quali- fied to-offer EPSDT services a-result; in some places, children wait as Jong as 6 months for an intment for screening ort rearment services. -Often, too, children cannot receive EPSDT services from. the providers which can meet their needs best: At the time of our study, 19 States relied primarily on country health departments to the ex- , clusion:ofwhost of other qualified providers. S. 139 . does .not correct this problem. Provisions must be added setting out explicitly. the States' responsibilities to actively solicit provider partiCipation in - CHAP. . - . Third, EPSDT program standardsand the mechanism for insiirint adherence to them are inappropriate and weak. S. 139, is deficient here as well. We hai-e, therefore, recommended that several administrative changes be made :.that outcome-Oriented standards be used for deter- . mining penalties as well as bonuses; that CHAP.implementation plans. be developed by States, nd present loopholes in Federal compliance procedures be 'eliminatfd. Lastly,' we urge that States be required to Maintain at least their.current-eli7ibility and sersiccs policies for the under-21 population so these new Federal funds expended by CHAP result in strengthened and expanded 'health services. We.-and many others. know that EPSDT shortcomings have been, due,..in par, to the very poor peformance by HEW in administering this program. 'While many of the failures occurred in past .iidininistra- tkins.the performance of this administration has been unimpressive as well. Screening -levels .are not increasing as they should.' Badly - needed hew regulations and reporting requirements have been ,under ! review for a year and a half and have not been issued yet. In 'light of the Ilepaitment's commitment to cut medical costs, it is all the more intolerable that it has made little progress to improve ibis preventive care program for .children, -which (hies save money- in the king run. EPSDT and CHAP can be adininistered well, but it will require an understanding. by the Health -Carr Financing Administration of the program's uniqueness, and a Federal commitment and leadership; which EPSDT simply has not, and still does not, enjoy... We. urge Congres to build in certain assurances of tonstrnctive Federal 11Fdershp. . . First; we recommend that Congress the Secretary to subMit an - annual'reportiOn the progress made 'by Sta` tes in "enrolling. Children inCHAP alIa.proViding them with high-quality services.% Second. we recdmmend that CHAP be administered by an identi- fiable.unit. The office should have clear authority and saifficient staff to set programs standards, devise reporting requirements, work with States .to promote proper implementation, and monitor program qUality. It is not acceptable to spread these. functions through various parts of medicaid.- CHAP's. charge requires a special focus in the agency, as well as support from the highest levels in carrying out its -unique 32. mission. .The reason is that -it is unlike other parts of medicaid and medicaret CHAP is concerned not onlY with financing, but also with setting up .a delivery system to actually reach a targeted population -with a standard of care. .I would like to summarize the changes-we urge which dr, entail additional costs. Our written statement contains the rationale and implications of each. We recommend coverage of routine dental care fOr all medicaid youngsters: In addition,. a.. CHAP health assessment should include a referral to a dentist for any Child not receiving routine dental care. No. 2, we recommend coverage of all health care for which medicaid payment is available for each child enrolled in the CHAP program. considerations dictate any limitation on care subsequent assessment, these limitations should be confined to expensive sery- If cost t to ices affecting the least number of childreri. e, we recommend expansion of medicaid eligibility to all chil- dre under age 21 in which meet State income requirements, which shouki be at least set at an established minimum. No. 4; we recommend extension of meidicaid eligibility to:low- income pregnant women who meet-income requirements. The total package of our. amendments.fo S. 1392 would cost roughly $300 million in fiscal year 1979. This may sound like a lot of money in these timestbut CDF believes the expenses are entirely justified, given the cost savings which will accrue to taxpayers eventually and the very real physical and emotional selief that children will derive. We believe' v it would be shortsighted and mistaken to enact a package which excludes:any of these amendments. EPSDT has a track record by now, and hard; data are coining in .which clenionstrate cost savings:It -is very interesting, Mr. Chairman, that in North Dakota, for instance, Federal medicaid expenditures were significantly lower-3D- to 44-percent lowerfor children who were in the EPSDT program than for those Ivho were not; Expencii- . turns for in-hospital services were 4-7- to 58-percent lower for those whd had been screened. In conclusion, I would like to talk for a moment about a legislative matter related to CHAP. Based on conversations with congressional staff and other .persons interested in ,Child health, we have become . aware of agroWing interest in considering changes this year in title V, .maternal and child health programs. :. CDF agrees that title,V. warrants serious examination. After more that 40 fcars of program operation: it is time to reassess What title V's focus should be and boy:in seeomplish. it best. Bat the issues' plex; and we believe it is unlikely that the fundamental kind Of reeval= nation needed can be done before Congress adjourns. While certainly title V and CHAP are related in some ways, we believe the CHAP program we have recommended should be enacted this year and that title V should receive consideration by the 96th Congress. Children need the benefits of CHAP now. Low-income chil- dren who were not yet born when EPSDT was enacted in 1967 are now riearli 11 years old. : The proposal we have just described is iustified, and has broad support. We urge you to pass CHAP -before adjournment in October so that these children do not go any longer withput basic health services. 33 .Senatot'lluszcoP7. Thank you very much, Ms. Lazarus. "Staff will submit some questions to you, and you may. answer them as soon as possible. . A . . [The prepared statement and attachments of Ms. Lazarus follow. Oral testimony,continUes on p. 47.] . . .. - - . STATEMENT or. THE CHILDREN'S DEFENSE FUND .. Chairman Talmadge and members of the subcommittee, the Children's Defense Fund appreciates the opportunity, to appear before this Subcommittee to express our views on the child'health assessment program .(CHAP)'.."a bill tostreagthen. and improve the earlrand periodic screening, diagnosis and treatment program and for other purposes." There's no proposal currently beingacted on by. the Congress.which has greater significance for the health' of Children in this country. This important bill deserves prompt and careful consideration by the committee. The Children's Defense Fund (CDF) is a.nationaVilonprofit, child advocacy' organization created in 1973 to'gather evidence about the- conditions of and-to address systematically the needs of American children. We have issued reports , on specific problems .faced by large numbers of children in this country, in the areas of health care, education, juvenile justice, and foster care. We seek to cor- rect problems uncovered by our research through Federal and State policy changes, monitoring, litigation, public infoimation and support to parents and local community groups representing children's interests. CDF has recently published'an in-depth report of the progress and problems of the Early and Periodic - Screening, Diagnosis and Treatment (EPSDT) program. EPSDT i. Does It Spell Health Care For. Poor Childrst?, issued in June. '1977, describes the way the program Is operating, documents the extent to which it is failing to meet the basic.health needs of poor children, and sets out the con- trete steps needed to make EPSDT work better. 1 . .. dletatuie many of the necessary refornis require legislative .changes, CDF is delighted that the Congress is developing a Nan to modify' EPSDT. We are .. pleased, too, that members of the Senate have taken an increasingly active inter- eat In thebhportant questionof how to improve the EPSDT program. We.appre- elate the willingness of the subcommittee to schedule these hearings at a time when the Congress is confronted', with a full agenda of pressing issues, and we are standing by to help in any way we can to expedite consideration 'of this legislation. This' increased 'interest .in EPSDT is reflected not only in the scheduling of the hearings, but in the work of Senators Chiles and Cranston who have actually developed legislative proposals. We would be pleased to work with the Subcommittee and any 'other interested members, of the Senate and Hotise to shape all of the proposals into a bill which can be enacted this year. During the course of this testimony we will summarize briefly the principles' we support in S. 1392 and the amendments to it introduced by Senator Cranston. We will devote the remainder to "setting' out -our views on the issues which are treated differently by S. 1392 and the House bill, H.R. 13611, as reported out of 1 the Committee on -Interstate and Foreign Commerce. Our recommendations on these unresolved issues are crucial to make the plan effective. We urge the Committee to act expeditiohsly to amend the billaccordingly. Children 'need the benefits of CHAP now. And because we believe that much. - of the Committee's attention next year should be devoted to other issues of national health policy, '-it -is essential that needed reforms ka EPSDT and MediCaid beMade before the Congress recesses this year. . : . z___. . . . . . . .. , POOR CHILDREN'S IMMEDIATE NEED FOR BETTER 'FIE.ALTII CAE . . As EPSDT has documented. children in low income families have a host of unmet health needs. Nationally in fiscal year 1976, for every three children screened, two.conditions were found needing follow-up care. Between 60 and 80 percent of these problems were pieviously unidentified or uncured for. Fewer than 1 percent"Of children screened in EPSDT had ever received a complete physical examination. Screening uncovered such Conditions as incomplete immu- nization ental problems, low hemoglobins, vision and hearing disorders, high levels of In the blood, genitourinary and respiratory infections, parasites and skin dise Most of the problems uncovered by EPSDT can be corrected or at least eased IF providing children with basic health services. The consequences of not doing so are monumental. Children suffer needless pain ; they encounter difficulty in 34 school and In. jobs; and sqctely eipends ifs of dollars treating proldems which could have been prevented. "Archie Douglas" is'a child now living.in the Disfrict, of Colfimbia. Isis stdry allows the frequent results of inadequate health care.. Archie Douglas is now eight years old and has already failed the first grade ttrice. He.bas always avoideA going to. school whenever possible. Last year.hie teacher reported that when in class, he had a short attention span. misbehaved , frequently and was generally,. disruptive. After.twfryears of first grade instruc tion, his language skills are 'those of a five. year old. This is true despite the fact that he excels in the nonverbal portion of standardized intelligence tests. Archie comes from a stable,. intact. tower-inceme family. . Archie .was a full-term, normal healthy habi. He received his health Care . during infancy. from a cit!F clinic. When he was 18 months old. he had a fever s and. an earache. His "mother, relying on her mother' adVice. rocked him. to soothe his crying and ease Archie's pain. gave him an aspirin every few hours and used a 'commercial ear-drop preparation. While rocking him. his mother noticed that some fluid began draining from his ear. Archie seethed less dis- tressed after the fluid drained. and he recovered completely within a few days. Three months later the fever and the earache recurred. This lime both ears were affected. Home remedies brought no relief and Archie was taken 'to the clinic. The doctor diagnosed'hijateral otitis media: This is a comtnon" childhood illness. easily diagnosed, and easily and effectively treated by antibiotics. Mra. T Douglas was able to pay $15 for antibiotics only by deferring her rent payment. Because Arcfiie seemed .to recover in a few days. his mother discontinued the. medication' prescribed by the doctor before the full antibiotic regimen was r completed, Within a month, the condition returned. and this time rocking, ear drops and a few leftover antibbitic pills were administered and Archie seemed to recover'. With the exception of these illnesses. Archie was a health,. active child. Other than Visits to the clinic-for immunization, his mother was grateful that he.never needed to see a doctor.; . This year Archie has a new first grade teacher. On his recommendation, Archie's.mother took him to &speech and hearing center for an evaluation. They' -found that 'Archie has a bilateral hearing kiss that probably resulted from his early bouts with otitis media. He has slightly more hearing in his left ear (30 dB) than in his right. (45 dB). . - Archie's bearing loss .is Considered significant. He has frequent difficulty with normal speech. sounds, and his difficulty has probably been the cause of his school problems. Archie's hearing problem can be alleviated by a hearing aid, bidet this point, he also needs remedial education and his mother needs coun- seling. and. support. Even with help. it will be difficult for Archie to overcome his initial impressions that school. is incomprehensible, that he cannot keep up. and that he is a failure. Archie could. have been spared, much of his suffering through a program of. " tarly screening and follow-up care. While it is unlikely that screening Could have identified his ear infection when it' first developed (unless his screening appointment happened to be scheduled when he was sick), screening within the next year. or so wo.uld,haie identified the-Dearing loss much earlier, wIlik he was tie() or no years old. long before it seriously affected his language skills. Once7his.problem was identified. Archie guild hive gotten a hearing aid and . . s- services in sithool Suited tohifi special needift., . .' . Miltlitthet Of children like Arebieneed tJ basic health care which they efirrently do not "get, -AccOrding to projections by the Congressional Budget Office, among Medicaid-eligible children in one year .alorie. 3.200,000 need immunizations 2.184.000 need treatment for anemia. and 2.210.000 need care for vision or hearing impairments. If the health problems of children who are poor but not eligible for Medicaid were- considered, the numbers would, of course, become. much larger. '. WHY IMPROVE FXRDT Numerous reports, experts, and other organizations have pointed up' the shortcomings in the performance of EP$DT. In nearly every respect. this pro-, gram has failed to realize the promise which many helloed it held for poor children when it was enacted hack in 1967. Our own findings have convinced us that the only way poor children will receive truly effective health care is .throngh a national health program designed to assure comprehensive care to all Americans. The enactment of such a program is our principal goal. However, 35 dren cannot go without basic health care until a^ national al health pro- 5. gram-4 enacted. Experts agree that even if national health legislation were introdficed immediately, it would be at least ft:Ur years until services become available. This delay la dire to the time'tequired to legislate, plan and implement any major: new program.. N The fisst'reaSon to improve EPSDT now is that, until a new national program is in place, there\are no other sources of health care to which many poor children can turn. for primary care services.--.--Dther federally-financed health programs for childrenincluding Community Health Centers, comprehensive programs under Title V, and Migrant and Indian Health programSreach only a fraction of the children, on Medicaid. According to. recent figures, these programs were estimated by HEW) to have re,ached 1.7 million. children. This compares to an -estimated 13 million children certified for Medicaid. These programs have been effective and their expansion is necessary to fill the gaps in the delivery system through which EPSDT and a national health Pro-, gram operate. Therefore, we urge that they be expanded immediately. However, it is unrealistic. to expect them to gear up to meet the needs during the next year or two of the .millions of children who do not presently . baye access to their services. As new resources are being developed, reforms in EPSDT can bring , improved services to poor children now. Thus we do not hesitate to recommend an increased investment in EPSDT despite our clear awareness of its limitations, Ruring the next few years, EPSDT can provide services which many poor dren have not and will not receive unless proVided,through EPSDT. Data show that .most children reached byEPSDT had never received comparable services elsewheie. For instance, the .EPSDT Demonstration ProjeCti found that fewer than one percent of the almost 7,560 childrenscreened had had a previous exam- !nation comparable to what is called Tor 1,3y the program-Sixtylo eighty percent of the health problems found in these chfldien were pre.vidugly unknown find AM- treated,-even though 80% were chronic. hp Baltimore, physicians from the Uni- versity of Maryland screened 361 children ; 335 of them bad referrable conditions. In their iriew, "not one of these conditions would otherwise have been recognized so early in its course" without the pr ram. The second reason to strengthen t1 Tats is that EPSDT can'improve the. health status of children ,reaclied and reduce the amount of money 'spent on health care.Id.North Dakota, total expenditures under Medicaid were com- pared for children who bad been screened and for those who bad not. Per capita expenditures were 36-44 percent lower for those screened than for the unscreened children. Expenditures for in-patient hospital services were 47-58 percent lower for those who bad been screened. In Michigan where children are on the second cycle "OftPSDT screening, diagnosis and treatment, the rate of referrals for health problems found through screening bas dropped significantly for .thode returning for re-screening. The referral rate has dropped overfill by 13 percent The most significant reduction is found in the rates of referral for ithmunizations (from.26 percent-18 percent), as a result of physical assessments (42 percent- 31 percent), and review of health histories (10-7 percent). The third reason to improve EPSDT is that. in the process of making EPSDT function more effectively, we will eonfront and help ,to resolve some of the key' problem that any national health prograin will have to address in Arder to- be effective.--If we are 'not to duplicate the mistakes of wasteful, piecemeal and inadequate health cafe programs of the past, we must (a) develop effective ways to reach out to families .currently otitsilie the health care systemal (h) establish standards for complete, .quality care and methods 'to monitor and enforce these standards; (c) inublve more dochits hnd clinics as providers in publicljr-finfinded ' programs; andad) provide incentives to develop 'health resources where they currently do not existIn urban centers and remote rural areas. Reforms in the EPSDT program will strengthen the foundations on which a new universal pro- grOus can be built. s PROVISIONS CURRENTLY IN CHAP WHICH ?DP SUPPORTS %. S. 1302, including the Cranston amendments to it, includes certain significant Improvements which CDV' supports: Inclusion in Medicaid of additional 'Children and youth aged 0-21 who are not currently on welfare but would quit litres "income eligible" children. Inclusion in Medicaid of low income pregnant women. ,Provision of a clearly defined, comprehensive health assessment, rather than a Screening. Provision of an expanded package of health services te- children who have betn assessied. Extension of child's eligibility for Medicaid to help assure that needed fol- lowup care is received. Defining providers' responsibilities under.the program to include provision of :health 'assessments and provision or at least arrangement for followup care. Encouragement, for providers to offer rmatin'e forms of treatment as weLL,lis assessment, within a reasonable period of time. Increased federal share of CHAP costs. Provision of a financial bonus to states which provide assments, treatment, and Immunizations to an especially high proportion ofeligible children. sAk Withholding a share of. states' Medicaid administrative funds rather than of .ANDC payments' for failure to meet program requirements (assuming Congress inclpdes a financial penalty for noncompUance). While we endorse the many good provisions listed above, nonetheless we believe other crucial elements must be. added, 'without w the package will not be nearly as effective as it can and must be.' During E DT's ten-year history, a great deal has been learned about hOw best to meet t e needs of children and in what respects the current EPSDT program is'deficient. These lessons should cer- tainly be applied to the design of CHAP. . ' SUMMARY OF CDF REC5AIMENDATIONS ON KEY .UNRESOLVED ISSUES IN CHAP Some'of our recommendations require only nominal increased costs..The costs of others are slightly greater but extremely modest in the context of Medicaid as a whole. According to projections by HEW,..the total federal program cost for ) 'these changes would be roughly $265 million over the cost of the administration's bill and within the Medicaid budget authority approved by Congress for fiscal .4.; year 1919; $235 million represents I s than 2 percent of last 'year's medicaid expenditures. Below isa summary of CDF's sitions on key unresolved issues, followed by a liscussion of eackrecommendati n. I. AnthraitExTs 'Waxen INVOLVE NO COST OIVIINIIIAL COSTS, , A. Encouraging all quali cd providers to participate in CHAP CHAP should require states to identify n11 qualified provideri (including dental providers) and to encou age their participation in CHAP by offeringadminis- k, trative Arrangements which can be expected to elicit their involvement. These "'. Include adequate reimbursement rates and prompt paymenE bf claims. .. The criteria la the bill defining a CHAP provider should be modified to make clear that' proiriders which 'can, take responsibility for assessing children and assuring_that they receive complete CHAP .services, should qualify. The listing of such pr A. ders should explicitly include coMmunity health Clinics, private prac- titioners, ay care or Headstart piogrtkins. rural health Clinics, public health departme tS, maternal and ;child health. centers and any other entity that can meet the responsibilities assigned toproviders. : . . . . . . - B. Assuring that CHAP serried get'to needy children As a' progratn requirement.: CHAP should establish outcome standards which states are expected td meet. The standard should measure performance in enroll- : ing a reasonable proportion of eligible children in the program and providing . them with needed assessments and treatment. , CHAP shOpld require that the Secretary gather data tp assess states' per- formance ill :enrolling eligible children in CHAP and in providing a reasonable -41.propartion of eligible. children with health assessments and needed treatment. CHAP shout be modified to require 'that states meet key, program require- meets Including outcome standards, and that the "penalty sanctions" be used 'by-the Secretary fo an infraction of program responsibilities.. . . CHAP should re re that the Secretary review every state's program at least twice 'annually. he Departnient should complete its review within . 6 months of the close of e quarter under review. If the Secretary determines that. a state ,is not meetin CHAP's program requirements, heimust levy the . , 37. financial penalty and require,.-the state to take necessary steps to meet the Congressional mandate. Before any order of the Secretary becomes effective, the state can seek administrative review on the appropriateness of the Secre- tary's finding. The process for reviewing a stats'appeal should be carried out expedigously. ft 43 o. 0:Developing States' capacity.to deliverCHAP services Under CVAP, States should submit plans to HEW which show how the re- quirements of CHAP are met and which demonstrate the capacity to tarry them out as described. There should be substantial public input in the develop- ment of theplan. CHAP shotild require that Medicaid agenCies report to. the Health Planning and Title V Maternal. and Child Health' figeneles idenilfied health shortage areas for children so h strategy can be developed for building the necessary resources. *- . D. Building accountability in HEW'8 adMinistration (4 CHAP S. 1892 should specify that Congress expects 80 perpent of eligible children to b1' enrolled in the program five years folloWing CHAP's enactment: On an anneal basis, the Secretary should report to the Congress On the Department's S. 1392 should require that within 6 months of CHAP's actent final progress in reaching ;his'goal. m 92 imp4menting regulations should.be in effect.' qi it Si, 1892 should establish that, on a biennial basis, an independent e nation of HEW's administration of the program be conducted and submitted to the COngress by an outsidepanel of experts representing the interests of recipients. IL AMENDMENTS VkiliCH INVOLVE ADDITIONAL COSTS , 'A. Assuring effective outreach . CHAP should require states .to allocate a. certain minimum portion of funds (.2 percent of total Medicaid expenditures or 5 percent of CHAP expenditures) for public education and for efforts to enroll children in the program. The, exact:amount should be in proportion to the percent of eligible phildren not currently emqlled in CHAP. Nonprofit organizations locatml in AM' target community as well :.as public agencies should' qualify for reimbursement to perform outrea01:2'; , For ontreach 'Performed by nonprofit organizations located id the target ',...conmunity, states should .receive 90 percent Federal reinitursement for the. expenses of enrolling new children, up to a reasonable 'level for the coat of each child enrolled. States which fail to. attract to the program a reasonable proportion of eligi- ble children shouldibe required-to develop .a new outreach program emphasizing the use of organizations located in.the target CommUility. . tr, . . B. Covering.health services following an assessment . The language 'in S. 1392 should be clarified .to make explicit CHAP's intent: that children in the ,pregram (i.e., who have been assessed) receive health care needed for problems found duriailthe assessment as ,well as for problems . which arise in between the times they are assessed: The provision exempting states from treating children with "mental. illness, mental retardation, or developmental disabilities" should be eliminated. CHAP should provide health services, 'including mental health services, for all Con'. ditionslohnd and should refer children, as appropriate, for needed educational and social services.. . C. Providing dental care The dental provision in 'CHAP should be replaced by a requireMent that states provide such dental 'care as'is pecessary for relief of,pain and infection, for restoration of teeth, and 'Maintenance of dental health. CHAP shmild not . ,allow'the receipt of dental care.to be predicated on medical ordental screening.' The level of federal reimbursement for dental care under CHAP should be . modifiedto make it the same as for other health services. . , 4 . I 38 : D. Maintaining State effort in the program The federal-CHAP expenditures should pay for expansion of services beyond what 'is currently. provided' under. HPSDT. To accomplish this, states should be *expected to maintain at least their current services and eligibility levels for children. ' E. Extending,medicaid to "income eligible" paiith, aged, 0-21 Medicaid eligibility shoultbbe extended to children and youth between the ages of 0 and 21 who meet income qualifications for welfare but do not presently qualify for Medicaid becttuse thTy fail to meet other welfare requirements (e.g., -they are poor but live in intact families). States' income criteria for eligibility should meet a Minimum national floor. The criteria for eligibility should allow children to meet the income standard. by deducting the family's out-of-pocket payments for medical Care. SUMMARY OF IMPROVED BENEFITS CITAP PROVIDES . . Medicaid eligibility for approximately 2.5 million low income children and youth.' Provision of medicaid services for approximately 64,000 low income pregnant. women aged 22-44.' .. . . Provision of health assessments to 600,000 more Children in fiscal year 1979. . than would receive them through EPSD17 - Coverage of a gotnprehensive treatment package of benefits fonun estimated 4.1 million children; projected by HEWlo be up to date on health assessments, fiscal year 1979. Coverage of routine dental care for all medicaid eligible children. Increased federal share of the cost to states of providing' expanded benefits and eligibility. Financial bonus to states'forgood performance in CHAP. RAIIONALE.Fort CDF'S RECOMMENDED AMENDMENTS Onr EPSDT report Includes extensive justifications for the changes we reeom- mend in the program:. Here we will deseillie briefly wily ;they are necessary. 1. Encouraging all qualified in..oviders to partiii pate in CITA P.CITAP's clear - intent IS to .make sure that poor children have ready neves!: to CHAP services . by involving the range of providers who are acceptable to poor families find qualified to give needed:care. These include Community Health _Centers. Chit.' dren and Youth programs. Head Start proarank solO ainl group practice physicians, outpatient, departments of hOspitals and the like. While we strongly support this goal, we believe that CHAP. a!:: it now stands, lacks adequate' provisions to attract all qualified providers' partieiliat ion. Medicaid law presently calls for EPSDT programs to make the maximum use of existing, resources. Flowerer, the intent has not been carried out beeniise the language, is too general and the federal monitoring has been lax. As 'a eon- . sequence, for instance, last Year. 19 States relied 'primarily on county henit14. departments, at the exclusion of other qualified providers. to screen eligible children. CDF found that in other 'states, qualified providers are ,effectively excluded from participating in EPSDT dm. to low reimburseinent levels or imippropriate standards for certifying providers. Thus, children..are denied . Recess to comprehensive health centers and other providers which are often hest suited to attend to their needs. Hopefully during these hearings the Snbeom- mittee" will hear thcl testimony ,of providers who have, encountered first hand the barriers or disincentives to providing EPSDT services.' Although S. 1392 currently requires states ty "encourage participation by' physicians and health care centers." this provision cnn he expected to he no more effectual than the similarly vague requirement under..EPSDT. Based on I According to projections by FIEW. ofileetif the DeputyASsistnnt Seeretnry for Planning and Eralnation/Health. Assumes enverage for ehildren and youth aged 0-21 and a'national minimum income starulnrcl for $420o for n family of four. e . According to.,projections by HEW. oilier of the Deput7 Assistant Secretary for.Planning and Evaluation/Health. Assumes a national miti'llnum Income standard for $4200 for a fa m117- Of roar. According to projections by HEW, office of the DeputfAssIstant Secretary for'Planning and Evaluation/Health. 39 what- is now known about the reasons qualified providers do not participate in EPSDT, a more explicit provision can and should be written. Therefore we recommend that language be added requiring states-to offer provider agreements to any qualified provider. These should include community health clinics, dentists, solo and group practfeainedical practitioner's, day care or Headstart programs, rural health clinics, public health departments, maternal and child health cen- , tern,'- and any other entity.; that can meet .responsibilities assigned to CHAP providers. CHAP should explicitly require states to identify all qualified Pro- viders and to- encoprage their participation in the program by offering adniin- istrative arrangeinents (including reimbursement rates and prompt payment of claims) which can.: be expected to elicit their involvement. HEW should be charged with monitoring state performance in this regard and with reporting to Congress on prOvider participation in CHAP and the steps being taken to use all qualified providers in the program. 2. Assiiring effective outreach.When the Congress enacted EPSDT in 1967, it recognized that "organized and intensified casefinding procedures" were among the essential first steps in getting basic heath care to needy children. Since then, nearly every study of EPSDT has concluded that outreach (or public education about services.alid assistance in using services) is most effectively carried Out by community residents who are known and trusted by the target population.' Organizations which frequently perform outreach in this manner are community clinics; -Headstart prograins,' church groups and the like. Although S. 1392 p harges states with "assuring the availability" of outreach, it fails to include rovisiona which guarantee that suffielent funds and effective methods of out- reach will be employed. . ' - The outreach provisiOns under EPSDT currently, including the financial sup- port available, have not been adequate to effectively inform the majority of- ' eligible: Children arid assist .them to get- health care...CDF found that EPSDT outreach 'usually consists of sending, welfare recipients a written notice (which families often cannot understand or read) and sometimes having a welfare . :' caseworker explain the program to the family during certification or recertifica- tion for welfare benefits. We found no organization other than the welfar6 department reimbursed by Medicaid for EPSDT outreach. The results have been poor. In fiscal year 1976, for the 13 million children who were eligible. EPSDT provided only about one-quarter of the Screenings chil- 'dren needed, according to minimum standards set by the American Academy oft,. . . Pediatrics. Unless provisions for effective outreach are included ih the CHAP program, the same inadequate situation can be expected to prevail : although CHAP 'will pay for essential services, few children in need will receive them. While we believe states need flexibility to design outreach 'programs suited to particular needs in the state, we believe CHAP must contain certain minimal guarantees for effective outreach. Therefore, we recommend that states be ex- pected to earmark at least a certain .portion of the program-budget for outreach, totaling approximately .2% of total Medicaid expenditures. or 5 percent of CHAP expenditures;. that non-profit organizations located hi the target com- munity (e.g., community clinics, and Ilea&,Start programs) qualify for reim= bursenient, and that states receive a iinfIncial incentive for outreach activities known to be effective (90 percent Federal reimbursennfnt for outreach by non- profit organizations located in the target community, up to an amount of approxi- mately $6 per child enrolled.) If with this incentive. however, states do not attract a reasonable proportion of eligible children into CHAP, they should be required- to establish a new outreach program emphasizing the use of organiza- tions located in the target community. 3. Covering health services following an assessment.According to HEW staff wbo developed the proposal, CHAP seeks to provide coMpreliensive health serv- ices to children who are in a program of ongoing health supervision. Thus, S. 1392 calls for providing to "any individual under the age of 21 who has received his periodic assessment . . . all care and services apprbpriate for individuals under age twenty-one . . ." We strongly support the principle underlying, this provisionthat states should .make available to children basic health services as needed. The fact that some states currently opt not to cover needed treatment services and primary care services (as is the case under EPSDT) is Unconscion-1 able. After all,-the purpOse of preventive and ongoing health care for children is to provide them with the services needed for the' problems found. . I See "EPSDT : Does It Spell Health Care For Poor Children?" p. 90 and following. 40 Vhile we strongly support CHAP'S thrust regarding coverage of,licalth Sery ices following an assessment, we find S. 1392 deficient in two major respects. : First, the.bill 'Mu* make explicit that CHAP entitles children In the program (i.e., ;who.' have been asedssed) to. receive health Services needed for problems found during the assessment as well as for problems which arise in .between the times they are assessed; regardless of kvhat(ervices are covered under the State plan. It make no sense for Medicaid to ay or penicillin only if a child is found during a health assessment to have strap throat, but not pay for the drug if the child comes to the pediatrician with s rep .throat two months later.' (Eligible children can, of course, receive other Medicaid services as well%) In sum, the language shatft4make clear that CHAP provides children 'With it range otessen- tial health se es for needs which occur while they are inthe program. This concept is clearly a step forward froin EPSDT's narrow concept of a program which, screens and is concerned with treatment only for problems found at the time Of screening. . . Second, we oppose the provision in S. 1392 which allows states to avoid pro- viding treatment for children with "mental illness, mental retardation, or devel- opmental disabilities!' Such an exemption. runs counter to the coverage for,chil- dren With all other conditions and is unacceptable for several reasons.' A significant propOrtion of children in CHAP will he denied important health Serviees. As data on health conditions found through EPSDT screening show, foukhly 10 percent are related broadly to growth or development. In mils view, this exclusion may signal to states that one acceptable way of dealing with new financial demands of an expanded EPSDT program is to limit treatment coverage ,areAs a result, states which opt to cut back 'on Medicaid coverage eare likely to cut ont the services needed by millions of children. ' . Wrifing an exclusion based on a particnlar health condition is extremely dam- aging to recipients. That approach requires that one determine the reason a child needs a particular service. Doee,lor example, a mentally. retarded child need a , medical and dental service as a result of the mental retardation or for some other reason? Because it is usually impossible to determine the cause. we fear that states will simply decide not to proNde most health care for children who have the'specified conditions. in addition to discriminating against children with cer- tain kinds of specal needs, an exemption tied to etiology encourages labelling and overclassification of children (with the excluded condition) in order to avoid payment for services. We elan find no acceptable rationale for denying needed health care to children with ,developmental conditions. While It is trne that several other federal pro- grams provide Services to handicapped children (e.g., tievelopmental Disabil- ities. Crippled Children), they reach only a small portion of the children in CHAP who ne such services. For instance; thelargest program of health care for handicappeTchildren. the Crippled Children's Program. serves roughly one- half million children each year. Yet of the 13 million children currently on Medicaid, a projected 2M million reqnire health services for developmental needs. The cost considerations. which in large part dictated establishing this exclii- sion. can be accommodated in other ways. First, if CHAP is amended to clarify that it provides for needed health care (as we recommended above), CHAP will not be required to pay for related services. such AS edncational and social , services. which children with handicaps may need. In addition, there is consider- able evidence that cost considerations can he accommodated by institnting careful , quality control standards and peer review. Such measures must be established and enforced vigonrously before we would find it acceptable to consider limiting coverage for essential children's services. - We therefore urge that the service exemption now in S. 1392 he dropped. Needed health services, including mental health services, must be. provided. EPSDT, as well as other sources of data about clfildren, show that mental health services constitute a Vital part of health care for some children. They can be helped immensely hy. relatively inexpensive and short-term mental health inter- ventions. mental health.jititylces which. must he covered at the very least. If cost considerations dictateikeinelimitations on care subsequent to an assessment, limitations shonld be &Signed to expensive services affecting the least number of eligible children (e.g.. services in a psychiatric hospital). 4 Providing dental care. Dental care represents one of the few respects in which the CITAP requirement is potentially a step backward from present prac- tice in the states under EPSDT. EPSDT requires states to provide the dental services available under the state's Medicaid plan and "at least such dental care ' '1 41 as is necessary' for relief of pain and infection and for restoration of teeth and rPaintenance of dental health."' States have interpreted this regulation flexibly wifftthS result that some pay for needed dental care for childreh who haVe not had ft dental screening while others predicate coverage of dental care on being referred during an EPSDT screen. Under EPSDT,' the federal government re- imburses states for EPSDT dental care at the same level as for other.medical meriices. , .CHAP'S provisions for dental care are inappropriately restrictive on two counts : (1) CHAP would reimburse states for dental care at a lower rate than for other CHAP services, thereby demoting the importance of the services; and (2) states would be required to pay- only for treatment of conditions discovered during an 'assessment or on referral to a dentist at the time of an assessment. Coupled ,with the lower federal match and the ct that dental services are viewed as 'rehi- tively expensive, we fear there wi be minimal provision of dentid care in the states. This is unacceptable. There'is wide consensus that children need routine dental care to avoid pain and subsequent probleths, including the development of speech impairments and malnutrition. Because of the almost universal need for dental care, experts agree that it is unnecessary to screen children for .dental problems but imperative that routine dental care be provided. Routine dental care for children should include an eniphaAis on the preventive measures which are knoWn to be effective. Based on the needs of children, the most, sound dental policy under Medicaid would be to require states to cover rotitine and emergency dental rare. While it would be more costly than the dental portion of EPSDT currently, HMV's esti- mates show, that the costs are modesebecliuse if all eligible -children were en- titled to such care, the experience under EPSDT and Medicaid suggesta thata relatively 'small portion of those eligible would tietually use the services (par- ticularly during'the first few years of, the:program): In addition, the cost per child would decline as more children receive dental benefitsnad their dental health improves. Therefore, we support coverage of routine all emergency care as Medi- caid benefit for children. C ldren not receiving routine dental care should be referred to a dentist as part the health assessment. Dental expenditures should be matched at the same lev 1 as other health services under CHAP. .51 Asauring that CHAP Triees get to needy children.The Congress ex- Pressed its desire to make sure that children get EPSDTservices by enacting the EPSDT penalty provision in 1972. The experience with the EPSDT penalty points up the inadequacies of current enforcement activities, certain of which are not corrected by S, 1392. Existing provisions have not guaranteed that children receive assessments and treatment. CDI4' found, for example, that during the first quarter the penalty was . in effect, 20 states or territories which met the requirements under the penalty iiirrovisions performed fewer than one-third of the screenings required according to the AAP's standards. Tile nature and administration of the penalty require-, 'merits have led to the failure to achieve Congressional intent, One element which must be built into CHAP is 'a requirement that States meet minimum outcome standards; enroll a reasonable prolortion of eligible children in the program and provide them with needed assessments and treat- ment. S. 1392 includes such standards as the basis for giving states a bontis for food performance; however. using perfoniance standards for thig limitedvat- pose will not assure that all states perform at a satisfactory level. Because of the built in financial disincentive to provide care, under medicaid ,( for every service the state provides, including CHAP. the state hears a portion of.the costr. there must' be minimum expectations related, to outcomes for children. The exact standard may vary for each state but it should represent a reasonable increase over performance each year, until an acceptable level is inet,The Secretary . should be specifically authorized to gather data to assess states' progress. Unless such standards are penalty issues which are monitored and apply as minimum expectations in each' State, it is predictable that many Will continue to function . at their current unacceptable We are pleased that -S. 1392 includes incentives for states to meet outcome standards. Ili addition, there must be measures capable of eliciting compliance when states fail to do so. The financial penalty established in S. 1392 is an im- portant tool. However, based on an examination of EPSDT's enforcement history,' 1 45 C.F.R. 240.10(a) (3)(lV). ; vor dIseussiou, see Chapter 2 of "EPSDT: Does It Spell Health Care for Poor Children?" `l t 42 we have concluded that the financial penalty alone is not. always effective .in' bringing about the desired improvements in the program. Thus, we recommend that the Secretary be given an addiOnak enforcement tool: to require that, so long as states receive federal funds or CHAP, they take steps (Set out by HEW and agreed to by the state) to mee Congressional man dates. More specifically; if the Secretary determines that a state is not meeting CHAP program requirements, he Should issue a notice of on- compliance and an order which sets out the outcomes the 'state is expecte to meet and the,. corrective steps to be taken to bring the state into compli ce. States should have the option of entering into a binding agreement to meet the terms of the corrective order yithin an agreed upon, period of time or of seeking administra- tive review of HEW's Ending of. noncompliance. If at the 'end of the correction period or the administrative review, the state is found not to be in compliance. with CHAP requirmeents,. the corrective order is immediately enforcenb . A. portion of Medicaid. administrative funds could be withheld as an a onal inducement for states to take needed remedial action. Finally, for the sanctions to promote compliance with CHAP reqUirements, application of them must work more expeditiously than is the case under EPSDT. HEW has taken an unjustifiably long time to complete compliance reviews hf each state's program. In addition, because of the cumbersome process 'which now exists for appealing a finding of non-compliance, no funds have yet been withheld prom any state even though one. penalty_ provision has been in effect more more than four years. It is essential that. Congress 'set timetables, to assure prompt review of state programs, appeals by States. and application of the sanctions. 6. A/date/mm.0.0f ',Vote effort.The piimary.purpose of CHAP is to encourage states to strength and expand health care for poor children. Because current state expenditures are minimal in relation to the amount nicessary to fill the unmet needs of children, we believe that federal CHAP dollars should be'" programmed to expand services beyond what is currently provided. Although we do not oppose fiscal relief to states, we cannot accept it at the 'expense of an Improved, expanded program which children. vitally need and are not now receiving. We recommend that a state maintenance of effect provision be added to CRAP. After examining various proposals, we have concluded that thtt most effective Aspproach is to require that states maintain at least their current services and eligibility levels for the under 21 population. Such a provision would help assure that new federal funds contribute to services fort.hildren not now served and that Medicaid services currently covered for children are maintained. 7. Afedicaid eligibility for "income eligible" youth aged 6-2.1.While S. 1392 takes a much needed step 1,3-Anil:int: children under age 6 who live in extreme poverty eligible for Medicaid, it, fails to include children in the. same family.who are older. Yet, as EPSDT data show, children and adolescents aged 6-21 have as high or higher rates of rrohlems foundin screening and are as much in need of basic health care as younger .ehildren. In order to reach the 'most need"' poor children- and to avoid discrimination among children of different' ages in the same family, we recommend support for the amendment to S. 1392 which extends Medicaid eligibility to all children (up to age.21) in families which meet income but not welfare requirements. Using income as the sole basis for Medicaid eligibility for Children any youth. aged, 0-21, will go a long way in removing the barilers standing between the neediest children and basic health services. HoiVever. the exceedingly low income standard used to determine eligibility in some states will still operate to exclude Prom ? the program some of the poorest children in the country. In 1977, in ten states or territories, children in families of four persons where the family Income is only $3.000 would not qualify for Medicaid. To bring state standards up to an acceptable level. we believe that CHAP should estafilish n standard income floor which States must meet nt the very least: We find 'the level recommended by the House hill$4200 for a family of fouracceptable. According to HEW's projec- tions, the provision would entitle approximately 2.5' million kdditionfil children and youth to Medicaid services. . Finally, we urge that the income standard be applied to allow families tg qualify by meeting it outright or by spending down to meet the estahlished level. The intent of an income based eligihility standard Is to-reach children most unlikely to get needed care because, their family lacks adequate income. Assume a standard o 900. A child in a family earning slightly more than 14.200 but with large m 1 bills !sitar-more needy (in terms. of income available,to meet , . A 4 43 the clfild's health needs) .than children ip families .based on income alone. Not taking into account the cost of medical care incurred, as well as basic income resultri in excluding some of the neediest youngsters in the more than 20 states Which do not cover "the mediCally needy" for Medicaid/services. 8. Medicaid bligibitity for. ioto income pregnahr women.--We strongly support the amendment to S. 13112 which would extend Medieald coverage to low income women during the term of their pregnancy and for two months follOwing ite termination. Currently, onlynine states provide Medicaid coverage to-low income 'pregnant women who have no children. While these women are likely to qualify for Medicaid as members of families, with dependent children once.the child is born, they gib unable to receive prenatal care through Medicaid during their firstpregnancy: The,,inclusion of coverage of prenatal care for low income pregnant women by. all state Medicaid programs would have a significant and positive effect on the - health of children and would bring considerable cost savings in the long run.' Prenatal care helps prevent fetal and neo-natal health problems and pro- maturity, conditions strongly associated with birth defects, mental retardation, and later health and developmental problems. For example, one extensive.study found that prematurity' rates among mothers who made Weir first,prenatal in 'the first trimester averaged 43.5 percent while prematurity. rates average 23.6 , percent among mothers who made no visits at all.. . Adequate prenatal care reduces the particularly high incidence of problems associated with teenage pregnancy : problems such as toxemia of pregnancy and . preinature labor as well as low 'firth weight. These are responsible fora variety of ,health problems in infants and children. Jo ' Despite the dramatic benefits of prenatal care, women who are most likely to pave complications in their pregnancy are the least likely to receive early pre- y .natal pare. For example, seven out of ten mothers under 15 years of age receive no prenatal care during the.first trimester while one-fourth never receive any . prenatal care or delay receivIngit until the end of pregnancy. Low Income women, particularly, go without needed prenatal care. Dnring..1975, while 69.4 japrcent ofall U.S. women began prenatal care in the first trimester, only 53.8 peiOnt of All Black women began prenatal. care during the first trimester. Furthermore, .5.8 percent of all wonien in the U.S. received no care or recei't'edcare only in the final trimester while percent of all Black women were in. tliis category. The necessity of adequate prenatal care for the future health of n child is unquestionable. - Including an eligihility provision for low income pregnant woman in S. 1392 would help to insure that no important omission Nis been made in the attempt to assure the continuing health of all low income children. 9. DccelopinyStatee capacity to CHAP scrviccR:TTnlike other Medi-, caid.Services. CHAP charges states with putting in place a host of services and seeing that children receive them. This calls for a kind of planning and adminis- trative capability different from other Medicaid provisions. S. 1392 does not adequately address these affirmative aspects of the program; nor does EI'SDT as it is now administered. To carry out an effective CHAP* program, states must set out a !Strategy capable of meeting progrhm goals, build a statewide systeni for d6livering` the services. and gain broad based cooperation from a range af,, personnel who work with children. Under 'EPSDr. there has been little and in some places nn attention to theseactIvitleFs. We therefore recommend that states develop an annual state plan demonstrating the capacity to. meet' program requirements. We urge. tdo. that there he public hearings as well as other mechanisms needed to assure substantial public input in the development of CHAP plans. CHAP must .-also begin addressing problems of the inadequate number or the inappropriate kinds of health provider:4 for children. While Medicaid. with its reimbursement approach, cannot.. single-handedly address resource problerns. it can do a lot to help identify shortage areas and work with other health delivery and health planning programs to begin- filling gaps. CHAP should require that Medicaid agencies report to the Health Planning and Title V Maternal and Child Health agencies.identified health .shortage shortage areas for children so a strategy can be developed for building the necessary resources. 10. huildinit accountability in ITET3"4 administration of rirAP.---As this Sub- committee is well aware, the history of EPSDT has been characterized by foot dragging at the federal and state levels and a Pronounced failure by HEW to The following data are deilyed from materials prepared by the Institute of Medicine for Its Conference on Prevention, February, 1973. -44 provide the neeessary support and leadership.' We ate extremely hopeful that this Administration 18 committed 'to vigorous action to see that children re- ceive the benelitsto which CHAP entitles them. At the same time, we believe it itnportant-for the Congress to Institute certain minimal forms of accountability. CHAP, as ptesently written, does not include such measures. Had EPSDT included benchmarks against which the Congress could monitor the progress in providing children with needed re, EPSDT's poor performance would not have persisted these ten years. We i elieve it essential that they be established under CHAP: Therefore, we recom end as 'a target that 80 percent of eligihle Children be enrolled in the progra within -five years of enactinent. Our summary bf recommended amendmehts eludes two measures for keep- ing the Congress apprised of the Department' prof ess in meeting these awls. In addition, we recommend that CHAP require ecretary to issue finalWo- gram regulationswithin six months of.passage. BEYOND EPSDT BMW: ADDITIOnAL LEGISLATIVE CitANGEs 1.- Resource development funds.OUr work has convinced tis that chalices in EPSDT can bring rapid abd widespread payoff for poor children. But because of built-in limitations in 'What klediChid can accomplish, measures beyond re- forthing EPSDT tare called for One crucial measure is , the development of nor/. health .care providers in the .many areas where children do not have appropyinte sources of care close by. Based on a preliminary analysis by HEW, an estimated 16 percent of children on AFDC children ,live in counties designated as shortage areas; the percent is elightly higher, when all children are taken into account. We are extremely pleased that the roughly $25 million in the original CHAll budget was allocated for the purpose of developing prhuary care resources in underserved areas. But while it signals attention to a very important prOblen(, $25 million cannot begin to provide assistance in Many of the communities across the country in ,need of it..We hope the..Cougress will see fit to under- take a significantly expanded program orresource development to Make available start up funds, technical assistance, and continuing subsidies as needed in shortage areas. 2. Reforms in title V.We believe that Title V. the Maternal and Child Health provisions of the Social Security Act. provides an excellent vehieileAhroughs which a variety of needed changes in health care delivery; for ciiiin een can he effectuated. However. carefully thought out legislatiVeSevisicina..)Oild be .needed for Title V to function in this way. We are in agreemetteith the growing number of .grourfa and organizations which Suggest that a serious consideration of Title V refOrm is needed. We believe that' consideration of legislative changes in Title V should be a high priority. and we are strongly , Committed to a thorough examination of the prciblems and remedies as soon au possible. One of the biggest deficiencies in the program is that there is no 'administra- tive apparatns (operating between the federal level and providers of service at the - community level) which is capable of assuring that high quality care is provided to all needy children. Improvements should be. considered .for key aspects of the program Including: he mandate of Title V. allocation find pro- gramming of funds under Title V. arftl methods of assuring accountability for prograrh funds. Changes in these aspects of Title V must be taken into amount in designing an efficient administrative structure to carry oat Title V's charge. We believe it is unlikely that the kinds of fundamental reform needed in Title V can be made before Congress adjourns this year! The changes are complex and inter - related. Major reviews of Title V. are underway currently by HEW. the Congress, and non-governmental organizations. With information gained ft4tm these .studies. Tittle V reform can and should he placed at the top of next year's legislative agenda in the area of health. An amendment to S. 1392 proposed by Senator Chiles (Amendment No. 10091' would modify Title V to set up a system of "lead agencies" to Coordinate and develop child health services at the local level. We strongly support setting up an adMinistrative structure capable of remedying the gaps and inequities in health resources for children. Medicaid and CHAP currently lack the capacity to create a rationaldelivery system (to develop services where needed, coordinate existing fragmented services. etc.) The function is an essential one. and until it is performed properly, many children will not receive needed care even though CHAP entitles them to IL While, legislative changes in Title' V seem Co u4 a I See "EPSDT": Does It Seen Health Care for Poor Children ?i pp. 59 -5a. 4 to 45 logical means to define and assign the needed responsibility, in our view the 0 proposed "lead agency" proposalis unlikely to fulfill its intended purpose. We find the proposal to be deficient in several respects : Lead agencies lack staff and /ands to assess what-the problems are and provIde.technical Assistance to remedy them. . Lead. agencies lack the power to bring about necessary change. They lack the ability tro review the allocation of funds and to reprogram funds going into the area. In ddition, they have no new funds to fill gaps. Lead ag ea have, no leverage 'to elicit frour prcividers in the area neces- saryInforrnation regarding funds spelt and services delivered. . Lead agencies are giyeit neither the authority nor the charge to monitor the quality of dire given children and assure that acceptable standards are met. The proposal lacks necessary clarification of the lead agencies' powers in rela- tion to other entities with a similar charge, such as HSAs. It would be a' serious mistake to embark on a new administrative scheme which is likely to fall. Particularly at this time when there is public skepticism about new federal directives, it Ip.:;essential that changes made be workable and effective in. meeting agreed utanfgoals. For thisreasOn we oppose passage of amendiiient No. 1029, and recoipinegd instead that the "lead agency" issue.. be taken up next year as part oritliiroad reforin of title V.. We look forward to working i'Sith all interested 'parties to examine and ' improve theTitle V program. . . ' Thank you. i , Senator HER 114. N TALM AMIE, Chairman, Subeomnitnee on Health Finance, Committee, Hu sell senate Office , . Building, 'Washington, D.C. . , . DEAR SETATOR .ThLMADGE :. As You know, the Childrens Defense y'und prepared extensive testimony on S. 1392 Which we submitted to the Committee. and also had the Opportunity to present oral testimony. However; we would like to add for the record our support of a provision in the House CHAP bill, as reported out of the Interstate and Foreign Commerce Committee, related to Medicaid eligibility. This is the provision in H.R. 13011 which allows states to extend Medicaid eligi- bility to. children'who have been in fostercare rud who are hard-to-place because of a condition requiring medical care and services. It is estimated that at least 100,000 children are lingeringin foster care who have not been adopt4c1 bemuse of their special needs. A large number of these children have handicapping conditionsoften multiple handicapswi ch require continuing care and treatment. Although often eligible for Medical I while in foster care, these children frequently lose such eligibility when adoptet and may be ineligible for coverage under the insurance policies of adoptive parents heca Ilse their handicaps constitute a pre-existing condition. The absence of Medicaid coverage for . children following piacenient for adoption serves as A liseal disincentive to ing permanent adoptive homes for these children and ,keeps them in fos rare nt public extease. The Inifilose of covering hard-to-place adopted children' under Medicaid is to enconrage and facilitate adoption of these children with speCial needs. For this reason we would appreciate your careful consideration of and support of this amendment to S. 1292. Yours sincerely, ,, , WENDY L.tzARts. Health SpeeialiNt. QUESTIoNS RI-13MITTED TO Ms. I...tzAltis nv SENATott ituttroFr AND HER ANsWERs. TO 1411ENI . b . . Question No. 1. In order for any screening and treatment program for children to succeed. qualified providers must 'pa rticIpate, This has been n problem with EPSDT. What n re your recommendations for overeoliiing this problem in CHAP? Answer. Medicaid law presently calls for EPSDT programs to moke the maxi,- mum use or existing resources. But the intent of thisgeneral language has nit been carried out in the program. Although S. 13i2 requiresNtaies to "encourage participation by physicians and health care eenters.."..this provision can he eXpected' to'be no more effectual than the similarly vague requirement urrently in EPSDT. Unlike EPSD14, CHAP must remitre states to solicit actively the CHILDREN'S DEFENSE Fuse, Washftrgton, D.C., August 16,1973. 34-464-7 7S--,-4 46 -cooperation of providers. This will involve informing providers about the pro- gram, urging their, partiCipation and working out contractual 'terms which are acteptable. - We therefore recommend the following changes in 5.1392: . (1) Language should be added requiring states to offer provider,agreemeats to any qualified provider. Qualified providers should speCifically. include community health clinics, dentists, Solo and group medical 'practitioners; day care or Head- start programs, rural health clinics, public health departmetitk, maternal and child health centers, and any other entity that can meet responsibilities of CHAP providers. '.(2) States shouldexplicitly.be required to identify all qualified providers and to encourage. their participation in, the program by offering administrative arrangements (including-reimbursement rates and prompt ,Payment of claims) which can be expected to elicit their involvement. 13) HEW should be charged with monitoring state performance in this. regard and reporting to. Congress On provider participation in CHAP and the steps being ttiken to use all qualified providers in the program. Question. No. 2.. EPSDT has reached only a small-fra4tion of eligible children with services. Why? Do you think that theprovisions in. S. 1392 are adequate to, solve this problem? Answer. In fiscal year 1976, for the 13 million:children who were eligible, ,EPSDT pro.vided'only about.one-quarter of the.screbnings children needed. Poor showidgs Anal as these are exPlalned*by three critical problems which plague the EPSDT program: First, the outreach provisions under EPSDT including the financial support available, have not been adequate to effectively inform the majority of eligible families. about the program and. assist them to get Amain) case. CLIP has found. . that EPSDT 6litreacli usually consists of sending yelfire tWipients a written notice (which families often cannot understand or read) and sometimes having, a welfare case worker explain the prOgram to the family during certification or recertification for welfare benefits. These have proved to he ineffective measures. COE found no organization other than the welfare department' reimbursed by Medicaid forEPSDT outreach. Second: EPSDT programs have failed to encourage the participation of a range of providers despite fhe fact that Medicaid laws calls. for EPSDT programs to make.the maximum use of existing resources. As a consequence, for instance, last year 19 states relied primarily on county. health departments to the exclusion of other qualified providers, to screen eligible children. CDF found that. in other states qualified providers are effectively prevented 'fun» participating. in EPSDT due to low reimbursement levels or inappropriate standards for eiTtifying pro- ciders. Thug, children are denied access to comprehensive health centers and other' providers which are often hest suited to attend their needs. Often, too, they wait as long as six months to get an appointment for screening or treatment.. . Third, throughout the histoxy of EPSDT, the federal government has failed to provide.the necessary support and leadership to assure that children receive the 1enefits of the program. A chronology of federal Action In the implementation of EPSDT Shows that more than four years after the program's enachiient: and More than two years after its effective date of implementation. HEW had. riot pro:dolga tea regulationsso critical for guiding- states to begin EPSDT programs. Final regulations and guidelines when eventually published, deferred requiring full implementation for yet another year and a half. HEW did not conduct.. reviews of state programs, until two-and-one-half :fears after EPSDT's effective date. Once having conducted such reviews. HEW failed to net on its findings and . to date. HEW has not issued final regulations to clarify states! obligations in complting with the reqnirements of EPSDT's penalty provisions: Without a number of amendments. S. 1392 will not overcome EPSDT's failure to reach. eligible children with services. CDF recommends that S. 1392 he amended to address directly the problems of outreach. provider. .participation,, and federal leadership.. (1) Although S. 1392 Charges states with "4issuring the availability': of opt- reach It fails to include provisions which guarantee that 'sufficient frinds and methods of outreach be employed. We recoinnlend states be expected 'to earmark at least a. certain portion of the program budget for outreach, totaling approxi- mitely .2 pereetat of totalMedicaid expenditures or 5 percent of CHAP expend': tures:.that non-profit organizations located in the target. eommunity (e.g.. com- munity clinics, and Hend Start programs) qualify for rehulmrsement: and that Si . 47 :states receive a financial incentive for outreach activities known to be effective (90 percent -Federal reimbursement for outreach 1,1y non-profit orkanizations located' in the target community; up to an amount of approximately $6 per child enrolled.) If with this Incentive, however, states do not attract a 'reasonable propotitIon of eligible children into,CHAP, they should be required to establish a new outreach program emphasizing the use of organizations located in the target community. (2) Although S. 1392 requires states to "encourage participa-tion by physicians and health care Centers", this prevision can be expected to be no more effectual than the similarly vague requirement under EPSDT. Theexplicit provisions we have included..in Question 1 above should be.added to S. 1392. ,(3) We believe it essential that benchmark's he established against which the -Congress can monitor CHAP's progress in prvoiding children with care. S. 1392, as presently written, does not include such measures. Therefore, we recommend as a target that 80 percent of eligible children be enrolled in the program within five years of enactment. The Secretary should report to Congress on an annual basis the Department's progress in meeting these goals. In addition. we recom- mend that CHAP require the Secretary to issue final program regulations. within 6 months of passage. Question No. 3. Why do you think it Is important for Congress to act on . S. 1302 this year rather than wait foie a total overhaul of the title V MCH program? Answer. First, the health needs of poor.cWdren cannot wait..An estimated 13 million children now on Medicaid could getiltally needed health services over the next few years through CHAP. As our testimony explains in greater detail. most of these children have not and will not receive basic health services unless provided by an improved EPDST program. Second. there is wide consehsus about how EPDST can be made to work better. Numerous studies have pointed to the same deficiencies. These can be corrected through relatively simple legislative and administrative changes. And there is broad politcal suppott to make these changes now. Third, overhaul of Title V need not be done at the same time as CHAP. Al- though the two programs are related in some ways, any necessary conformities can he made through Title V later. In addition, to deride whether or not and how to overhaul Title V will take considerable time to (10 properly. In the. mean- time, many children from low income families will remain without access to or ability to pay for necessary health care which CHAP can provide. Senator RanicoFF. Ms. Katz, please. yr, STATEMENT OF MARILYN K. KATE, CONNECTICUT LEGAL SERVICES, INC. Ms. KATZ. Thank von, Senator. My name. is 'Marilyn Katz, and I am an. attorney with Connecticut Legal Services. In that capacity, I retire-. sent the people who are the intended beneficiaries of the CHAP legis- .. lation, poor children and their.parents who want health care for them. There are many aspects of this bill, as Ms. Lazarus has pointed out, which deserve. close consideration, but one of the greatest concerns to my elientsis dental care, for three reasons. First, it is an inexpensive service that all children need and want, and invariably suffer if they do not get the care. It haS proven i),e results. 'Parents and children see the benefits of dental care immedi- ately, as well as over tl long rim. It is something that the children and their parents can par icipate in directly. 11 -is 'within their means. Unfortunately. this bill that is now. in front of your committee fails to recognize the importance of such care, to my clients. It does not in- chide dental care as a mandatory service. Rather, it requires fiat an assesment be provided' before children can get dental care. Tiler is less reason to predicate dental care on a prior assessment than there is with most services, because we know all children need the L. service. 7 48 Ah asse.ssment can serve a useful purpose, however. It can be the opportunity to refer children to a dentist who might not otherwise get there onthei coveri each of these points in a little o Before greater depth, I would like to ask you to look at,the medicaid program from the point of view. .-of my clients.. . Most of them get very, very little care under medicaid, even thtnigh the medicaid .budget growSas does the rest of the health care sys- temphenomenally every year. In Connecticut, we have a $300 million medicaid program. Only $15 million of that program goes to the non institutional care.' 4. That is less thtin 5 percent, or$75 per recipient. Of course, it is important that people who need institutional care get it, but that covers very few individuals. In Connecticut, 7 percent of the medieaid.recipients get 50 percentof the medicaid dollars for nurs-.' ing home care. This leaveS verplittle for all The children and all the parents for preventive care. . . Most institutionarservices.are provided to people, not by choice, but because they have reached the end of the line ; they have no choice. They are compelled by the necessity of their condition. .-Ainfortunately many of the services are of dubious efficacy. Studies d-ime by your sister subcommittee. the-House Subcommittee on Health. have uncovered abuses in surgical 'techniques and nursing. home care. But dental care is something that is of virtually universal applicabil- .ity. Almost every single child needs dCrital care: nd those who qualify for medicaid need it most. . . . As a Legal Services attorney. I ant astonished by- the number of glients I see as young adults who have lost teeth as lack of dental car. This loss is tragic becatise it. is completely' unnecessary. Preventive , . dental care is one ofthe most universally effective health care sbrvices. Not only does it result. in improvement in Children's health. but it is one that the children and their parents can see immediately and can appreciate. They can understand the connection between the dental care they get and the results. This experience is a very good one in ..) itself. and it,. is also. important as it lesson in regular health care. This lesson continues because dental care involves my clients in It MI v that they find within their resources to perform. Unfortunately, there. are many necessary medical treatments that simply are beyond the means of my clients to participate in, that reqUire special living a r- rangeMents. regular, appointments. transportation. . But dental care; between two regular visits a year. requires only a simple toothbrush and some dental floss. A child can be taught to care for himself. . All this makes dental treatment the ideal service to include and emphasize in a child health program devoted to coulKeltensiveness and prevention. Bat rather than encouraging dental care as a.cornerstow, .,.. of a child health care. program. the administration treats clental care like a stepchild. ] .. - Section 3(G) (ii) of the bill broadens the responAibilitv of the States to provide most health services. whether the condition neees.,-':.-> sitating the service is discovered in an assessment or not. However. this . section makes an explicit exception for dental services by requiring 5'' 49 . .i. only e`the treatmpnt of conditions discovered during an assessment." Senator, this i3 a fundamentally mistaken approach to.dental care. It just makes no sense to require an.assessment before preventive dental services areprovided; just as we would not screen children before we give them 'iratcinations. Dental care should be, considered a public health measure. Dental disease is just not like diseases where the inci- dence limited and unpredictable and where you*.have tt-qhave mass screeNg in order to single out the children who are afflictkd so that they can be treated. b MoreoVer, when dental assessrlients are not .done by dental profes sionals very few children are assessed as needing dental care. In Connecticut, less than 6 Percent of the cl?ildren who keceived screen- ings under EPSDT were identiked.as having dental problems, though we know that 95 percent, by IIEW's ow11 res, need dental case. To predicate the receipt of dental .care an irrelevant assessment is simply irrational and the effect can onl, 5e to reduce the number of children who get the care they need. However, such assessments, CHAP assessments, can serve a useful 'purpose. They can be an opportunity to further incrse the number of children getting dental care. Simply requiring reimbursement if the child finds his way to a dentist is not enough. In Connecticut. our experience proves that withoutreferral and folloWnp. many children still do not get care. ale Connecticut is one of the richest States in the Nations It provides one of the broadest' ranges of medicaid services. including coverage of all flental care without the requirement of a prior assessment. Yet, , less than 20 percent of medicaid eligible children received any dental care this past year. , 'The administration approach does not respond to this problem either. Itsdoep not require that children who do receive a screening package under CHAP are automatically referied to a dentist for examination and treatment and followups to see that are is received. 'Instead, the current bill includes that meaningless assessment I :talked abouras a part of a regular screening procas. The adthinistra- tion is now proposing an amendment to the bill which will allow a State to have a child who has been .assessed for other conditions referred to a dentist, bid would-not require a State to follow this pro- cedure. This "choice" makes no sense. But if limitationn on dental ,services are to be imposc;d: if Congress is worried about costs, do.not attempt to control costs by putting arti- ficial harriers, meaningless assessments, in the waY of childrengetting care. Instead. choose which dental care services you.owant to cover by considering the need for and the efficacy of each service.. I would suggest .to yon that the current definition in the medicaid regulations is"a good one, and this is one the!, I notice Senator Childs used primarily in the amendment he- offered 'before your committee to the administration bill. Another good definition related to need and efficErcy.is,found in the House bill. y-... - 'After specifying coverage in such (a'deOition I would then pro- pose that you amend the bill to include dental care as defined in the definition in the list of required medical services. t-o 50 In: -addition, ble bill should be amended to require that assessed' .. children be rejerred automatically to a dentist arid-CHAPfollowed . up to assure that treatment is received. . . 'On behalf of my clients; who are low- income children who depend on your decisions for their future dental' health, I respectfully request . your careful consideration of .these recommendations. : Senator RIBICOFF:Thank you, Ms, Katz. The staff will submit some-. qrieitions and we would appreciate 'your responding to them at your earliest convenience: . i ,.. [The fOlfowinglYas subsequently supplied for the records] Atcawzas To QUESTIONS SUBMITTED TO MARTI:TN KATZ, ATTOYINET WITit CONNECTICUT LEGAL SERVICES . . I'' ' , . .Question 1. Ms Satz, you obviously believe strongly-in thi need for basic and comprehensive dental coverage.under MAP. Cost estimates for mandating this' . coverage range widely. What has been the Connecticut experience? What is the . reimbursement rate for dental providers? HoW is-their participate rate ?. Answer: Total expenditures are, of course, based on the cost of the services per child times the number, of children using. the service. The Administration has estimated a. total exnailittire of $78 million for the first year of mandatory . . comprehensive dental C;IFFerage. and automatic referrals of CHAP.screened children. This total- figure is based 'on- a. cost estimate .of $107-per child and a user estimate of 35% of eligible children being screened under CHAP. and referred . children. to dentists and half of-thege actually receiving treatment and of 25% unscreehed Children receiving dental care. ,,, . '-, The Elouse Budget -Staff cam 'tip With a lower total estimate or the initial year, $21.5 million, based on a similar cost per child estimate ($100), but pro - jecting ., . . . .. only 6 months of Operation and loWer (and we 'believe unfortunately. more realistic), user rates. The -Rouse estimate of $88 million -for fiscal 1980 is more similar to the Administration's 'projection for the initial year. It depends on -using the $100 per child annual cost for each child receiving dental treatment for the first time and $40 per child annually foreacli child after his or her initial yeaf. .. A , . . , .. . , The suinption of the Meuse Budget staff that costs will decrease once years . of, neglect are ,corrected and prevPlitiVe maintenance is instituted is! supported by recent experience in onnectientConnectielit's%state plan provides coverage for dental services for all Medicaid eligible children. 'regardless of, wh`ether3. they have undergone nn EPSDT Screening. Yet because the State was trying to co-I:lira. . costs by excluding certain preventive services from coverage and by, maintain,;\ lag unreasonably low fees, very Yew children iveremeeiving care and the uumbeii .i.t was declining: , t . Jitst this mst year, the fa,lse. economy of Aus.la, a. liohc.N was 4111ifested. FroM . .fiscal.1976.71971 tofl4a 19.17-197S, total expenili titres for chi-ldren's dental care., in,,-COnriedticut increase miry' slightly from $1,1 million to $1.6.Milliou.flowever, :-. beeftilSe the number of hilflren receiving pare declinAd 20% froM 20.000 in -IOW--; .1977, to 16.000 lait Year. ,the. average .cost per child receiving dental we 'irosC, froth $65 to $100. There-wini also it signifleant.cluinge..ing the, tylieS of doevices-; 4 Tendered: for the first time expenditures- for the ;nos( expensive. restorative . ..."." '=services exceeded the expenditures for preventive ?age and routine work such ftS . . .....- ilinple fillings. , - . '°' The Departnient of Social Services.'which administers the medicaid and etir,. rent EPSDT Programs in Connecticut shared opt Corieerq.thattliUCcost-fier child was going up while the number of -ehildren being' Sited: was 'declining. ..They '- .. .. concluded that limitations on preventive services and .the lee :levels'fol. covered services, hich had betome increasingly ton lot were musing, dentists to refuse. to provide preientive dental *care. When ehildren did .not. get the preventive care !:: they needed, their dental health worsened. Those wilt; finally' did get to-thd 4entist r clime. in an advanced stage of .d6ntal disease. .often ,vih.en pain had become un- bearable.. and usually then required more extensive, expensive restorative.Work.: It was the decision of the Department.of SacialServices, aided hy consultation with ;myself and other attorneys from Connectient, Legal Sertiees and with representatives of the Connecticut Society Of Dentistry for Children, to raise the fees and add coverage for' the .fleceSsarylfreventallye'services. . ... 0 k----- \ i., 51 The-folloWing-claattiuminarizes-the-d12anges-ia the_program . Before After . May 1978 May 1978' 1. t . 46 SS 2. . X , . wings. ..., 5 5 , . ritileonnal :font teeth C. i 1 11 , 6 4.. Topreartnoricle 6 c 8- 5. Sin& Mang. 6 111p to13. Thuslhe average cost:-fer.a child who is being seen for the first time Is now between $23and $27, plus additional fees for any necessary fillings. The second of . . the two annual.iiiits.which would include only. the: cleaning and -x-ray service . costs $11 to $14, plus any necessary fillings. 11, - . .- '-'Along with the additionsto-services and fees, the- D1partment has added about .'. 30 Ef..SDT outreach .workers in its District offices who provide direct referrals to children and their-parents from a fiat Of dental providers-In each geographic ! area and whO follow up to 'see that. the services.are received. The districts, are , just beginning their reporting system so no statistics -are available yet. HoWever. the Department expects total exPenditures to rise initially as more children are reached for the first time, and then to of as Mare. children .need unly pre-- ventiva and. maintenance care, and th inct enc.e of .the more expkisive restora- tire work declines.: . ..Connecpcut's recently increased fee and expanded services should help ex- .. pandtheUvailability of dental providers for poor children. The State reports teat more dentists have.'. expressed an interest in participating in the program and have signed up as providers to receive direct referrals from the State. Currently. only1,600 of- the 4,000 dentists in ,Connecticut submit cIaims-for medicaid' reim bursement. and it is not knon how many of thege providers'do not see children._ More significantly, although 1.600 had ...at least one claim for dental care reim-. . `of under medicaid, only abdut 300 detitistsSubrnitted dyer $2.500 worth 'of claims.. (An amountione would expect to be billed if. all medicaid eligibles were receiving care and all. dentists" were seeing 'su'c'h patients in equal numbers). Of conrse,-it.ls.unrealistic and'unnedessary for adequate care. to' be available for. every .tleptist to treat. medicaid eligible children:And medicaid fees do not G have to-equal flies for private 'patients (in, Connecticut the current fee's are less., than one-half 'the Blue Cross rate)._ ut the-Statemedicald agency should be - required by exPlicitjederal regulations. if' not, by statutory language, to devise a proper fee structure and -to affirmatively enlist. 'a. sufficient° number of .pro- viders-to adequately serve poor children loader CHAP. In conclusion, even assuming the Administration's estimate of $100 annually. , per child is correct, dental care.. is a relatively lew cost servile compared with 'other child health mat services. Qne vsiit to an emergency room can cost more than a year of dental care. Furthermore, as Connecticut at least has begun to' .recognize, toregoing these .prevrdive services will lead to increased direct ftiosts later for more expensive restorative care. ;And a total oust of $78 million for dental care coverage for "all the medicaid in our nation for a year is alSo a very, very;small amount of 'money. Itots.,Iess than the amount spent annually for. only 7.000 adults receiving :nuisinehome care in a small 'state like Connecticut: It is less Than one*week's worthut care for hoSpitalizell medicaid recipients in this country. It is surely a small investment for the possible returns in health care*Ihr our' children. . ...Question Z. Anytime a new service is added to a federal health program on a , fee-for- service basis, we hear horror 'stories about fraud. There Would seem to 'be some potential for abuse if dental services were mandated without safeguards.. Could you address this question? ..Answer : As your question indicates. the cost-effectiveness of any service cap be diminished by fraud and abute. Fraud usually refers to a provider's claim fol. -!. reimbursement .forn ifervice which has not actually been performed: it can also include -duplleate billing for the same performed service. Abuse oh the other' hand, usually refers to.a.claim for reimburseinent for a service-which 'Was ac- . tually performed bufwhich was unnecessary. 52 Fortunately; preventlire . dental care is one of the health services least sUb- ject to abuse. Like innoculations, the need for the service is- universal; all chil- dren need a dental-exaMination, x-rays, cleaning, topical flonride application and instruction. For simple restorative work such as fillings,. the fees are.gerierally low enough that there is no incentive to do .unnecessary work. According to Steven Press, the.Director of the Connecticut Medicaid Program, a dentist will not spend half an hour of his valuable time doi4g an unnecessary filling for a - small fee.' Connecticut has conCluded that it is not cost-effective to-Use abuse- prevention procedures such as prior authorization for Preventive or simple re-. storative work. , Connecticut. used to, reqnire dentists to submit requests for prior authorizatioin for all dental services; the submission ordinarily included x-rays in support of the request. Earlier this year,. a study was undertaken ,which demonatrated.that no abuse of simple restorative services. was being. uncovered by the prior au- thorization system, but it was costing the Statee-a significant amount to pay.den- tal consultants to examine all.the reqiiests. Such a Ostem .was also unduly bur- densome to dentists and patients who world have to wait weeks for approval; many patients s-bpcame so discouraged they never returned for treatment. Therefore, .Connectictit.first 'eliminated prior authorization for all dentatiery- Aces. nnder $50 and:subsequently (is-of July15, 1978rextended that exemption .to all services under $100: The dental consultants continue to require requests for frier. authorization' (supported by accompanying x-rays). for more expensive serivces Where it is also more appropriate .to have a second .opinion from .the I client's point of. view. e.g., extensive bridge work, denturei, etc. Of coarse, zraYs are genera/1y available in a patient's file if the State wants to check that routine restorative work was indeed necessary. . . Dental care is also one of the health services where the detection,. and there- fore the deterence, of fraud is easiest. Unlike- Many services, _dental services produce a visible. identifiable result. Paid dental consultants and x-rays can be used to check- that work for which reimbursement is claimed; has indeed- been performed. Connecticut is currently prograMming its computer system to institute- HEW's Project Integrity. Project. Integrity is based on programming a state's com- puter to supply the names of providers who have a higher than...average number of services billed per patient. The State can also detect double billing.by checking the service codes on the bills to see if. more than one claim for reimbursement his been made for more than one filling clainged in the tonne part of a patient's tooth. The State will then run audits on providers for whoM it has .questionable pro- . Ales:Part of,The.andit will include the examination of- patient flies x -rays and part will consist of requesting the patients to submit to open-menth Ina- flops. It will be easy for a dental consultant to tell if the claimed work. as ac- tually been performed and whether It has been done-satisfactorily. It As esti- mated that the majority of.states hive the computer capability to run the Project ..Integrity 'programs. Even without. pin-pointing particular prOviders, a state caidtt eco micallY conduct an effective number of spot jchecki:on -dental provide ally if the number of significant providers is limited. as -It is in Conngett I conclusion, I submit that onr experience in Connectictit demonstrates. th comprehensive dental -care for poor chilitien under Medicaid and a °made it r (Considerations of cost or of abuse andfrand control weigh again man fr: referrals to dentists of children screened' under CHAP. Senator Rmicom Senitor Dole? . Senator Dots. I.will follow the same procedure if I havemteiltions. .SenatorBruciox,Dr. Barber, please. -% -., STATEMENT OP DR. JESSE E. BARER, PRESIDENT,..NATIOITAL MEDICAL ASSOCIATION, ACCOMP BY DR; ROSELYN. RAYNE. EPPS, NATIONAL CHAIRMAN,. ,PEDIATRICS; SEC - TION; AND i tERTRUDE T. liuNTXR, PROJECT DIRECTOR, NATIONAL TiON PROGRAM OIL THE NHL Dr.. Senator. Itibieoff. Senator Dole. I ..am Jesse Barber, M.D., president of the National Medical .AssOciation, which represents 5, a I ----4pproximately-81000-blick-physiciansin-our -Nation-Our orternization___ has traditionally been concerned about the health are of 1 children ; but particalarly about that of the low income, minority., and other nnderserved population. ' : We .are,- pleased to have this opPortunity to. Present testimony, on Senate ball 1892, Child Health Assessment Act. With the today are : . Dr. Roselyn P. Epps, clalairman of the pediatric section of the National Medical Association and Dr. Gertrude T. Hunter, project director, na- tional iiinumization program of the National Medical Association. By virtue of our traditional and historic role in the urban andrural. communitiesrwe view the enactment of this legislation as having a potentially positive impact for .. , 'roving the health status of the children and youth who will be , led tobenefits under this act. We have reviewed the companion-bill H.R. 13611 and endore sev- --- eral improvements over the original bill. We believe that the follow- should beaincluded' in the final legislation; namely :. o. 1; the assurance that appropriate. prenatal and postpartum care be made available for needy pregnant women; , No. 2, efforts be made to-increase immunization levels of children which is consistent with National Medical Association's immunization projects; . No. 3, the inclusion of adoptedchildren with special needs as 'partici- ipants; No. 4, prolision.for, routine dental services; as defined in 13511; No: 5, removing some of Ihefinancial barriers to participation in the prpgralb; - .4 , - No 6, no enrollment fee, freniiuni,' deduction, cost sharing or -similar charge with respect to any of the care and services will be . imposed under the plan; and : . .:. ' No 7, study and demonstration projects on provideilaiticipa4on: .. . There are other areas about which we have concerns,, an it is to these. suet tre now "wish to speak.. .. , - ' No 1, continuity of cafe. Although the bill speaks to comprehensive= : ness oftire, there is no assurance that fragmentation, duPlication,'und. .., .., omission .of services will not continue. For instance, there is'zio proiri- sjon for continuity betweeit assessment, diagnoses, treatment, and folio -up. In order for these activities to occur with continuity provi74 . sit:Ins for education for recipients and providers, outreach and tracking . are essential. No. 2, nutrition. The National Medical Association was struck by the glaring omission of nutrition as an identifiable component of this legislation. Although it may be implied in the term "preventive health' care, for persons defined aS "low _income," nutrition-education-and appropriate food services are abSolutely essential for growth and 4e- velopment, maintenance of health prevention of disease and recovery. from illness. We would strongly urge that provision for `nutrition . servIres be included in this act. No. 3, utilization of all health resources. Although the 'act permits' participation by all health ca e providers--public and' private--Ahere is no assurance that they will e utilized or will be able to participate in the prep' . Deterrents to 11 utilization 'of, all health' resources include.. State egulations that rohibit participation b\e' some pro- viders, unrealis is reimburgement for costs of health care Aeliverv. and exclusion of malpractice premiums as a factor in determining reim- bursable costa. ' - . These faCtors are cri cal to providers in underserved areas witkh large concentrations of .1 -income-families. Some providers are uri- able to absorb theleitdditio 1 costs and are forced to relocatefurther -contribiltimt. to the roaldist bution problem. Prior to passage of this . bill, cOnsidtifation shcaild be given to this problem and remedial action taken. . . No. 4, eligibility forservices. Although provision ,is made f9; eligi- bility for services from the prenatal period to age 21, in reality numer- . ous restrictions and qualifications exist which can interfere with ade7- quste health care at the many crucial periods for thiS high-risk popula- . ton. In reality, the ad does not reflect appreciation for the life long: - consequences of.poverty and inadequate health care and the dynamics of growth anddevelopment. . The National Medical:Association believes.that any individual who becomes eligible for:this program at any point in time prior to reaching age of malority'shOuld remain eligible without restrictions until the age 9f 21. Only then can:we effectively break the cycle of disease and poverty and raise the oYeall health status of the citizens of the United States reflective of the level of which we are capable and of. which we can be.proud: . . . _Thank yonfor the opportunity of appearing before you. Dr.Epps and Dr..Hunter, would you like to:adtl anything? Dr. Firms. We would answer any questions yoii may have. Senator RIBICOFF. I have no questions at this time. We might submit some questions to you and we would appreciate a response. at your -earliest convenience. Senator Dole? . . 0 i Senator DOLE. I.will do the mine. % I want to agree with the second point you made on nutrition. As a member-of thee NutritionCommittee,..we have been having some suc- :cegs, finally, in the food stampprogram and the. school lunch program of getting some nutrition component. 1th ink that is an excellent point, . ancl Twill certainly focus on it. We have spent. $50. a year for driver training for children and 50 cents for a child-foi nutrition education. - 'SenatOr Thratcoier. I would say to mydistinguished collearrue. if we would'iransfer the nutrition procrrahi to the Department of Eiliteation instead of Agriculture. we miaht, paybe be in a, position to do some- -thing -about edricittion in thekfielel of nutrition, but it is going to-be a -tomyh road to hoe over Senator Dole's opposition in the Senate. .. , Thank you Yery much. We may have some que.stions to submit to yon. ,.. .' Dr. Levitas? . 0. . . . ., N, Dr. NOApitz ?' : .-- . Dr. LEvrrns. Senatgr Talmadge asked one to expre is, personal regrets that he coulfliVot be here thismornino..,The sident asked the Setiator to be with him in Missouri today. so he Is eeompanying President Carter to Missouri; Senator tfilmacke has informed me that ton are the brother of run,9-ressniaty Elliott Levitas who represents :-.Georgia.'s Fifth Confrressional District, . Wre.weleome.you.here today, and are leasedto have your testimony, -Doctorei, . . 55 I,- ItITEMENT OP DR. THEODORE LEVITAS ON BETTATY pr THE AIIERICAtt DENTAL ASSOCIATION . I , . De.SEvires.Thank Yon, Senator. I accede to the President's priority Over my Senator being here, and I respect Senator.Talmadge's decision to accompany him. ) Senator RIBICOFF.- I.do not knoli if that is always wise. Dr. LEVITAB. Mr. Chairman and members of thecommittee, I am Dr.. Theodorb .C. Levitassof Atlanta, Ga., where I am engaged in the . . practice of pediatric dentistry. I am here Liday representing the !finer- 'can Dental Association, the Ainerican Academy' of Pedodontics,. of whichl am ivpast president, and the American Society of Dentistry for Children. . It isa privilege to appear before you,' and I am actitlY aware of the persdnal, significant contributions to the Anierican governmental prop re,ss. that both you .distinguished g,entlerne.nhave made. . In view of the constraints upon the time of the committee, I will be as brief as pOssible in summarizing. our Problems with S. 1392 t. `:Child Health -Assessment Act as .proposed by the administration. longer, more detailed Statement,: has been stibmitted for the reco Fiiit,-I.Itourd like to point out: that. it probably woi 1d notlue nec- essary for us to appear. here today if the House of RepreSentatives had been- willing t.o adopt an amendment proposed by SenatOr Ribi- coff in 1965 .which would have mandated dental care benefits for poor children under the original medicaid legislation. At, that time, Senator Ribicoff,.:t Ott made. an eloquent plea for the amendment and.. concluded with the statement that : "The need for including dental.care as one.of the required benefitsfor needy children. is clear." . . . . Senator Rtatcorr. Doctor. what contribution does dental care make to the overall health of a child ? Di. LEvrrAs. I think that it would be fairly. obvious; Senator, that !the- omission. of dental care is going to produce. severe pain for chil- dren who'are susceptible to dental disease. Statistically, we know that. an excess -of percent of the population of America. has some type -of dental disease. There is 'nothing more painful-than seeinc! a 3-year- old. as.I see On a fairly. regular basis. who is su fie ring. from dental. pain. . If you.extend this, perhap-s, into the school-age period, a child who is .suffering from dental disease simply cannotconcentrate on his studies. Aside from that, it an lead into other medical problems by becoming a serious physical .ailment, serious disease processes. The. difficulty, or the most important thing to me, 'is that dental -.fiserde is preNentable No. 1: and, correctable, No. .g, relatively easy; if e-kife_etrildteh'.14 Olt& rlight age; coasegliences of the faihrre to prO- Yiaiiklental.c...are at an early. age ? Yon: say that dental disease. is pre- yentable and you can check it. but what are the conseeluencti for the person if it is not provided at an early age? . Dr. LEvrrAs.- There can be serious problems resulting from Infection, -abscessed teeth. that will extend to other areas of the face and neck :and other parts of the body. This should be obvious. 56 It means a premature loss of primitry teeth, and even permanent teeth. This can cause developing maloolusions that ultimately can have a psychological effect On a child if he presents an unsightly appearance to his clu3smates and, as he gets older, when he goes out to seek employment. Strange as it may seem, the mouth is one' of the first things that is seen by a persOn appraising a candidate for a job., and decisions can be made not on the person's ability to work, but on what his physical ap earance may look like. So this is going down the road a bit. Senator REBICOEF. Taking preventive dental care,,if you fail to "un7 dertake this at an early age, what** the monetary consequences, the cost in later life to try to,remedy or-to correct a bad' dental situation that could have been corrected in earlyyears ? Di. LEVITAS. At the moment, I do net havettiV exact figures. These can be supplied to you, I am certain, by our association. Senator RISICOFF. Would you.do that ? Dr. LEvrrAs., Yes, sir, we certainly will. 1 [The following was subsequently supplied for the record :] The cost ,aavings-attributable to a sound, preventive dental health program for children are difficult to establish in precise dollar amounts. It is not difficult to establish the fact, however, that such savings are substantial. Bringing a generation of children to adulthood with good oral health is far less expensive than attempting to repair or restore the consequences of years of neglect. Statistics complied by the Armed. Services indicate that for every 100 recruits. it is necessary to perform or supply 500 fillings, 80 extractions, 25 bridges, and 20 dentures. lilost of these conditions can be prevented with proper diagnosis, care and dental health education with significant monetary. savings in -the cost of re- medial treatment. . Dr. LEvrtAs. I would follow up on your comments by saying that. in any instance, preventive care is going to be less expensive to the Government, to the country, to the individual, than corrective proce-, dures at A.-later time, so that it makes sense to devote our energy and our expehse. of the moneys that are avairalle to providing preventive dental care as opposed to worrying about corrective procedures later in life. Senator RnncorF. You may proceed, Doctor. Dr. LEv.rrAs. Senator Ribicoff was absolutely correct 'at the time of that statement, and the need is equally clear today; In our written statement, we hare recounted the association's sup- port of that amendment and 'subsequent efforts by the Senate to im- prove dental care programs for poor children. When the EPSDT program was adopted in 1967 with the support of the American Dental Association: dental care was to be included as &mandated benefit; but the program languished- for-more than 2 rears until a awsuit was brought to require HEW to carry out its provi- sions. en today, it is characterized by indifferent and faltering impleth ntation and the regulations. seemingly requiring dental care, are applied on a piecemeal, fraginAnted basis. if at all. , That brings us to S. 1392. arid 'lire situation ishistoricallYunique for . us because it is the first time we 'Rave been faced with a bill that proposes incentives to reduce the minimal dental benefif'S currently being offered to poor Childrek In the past. our testimonfin behalf- of children's dental health bill lla4 been directed toward improvingThe . . ) 57 status quo. Today, it appears that we -are struggling tp maintain a status quo that'everycme admits is grossly deficient. Ptelithinary to outlining our objections to certain sections 9f S. 1392, I would like to say that we recognize the importance of a health care needs of children and support provisions of the bill broadening the definition of dependent children as well as the emph in the bill on inpmlrnizations ,ancl other necessary services. ' Chairman, under the existing EPSDT law and regulations, States are required, on paper at least, to provide : Such dental cafe as is necessary for relief of pain and infection and for restoration of-teeth and maintenance of dental health. Section 3 of .S. 1392 in practical effect would repeal this proVision by the following langillge which requires: The inclusion of. all care anddgervices appropriate for individuals Under age 21, but not necessarily including dental care when not for the treatment of con- ditions discovered during an assessment. Senator RIBICOFF: One of the probleins and one Of the objections to covering preventive dentistry is the potential for abuse, and there have been some abuses. How do you monitor this to assure that there are not abuses overcharge, care that is not really necessary in cer- tain localities. How would your organilation handle as situation ? Dr. LEvrrAs. Senator; you ask 'a loaded question, as I am sure you appreciate. There are abuses in every facet of life that involves human people, individuals, and to a large degree the responsibility must be placed upon the shoulders of the person mvolved. That notwithstand- ing, however, there will be people who wild take advantage of situa- tions and who will abuse them. We-would like to think that the professio I peer ew committees that are existent in all types of organiiatio perh s, are the best . ways of monitoring these abuses, by calling them to the attention of theft Oilers of the professionals, 'the fellow professionals, and having thgse particular situations examined. Frankly. I am not a Solomon to give you specifics as to how to con- trol an individual who would choose,to violate the law, or to take advantage of a situation. - It has been a problem in our profesiion, and every profession, includ- ing these hallowed halls in which I sit' oday, and I respectfully sug- ,Yest that it is somethinn. that we, as humans, will have to struggle withx-perhaps until the end of time, because it involves individuals as*Po,sed to ones who would attempt to do t1V rikht thing, and frank- ly', I am veryplease,d to tell you that the vast ajority of practitioners do subscribe, to honest nethois of treating their patients and submit- , tiny their claims for fees. Senator RIBICOFF. When you are talking about #entistry and young children; the difficulty of gettinfrthem downtown or in the neighbor- hoods to the dental office looms large. How about the clinics in schools where the children are anyway and wire they can be examined ? What about a time allotted for dental care With private practitioners coming in early in the morning or at a certain designated time to do the work under supervision in the schoollio Dr. LEVITAS. It has been my eijoetience that this is simply not the way to do mass dental treatment for the children. I practice in an gf area removed from downtown. Atlanta, that is removed from the resi- dential areas where the Majority of the medicaid patients mir.ht. be expected to live.Yet I see large numbers of medicaid children in mY private office who come to ineby busor by private car.. I firmly believe that where there is a will. there is a way for patients to come to the offices. Just as Some patients who are able'to pay their- , own way in.dental offices or for dental care choose not to accept dental. treatment, there will be a certain number of medicaid patients also who will not accept it. The prospect of treating in clinics. first of all. I think you hiive to urtilerstand:as I will mention a little bit later that perhaps thee-. quarters of the dentists in this country practice in private offices. I- go To a clinic for indigent children on regular basis in Atlanta to . provide Services. 'Riese are children who are not eligible for me4caid and children who-are.not eligible for.any other type of assistance. so through our local welfare agencies there is a private clinic where we provide free services for the children. . But I feel that the practice of .dentistry should be in the hands of the private.practitioners in their 'offices where they are able to see more patie6t, berause they are following the daily. normal routine prove- dures..To do it in the school setting- simply does not seem to me to be.the place where dental treatment should be offered. . Senator inueorr. Wile% yiiii.have a-situationwhere it is Atlanta. -New York, Niita" shington--whera you have pour child rt'll who have little timtivatiow;orit lack of knowledge by tholia'rents or themselves. and the difficulty of getting to a dental office, bunt they are in the school- house, are not. so many children going to miss preventive dental care by having to..0-0.to a dentist's office -- Most dentists I know are very busy Men and women. Di.' Lawn-As. I choose to think they can get t hat care. I give t hat care, if Filthy be so bold to interject. Senator RIBWOFF. Do you think you are the norm ? Dr. LEYrrAs. I would certainly like o think so. I du sure there are people who would question whether I ant the normim, or normal. lint that is beside the point. T would like to think that I am. Perhaps in vision is clouded a bit because Of my: concern in thii;- Matter I 'think if you separate the two thin,rS yoirinentioned a mop-iM ago, prevehtive and 'instruction in contra:44o ti-eatment. if you are talking . Jibout instruction, home care procedures for preventive care. proce- r dures for instructing children how to take care of their teeth :.perhaps this very well could be done in a school. setting by auxiliary. personne-r who are trained iri dental or ,,in dental schools to -provide this type of instruction. . I. think perhaps there is way to.do that: The administration of fluoride month rinses could be done in 4hese places. But I am not sold. in my own mind. on'the idea oftryitw- to create clinics. The amount of Money that would be spent in establishin!, a dental clinic in enough schools-i-liow many schools are you piing to provide a dental clinic in ? Are you going to establish a dental office in every ,school in .,medicaid neighborhood, for example? r" Senator ETBiCOFF: If you were really going to make it work;, the answer is "Yes"by the local. health .departments, the ..State, or the. , , . . . localities. I am trying to think of the different dentists- I.have gone to in niy lifetime, personally; 4061 I am trying to envision, those dFhtists taking a lot ofpoorkids from the ghettqs of our big cities and treating them. . .. To be very, very frank with you, I could see almost all of these den- tists whom I know, going to a schoolhouse and spending an hour or two early in the Morning, S to 9 or '8 to 10. I c9uld.see them doing thatin cooperation with the local dental society.. '-,ti I think you liave.a very big problem. . Dr. LEVITAS. Senator, we in The dental profession are aware la the fact that we have a major problem. There are some .dentistscand I am not Shying this.in a critical sense. at allthere are some dentists who- simply ,chooSe.not to see children, and this I respect. There are certain physicians who'choose not 'to see children. for ,Whatever their reasons. It. may be their training or personalties or desires. It can be a . lot of things. -. . . . , ;. -I believe if some of the tedtape, if some of the hassle that is given to the providers in the profession were eliminated., there would-be a lot, more private practitiOners who would be willing to seegatients within the walls of their private..ofliee as opposed. to 1m vinglo'nurke a trip across town, for example,. which is not just one hour froin S -. to 9, as you put it, but it very well .could involve 2 or, 3 hours bf time away from the oflice where the?; might be product4 in seeing other .patients. i Senator kIBICOFF. You may proceed. Dr. lisvitAs. I was saying. inclusion of section: 3 of S..139-2. in prac- tical .effect, would repeil this provision by the language,. Which re- quires the inclusion of all care and services appropriate foi-.indi viduaN .Ainder age 21, but not necessarily including dental care, when not for the treatment of conditions discovered during an assessment. arenthetic.ally, Senator, just call up a dental supply man or a detail rrufK and ask him what it would cost 'to establish a reasonable dental office in a clinical facility. It are astronomical : it is incredible. 'The amount money, if we are talking about cost effectiveness in dol- lars: we are getting into an entirely different hall game, if you are going to build clinics throughout the country in schools. .. . The provision just mentioned i.wholly unrealistic unless its purnose is todeny needed dental care to most of the Medicaid eligible children Age the country. f . Had the administrations authors of the till taken the time and- effort-1.6 review the information -available from their .ow sources and perhaps they die -they would have discovered stu - t show, for, example, that as many as 97 percent of poor children examined.. . were.. found 7to require dental care before. age 6. Fu4lier. they would have found that in the early days of ITea&tart.significant amounts Of money were ill-spent or wasted by requiring dental assessments or savenings-without followup treatment. . .'Other, more reeent data shoe:II-Mt only l'a small percent Of children who are assessed actual y are referred for needed treatment: . Tills imsfortunate sta e of affairs would become the ride uncle, S. 139:2 betause there Wile req irembnt that persons trained in the detection, of dental' Veit* partieitiete in the assessment program. This Kill as,' sure that only the.Most gross conditions will be found. This omission . . . L.. Z.) < l I. 4 is compounded by the failure to recognize that much dental disease will occur and remain untreated during the periodbetween assessments. This approach is cost- ineffective but more importantly, it ignores the long-range health benefits to be gained by continuing preventive dental programs during the formitiVe years of childhood. . We strongly recommend that the bill be amended to provide foi di- rect referral for dentalcdre and otherwise correct the deficiencies we have noted. ' ... Another serious defect slid perhaps of more long-range detriment than any other is the exclusion of dental carefromnthe 'higher Federal matching contribution proyided in section 7. As we understand the pro. posal, services "other than dental and inpatient care" would hence- forth be matched at a iate between a mimminn of 75 percent and a maximum of-84 percentlis compared to the current range of 50 to 78. This, of, course, is an open invitation to the States to reduce even -further thttinadequate level of dental care now prov. ed to poor chil- dren and an encouragement to them to refrain from b oadening cover- age of such care in the future. Although-it would see difficult to take a step backward from the present EPSDT program under which only 1 in 5 eligible children receives services, the administration has sus -: seeded in designing one of giant-sized proportion. . We strongly Teconunend that section 7 of the bill be amended to include dental care in the higher contribution rate that is proposed. We also must disagree with the reliance.thet is placed in-S. 13!)2 upon the utilization f so-called healt care centers for assessment and treater ment. This is yllirticularlyinapp opriate and probably unworkable for dental care since more than thre quarters of all dentists practice alone in private office settings. Our rganizations believe that the medicaid population should have the am6 access to care as the popullition in general. Emphasizing a delive anisth not widely used by the rinblic serves to set the medical inible children apart, clearly an undesir- able effect and we would /;ge corrective amendment. - Based upon considerab years of expetirce, we anticipate that NEW will attempt to def d the! oxelilsionary dental care nr&visions of 5. 1399 on budgetary donsideratioiv. We believe their estimates can r he shown to be high, but in any event, we think the Government should be willing to make a reasonable humanitarian commitment .to the im- provement of the health care of poor childreti, for general li,altli and dental health are inextricably intertwined. Let me assure you that dental-care is too.expensive not to be prcivided. As you can see. Mr. Chairman, we have 13orhe serious concerns with this legislation. At the same lime, we strongly support the purpose of improVing health care for children of low-income families. We have f prepared amendments that would remedy the deficiencies we have mentioned and we would he pleased to submit these and work with the P committee toward further improvements. We are pleased with the suppiirt given us by the Children's Defense l-e:. Fund and the Conneetieut Legal Services. and we are appreciative of....".;,.. the amendments already introduced by Senator Childs which' are , directed toward the same objective. We subscribe to the theory that the luck of dental treatment is too expensive not to proyide it for those less ,' fortunate than we. 4 '- sl g7r Ad 61 The AmeLean Society of Dentistry for Children has, as its model, the words of the philosopher Goethe : 'Little can be done or grown-up . . . peo The intelligent man begins with the child." s , members a your compittee, so, too, hould we begin with n. child. _ Thank you for your time consideration. Senator Rumor,: Thank ry much. [The prwared_? statement o . Levitas follows.] , STATEMENT or vim 'Afaisfcsa DENTAL ASSOCIATION Mr/airman, I am Dr. Theodore C. Levitas of Atlanta. Georgia where I am engaged'in the prietice of dentistry specializing in Pedodontics. I am also repre- senting the American Academy of Pedodontics, of which I am past president, and the American Society of Dentistry for Children. I am pleased to have this opportunity to present the views of these organizations On S. 1392, the Child Health Assessment Act. As I believe this . committee is well aware, the American Dental. Association has traditionally placed its highest priority on the dental care of children. The develonnent during childhood of effective regimens of diet,.professional treat- , ment, and home care is the foundation for a lifetime of sound oral health. Dental care for the children of indigent faniiites and families that are mini- mally self-sustaining is frequently neglected.' This occurs for several reasoas, but certainly severely limited finances is a significant factor. Because of this situation the Association has long advocated theinclusion- of dental services in *health care programs aimed -At these children. and, also has promoted the inlroductiOn of separate legislation to the saf&effect. . - With the indulgence of the committee, I would, like briefly to review some of these efforts: In 1961;- When the:Association testified on medipaid, we urged that if resouregs would not permit coverage of all needy pe,rerons, At least dental care fOr children should be mandated. Such an amendment was introduced by:Senator Ribicoit and was approved by-tiMs Committee and passed by the Senate.,IInfortunately, it was dropped in the Smile-Senate conference on the bill. In 1967, at the urging of the Association, the then administration-gni-knitted to Congress a bill truthbrichig among other thingi pilot dental projects under Title V of the Social Security Act. The bill "was oasstd hater° funds were allocated for such projects during fiscal years 1968, 1969 or 1570. In 1971, $500,000 were alio- cated to seven dental projects serving about 10,000 children. The next year about. MO, were allocated and 6y the terms of the law the program was merged into ot LIU ass ity Act wh ben-eats. V projects. lotion vigorously supported the 1967 aniendments to the Social Secur- Halted EPSITD and Included dental care among the mandated e pr rn languished for more than 2 years until a lawsuit was brought to' regal HEW to carry out its provisions. Even then and up to -tPe present, progress has been paififully slow, which of course is one of the reasons we are here today. $n 1971, follottring a comprehensive hearing in the Senate. C Children's Dental Health let introduced by Senator Warren G. Magnuson and strongly supported by the Association was passed by the Senate by a vote of 88 to 1. It provided grants . for children's dental health care. projects: fluoridation grants on a one -time voluntary basis, dental health education and other programs.to develop effective . preientive dental programs f9r children. The bill was not considered in the House: In 1975 Senator Magnuson Introduced a revised version of the Children's Dental Health .Aot, again with the Association's support, which was designed - . specifically to augment the floundering EPSDT program by authorizing dental,"" project grants for dental care and.services children of:pm-school and school age who qualify.for Medicaid. The bill passed the Senate as an amendment to the National Consumer Health Information and Health Protection Act of 1976 but waallot inclUded in the final bill reported to the floor of the House. That brings us down to the present, Mr. Chairman and the situation is his- torically *dune for us because It is the first 'time we have been faced with a,bill ' that proposes incentives to reduce the minimal dental care beneflte currently being offered to poor children. In the past, our testimony in support of children's, . 84-464-73----, 5 , dental health hills has beep directed toward improving the - status quo. Today, it appears that we are-struggling just to maintain a status quo that everyone. admits ' is iLrobely deficient . . Before getting into the specifics of our -objections to certain provisions of S. 139Z I wish to make Clear that we recognize the importance of all health care needs of children, none of which should be neglected. We therefore support the broadening of the definition o "dependent child" and the assurance of continuing" care for children whose families' income increases beyond the letel of eligibility as provided in the bill. The increased emphasis on immunization also is deiirablet 4Ilid necessary. . , - The new penalty provisions in tfection 7(b)(1) appear to be an impryvement, but we believe-Congress shosid tontinue to. seek methods ofassuring compliance without reducing a state's health care funds. The monetary incentive for good performance also is atlinaportant innovation. While section .0 Weeks vaguely to encouraging.provider particiPation in 'Medicaid tinder regulations of the Seem.- tary, the erns of this matter lies in the unrealistic reimbursement schedules that are in effect in many areas, an issue that shouldbe addressed directly. To turn now to our specific concerns with-S. 1'.192, Mr. Chairman, it is our opinion, with all respect to those in thesedministration Who drafted the bill, that . its preamble would more accuratelyllescribe its provisions related to dental cure if It said "To weaken and emasculate the early and periOdic screening, diagnosis and treatment.program". Althongh the EPSDT program in many respects has been seriously deficient because of faltering and indifferent implementation and underfunding, its weak- nesses do not lie in its. underlying intent or In tMe scope of its benefits.*CHAP, on the other hand, represents a step backward, if that is possible, in its exclusion of benefits, its-cligqcentives to the provision of comprehenSive care and itsreliance upon delivery settings that do not exist in many areas or do not lend themselves effectively or economically tp.meetieg, the total health needs of the children to be served. Mr. Chairman, under the existing EPSDT. law and regulations States are re- quired on paper at lea*, to provide "at least such dental care as is necessary for tellef of pain and infection and for restorations of teeth and maintenance of 4 dental health} .." (("FR 239.10 (bi- (11'efI'l). Section. 3 of the CHAP legislation in practical effect would repeal this provision by the follOwing language which requires " .* the inclusion of all care.,and , services appropriate for fediriduals under age- twenty-one (hut pot .necessarily "including dental care When notfor the treatment of cOnditNag discovered .1 ' during an assessment)." s. . This provision is wholly unrealistic unless its purpo.se is to deny needed dental eve to most of the medicaid-eligible children in the country. Had. the admittis- tration's authors of the bill taken the time and effort, and perhaps they did.. to . review the information available frOni their own and other independent Sources, they Would have discovered from a report on the health status of children of "( tow-income families in the maternal aud child health program that in 19(19 dental patient visits for all children froia families with incomes of $7.000-$10.000 was four times that of children from families with incomes of $3,000-$41.000: that only 40 percent-of children under age 17 from low-income,familiefL bad ever hoen to a dentist ; that .97 percent of.suah -61fildren were found to require some dental care before age 6. From a report Delivery of Health Care to Child 'of the American Academy of Pediatrics on thti etc they wotil have read that "Dental disease is nearly universal in children ag2i 50 percent o preschool Aildren bare one or more decayed teeth. Poverty intensifies neglect s that children from low itupme felines have fire tidies as many untreated deco teeth as the average From another report they could llave found thn.t\ilen bisek teenagers' health' statns was examined in Harlem in 1972, dental disease Was found to be over- whebi2ingly thimost common problem, from their own records that in the early days amonnts of money were ill-spent, of wasted eh many times prodneed a well-Intended chart' ,that collected dust instead of resulting in needed follow-tip dental treattnt. They also conld have found from-more recent experience under EPSDT.tha in states requiring screening badVndentista as a prerequisite to dental treatment Only a sinall percentage artkaally referred for care and those Sften include only children- with the most visible or gross conditions, usually involving severe . Farther they would- have fou of_the geadatart program signi by requiring dental screenings w pain. According to data gathered by the Congressional Budget Office only 25 Per' cent or 500,006 of the 2,000,000 (children) prpjected to be screened may actgally be referred for dental-care because some states are reluctant to "finff dental' problems they would. be required to treat. This alhfortanate state of affairs %%ill become the rule under S. 1392 because there is no requirement that persinis.tra hied in the detection ordental dIseaSe partIcipate in the child assessment program. an omission that is compounded by The failure to recognize that' much dept al disease will occur and remain-untreated durink tie intervals between assessment .7s. This litany of the PaRil3r discoberablt and obviolis could lie continued to include notice to the Department` of Health, -Education and Welfare-that children with seriously diseased mouths do not perform well in school or in work, that'oral dis- figurements-are handicappi4 to youths seeking employment, that thousands of man-houb of work per year.are.lost because of oral disease, and, perhaps most importantly that dental disease is among thamost preventable rf. all maladies. It is for these and other reasons that the delfts' prbfession has repeatedly urged State agencies to conserve resonrcds and get fo the business at hand by foregoing dental screening is favor of Automatic referral to a dentist for. diagnosis and treatment. This IS gre most cost effeCtive way of meeting the dental health needs of eligible children and we erongly urge that -the bill be amended to this effect. In this same connection we strongly object to the requirement In 5.1392 for utilization of comprehensive care providers for assessment *and treatment. This requirement is particularly inappropriate, and almost certainly unWorkribles for dental care since more than-three quarters of all dentists practice alpine in a 'private office setting. Provisions which result in restrictions on the types of pro- viders- which- can participate in. the CHAP program run totally counter-to the basic intent of this legislation. One of the key elements which will -determine -) the success of the CHAP program, is the ability to attract providers who are A Willing to participate in the program. A reliance on a single type of entity, -par- ticularly one which is not generally available and certainly is almost unavailable jr dentistry; will inevitably limit the number of providers whip participate. The American Dental Association believes that the medicaid eligible population should have the same access to Care as the population in general. Emphasis upon - a delivery mechanism which is not widely us,edby the public serves to set medic-. aid eligible children apart, clearly an undesirable effect. The Association believes it ta imperative that all providers be eligible to tiarticipatetizi the program and to provide care tohligible children. . . One of the most serious defects in S.1392 and perhaps more long-range detri- ment Than any other to the provision of needed dental calfbr poor children .is the, exclusion of dental care frdm the higher federal matching contribution prb- vided in Section 7 of the bill. Under existing lad'. the federal contribution for dental and other health AA-tees ranges from 50 to 78 percent and averages 55 percent As we understand, the propoled formula under S41392, services "other. thltn dental and inpatient care" would hericeforth be match-hd at a rate between a minimum of 75 percent and a maximum of 84 percent. , This, of course, -is an open' invitation to the states to reduce even ftirther the -inadequate level of dental care now. provided to poor _children and an en- couragement to them to refrain from broadening coverage of such `care in the future. Although it would seem diffipult to take step backward from the present EPSDT program undea which only one in.. live eligible children receives any service. the Administration has succeeded in designing one of giant-size pro- portions. insofar as access to dental care is concerned. Mr. Chairmen, our association hae Anne 'specific recommendations foi- amend- ments which should be made to 1392. Initially we believe that the medicaid prograis must .he amended to clearly mandate dental care- for eligible children: This is an,amendment which was -introduced by Senator Ribicoff anti agreed to by the Senate in 1965 when the medicaid program° initially was enacted. Adoption of that amendment yery likely would hate eliminated fife 'necessity for our discussion today of the inadeqtlacies of the medicaid.program.ln prmid- ing dental care for Children. I am taking the liberty of appending Senatizr Ribleoffs statement in-behalf of that amendment whle is as eppropriate toda-y as it, was .then. Establishment in the, law of a requirement that all state medicaid plans provide dental .care for children will be 'a' significant. step. - toward finally assuring that these children receive necessary dentlii care. We also believe strongly that it is- time to formally eltminate requirenients. that there be a dentarRereening as part of the assessment process. As we have stated. 'the needs` of low-income children for dental care. are 'Po widespread , there must be direct referral'to a dentist fo rnecessary diagnosis and treatment C 64 .Inclusion of a direct referral, requireinent as part of the CHAP program, will help assure this Third Mr. 'Chairman we believe. that there would be a tremendous increase in the incentives to the States tO see that -dental' care 'is provided to eligible .children if the Federal leVel of matching to the States for this care for cididreu .who are in the CHAR.Nprogtam is-.at the higher level proposed for . other. forms _ *of health care. Unless the states are shown that the 'Federal government is finally committed to assuring the 'availability of dental care through its offering of the' higher matching level of assistance for this care, there will be, a cos- tinning threg that the States ,will notdevelop this priority on their own: _Our ..fat%rtli'reeotainenclation amendment to -S. 1392 is to eliminate the : . rest?ledona On 'the types- of practice in which providers of :care must: engage in.cirdeAtty participate in the program.' All practitioners, no ,matter what their torniThf;Prartike, should be able ,to participate in the 'program. As eve have said thislithe way to help assure the maiiinum level of practitiopers' participa- . pont a level whichimist be increased in order to have a successful effort. Senator -.Chiles has introduced an atheadment to S. 1392 to 'help fcorreet,the dental ,defjciensieS in this' bill. We are most grateful for his concern. We ivould be store than pleased to work. with-.-the Committee and staff la developing the appropriate additional languagetO accomplish. our Suggested amendments. ...Finally, 'Mr.. Chairman, based ].upon . "considerable number of years of ex- perience, we anticipate that the Departnient Of Health, Education and Wel- -fare attempt to defend the' exclusionary dental care provisions of F.. 1392 on the basis Of budgetary consideratiOns. In this regard, the DepartMent's estimates of costs' as reported to us appear,to be based 'upon Cinestionable as- sumptions' and are significantly inflated. We would. be glad to analyze the De- partment's latest projectiona and 'provide our cost estimates for the -record: In 'any. event. the government should be willing to maiee a; reasonable, human- itarian commitment to the improvement Of the- dentalhealth of poor children. Mr. Chairman, as you can see we have some serious chkerns with this legis- . latiOn. At, the same time,, we support the basic philosophy of the, bill which is* to improVeAtettith care for low-income children. We liope that a final- bill ' can be developed which will. improve the availability of 'dental care for -14iw = - income children withou(,overburdenizig the: adMinistrative: aSpeats of the , program op' increasing the` regulatory burdens associated with it. .Wet would ' /Ike to a splatin develOpnient. . Thank yott for your time and your consideration. . ICoogresidOnd Record. Washington, D:C.,Tuesday, Nray 15, 1965] 'AMENDMENT Nos. 189 AND 190 Mr. IlitacOry.-Mr; President, Jr, submit, for appropriate referent*, two amend- ! Maas to H1R..6675, the Social Security Amendments of 1963 now before the Finance Committee. The first amendment extends equal tOatment under the bill to the 'dentists of the Nation. A's written, the bill would deny the right of a .patient to selett an .oriti.surgeop 'to perform oral .surgical proceduies that Would ...be covered performed by a physicialtn- an Osteopath. many dentists *who. have completed inteKnships and residencies in oral sorgery regularly remove oral tumors, take bioifsies, reduce jaw fractures, and - perform other services not involving what might be described as routine dental work. Throughout 'the country, there are hundreds of dentists'Idmitted to' 'hospital practice. .Nearly '40 percent of the Nation's hospitals have -formalized dental services and virtually all hospitals permit dentists to admit patients for. oral surgical services. All contracts under the Federal Employees Health Benefits.Act recognize the rights of dentists in this regard as do other private insurance plans. e Itis only simple equity to allow patients to have their oral surgery performed by qualified oral surgeons, and that is what this amendment would accomplish. The second: amendment relates to dental care for needy children' under part 2.of title I. grants to States for medical assistance. In its present form, the bill requires State plans to include five:kinds Of services for persons eligible for. medical assistance in order to qualiffkfor Federal partiCipation..pental care. Is not one of these five services. I Wliebe' strongly that in the case of needy children it shciuld be. Not too long ago tlie Director of .the poverty program described the care received by a youngster from One of the great cities of title Nation who joined the Job Corps, During the first days he was there, the -*y simply refused to 65 . . . . eat. The officials of the center were, naturally, concerhed.and did their. best to find opt what causpi, the boy to act in this way. They believed, I Suppose, as most of us would' have, . that the boy was apprehensive ot4lenely or confused ; i 'by the changes that had taken place n his life. The explanation was siMpler than thatsimplex' butin many ways more tragic. The boy..wonldn't eat because. it hurt him to eat. His mouth was so diseased, his teeth so riddled with cavitieS . that it pained him to eat nourishing food:. - .,:. .' ' . . . . What a sad story, Even-sadder, I believe;`are :the studies which show that o this boy's problem is shay by many others, Just' a few statistic document this. For example, 60 pe of the childrenrbetween the ages of 5 and 14 whO are members of families .wh se income is below $2,00%a year have never se n a dentist. Even If you go u the itibonie scale as high as 1$4,000 a, year, there °. . are still 40 percent of .the childrenwho have never received .dental care. ,,.. And irrespective of income, 24 percent of Urban children betiveetV the ages . s of 5 hnd 14Are never seen a dentist ; nor have 29. percSat of the same ag4 group . In rural no' rm families or 42 percent .of tipse in' rtiral farm areas. .i . . .. Think of the huge sums spent do dentifrice advertising:. Tet hundreds of . thousands of our children are withchit dental care. A society that can afford toothpaste nds can afford a dental care program for. 'needy children. The need for including dental care as one of the required behefits. for needy Children is clear. In his health message of 'January 7, President 'Johniondlasked Congress to adapt the. Kerr -Mills program "to permit specific Federnl,participa- . .4, tiOrilripaying cos s'ilticieclical and dental care for chiWren in medically needy ... faniilik believ we Should honor .the President's " 'I a commendation the amendment I Am submitting would do so. . _ I. ask tinanilnous consent that the..ameSdments .be painted at this .point in ,,, ... the RECORD: , , . . . . . . . ' . The ACTING PRESIDENT pro tempore, The .amendments'"will be, received; printed, and appropriately referred ; and, without objection. the amendments will be printed in the RECORD. - - The amendments were referred to the Committee on Finance, as &Mows: . , . ., A NlENDN1ENT NO. 189 ° '' 1 . . : :.,.: On page 127. line 1.7,'.after."State plan" Insert "(except to e extent.reqUired by .Clause (A). (ii) of paragraph (13) )".. On page 129, line 7. strike out "clauses (1) through .(5)" an 'sett in lieu thtrtOp!.(f ) clauses (1) through (5), and (11) in the 'case sit dependent children, elapse 10)".. , ..AMENDMENT INTO. 100 On page 64, line 18, strike out "Association" and insert in lieu thereof "As- sociation, or, in the case of an Intern or resident-in-training in thv field of . dentistry. approved by the Council on Dental Education of the Americhn Dental Association". ° Ofkge 82,11ne 2, 'imtnediately after the' period' insert "Stich term,. When appliell to professional services performed by a ()elitist.' shall be limited to ." dental sertices and -oral surgery of .the following types: (A) prompt repair of accidental injury to natural teeth, (B) reduction of fractures/et-the jaw.Or . facial bones. (C) removal of stones, from salivary ducts. (D) e-xecisfdirbf cysts or tumors,torus platinus, and leukoplakia, and (E) othei, cutting surgery on tissues of the mcruth..otheitharigums, when not perfOrmed in connectionwith the extraction of teeth." . On page 82, line 6: after "surgery" insert ". ordentVary.v.. On page 83. line 5, after "(6)" insert. "(A) ". On page 83, line 7. strike out "and'. On page 83. between lines 7 and 8, insert the following; . "(B) dental prosthetic, AleviceS, Int only under circumstances when such devices are required for I-10 prompt rr:pair of acridtntel 'injury :.and". On page 88. line 21. strike out "or. On pnee 88, line 24. strike out the period and insert in lien .thereof a senile:Mori folloWed by the wqtd "or". On page 88, betWeen line,s'24 and 25, insert the following:. / . "(12)- where_such expenses are for dental services otheetharr lio.4described thesecond Seri tencetet sectl on.1861. ( q `41k Senator RnneOFF. Dr. Noshpitz .,. - 66 STATEMENT OF JOSEPH NOS/CPITZ, M.D., PROFESSOR OF PSyCHI- , ATRY, GEORGE WASHINGTON UNIVERSITY MEDICAL _CENTER ON BEHALF OF AMERICAN XCADEMY OF OliliD.-PSYCHIATRY, AMERICAN PSY-OHIATRIO. ASSOCIAT/ON; $.1fONAL ASSOCIA-. TIM OF PRWATE PSYCHIATRIC HOSPITALS,, AMERICAN ASSO- CIATION OF PSYCHIATILIC .SERVICES FOR CHILDREN, MENTAL HEALTH ASSOCIATION AND 'ASSOCIATION FOR THE ADVANCE- MENT OF PSYCHOLOGY Dr.. NOSIIPITZ. Mr. Chairman and members of ;the subcommittee, ' my name is Asepili D. Isloshpitz. I am past .president ofthe,American Awlemy of Child Psychiatry. I am here to present the joint testimony of the academy, the. American Psychiatric Association, the National Association of private PsYchiatrie Hospitals, the Americanssocia- "6 tion of =-' :PEyohia*vices for'Children, the MentarHealthAssocia- Lion, *and the Association for the ,A dvaneement of Psycholo v on S: - 1392, the Child'Xalth Assessineitt Act.. ; .-.6S, I am accompanied here by Miss Ludie White, ptAident of the North Carolina Mental Health Association, and ti inembei Of.ith ,NakiOnal Committee cinChildhdod and Adolescent Mental HAlth.. We wish to addiegs f.he clauSe in section .3 of this bill which limits provision of treatment for those children who have been screened and diagnosed as being mentallyill, mentally retarded, or developmentally disabled. SpAically, we refer to lines 0 througlk4 2 on 'page 3of S. 1392 is introduced Which read : .".(but ot becesgaillily inclUding (1) those for the treatment of. mental illness, ental.retarilation, or devel- opmental disabilities . .:'," The result of thiS parenthetical Clause is the eXclusion. of Such 'treatment altogether. The failure to mandate thichserVices fol these children is disturbing.to the members_ hip of each Of.the organizations I represent. . . ':CWe know how difficult it is to .'treat m reat children afflicted by enta Ul- nas, mental retardation, or Oevelopment 'disabilities. Much time, much motiey;.much skill and human effort are-entailed. The paradokicaront, : .. \ come' has been that traditionally, these children °Were excluded. from p service rOgrams. In the past, such discrimination. regrettable as it may be, has taken place through an act of omission. lIrreVer. Ailiiis bill. is unconscionable. The legislation. explicit,ly authorizes the denial of `' Itreatinent to this entire group of children in need.. .... -, Such a deliberate omission stands in dir ct contradiction 'to the reedmmendations of the Report of the Pre Mental Health. Stating that "helping ell must. be the Nation's : ident's . Commission on .... first priority in preventing mentalidisabilty," the.ComrdiSsion recom- mends that : A periodic, compreltensive, developmental assessment be avaIl b, e . o all. chi!- 1). f) 11 , Area with cofisent. of parents and Witletnaximal. parental involvement in all staees of the process. i In its explanation Of, this recommendation: the, Commission ex- plicitly mentions the child health assessment program. Noting that, . . at prrent: 1 . . . , .. The ,Eirly..and. Periodic -Screening;; Diagnosis and 'Treatvnt Prwram of . A TipeiXIX of the SoehiVeeltrIty Act does not include the nva 14141ity of treat ment and service.tfrovisions t9° cover mental illness mental retardation, and developmental disability when these conditions are din osed f C. ^ 67 The Covrfission states that : . .:: . The proposed child hearth assessment program should mandate that tuek P. services be available. 'As it stands new, S. 1392 excludes mandatory treatment for children " diagnosed as mentally ill, mentally retarded; or developmentally dis- .abled. The ibiplications of this 'provision need, to be clearly faced.. .Optionaltreatment is tantarneurtt to 'exclusion. The:re is a history to this, and the*iin 'of its teaching is that optional. coverage ..forMeritall ,,,, illness.mearis no coverage, : , ..- . . .... _-1 This stands in radical contrast to, the bills declaration of purpose :; .!' To continue and expand the avidlability of h.ealth care to ?Children whOse . families do not have adequate resources to cover the cost of such care and to strengthen efforts to assure adequate child health 'assessments, diagnosis; treat- ment, and periodic reasserssment of all. eligible children. That statement of purpose says (Me thing: the language in whiCh lenislation is 'couched says something,. quite* different. In essence, the bill. states that if 'You are a poor child whose health has been as Sessed, and you are found to be mentally ill, mentally' retarded, or developmentally disabled, then care and services need not be provided. . In effect, S. 392 declares that a 3 -year -old diagnosed as having diabeteS or kidney disease Will be treated while th'at same child found to have psychosis, neurosiS, or deppession will be 'labeled, but, not treated. Wuhave received conflicting messages from the administration in jthis area. The President's CominisSicin on. Mental Health has been a very visible force in advocating' treatment of mentally ill children. At the same time., the Secretary of the Department of flealth,%Educa: tion. and Welfare is on record as Supporting optiOn0 coverage for -children' with mental illness, mental retardation, or developmental dis- 'abilities. We look to the Senate to assert its lead ship role in brining the needeeseeicesto these special children. . Diagnesia an,d treatment of mental and motional illnesses amen°. . tchildren are the first line of prevention. Experience .indicideSAhat the failure to do so has already had severe consequences and Will continue to-hare a profound dyed. in futiire years. HOwever, if a child's Mental and emotional illness, mental retardation or developmental disability is attended to as nearly as possible to tOstiine of its inception, the result will be more normal development throughout childhood and a far better change for later entry into. society as a productive adult. Negle.ct at this early age is not only wicked, but from the standpoint -of a healthy and productive ,society. it is also stupid. The early treat- ment of emotIonal and intellectual disorders benefits not dilly. the individual and the family, but also society asoh whole. More than. that; the cost of treatiiienfat an early age. is far less than the cost eflifeleng disability, social services. Unemployment or delinquency. The fact is that America is presently iinderserving its mentally . ill children. There are approximately 88 million children and youth in the TTnitecl States,' who constitute about 40 percent of the population. If one uses. the .commonly swknoWledgefl figure of .10 percent of the population reaiiiring services .fermental or emotional illni4ss, We.wonld estimate that close fo 9 million, children.have demonstrable Psy.chiatric, priibleinS. Only about 10 percent of this population, or Om:4_900,000 dren, receive any treatment at all. 4 . !,4 I 4 ' Thus, this pro 68 offers ngresS the potential to provide a sys-. tem of active tre tilt for dren in need who are presently peing ., seriously negitcte :. . ..;_.-.:.11e. proponento-:of. Optional. coverage advance the argUment that ren..-diaignosed as .mentally ill, ,,mentally retarded or develop- ineirtaNdiSabled are.adequitely served through other means, such as ' the .cornmuliity-inentalhealth centers program'. Originally, most oft .. the CMHC syst.ented children'S; se ices entirely :- ater, they were phasedinonly.after 'a:cOhgre 'onal ndate., ., . Regrettably; the 'pattern or gt ervice.' delivery lii.S. heel) very -spsradic.and diSorganized. -....--. . Senator RtincoFP.'It is obvious that the lid:ministration does not .want to go as far as you think that they ought to g.6.::.:",;,..-,-.,..: . . I would like to g-6 fare I am not so sure that a majoritrorCongress . is willing to face up to mandating complete coverage of mental health-- -.., .,.. problems and developmental disabilities., . . . If that is the case, would you have a suggestion as to a midway point. a big step forward; if. we .Cannot get it all ? . I would li,ke to get it all, but I happen to think that I am in. the minority. .. .- . Do you have a step that. you. Would recommend't hat we take ? Dr. Nosnrrrz. Well; there is a curio s emphasis on hospitalization . as Coverable versus outpatient treatn nt as less worthy, or leSs neces- sary or less immediate: Senator Runcou. Personally ain for more and more outpatient and home-patientTare in every phase of the health cycle, but again, yon are. talking to one who is very sympathetic to your point of view. By now, we have to face the realities, both from.the executive and .- the legislative branches. Do you have any suggestion of where we could go meaningfully if .we cannot go all the way ? . Dr.. NOSIIPITZ. It me address two points. In the legislation as it stands,a provision is made for coverage of hospitalization of children in general hospitals that iiKe psychiatric units. This is a. curious paradox.. If one looks at the actual figures, it costs more fa treat the children in general hospitals than it .doeS in the Private, psychiatric hospitals You: can check this out With Children's Hospital right here ih the District of Columbia. Second, the general hospital's psychiatrie divisidn does not have to meet the standards for psychiatric facilities set by the Joint Commis- sionon Accreditation of Hospitals, JCAH.:-That standard. does not have to be met by the psychiatric division of a .general hospital. It does have to bed-net by all Rsychiat*hospitals. . . So that is one illustration of where careful attention to some of the- -kinds of details of service delivery can make a difference in the cost of these thing* as well as in the efficiency. .The-second point that would like to,tinderline is that. there a many .ways of in outpatient services. One can do it Via HMO's, one can do it in a variety of ways. I Iknowlthe 'outpatient services at Children's Hospital where I am a full -time staff person now, right here in the District: the outpatient service expenses for an hour of psychiatric.' time,. my time, are greater . than I would charge q.s.a private practitioner sitting in my office. v. ft. '. 69 If I were in just plain private practice,no connection with the hos- , pital, my charge per hour is less than what is billed for a. medicaid patient there. .. Senator Rmicorr. In,other words, what you are saying your cha,rge . for a private patient in your office is less than a hospital charges the medicaid patient for the same service? , . Dr. NosHigrrz. That is correct. Less 'by over(,$12 an hour. 7.- Senator Rnnooik. That is a. very. interestingfigure. . 4. 1 would suggest that you or your colleague at your mutual .con - venience. might have a conference with. Mr. Constantine of our staff about. whether or not we can find a nliddle ground to. achieVe some of these objectives. , Dr. NOM:FITZ. We would be delighted to do so. We will work on making the arrangements. Senator Memoir. This is one of the. great problem's in all health care, the mounting ,c6§ts. The costs are really what keep us froin get- tingmore and more into the "whole health care field. And I think we should be examining, more and more how to lower overall health costs. This is the basic argument now between President Carter and Senator Kennedy over the impossibilityin an inflationary period --b of covering all the health costs when you have skyrocketing health needs. . f . 1 , I see that the Secretary just walked -in and Mr. Secretary, Dr. Noshpitz was just saying that the amountOf money he charges for a:. "."x---.Rapient in his office is $12 less. than -a general hospital will chargé to Medicaid for the same service. You have this basic problem where you avoid certaintent and . my more money under the recrul Lions. I think this is an ongoing . )roblekn to which we have to adc r s ourselves. I imderstanfl the President's nt of view, and what he is trying to achieve, and the Secretary's oint of view; but I think we do have the problein of examining all the delivery of health, services and ds- termining why a hospital charges more, for a medicaid patient than you--and look at your credentials; 'you are a professor of psychiatry at George Washington 'University. You appear here on behalf of the American Academy of Child Psychiatry-..the American Psychiatric Association, the National Association of Private Psychiatric ..Hos-;. pitals; the American Association of Psychiatric Services for Chil- dren, the Mental Health AsSociation; aiti.,,..Ilie. Association for the Advancement of Psychology. So I am asSiithing-that yoti have reached a status among your peers as a leader.. and: hefs 4). private patient 'cones to you and *Our charge is less to' -then' than the charge under medicare and inedieaid .in a general liosiitat. That is -hard to take. The. staff has asked me to ask you. is Tt generally true that the -professional service that the iiierage psychiatriAt 'charges is less than the chargethe professional chargein a hoSpital for.the same type of »sych iatric service ? . Dr. Nosnerrz. I. would like to loof into the generality of that. I 0 know it. is true in a number of instances. Whether it is generally true. in the sense of surveying every general hospital in the country Senator RIBICOFF. Let's take the one yo now. I would say that would probably be the norm, generally, around the. .country. Its similar, but here you are in Washington. You area pro- I A. 74 t 70 fessor of psychiatry, but'you ate also allowed to see private patients'? Dr. NOSAPITZ. The patients pay the hospital, but I am allowed to seeprivatepatients.-. . . - . Senator ICon.. That is an interesting point. f I would ItOpe that members of your association might sit dowii with- Mr;Constantrna and I would .suggest that probably. while the Secietary is here, thathe assign a member a his staff to it in on that conference. I know what the Secretary .is trying.to achieve; he is trying to get the best seryice tha-t, we can give in the health field at the lowest cost. He recognizektivrffifficulty that we are all under, but this is a very challenging thingthat you have just said, and I think hat we ought to pursue it. you? I think the SecietaryAalked in in time 'to get thel terchange. Did . Secretary CALIFAxo, I did, Afro. Chairmitn. Senator hIBICOFF. Thank you very irmsh for beidgaWitlius. Your en- tire statement will go into t1 record as if read; The fact that you hate d*pped in' here is of impoilance and I, am very. plaaked that the Sec.rethxy. is vith us; and the stair, go we can pUrsue it. -Thank yod very much, Dojtor. [The preparektatement of Dr. Noslipitz and the American. Associa- tion of PsychiatriC`Services fOrCliilaren ollows. Oral testiinoi -tinueS on p. 177.] STATEMENT'' OF an AMERICAN ACADEMY OF CHILD PSYCHIAT.RY. AMERICAN PSYCITIATRIC. ASSOCIATION, NArIONAL 41MCIATION.f-Tir PRIVATE PSYCHIATRIC` HOSPITALS, AMERICAN ASsOCIATI9N SER149.0. FOR CHILDREN., MENTAL HEALTH .AfiSOCIATION AND THE AsSOCI&TIO:i FW THE ADV A cE- MENT OF PSYCHOLOGY, 30SEI, D.. NOSHPITZ. M.D.,. AMERICAN ACADEMY OF CHILD PSYCH TRY and members of the sulvinunittee, my name. IA Joseph D. am past Presideht of the Amercian Academy of Chihl Mr. hairma Noshp tz, M.D chintro., and I a here to present the joint testimony of the Academy, the Ameri-. Can PsYchiatric Association,. the National Association of Private Psychiatric Hospitals, the American Association of Psychiatric Services for Children. the Mental Health Association, and the .-Xsso.cintion for the Advancement of Psy chology on S. 1392, the Child IlealthAssessment Act. e wish to address the clause in Sealon 3 of ;this bill which limits provision .ttreatment for those children who have been screened and diagnosed' as being mentally ill. inentally. rt\tagred, or developmentally disnlifc,d; Specific:inv.:we refer to lines 10 through 12 page 3 of S. 1392 ns introduced which rend : "(but 'mot necessarily, including. (i) those for the treatment of mentaI111ness. mental retardation, or developmental diSabtlities,* 4'.." The restilt of this parefftheticai clause 'is the exclusion of such treatment altogether. The Inilure to mandate such services for these children is disturbing 1.6 the membe$s'hip of each pf the orxnnizations I represent. - We know hbw diffichtlt it is to-tient children 'afflicted by mental illness. mental retardation, oVdevelOpmental disabilities. Much time, much money, much Adil and human effort 'are entailed. The'paradoxical pntcome has been that t itionallv. these children .Wereexcluded from service programs..In the past, si discrimina- Mott regrettable RR it may he. has taken place through nn act. Of ission. How- ever; this bill is un nscionahle. The legislation explicitly anthori .es the Iienial of treatment to th s ntire group of children in need. Such a deliberate omission stands 3n llitcct contradiction to the recommenda tions of the.'Report of the President's CommiSsion on Mental Health. 'tating- that "helping children must be the Nation's first priority in preventing:Weal-0V disahility." the. Commission recommends'that "A periodie.. comprehensive. (leirol;_ opmental assessment be available to all.childrenovith c4)nsent of parents.and With maximal parental involvement in all stages of the process." In '1,ts explanatiek ottlis recommendation. the Commissio xplicit17 mentions thr Child Henitiz: Assessment Program: Noting that, a esprit, "The Early anr)1. Periodic- Arre,,n- : 4 71 Ing, Diagnosis and Treatment Program of Title XIX of the Social Security Act ' does not incin the availability of treatment and service provisions to cover . mental illness,, ental retardation, and developmental disability when these conditions are die osed,".thiCommission states that "The proposed Ohild Health Assessment Progr should mandate that these services be available'. (Emphasis added.) . As it stands now, S. 1392 excludes mandatory treatment-for children diagnosed as mentally ill entally retarded, or developmentally disabled. The implications of this prcivIejali need to be clearly faced. Optional treatment is tantamount to exclusion. There is a history to this, and the sum of its teaching is that optional coverage for mental illness"means no toverage. . -1 This stands in radical contrast to the hill's declarations of purpose : "to continue and 'expand the' availability of health care to children *hose families do tlot have adequate resources to cover the Cost of such care and to strengthen° efforts , to assure adequate child' health' assessments. diagnosis, treatment, sand periodic r reassessment of alit eligible children." ,(Emphasis added.) That statement of , purpose says one thing : the language in which legislation IR couched says some- . thing-quite.different. In essence, the bill states that if you are a poor child whos)e . health has been assessed, and you are found to be mentally ill, mentally retarded, or developmentally disabled, then care and services need not be .provided: In effect. S. 131)2 declillbs that a 3-year-old diagnosed as liaving diabetes or kidney disease will be treated, while the same child found to have psychosis,. neurosis, or nepr ssion, will be labeled, but not treated. - We ave received conflicting messages from the Anmisnistration in this area. The sident's Commission on Mental 'Health has been a. vecy visible force in advocating treatment of mentally ill children. At the same time, the Secretary of the Department of Health, Educatibn, and Welfare is on record as 'sulmerfing optional coverage for children with mental illness, mental retardation, or devel- opmental disabilite4..We look to the Senate to assert its leadership role in bringing the needed eervites to these special children. ., . 'Diagnosis and.treatment of mental and emotional illnesses among children are the first iine of prevention. Experience indicates that the failnre to do co has ;already had severe e6nsequences and will continue to have a profound effect in future years. However, if a child's mental and emotional illtIless, mental retarda- tion, or developmental disability is attended to as near as possible to the time of its inception, the suit *ill be more normal development throughout child- liooduand a far bet xi chance for Inter entry into society as a productive adult. Neglect at this ea y age is not only wicked. Imt from the standpoint of a healthy and productive society,,,it is also stupid. The early treatment of emotional and . 'intellectual disorders benefits not only the individual and the family. but nisi) society as a whole. More than that. the cost of treatment at an early age is far A less than the cost of lifelong digability. social services, unemployment. or '".... nelinq ncy. . The let is that 'America is 'presently underserving-itsMentally ill childre c The are aproximately SA millio'n.chiJ ren n pa:youth. in the United States. wl eo Mute about 40 percent of the popul I don: If one uses the commonly acknowl edged flgnre of 10 percent Of the pop dation requiring services. for mental 0 'national illness. we would estimate that clOse to 9 m llion children have de- eiimonstrablp 1-Aychiatric pioblems. Ohl about 10 perc of this population. or about 900.000 children. receive any tre, fluent at all. . . Thus,!this prOgram offers Congress the pitential to provide a system of active treatment for chIldku inneed whoa presently being serionsIT neglected. .The,. proponentg of optional coverage advance the argument that children 7 diagnosed as mentally ill, mentally retarded, or developmentally disabled are, adequately ..4erven through other means. such as the Community Mental Health CentArs PrograM. One can onlv seriously questiOn those .who 'Advoente this as n solution. Origiwilly. most of the CMLIC system omitfed children's services entirely; Inter,.tlicy were phased in onlyafter a COngressionnsl-fnandate (Public-- Law 94--63).. Regrettably. the pattern of such service delivery has been very sporadic and disorganized. Tildeed. the Task Panel Report on "Mental Health 'rand American Families." which accompanied the Report of the President's Com- mission on Mental Health. noted that the CMTIC program has failed to meet children's mental health needs. It stated : "Pnrt r of the CMITC Act. which began to provide discrete services for chillip6i, is being dismantled: In many centers, ident-iflale children's progiams are not evident,: and children and adoleseents with serious Tental health problems are being inadequately serviced." (See "Task . 72 1/4 4 .ranelReports Submitted to The President's Commission on Mental: Health," . . 'Volume HI, Page 62X) . . . The. statistics speak for themielves. The CMHC catchment areas Serve 40 percent of the poptilatigm..Several years ago, the Mental Hcalth Association estimated, Very conservatively indeed, that of the disturbed children in this country. only 2, million' fell 'Within. catchment areas.. In 1975, however,. only 300.009:cfif1dren were seerp in the CMHC system. The rest' were not seen because of lack ofstaff,lack of funding, not gh specs ically trained cliniciaas, inappro- priate field s, etc. From these fl res,. all too obvious that the program does nto adequatel serve the children need. . . a/ But it is n t just this one By tem that falls these Children. Today, milk 29 states preVide Medicaid optIons cover thecare of child patients'in psychiatry! hespitatIN In 197k:tile Office oEduCation, DIIEW, suggeStedthrft only 55 percent of 7.8 million handicapped children were served by educational programs. More- Over, th'e same study ,noted thatonly 13 percent of emotionally disturbed children are ester reached. . . . Amother 'argument four refusing tosmandate these services. is advanced by the Medical Services Administration inoiv the Health Care Financing Administra- . tion). According tbtheiy view, there are no adequate cost controls hail the treatment.is too 'costly. In point of fact, this same MSA has stated repeatedly it does not have data on the cost of treatment of the mental or emotion disturbances of Medicaid children. Hence the argninent %is fallacious to begin with : in any I. case. it,would he a sorry reason to deny treatment to ill, retarded. or ills:11)1(1V children. , The Americdn Academy of Child Psychiatry, the American Psychiatric A.sso- cdtition,' the National Association of Private Psychiatric Hospitals, the American Association 'of Psychiatric Services for Children, the Mental ItliApisoeiation. Arld the Association for the Advancement of Psychology urge Sea te Finance A 'omni ittee to eliminate all language that am kes it optiona or the states to extend treatment to 'the mentally ill. menallyretarded. or ifevelounientally dis- abled child. In additionifwe recommend strongly that the CHAP prograni be . required specifically*' assess alt child health and mental health needs. and then to, provide all subse*ent active treatment that may be 'necessary. The House. Committee on Interstate and Foreign Commerce has taken a first major step: it has mandated treatment for children screened and dirMosed with - mental illneSS mentalretardation, or developmental disability for all lint in- patient treat ent in psychiatric hospitals. We hope that the Senate Committee ; -will go beyo this to insure" that all treatment iodaiiies ogre available .on a mandatory b sis, and that exclusion by diagnosis ortype of treatment will be eliminated in the legislation. * I respectfully request that the article. "Toward a National Policy for Children." . be included in the "record.oP this hearing. I#11 he ph seal to answer any goes tions you may have. and wish to thank yon again for the .qpportnnity to testify: :, , . TOWARD A NATIONAL POLICY FOR CHILDREN +r hi . (By Joseph D. Noslipitz. M.D.') ... .. % , The most obvious thing aliont our national poliq for childrim. is the fact of ies abseuce.,Thi. I. a' phenomenon that has troubled'inany child psychiatrists for a long time. I oi id it to share with ,v0h-sorne of the ways in why and other colleaknes have tho ht about it. rind some suggestions that we h gradually. dereloped..I pi 111, present these views in two parts : first. to'explore w it comes '11 alront that w lave no stated national policy for children. and to revi It- briefly some of wha we have-find have not done.for onr yinulg; and second. uggest in an experi kill way what we can try to do. , Cnri he major hazard in approaching this topic is a Inowledge of history. Santana was probab/Y quite right when he cautioned tifat we would repeat history if we would not remember it: in thts instance, however, as a natio , we seemed compelled to redo it in spite of remembering. . When it comes to our children, we are a singular people. Our best known era song is Rock-A-Bye Baby; and our first prayer, Now I Lay Me Down To Si p. , Dr. Noshplez is Presideneof the American Academy'of Child Psychiatry and delivered this speech at the Annual Meeting of th cademy. October 18, 1973. in Washington. D.C. Reprints may be requested trola,Ithe nut at 314 34th St., NATI., Washington. D.C. . I& 20008. T. ''' i t. /4. 4 1.../ '-.4 `, 0. I 73 .Thus, before Ontchild is 2% we have thrown him out of .a tree every day, and killed him off @very night. Here in Washington we have also managed to kill off OM Children's Bureau, and seem to be In the process of ilismantling the Office of -Child Development. About five to eight years ago our nation invested in a very major effort, the Joint Commission on 'the Mental Health of Children, and more recently still, we held. a White House Conference on Children and Youth. We wait in vain for their many explorations and recommendations to appear In the form of new agencies, or new legislation. Could we say, conservatively, that there appears to be a certain 'ambiytliiippelii our relationship with our children?.. 'Let us'Stay with Santayana a bit and look at our history. Back around the. turn of the centuryFrend's work first earns into view. Clifford Beers wrote "A MindThat Found. Itself' (1908), the first Juvenile, Court was established Chicago, and the mental 'hygiene Movement was launched in America. Within the frame decade 'Theodore Roosevelt called :together the first White House . Conference for C'hildien, and, in large measure becatula of its recommendations; the Children's Btireau was established in Washington. . Thereafter, the press of history, the first World War, the 'stock market crash,. and the Great Depression' sucked tip the energies of our nation, and attention turned away from programs for children. The White HouspCUnference continued to zneet every tenth year, and the 1930 Conference produced a set of recommenda- doh§ that could readily have been transformed into' a national polity. which indeed could still serve in that way: But no one -listened. and thereafter the . White HouSe Conferences -seem to have functioned as' gratifyfng enipunter groups, and little else. On the .other .hand. the Depression produced its olfn demands,, the Social Security Act was passed, and welfare legislation in the form of Aid to Dependent Children did become established. The Supreme Court decision of 1951 owned' the floodgated on the racial issue, . and the long p,ent-up torrent roared forth. In its wake came a host of concerns with the minority child : the impact of poverty on development;- the many questions about "cultural deprivation." and the signiticancevf different edu'ca;---1 tional variables on how children grew and learned. All This was asSbeiated with a postwar baby boom.that successively inundated the schools. IlLd social ifgencies, and the correctional institutions with myriads of youngsters ffeeding, well', just t about everything. shattering categories, disrupting the established ways of doing. things.,and sharpening trim sense of social need and social responSe. To make matters worse, people pourtir,out of the farmlands and into the cities; and olgelf the cities and into the suburbs, so that the very fabric of social rela- tionshirT, of rootedness in place, of unity of family, of ongoing connectedness 'with a matrix of practice. value, and traditionall thesewere rent asunder and swept away as the numbers of people grew,and as they changefl their site and 7-N mode-of life. And television came. It should'come as no great surprise that children felt much of the bruqt of. all- thisg there were so many more of theta than ever bef(kre. and tie one was quite ready for them. The -family was forever on the move, society Was far more. unsettled than before, and grandpa and grandma no longer came over, comforted you, and baby-sat. Rather, you talked to them on the phone. long distance. Everywhere there was social ferment and any effort to deal with the huge new problems, all manner* of theories weie advanced, and all and of legislation passed, every: cabinet department in the U,S. federal -system developed qome / program to try to do,something for children. and each of therm focused on a different group of children tri.a different way. Presently a. ragged, crazy -quilt pattern of patchwork services.Snd agencie,s Caine into being. All types of things . were to be done fqr, children, buf oftea'the s trogram clashed and- jostled. against one another they overlapped-in some 'arms, or failed in their totality to cover other areas. Somehow they often did not reach children h'ild families.who needed their services, or they did reach needy .people whom they could not serve: because of some quirk in legislation or iu regulations. And there was chaos in the land. his stae of affairs in turn heralded he establishment of the Joint Commission on the Mental Health of Cbildre hat is n t quite accurateine-could devote an essay toAe peculiar impac of th individual variables of great meron the gstablis nt of children'i egislatlo . In this case. Kennedy's contribution came bizarrely enough throug the mann . of his death, hnd the -eongressional bill which created the Joint Commissio was actually nicknamed the Oswald bill. As Rexford (4969) has noted, so of our legislation for children seems to happen because we want to .defend ourselves against-them. 74 In any case, the Commission worked for three. years and produced a set of recommendations Which, under the basic rubrics of child advocnicwommnnity, .. , 'services, research, and manpower and' training, covered a very Lee Of areas and actkvities..Buperficiall,y, it, would seem that inch a statement could have served as a nueletis around fvhich, to build a national policy.-In fact, howeVer, it did not, and perhaps it IS worth pausing for a moment and considering why things topic the course they did. i . . The first, and clearly tire most important of the recommendations of the Joint Commission, was for advocacy. This word has become both &trollying point and a target ; it remained undefined and; perhaps for thdt reason, multidefinitional, - and it. continues to be an uneasy, oft-quoted, suggestive` evocative, but elusive idea in the. field. It generates much ferment, and several advocacy proposals andoffices of advocacy were initiated; somehow, however advoebey never moved og center, it did not quite catch on. For one thing, the advocate was supposed to unify the aitivities of the several fractionated services and agenckes dealing with childalf, to find' where they were, and what they were, learntvhat they could do; and then' coordinate them and bring them to bear on the childten and f mili s that needed thetalliogical-missidit; even a noble one, but one of cons era e complexity. - I r e Tier a presentation by Edward Zigler. a former Dir or of the Office of Child Development,' in Which he describes his eiperienc hen he came 'to . Washington% He bad been given to understand that he was to be the advocate for childrenin the federal government, that it was to he his task to coordinate ,iithi activities of the several agencies which had established children's programs oniwhich contributed in some way to meeting children's needs. He soon discovered that to career civil servants. when someone came up to you and said he was going to coordinate your activities,. it ineans.thnt he was going to take away your money; thus, he encountered a rash of 'broken appointments. delegations of meetings' to underlings, and cold.weceptions, when he set about trying to advocate and, coordinate programa for children..,LogiCally, advocaCy is a goDd idea ; politically, it Is bard to make it work. Another problem aspect a adyocacy was described in- a dAinp for the Advance- ment of Psychiatry Ad Hoc Committee Report (Noshpitz et al., 1972). It can t,also , be. seen in the history of advocates of the past. Let us-look at the Juvenile Court Judge. He. too, is. an appointed advocate of children. 01P:ea tg.see to it .,littt they are 'protectqd from the punitive aspects of law. and that they' i t " e w e d instead as misguided individuals in need o f t reatment, protection, super- ' vision, nurture. education, and training and.guidance. The judge's task is to '''. decide how much of each is necessary, and to assign the Fervicesto the child and . family, however it went, and another soul would be saved. The problem was and still is : where are all these therapists protectors. supervisors. educators, trainers. and guides to be found? The tumwer comes mostly : "Nowhere." The probation personnel attached to the court. be they ever so Skillful], soon had far, far too many cases' to handle; the foster placements which were implicit in stich,,a mission did not exist; and the back-up agencies such as the training school, hospitals, or treatment centers were destructive, regressive, or full. The result we know: the' Court became a well-intentioned agency which worked ineffectively. often ,hopelessly, against impossible odds. 'and succeeded chiefly in producing a high level of professional discontent and client recidivism. I Whose faillt,w t? Whose fault is it today? Well, nobody's 'exactly. or, more 'precisely sti verybody's. The System. Overtly we set tip a good program. covertly. moke ft fall We. You and:I. Everybody. I eve that t tg s illustrateson essential part of the problem which will face, y child-servin agency, one Which a national policy musVaddrests. All o`f. the money. all of the good work of anyone part of the system will .coune to natigta ''4 if there are not the necessary.elements present to _handle the full range of pro* leas whick.arise. Orli in tilts imperfect world not the frill range; then the large bulk of the needs. for if thitse are not met. then the untreated case sits ame(pg us', Some child, somtkednily fn the midshof us, proclaims his or her neld, perbolis by piteous pleas, perhaps by delinquent assault: but saying through his presence 'and his suffering.that "things" are, not working: that something more has to he done. and this Will ac4ily a small Socus hf demoralizatioh and dismay for neigh- bors and relatives, for p ofesstonalm and envies, for everyone who contaCts the situation, and it +will cast its cloud on 1. the good -work done about it. (liven . many, many such instances, given, in short, the state of affairs in the total Old . . 75, of child Care today, thelivhole system falls under the shadow of disquietude and uncertainty and begins to question its worth. Theyesult, often enough. is chronic demoralization and high staff turnover, .or nregrouping on a,lower level of ex- .. pectation, where fatittre is the expected outcome of one's efforts, and the worker, or the team, or the agency sustained only by the uncertain reassnrance that he andthers are doing the best they ean,,that they, are helping some children. And IndeeA, there is always the occasional and unpredictable success thee-comes from God alone knows where. . Such unhappy systems are, ails, not uncommon. In-addition to the court, they include the more backward state hospital programs for children, soffie of the institutions for the retarded, i..st of the tritining %drools for delinrents, quite a few public 'Schools in pove areas, many a special education class and, in sum, all tho many of our .chit : rving agencies. How are we ever to .eal with all this ne'e' 43 and with our system? No easy an- . ewer is currentleavailable. In fact, We do not kuow.how to solve the basic prob- lem, and one symptom df our Ignorance is that we spin so.many theories, and .offer so many answers. The system wAll.not respodd 'to further patching: it really needs aedoing, conceptually and empirically. Unless it is approached that way, .., with a .certaintotal overview In .mind, It is very &Abdul if it can be made to work well. That is not.to say that it will - network at all. It works today, for example, sloppily, inefficiently, and inadequately, but its does work : quite a few . youngsters are seen and moved about, and .some of them a relelPed. Many, many a . re'uot, and all too many end up more hurt than otherwise' lijk their education, their institutionallzetiiin.. or their unfortunate' unsupervised plateinent. In so many of these insfirocergti seems that neither the youngster nor tire system can win. The only gefluine'elyrice is,among different ways of losingone.ean ake some decisions there; . - What would it take Mph system to work? Fireof all, I believe that it needs. a . an idea : an-axi,gmaticldea, no proof available, bbt .an idea that everyone sub-, serihes to. This is peculiarly important. From the idea we can.genera.toa policy. And from the policy can flow technique and method:, But unless there. is some sort of underlying, unifying concept,'it is difficult to Create a really .workable pol- icy. In oneWhite House Conference after another. ip the report-of the Johit 'NW-Commission on the Mental Health of Children, end in mans tier areas. ringing formulations have been advanced aboul our children's needs, our children's rights, E. ''our stated ethics, and our cultural responsibilities,. Sad to relate, none of this seems to accomplish very much. MaYbe it is my personal scotoma, or perhaps it is A very American reluctance to accept ideologies of whatewr "kind, I do'not know: Perhaps a is effnply that these ethical imperatives enteT too directly into our areas oteultnral'anthivalence. I would therefore like to propose a rather simple fermulation which I will Call the Principle of Consertation of Development Potential. This principle states.. in'brief : a' culture sueceeds or frith{ in direct proportion to the way it enhances or impedes the development of its children. In other words. a culture that encour- ages..prpfects, and furtherit development will do'hetter titan one that does not; A culture can conserve developmentalpotential, or waste it. If it does conserve it, it will-makemore money, produce more inventions, achieve higher artistic lovels: provide its,children better parents. be more just to its citizens, light better wars if it hais to, and have more solidarlty.as A people.°More than .that, individnalsi --k -s-people will know more joy. : . This, then, 18 the underlying principle,' the philosophical set. I think of it as 1...7,:.:ti-ProsEnatic principle, the fruit of ob v.,ationgenti..e. _basis for action. It is a With trilmittedly,,,pial 's.;:fi). the child psychiatrist, develop- 7-r: he' heart:Orb-1-S work. e" how complex development is, with its many---c Leal dimensions. He knows that there is a nniverse of diSconrse covered. 9' word, and tbat we are a long, Ivey from being able to realize all its'?4 ions: netheleff Ft, he also knows that we do know somethIngohout it, and .. that s tcour national business to design our civilization so es to give the um multis, support, find opportunity to the development of each in- : Iv The ifolicy whlehsemerges from this Kincifde is- that it should be the Stated commitment of the United States Government to endeavor by every means at its command to presOrve the developmental potential of every child in the land. As we obat,rve children, we cant see that each stage of chiitlhood te.,comprised xpet of.moving elements that form a- complek wave"frorti.,6kin 40deVelop- ment nyoementiof intricately patterned interrnatedftWq ences that - ,r 4 4. Of .76 advance together,"flow to enhance, now tonfuse,. and occasionally to caned . . each other out. Bubithe larger resultant of all their varied interactions is growth. a progiessIve unfolding, all through the life cycle so that you and -I toe are net static, never cross sec One, we grow always, and we shalAontinue to do so until we artiveat what be t4e greatest groWth step of lid, .the momdlt we die. At no time, however; 'the rate. of suchlgrowth, and Its vuinertddlity, to insult: so' great as in childh 1 I i And. this in turn begets the need for societal concern,' ' societal protection, sod tai help, to see to it that within our children those deli- catei.intengible, fragile, weblike. processes unfurl/ with. all their richness and complexity preserved,- and that each stage builds securely on the health and integrity Of. what has gone before. - This is society's task, and from this viewpoint then must flow program. 'method. . and.practice. How,does one go about conserving developMent.? Please note the language usage here to "conserve.!' I employ thls verb advisedly, because I seek here to ally -myself with the conservationists *rather titan the educators, or the -sociologists, oreven the therapists. I do so for. two reasons. The first is that I think of the potentials of our children as an immense owellsprhig of uhgtely pnecious quality, a realizable asset that ilkpecullarly human in character; it is not primarily economic, although it Undoubtedly has extraordinary eeonomio implications; that is all too easily and quite typically wasted, `exploited, sot. destroyed ; that 'is gicz much lip service and insufficient support ; and that will reap us an abundant rvest if nourished, pregerved, and protected. In effect, I am trying toldipthe preservation of child development past our cultural ainbive- lence: I might add that' t1.418 approach has an Interesting precedent. It may ht% -apocryphal, but it is an oft-quoted story out of American history that over a century ago there were several attempts to bring brutal parents to book Pin mis- treating children, but'they were all failures. In those days, no statute coutd,be written that would interfere with a parent's -right to correct his ;sffspring ; no matter what a parent did; he was within the law. Finally, a easeof child abuse 3 was brought in under a then-existing code that decreed hunfane treatment for animals. Thd court tufed that children were indeed animals and so came under . the protection of the statute. Only then could some of.tffese abuses be,apprAthed. Today, there is a settee of events unfolding in the country whleh, while different in character, are nonetheless reminiscent of this same style of approach. Here- tofore, there has been no way to force a state to educate or to treat its young. Chttently; however, a group of inspired end determined young lawyer" is opening up a whole neWbattlefront With the culture over the question of cbgdren's rights. In effect, these. attorneys are using the adversary approach that is so deeply ' rooted in our ores to challenge .the culture, saying, in effect : if 7our -pro-. fesse ( ards and legal codes state that people have certain inalienable rights, what..bout the rights of our children tp humane care, to treatment, to editcation? . 4: please note. the plea is not for children qua children :' it is for 'elviPrights ()f a .particular group as a legal' matter. If you strop to think of it, .there's some- thing,schizophrene abont the feet that a state wonid.ha Os to be taken to court 'to . give children these basic supports to their development : from the print 411' view ., of the sapient of societal ambivalence toward children, opts etur only sigh. Q.E.I)., aatl all hail to onrinwyers. s . . : So I feel I am in line with established preeelknt when_ I foeus.oli conservation. And indeed, where children are concerned. swe hilve-something very important to conserve. We know that tlfere'rr crilleal rntellec. tual capacities that are !ailing' to unfold, multipotential stage. of embtional elegloptnent that. are not 'being. achieved, boundless capacities 'graw both physically and emotionally that are;, -, not 10elng realized, towering levels of psychosexual maturity that are not being' '. attained; and.Capacities to lovearf work that are being stifled and atrophied. We a. have 'Nato look-about us and we see all manner of snuffIngs out and Safikatings of the conteptual, the creatives and the hnmane in our developinicyoungsters4vith resultatt withering of some -portion of their potential hunianity. All Ibis because 'of our failure to throw the full weight'of auk efforts and energied'into the kind of work necessary'to protect.sfnd preserve these nascent and unachieved frtfltions ! 6, I take it for granted, that behind any consieryation program there is likely to . a wind detrlof love; a measulr of genuine caring fontwhat is presetved; or if rpht ' then there should beat least some self-love, an enlightened self-interest that can see beyond th0 immediacies of Cost and expense; It is self-evident that children who are better able to love are gning.ot make ter a better society ; children who are better able to learp. to remember, and to work are 'Oink to make id. a more productive society ; Children who are .better able to control their impulses aud . , :- s .' '''"' ,.- . T. . S 81 ,st st, . ..s... - I 7 , . , , . . . .. keep their emotions in check . are the ldkig-range answer, to our common yearidng for a safe society; and children who are able to dev,eloi tendenteas -couniaSsFop, ,, and feeling for other people w rely make for a happier sociffilf I. propose a , problem to our economists. If ou ould raise the average IQ leve our society 9 twb IQ points, what would be th direct ou out gross national product? My predic- tion is that it would be coneidetilble. More to the point, however, is the tact that While children as-entities ar not tare/full pSychosocial maturity is SO uncommon' that we ale not likely to meet more than two or the truly fully Mature, com- plettly. integrated human .beings in a lifetime: the potential fur such an outcome is i 'in, us all, but most of us never approach ft: I am talking here of conserving so thing that is in fact infinitely precious. .. .JI . he Second reason for invoking the concept of conservation is that it is an At4sustion-oriented Idea.; it speaks to things to d of task and programs and chan- nels for endeavor. Certainly that is era what w do need now. We need a Poiht; that will lead to action. Hol%, n, do we Pegi ? How, to repeat the (pies- / tion, does one g about conserving velopnient? Wel, to conserve it, we have to worry,. about it.r4Ve have tti.consi erits vagaries, it 'vicissitudes,. RS multiple potentialities in the face of inhere t difficuAles. We ha to devise preventative methods to avoid trouble, growth - enhancing tactics to m mize potential, and therapeutic and rehabil tative practices to cope with troub ' that do appear. We have to pay attenti to details. , . . As, I see it, thereat two levels at Miich the vjorleof eonservatiOn,mnst go on. One is the mufti. 11 of .family, potential ; the other, dt. Individual capacity. Family potential implies a heist of action programs: Musing, income protection. legal services, community organization, Fat control. disease 'prevention, nutrition, population control, city plhnningf coping Ivith racism, women's rights, adult edit- ation, marital counseling, and a whole universe of adult services that protect family function, enhance family feeling, and prevent family disruption. It implies 441at oveleach parents parenting that we cope with child aldse, that we teach corporations to think twice before they move families around, that.weleach hos- pitals how to nraintain dignity in .yvaiting rooms, that" we-teach police how Co approach family diflinultieS: that we leach politicians what they lose whtn they vote down family- support legislation and so on and on loran induense variety of programs. Today, however, we wanf.to look more closely at the other iev g level of the individual child, and to talk about how society can cup hand dund-eaCh .> young grower,. and preserve and protect and enhance thisnedglingstill he or she reaches his fullestseature,-his most faultful being. From the moment of conception to the moment of death, we are alMf as woven about with the liyipg strands-of our cultnie, fibers that can become 'wings with which we may fly, or tarturtefes to hobbje ns. or a noose to.destray 'us. I onr burden, then, and our mission to strive to shape our culture to nor larger" ends. Let me repeat the three dimensions of care with which society mkst approach each stage in the life cycle of each developing child : it mast seek to Maw. ent what- ever ham can 'be prevented, to enhance whatever catutcity is -.there, and to straighten and heal whatever-hurts. 4 During the work of the Joint Comtnissi.un on the Mental Health of Children. the question 'of service delivOryniodels conuna,nded a great deal otAttention..Rati, Prugh developed -an initial model which a Group for the Advancement -orsya- ebiatcy Ad Hoc C,prnmittee on the Report of the Joint Cormalsslion on the Sleblak-, .Health. of Children later elriberated into a mental health grid. I was a,,member ofe that committee, and I would like to repeat something of what was in that Group for the Advaaeinent of Psychiatry report. This.00ncept-of service delivery. was built on a notion of plotting the child's age against his levels of fonetioartl coo- petence, so that for each age there was a built-hi statement of what services he wofild need. In-Iffect, we can begin. by ,drawing a diagram. 11-e4 draw a , line, the silo' of 4- .grdiffh. Along Me length we mark a Series of poines. These points each -represent . a moment of development f they could labeled: pregnancy. infancy. the Arati- Sitional child, toddler, pre-sef oolr. early latency,. Prepuberty,' puberty, mid- adoleticeit, mid young adult; This, the ordinate. _ Next. w.e.draw.a line at right_angles to the growth line. What shall we plot as our E;econd dimension? CleaVy.Aildren-are many, things. joys and:problems, talented and retdrded; average and devianthow shall we regarditent Most use-, fully so that we can plan for them? The proposal iFf that we think of a spectrum a * s. , , t'r" / 78 ; . with -o end points. At one extreme is the child with' unusual talents He is =Veal; as.an extraordinary memory, or is cognitively rycocious, or A motile- 7matical-Marvel, or whatever-At the other end is' a_group I wouldCall the tragic Children, the severe' organic retardate, the lifelong nuclear schizophrenic,A.he vie tim of massive brain trauma, the child whoin can: ease; but when welcannot otherwisehelp. In between .there is -a wide range -of .possibilities, andI propose we list them 112..a series 'of eloSely demarcated 'categories in order of decreasing- competence add in4easing need for.help. This; then, beccii our abeissa ; its points: gifted child, competent child, vul- perable child, stressedchild, troubled disturbed child, and -tragic child. ow we take out our, rulers and draWlines from each point, lines vertically and lines horizontally,,and.16,.we:have a grid, a checkerboard of intersecting lines. Our assertion i. that whereVer these lines' meet and -cross, a set oil- appropriate soeialinstitutIons nInsetecreatedlto proVide the tripartite responSe that is neces'- '4saiy_for that ageogrotipwiththat level of need. .4. A few examples should illustrate how this.grid works. Let us considerthe early lattney child and the services' he would need'. We .follow along our grid lint for . this age gi-oup, and the first point we come to is the-gifted child. What does such a gifted.7-year-old require? Since.unusual talentli expose children to novel stresses and unique social pressures, there may be need. for parerital counseling tb help the parents protect the child's emotionaldevelopMent. Often enough, the :pres- sures are felt most keenly Within the child's own family. Along with this, the sehOol would have. to have anarray_of .special adaptations for the. precocious or exceptional youngster. For some .childpen these. would talent- 'enhancing programs such as special tutoring ; for others. it might ntealidi planffil avoidanee.of special training,-a minimUm.eulphasis.on.flifference. Idshefrt. talent needs carefully designed educational and'-emotional supports for its fuliconserva-. than. .. - Now let us extendour early lateneyiline .actoss .tai the next point, where we -.encounter the competent child. Thegreat.soelali2ink 4.nd facrlttating agenez _for . this, Youngster is the priinary.schooland our culture has indeed addressed3ithat Issue; most of our children do get an exposure. to: tliat'level of edneatiOn. What is tacking; howeier. and what We hope w are :apPrOactling -but have not yet achieved,. isii sort:af quantumsjinnp in.how to 'teach; a beginning appreciation.' that all learning .1..sAl cognitive-nffectiye proc:ess: 'and not just. a matterotrote, or ed4dttioning,;or compliance. or, intellectual' mastery. Our schools and our teachers are graspingthis alowlfoday; apdpreciouScapacities in our children that coula'have been kept opea'andpreserved are still being shut off and aborted .. , by thelailure.of our educators to address the affectiVe.cOmponent of the' learning . Whfitwe also are. only beginning to'deal with it the fact that-every competent . . play- shift 'columns. oq... our grid and become af, vulnerable oneA parental . a..serious medital Or surgital challew to tbe child himself; the all too common experiernv;.pf family breakdoWn, n lfts-e to a new and more denianding environment a variety.of factors cap transferiii- a yonngster who is growing Well into one who is atAiiqc. A series of social responses-in depth can help and preserve .the growth .pOteiltrmt;here: the presence of a guidance. counselor or a menhir health Professicine school; staff the,:preparation. ot the.family doctor and Ai...the.pediatrichin 01. rl(signize the impact otemotiOnal stresses on.thedevelopmental 11pracesseWargi tp k;ow how:to interirene ; the aVailithility of mental health can- sultation to,fathilies and to agencies serving the coniPetent child, such. n's camps; lindplaYgiound perstinnel, and traininF programs for sena!: leaders: and librarians 0 'and various Icinds of. neighborhood n'orkers :.the use of hdult education techniques to: eens'it* and rinform'yarents about children;03,. needs.; .nneso 'On, for a wi-de'li. rfingepf.probleme. Let ns advaace anothOr point on the grid. frYltn tii vidnerable'ehild to the tressed:child-Fie 'or she is having some trouble. or neurotic,. symptoms or fedelintme.nt.,behavio.- are *beginning hi he e% Here is the .»rime' -site of action for shiiit.:1- m av *therapy, afor family interven HMI, for belief egroupr. - activity therapy. M ,I Z.n.n cone from the pollee hthlne, league, the fos&r .. grandparent program, e Big Brothe'rs, In some areas tkese youngsters need probationary or. super orrsuppOrt. These may heliacked bylproperly designed group involvement's., .alOn with ii.wholehost of yeaphing-out piittprns borhout*Orkers ands. lal camp programs. In the:skhools; meattOhealth classes can be .of help with additional tutorial or specialeducation approaches- and 79 .- . . with opportunities to maximize the child's available skills or to find channels for -his.or her-interes abort, to do:the work of preremediatibn or early remedia- tion-necessary t o s set thislevelet disequilibriuni. If we proceed to .1. a next lidint, the troubled child/we encounter the need for ' intenske .pSychothe : y, pharmacotherapy,. child analysis, day care, or group home care. The (lister . . child would, in turn, require long-term residential treat- . Ment or other .forms- o 17-),,,tional care.. Finallz, we come to the trade child with the special lifelong 0 7;., lo. kr :The 'r she requires. At each point in..our grid there is a need for provi 0 ,j,,i; - ; . erns of intervention and support which that . - stage of chid developm 1.-.:--'4 : t.thatleyel of function. 4 . 16, -For contrast, let us j reid-adolescence and see swhat.happens along - that grid line. First, we en e ter-the talented adolescent.- It is a challenge ' worthy of any great cultu to r (wide for the special-abilities of gifted young- sters .sofethat eir talents e ...own, channeled; refined, and rewarded: It .strengthens bo the individua and his society when such a youth grows and flu.orishei.in. his of her areas of competence and obtains the richest frUit from higendowment All types of specialized and advanced training, tutorial prograins, work opportunities, specific camp ail?, school wettings; a/chance to meetarid work with leaderl; in their fields, along with emotional suppOrts'Ilhen and as, needed (te., an open -ended group the youth could attend if he' to" .which e .eoping Wi talent is, the focus of the work, and.with the back-up oradividual therapy o syciroOrelysishlt indicated) : all of these Would be at lectit part of the picture. . .' .. ' . . To proceed to. one more point on: line, the competent teenager might need .a puberty rife, 'along 'with his educed.= and his social experience. Many young- . sters seek Aft such .events, for inetanci, by joining a gang, or getting a driver license, or getting.into aF.paitleular college, or starting to work, or -through a first heterosexual epcomite.ri:-Thek experience enormous -anxiety:. and . tension "...about this ini(rial event; and they get profound symbolic as well as realistic ". satisfaction liebause they have'e4dured the ordeal. Instead of letting the puberty rite just happen, there might we-b' ed cultural response in.keeping with ' this. adolescent neek e.g.,_ a yecti..ot. pr atien for the -driver's license, with eceWes in social behavior, dating inacar,..t suited= .and control on.the highway, .. anll sorts of associated a:mice which would bring a. youngster into contact with social mores and'practices via the ceremony of beconying a driVer. The ceremony. ... itself copld be made a rich and rewarding experience taken very seriously by the whole *ial structure. .. . -.... . . These are a few illustrations taken out of the grid.. Qne basic 'characteristic inhejent in this pattern is that of assigning a child to a piertlenier, category which had Et)thing to da with hls diagnoOls, merelywith- the level of treatment required: . j This0 clearly a medical decision and .should be made by' the child psychiatrist. Thus!aa child with. school phobia can be claSsified as "vulnerable" and,re.quire some brief therapy, consultation to school, and work with the guidance counOblor, orlie-or spe can be diagnosed asdisturbed."-and be a candidate for institutionali- zation. Such distinctions are important for planning service delivery.. programs, ;i -..'and coMputing the economic?.of care: it could help insurance companies 7 coverage in terms of functional level. Hopefully/itwonld make the whole.,sucial ..I, management of a given child clearer and more consistent The point of this grid ..-. is that. in be.superimposed ob any comtuunity and the hard questions Can then "- ; beusire in terms of our policy.. whet services for children are present and what rib* hat more is needed, what is potentially available, what needs yet to be , . st tor? . . . 'Often enough, we are told we must choices, determine priorities, get first v ...). .....- -.:thinks done first. Sometimes this lias taken the form of Which,..age group.. needs '..: the most .help. At . various times in the past, the focus of public /Merest has been -. :onitdolescence.; not long ago, the emphasis fell "on the preschool child; more recently still, it has been on the first three years of life. . ...., 'Ant one cannot emphasize any one Pant. la fievelopment and say,."That's 10.-L , We'll prOttlettluit!" These is plenty of evidence that such a course simply 'does riQt work. or better or for worse, all the stages of ,development-are important, and the all freedaximum support... . ' . Let u *enexample. ik few years ago, one of the difeet creative and'inlegine-. 't . program et to 'be.devised.16 hell) this .nation's children. Was organized by J ins Richmo and his colleagnes..Ir Jl was called eed Stattliichinond recog *zed that there was 'a whole univee4 of preschool children*ho lacked an . .. .. . t,. ; 'l- - . .. 4 '._ .. .,,, 80- -e. ..,-.. '''- adequate fru' eof many Ingredients essential for development. He devised. a . , . . . . program tha rought thetie ichidlren a goodly diet of preventiim, enrichment; stimulation, and -edtication.-- Many of.Alie_children,__Whq. were entered into this program responded beautifully and began, to make.4vIdent and 'measurable progress. By the time they were ready to, enter seltool. they were doin,...-- well, . %NT$;k in g at a relatively good leveL The investigators connected with Head Start waited ayear and retested the,children along with-a group of controls.. children, who had not hadthe benefit of Head Start. Lritind helrold,,A,y the end of the year; ` . all, the initial gain of the Head Start children had`been lost ; tlie_two groups tested; . . alike. . --) . . The respbnAe it this wail twofold. One form tookAltedirection of Seeking to. continue enrichnient and stimulation.into first grade.' Evidently, the }loins needed . to be given.continuous support if they were to be niainiained. The other' took the tack of throwing the weight of help and research into the earlier.. years of life,. the infancy and toddler periodic. In Other words, the attempt to deal with one point in development gave only limited success,. and the efforts then spilled over into both collateraIs, both the stage ahead and the -stage pehind. . . As I see it, there is a crucial need to. support developrirent all up and down the. . line. There is no one phase that is THE ohe, the eritirai one Or. if You,like: each phase IS critical in redifferent way. If your prlosity is to prevent the Most serious organically based disturbances, then you must- coneentrateSnn genetie. int-tauter- Jae,- and neonatal events, for most such children are formed in that set of crucibles. If you wish to deal with the severe narcissistic problem. the. borderline ;child-, or certain forms of..psychosls, then it is the first year of life with its un- differentiated,- autiatic; symbiotic, narcissistic preobject and early object fqrzna- tions that must, beconie the focus of your efforts. If. on the other hand.-.it i's:. deliqquency- and the impulse disorders you would avoid, concentrate on the anat . phase; the toddler is the father of the delinquent, and the delingirent co often really an outsize 2-yea -old. Again, to preVent or ease the burden 'of the neurotic.. ' Oeto try to head 'off so-daily character problems, the focus of the work shifts to the oedipal period. when _this set of disorders is forged. Or, if it Is work difficulties. . that concern you, learning problems, peer relationship disturbances; and habit- training disorder's,' the latency child is your proper target ... and"So on and on. . But It seems to me it makes little sense to choose in this way-. On:the contrary,. It.wOuld he .the counsel of wisdom to. develop a model for a pattern of services. a matrix, that Would begin to greet the needs of lamilies and children at. every level. . . . ,, There has been a good deal of thinking about how to do this. The ,rtuthors of advocacy in the Joint Commission drew up a. master. plan involving multiple-. levels of government and a bureaucracy that " extended from the White House to . the community. There were careful descriptions of advoeac councili at every Al:level. -Unfortunately, one did not beat niuch response-to thi.- idea. Other overall ..mir . .--.:approaches have:been _contemplated, and today perhaps tit most widely touted Jong -range answer to needed services is the concept of national health insurance. This may be an answer of sorts..It seems to be based on thepresurrintion that if money is available to pay, for services.. Itnit, people want SOrvires,- why. services ' . will.spring up..AuiL indeed, they might,41tobably will. but I must onfess this kindof thialtinges me. Itis like saying, if we want housing, and: people can afford it,bhilders will come forth and build it. That, in fact, is just whatlutpl:. J)ened., and that is how. we Obtained . the .worAt features of.poputed suburban,. !... : -, aprawl. I wonder if somethlpg similar iä not - happening inresponAe to Medicare;':' .';:.:'43fany people are .receiving.: many services, and new arrangements for- Service.. delIvery are springing up. But it remains to 116 seen if the emerging Patterns are ..:. w.°7(iiiiiiital: 'One hears that waiting aoma], the4eorner may be kiddicare, where a ':',-141Adlar ElAtem for fundihg.services for materriatl rind infant 'care will be enacted. . ., Well it is good to know that of Iinaneing are -being thought through -attft-f;....-. arg..rencbineftnition. Brit that does. not. necessarily mean that the best pattern. ,. i". of services will thereby emerge, any more. than it did Wrt.khousing.in aubuflitav4.- .--: Indeed, eiren though most people.who wanted houses and &mid afford them (vere.:, - ;able to btu .their; many questions remain about the quality of the Houses turd of -,' the cnmmirnity lilt, _tjiat ensued. ' . . It .is -noteworthrItibink, .that- even in the housing area our cult-bre ia,trking a. new .towns,-plairee .1*m Oa' We Are not just nsing money :. we are'llt4inz ', efit new approach. Fr d thenApre have -ptarted Planning, designing, and btribling. . 0i* ability to create. We are daineir little looking ahead, a bitofthinking through before we Mild. I subjnit that.if We wereintpregted in conserving develbpinentak. , t- . . ..: ., p t-- ALJAJ 4. 81 t , .. .. . --.:potential,.$ome'Such thinkfqg might" weil go into our approach rvices. Insur- . '. arice-can-cloAgreat-deel n.help- people get services, but it is not-the-only:answer, . and perhaps not the-best answer. Alongside thecoverage, we. had .better do the _.. hard job of thinking through' who needs whift services and ho* we deliver them. -.this is the direction I wouldsee our.future thinking go. In resent years,- there has been an4fttempt to think this way about mental health services'Ior thd entire country. The Community Mental Health Centers were devised in order to do just that. Unfortunately, they were never given a chance to expand to the planned-for. coverage, and, more to the point, they left out the servicei for Children Up 'until today; no one knows°. it iille liow to put the children back' in. In each blaci whi h 'elects anderigages in SaBh a prograth, however, I would build in a grid comp etely': all thepecessary'services and-their missiOns to conserve developmental ?tidal. I would hope that each Such .site would * become a catalyst for quickening the interest and etciting the desire for .emula- . .tion by:adjacent areas. Each community will 'certainly be an experimental site; a sociological_gesearch project, wherein, to study linkages; Overlaps, social impact, .and long-range implications. Given adequate backing and support,. a lot °erfekt, and a lot of luck, such an idea can take root, can imry ive..and,can groW. Basically, it means thatbne has to sell an idea ; if that can be accepted, the pattern of sere- ' ices and their implementation will follow. But, when all is saidend done, this notional a grid of services for children and ...families is .only one model, perhaps a poor one. Surely, there are many ways of :approaching the matter of conserving developmental potential. The basic point here, however, is that as a cultiffe we need to And some way to do this. It is worth society's efforts and energies. to try to devise such a way. Indeed, to strive toward such a goal should be an urgent governing Mission of a culture such as ours;. to achieve'it .would be one of our,'proudest.aad most :niegnificent accomplishments. s is . Perhaps this is an. ephemeral risidn r .spili for you out. ef the cobwebs of my - elwn mindsubstance. onetheless,1 cawilnly state:Merl firmly believe that locked .away in most of us are very considerable riches, a wealth..of-creativity, and love, .asst constpctive energy that iit 'feet are never fully realiied. To strive fo unlock this and allow these potentialS their maximal realization are goals fully worthy .--. cif our common humikiljty. . . . .. 1. REFERENCES . , ,..".. . . % . Beers, C. W. .UW81,, "A .Mind That Found Itself." New *Vork : Longmans, ,, 'green. . U . Noshpitz, J. D., -Green; J. 111., Merger, M E., 'Switzer, R. E. Work, H. H.,... . `gads. M. (1972) .'!Criiis filehild Mental liegkh : A Critical Assessmentr Group-. for.. the Advancement of PSYChistry Report No. 82, . Renford, E. N.. (1969), "Childwen, child psychiatry, and:our brave-new. world; ... :Arch. Gen. Psychlat-20 :25-37. 4 .. f Arch. '. . 4 STATEMENT OF THE AMERICAN ASSOCIATION OF PSYCHIATRIC SERVICES FOR CHILDREN o .... . Mr. Chairman; distinguished Colleagues as the largest orgauization of chit", dren's mental health services in the country, the American.Association..dr Psychk . a (ric Services for Childreri, whose member services employ over 8,000 child mental 'halth professionals from all the disclplines,-wishes 1p cofnmend the stated intent ° of this legislation, S. 1392. . . . . It Is :unnecessary for us to reiterate the 'declaration. of purpose%contained in :section 2 of the bill. We certainly agree on the goal of-making quality healtbcare :available to those children whose families do not. have such.. care In 'many re- . . i:Tiectii the CHAP bill does improve and expand upon the early periodic screening Atop- maim and treatmentprograni:In fact, the legislation:appears to' be responsive to many of the criticisms that have born leveled against EPSDT in the few years .."' it has been operational:lt adds to the medicaid and EPSDT eligible population: .Those childrenrinder the age Of 6 (although we would like to see this amended alse, to include children !min 6 to 21) whose family structure presently makes_ them ineligible-for services. It Speaks to the Mime of continuity of care by con- tinning eligibility for mediCal assistance for 6 months after the family. is .no -*. longer inedicitid eliglbleibee use of higher inroine. It increases the linatatiaLiii- centivesfor tlykSta by. au enting the Federal match. It attempts to improve ' upori the qualltbr, continuity of care by asking the:States to enter into agree- . mentstwith cciinti ensive care providers for health resource, developmeWn ,. . yr .;... 3 82 areas with'a shortage of comprehensive care providers. And it mandates treat- ' ment tocallgoirditions-folmdin-the-assessment- of- children_with_ certain_nottible 'and shortsighted exceptions; namely, Mental illness. mental retardation, develop- "Mehtak disabilities, and for certain .kinds of dental care. 1. Nonmandatory Cb-verage of Treatmcdt for Mcntal Illnefur.The limitation on the treatment of mental illness poses an ubvioas problem to those of us 'elgaged-4n the provision of mental health sericps tq this group of particularly ." ;vulnerable, children. The bill as.'written In fact takes a regressive step from the .original, enabling legislation for EPSDT.,which. although not mandating federal "financial parti ipation in the treatment of mental illness, did mandate referral for treatment wises. As the present legislation reads, only treatment service,: presently avail by in the individual State's Medicaid plans would be covered 1.y C P. Since -in atient se,rvit:e's are now al.State option. as are clinic services. Mi healtbt eatment services will got be aililable to the CHAP children in those states VI Milo not include chuicand inpatient services in their medicaid plans. Only 2f6Ftates presently incinde.ibpa tient services,: 42 ineliule clinic ;zest-- ices. but nbtall of the 42 include mental*health clinic. services. The AAPSC has questioned many-of the DIIEW offleials who participated in the draftirs, of the S. 1392. We *pre told that the exclusion of mental health treatinent.servicek from the mandatory provisions, of. tbe Bill was due to the lack of available data on cost and utilizatithi of mentfil bealth.treatment services: by persons unger "21 yearg of age. We find this reasoning untenable. In fart, would like fa suggest that it places us n a ileatch 22" sitnntion, °AAPSO attempted to get data from the Medical S'ervices Administration about the cur- rent experience with mental health sprices to individualS under 21 in the title XJX, program .fol many years. We luiv sked : "IIow many children airk beim: served in the inpatient program and re the costs? How many chilciPen are beifillserved ton an outpatient basis th clinic. Outpatient. hosFital. and dividual pitovider services and *hat ate those costsr.WhatAve have been.told in the past is that HEW:doesn't know, that the data -are not broken down Mily.: Up.until July of 197.7, W W e were also told that HE didn't care about colt n7, such luta. that there Were too many, other concerns about the operation of the. medicaid prograin to bother with taking.a look at the experience in thetental . health area. When-the inpatient option invame law we er en suggested to the Department. that it would be relltivel?Funple to collect the inpatient data on mental health services to intlividuals under the azo. of 21 at the time of the- initial implementation of the prligrata; Init our remiests always fell on deaf ears. In .Tuly, 1977, we, received. fromethe acting direetor of the Medicaid. Enreti. .; written assurance that the collection etontpalaent cost and utilization data would "' become a high prioritx,Athehr: fiscal year 1975 evaluation plan. This assurance Comes a little late fo-W to quiver HEIrs insistence that the reason for the exchisidn of mental beartIr treatment is. the fact:that so little is knowii.about the costs of treating dental filnpsji in'ehildrenfAetnally. not a great deal of data.' .- afire available. but tluit ig; only fbecausi! oake has been interestqd in funding studies that would permit the colll,etio,ntof snel) data. A policy-paper- prepared . by a public health antil3lt on the staff oP the Assistant Secretary. for Plaimitt and Evaluatioli 'cites the hick' of rekeareh resources as one of the primary reasons for. the scarcity of prevalence ,atudies in the area of children's ltandicapping conditions (John Dempsey. "Handicapped Children and Disabilitr: A Polley Overvie*.Paper;" October 1976). In fact, this same paper state§ that ttlere is very little trelfurate,data on the entire population of litindicrippe4 children in the Nation,. but that data in The area of the mbntally ill are Aost lka.4.ng. One .ran takethe argunientgontlined in Dr. Dempsey'S paper incstep'faa-ther :.there liaise been no resources'availahle for the collection of preface dela and. thefejnive Imen no rekerces.available for collecting east and iiti a lata. The AATSC has attempted-to gather, hothfrom..its kilherslifp.and from other sources known to us, what prevalence and,' stlutilir on data we could. given the resources we could muster to collect ft. Vhat. s a h ve Annul are eon- . tanned. in 'the tables' appended. to this.statement. What 141-10s, Available doce; 'confirm what-We have been sayingfor many years based,: our own himaani tarian.instincts.Thamely. that emotional disabilities"a e etrpfead among the high risk children served by the EPSDT program: that lkof these children tan.lie served by relatively short .term. intervenfliA. and t'0" -the very small percentage who need the lengthier and more costly inpatiealt-, esidential case. the utilization and cost experienre in the small samtiling' of .$ es participating- in' the program,,does..not merit 14EW's decision ticiremove treatment of mental illness from the mandatory provAsions'Of the bill Mite appendix I). . , an fact, we would suggest to the distinguished members of this committee. that . ST-1392-aspresently-constitated-provides an--incentive-t,b-those--States-who are not presently participating In the inpatient and clinic options_ to place children . Who have been assessed by the program in tip diagnostic categories where States need not he financially responsible for treatment. This categorical approach to what is heralded tobe 2/- program promoting "more comprehensiye. continuing primary and preventive health care," is contradictory to. the stated purpose of the legislation. It would appehr to us that iKkvould be far more rational to eon- sider the CHA3IPUS. (Civilian Health and Medical'Program of the Uniformed Services) experience of lb:tilting costs through quality assurance measures such as peer review and stapdard setting, rather than arbitrarily delegating The health services relative to :emotional disabilities as unnecessary and too costly com- ponents for Inclusion-in a comprehensive health care program. The exclusion -makes no sense to us either from a humanitarian or from a cost effective of view. Our experience in the field, our participation in preventive aswell tt diagnostic and .treatment. activities have led us to conclude that for any illness it is far more costly in the long run 'not to treat it when it is first uncovered through r screening assessment nnd diagnosis. nod mental health is A part of good com- prelensiveppealth care: Tossmsider i as a separate and distinct entity, from the . entire otefrnm of bealth.in-to eontr diet what has become a truism today : that in dealisldg-Withprevention, primary comprehensive health care for any hull- vidual, you must dealWith theho r .To be a little facetious, this blunt . tempts .to separate thehtead from the . Our experience has - demonstrated ..ffii;deyastating impact emotional disab In a family member has °nein entire - faintry-. If the resources were made avail ble- to collect such data, we would be able -tff.sfe,triqnstrata.tbdat mental Illness n a 'child leads to losh of pro in ar-entiretraliftly, Parents iniss daysliom- nor* bgccause. sehoOl syste chlidren..imdsottieone must mustbe/ liom to supervis - 'Untreated'disabl11tleaCati4eadja e Of neon years, prolderns..wilien,.. years ott:end."Theiiieragee.Q.. in the. State :-yeiCrork IS . - year. placements.. n '3r-4y...future:placements co given access ;" -eatitlent resources at nn, We pay a lot of lip serWce to the fact, respared and that the guardianship of their activitraiwe asn society can pursne.To say t appears to, Say,*tliat we don't care about their mental health, is tantamount to ° sayffin that.' we care about our 'most precious resource only stklong .as,_we don't have to deal. with the uncomfortable fact that we may have fe channel some of our fiscal resources n'ew.directions if we are. to insure the future health of our Nation. - .We wouldsaggen, then, that this Chniniettee drop the /weskit exemptions for, . inandatiory treatment services froth this legislation. We would like to sea Mien/ .reimburseineat available for all health services.foriProblems uncovered through screening anclassesspene. ..; . There are severagOinerareas of tlfe Bill to which we Would like to-caltiftfr , atteution, ;I,. "; ' -2...Strengthcning the Outreach component of the progranT.7-1r own experience in providiagafirviceS to the low income population has taught . that an effective ,putreach program is one of theomost important pieces in nsuring acceskito care. *.,. Cnrrently, Sttrtes .must iffform MediCaid e ble 'children about EPSDT and encourageand helrlheni to;,ptilize viCeS. . However, Ituideq.udte mitreacli is demonstrated the ext ely low mtes of . participation, in EPSDT. ApproXimately 25 percent of eligible children Were sdreeneff in ;the last year.'Few states use the method of outreach known to he r: .proSt ffectlite in reaching 16w-incothe facilities : personal contact by those people t;_ 1d`peiq+cgmmliniti slknown and trusted by them.. For a relatively,;small cost. 'the -13114P. ,could b't greatly strengthened' by: (a) establshing per- ardS for outs which require, States to assess a reasonable' troll fif tilgitde childten b) incentives for outreach ° rtafffne the redgioa.thatcli to 90 PerceEt to States. for; outreach services pEttlymtd-Oy plvatp,,iio*profit Organizatlens or indivIduak with strong elm- :intrzittyf e.gaulTeitir'S MK oWlim s, connnunity, clinics,. c:) ; (c) ,requiratt 7StWO to:earn/ark' a +3m iapOrtion of funds for piililiedncation and for efforts 4 activity s cannot e child. vere actin outl roblems in e adolescent jnvenile stice 'systerfi for months. even yeazd§ sta, in a juvenile detention facility Qcie is bearing the cost of those avoided if .the,children were arly' chiffiren are our most precious Ithis one of theomost important en, as this bill as presently written I 84. ---to-enr011-rchildren 1u:the-program. nose-States which iall_to attract to the pro- gram a reasonable proportIOn of :eligible children should be req to develop a new' outreach program that mandates the use o workers andAlitganizations from the local communities. .. . . 3. Encouraging Qualified Providers to Participate in CHAPOne of the problems identified in the studies of-the operation of the EPSDT, program is that many of the qualified proVders have chosen not to participate in the pro- gram. The reasons for-this are varied but- S. 1392 as written provides few in- centives to patticipation. The AAPSC recommends that CHAP be amended to require States. to identify qualified providers, including child mental health prac- titioners and to encourage their participation in CHAP by offering, satisfactofy administrative arrangements such as adequate reimbursement rates an&prompt claims payment. We wOuld urge-that the Secretary be -required to review each State's performance in this area on an annual basis. The craiirn the billcletining CHAP providers should be modified th clarify the fact pro oviders such as Head Start programs. mental health clinic .. grams. etc. which- can assure that children receive CHAP services do qualify, even though they themselves do not provide all services. -- 4. Requiring Performance Criteria--SgAP should be amended. to -establish performance criteria that Statialtbe ent-ttect,t0:4aeot.: TheArlteriji should in- clude the enrollment of a reasonable proportion of...eligible .childieri in the' pro- gram and the provision of the required assessment and treatiAint services'. The .. .._ secretary should be required to gather data on an annuirt.baefs in order to assess 'States' performance in eniblling eligible children in 'CHAP and in providing a reasonable proportion of eligible childrea,with health assessments add, treatment services. CHAP should require tliat all States meet all. rogram frequirements and that the sanctions available to the Secretary be used for an_y lapse lip program resp sibility. - 5. eueloping State's 'apacity to Deliver CHAP Services. .CHAP pro-- visio f title XIX can be distinguished from the rest of the m efild 'Program by the fact that States --are charged with seeing that children served by the program. If the program is to be effective, then States must sit that the requisite services are in place forthe children in need. This requires a planning odd administrative component which is not adequately. addressed- in S. 13:12. States should be required to submit to HEW an annual plan, developed with the opportunity for substantial public input, that indicates how the requiretients of f !HAP are to be met. It should he required' tffilt this plan be utilized by the State Health Planning Agency to facilitate the integration of planning fdr. adequate health services for children with the planning for the State population as a whole. . . . . -We realize that medicaid in general and i'','HAP in particular are reimburse- ment niechanisms and not what are usually considered tO be health service pro- grams.INevertheless, we submit that with this requirement, CHAP can become E- an effectiv,e vehicle for identifying shortage areas. and with proper and adequate 4 administrative support and monitoring can be utilized in conjunction wth other ',' health delivery and health planning programs to 'aid States in identifying and tilling gipsIn Hie delivery system. . , We woul' ke to conclude Our statement by affirming our support for the ip- tent of tltb AP legislation. As one of the participants in the AAPSC Con- fer&nce On lopmental Screening and Assessment in. the EPSDT program oh- , seiTed In. a .working-paper prepared for the Conferenee, one of signif- icent..coritributionis] to the field of child health has been to uncover the pfdsebt . health. syetem'stinability to provide comPrehenslatand continuous health service for poor children, even givea,a financing mechanism." (Anne -Marie Foltz.."The .Polley Dile .. 'ning,and Cost-Effectiveness," February 1977). Many of the fees° if allure can be dealt with if the Committee accepts our stig- . :gestions-f catiOnlof HR 6706. . As A,A.P emphasized in the Pretol ue to its report on Developmental Re- view in the T program, a copy Of which is appended to this statement. (Ap- pendix II), . . .. "The legislatiOn.'authorizing EPSIY.0 (CHAP) ,makes it nationaladlicy that the: 4 development of our chifdreb, our future citizens, lie safeguarded so as to insure. that each Child reaChes.matUrity l'unetioning4it a maximum _level of develop- , ment. This goal is thahthe finding, the study; and.the treatment of disease. The guardianship lige health of children is in the national interest as well as In the interest-of the imilviduale ;ibis is the essence of EPSDT (CHAP)." ,- (4c '0' *r .- . .4 IL 85 Mr.-Chal se-has-the opportunity to tistosTate this statement-- into reality. It r hopii that you will do so on behalf of all children and youth in need. Thank very xpuch- APPEND= I TITLE x.lx BTAIE ISPATTExT DATA Wismar& State and County Mental Health Inpatient $'s (1976). I Total Federal - ... . Increase county hospitals .1, 600, 000 'Ilk°°° State hospitals 1. 531. 700 9,020 Prior plan 3, 766, 200 2.259,720 a Total title X171 )-1, 1- . tit 6, 897. 900 4,138, 7411 1.7P Peissylrania - . . 12 State-owned anie operated hospitals, (1 specifically for childrien and adolescents $ . - , March 1977. 300 children and, adolescents in the hospitals projected annually, $6.5011,000 Federal assistance ($21',1366.67/child ): pastern State Hospital (Trevose), average length of stay : Length of time: 3 mouths to 1 year__:_. 1 to 2 years ...OM 2+ year Reference : Correspondence to AAPSC from State, Depit meats of Public , o Welfare. - Percent 25 AOSC SURVEY OF MEMBER SERVICES' 1975 STAT1STiCS [Data based on 70 Lespondentsl Setting . Children seen Total number Percent by sex Percentby age , Boys Girls 0 to 5 Outpatient 43, 707 Pi 37.9 9.9 Partial hospital /day care 2,001 30.9 26.2 Residential are 704 77.8 22.2 .5 Inpatientcare.. 1, 621 61. 3 . 38. 7 .3.7 Total 44033 62.6 37. 4 10;2 .54. 4 6 ti'13 14 to 18 35.4 11.3 44.4' 34..6 61. 7 35.4 i .1 1 facalne of caseload 4. i 1 Percent , 1 43,000 and under .16.8 $3,001 to $7,000 23.9 $7,001 to $10,000 ,- 1 21.9 $10,001 to $13,000 r _ 16. 8 ' $13,001 to $20,000 - .13. 1 . More than $20,000_.4" .0.....- .- ,_ 7.4 -.Number of visits required for diagnosis :. P4eOnt W 5 r to 8- ..., 1 9 plus_ .,.. 0,..*. ' * - 86 J.E44140E-TREAThgE47---. . : - . Percent served in terminated Percent after - A. Outpatient (boors): 1 to 6 ° Ito 12.. , 13 b 30 30 to 90 Over 90 B. Daycare (months): Olo 3 3 b 6_ 12to 12 80 24 Over 24 C. Inpatie1 nt hospital (weeks): Orb 1 to, 3 . 9 to 12 Aber 12 4, D. Residential Center (months): 0 to 3 3 to 6 6to 12 12 to 24 Over 24 -.. . . -. i :A- , 20.2 20 .2 .26.7 25.2 7.8 11.0 12.2 37 11.3 25.4 29. 9 314 10 .0 11 6 23.5 . 44.0 8.9 .,,,/ 20.2 40. 4 67.1 92.3 100.0 IL 0 23.2 60. 6 92.8 100.0 11.3 36.7 10.0 6 447.1.. `91.11 . 100.0 r NEEDED SERVICES N OECREASING ORDER All ages 0 to 5 0 to 12 13 to 18 Residential Day treatment Potent education Hospital Special education Outpatient 1 7__ 1 1 2 2 I 2 1 3 r 4 5 6 4 5 , 6 4 3 ',..,"°!-!"-s- 3 5 :, _Er 6 5 Conceins (top 5 in decreasing order) : 1. Finances. -. 2. Program evaluation. 3. "Quality assurance. 4. Staff salaries. 5. Training.; . Soursies of fl.-- uids to agencies : Percent Volunticry. (united. Way, etc.) Fees : --..i." 12.,0 Patient, self pay " 9. 7 = , Patient, insurance 12.2 Fees : Contract for services ( consulatiOn and educational, etc.) 9.5 7.pet1 tax levy 9.5 State allocation , .-- _ WI . County and- city 3. 0 - Federal funds: S co . g ,grant__ Pa t F,' thildren'serVices t. Research -' r _ Title. XXX ,...,..,.:: Title XX tp,,w4,1, ,' Engowment funds - _-: ''-:-.,.v. , 1.9 CRAMPUS . - - - -. 1.8 Other .- - _, . 6.3 Allocation of State moneys : \ Percentt . (A) Directly .- 35 . %Via local government body . 75 (B) Difficulties with restrictions placed on !ands,: I . ,o Percent.? 'Yes t $0 i Some get moneys both maysAledce percentage totals grgoster than 100. , . . ° A - . -.. SS 9,i.V. 4 a. r- 3.3. 2. 1 . J.445 4- - 42 87 Mite (7483/ ue-Shietcrat (1974) . ..., . Thigh options -basis -' - . - 51 claims per1,000 covered population for mental disorders. .p. 11.7 percent of claims I" Benats pail.. $1.45. per person covered (3.6 Perqettt_folsi benef4). . - - .,,. 1.2 elaims.per '1,000 population -7. . .1": - _- 18.3. --ce-------__L (perceat ) Totat. 2. I:Ugh optioii-supplemental ( nonmember hospitals) : .4. - ._. $1.` 8. per. covered persons Amy' 05. 2 High optfon-supplemental (plinicians) : 20.8 pet $3.75 deductible ,...,"7,--__,._.7...._ ' 53. 4- ' Vaal (after credal:1We and coinsurance). Reference : Louis S. Reed, Ph. D. Coverage and Utilization of Care for Mental' Conditious under Health Insurance Various Studies, 1973-74 Americkn Psychi- atric Association, 1975. . (18.7) ,9 -TABLE.12.--BUJE CROSS AND BLUE SHIELD PLAN e& FEDERAL EMPLDYEES. HIGH DP7113,4,1973: BASICIfi PATIENT HOSPITAL BENEFITS FOR MENTAL DISORDERS. BY AGE AND SEX (I N GENERAL HDSPITALS AND MEMBER MENTAL HOSPITALS) Age Male s Female Total . Undel 19 19 to34 -35 to 44 v ' 45 to 54 . 55 to 64 65 enclave Alleges !tinder 19_ 19 to 34 35 to 44 45 to 54 '55 to 64 365 and over_ All ages 4 10 'Linder 19 19 to 34 i 35 to44_ 45 to 54_ ,_ 55 to 64 , -I 65 and over All ages... ., Under 19 - 19 to 34. 35 to 44 45 to 54_ 55 to 64_ 65 and over Alt ages a:, AdmisSions-rate per 1.000 1. 3 1.4 I 1.3a 7.1, 9.2 8.3 6.3 10. 7 8.6 7.6 10.1 8.9 F 6.7 6.9 -6.8 3.5 . 4.0 3.8 4.2 5.6 4.9 Days of care-rate per 1.000 34.7 4L.1 3 34.4 149.4 163.3 157.2' 86.4 169. 5 130.0 . 103.4 165.7 134.7 100.0 125.6 11215 60.9 74.4 '. 68.0 73.3 100.1 86.9 Average length of stay (days) 4 27.3 23.8 . 3 25.5 ' 21.0 17.7 19.0 13.6 15.8 15.1 - 13.5 16.4 15.2 15.0 18.1 16.5 0 17.3 18.4 17.9 17:5 17.7 17.6 ti 27 pct of averap rata. 40 pct of average rate. 3 145 pct of average rate_ 4 41 pct of overalls rate_ Average covered charges per covered person 32.39 10.47'. 32:45 11_62 42 .4E1i - 5.82 , ! 11.46 8.77 7.08 --11.39 6.90 _ 9.16 2.66 2.75 2.71 4.98 6.90 5.'95 988 . 00 -7/1:91.111LUECROSS AND BEUES14111111FEttERAL-NtillyPTIO. N-1973-110SPITACAREfORMEN-fAIDISORDERS- AS PERCENT OF CARE FO ALL CONDITIONS ft 4 T ill ¢. ;- , 1 .., Menial s'' An ', ) . , percent at . 4.,...:...° Age i . . IN conditions Minor N all i . -. 4 . .. :, '-' Ai - -. Adlnession-rahroir 1.000 t ' r 0 to 111. i I ...., _.` tO. 5 '- 1, 4 igi .. 4.1_ 1... .,... .... , .,3,.r118. 5 ; Elk: .;,- 4.,2 \.,,, '. . if - .' Days of care - rite per MOO ". 0 to 18_ e 249.4 34.4, AR 926.3 as. ofiAlfa Nol TABLE .14.-BLUE CROSS AND BLUE SHIELD .4 NOSPItA. OUTPATIENT BEN _ 13.8 Covered charges pe rson $25.33 62.42 9.6 "(.:(e- ,89.61 5.95 6.6 - OR FEDERAL EMPLOYEES, HIGH OPTION, 1973: BASIC. MENTAL:DISORDERS, BY SEX AND. NGE Aga Male Female Total' , , Under 19_ 19 to 34 35 to 44 45 to 54 IS to 64 65 and over ::- W 1'174 Sr e Admissions -rate per 1,000 AIL age% 0.1 0.2 10.2 . 8 1. 1 . 1.0 l.6 1. 6 7.1 1.1 75 1.E1 . 9 .4 . 1.0 .7, .4 .8 . . . Covered charges pet covered person :35 to 44 45 to 54 55 to 64 4. _- 10:0202 .82. .04 .03 Under 19 (5) 19 to 34 65 and over All-ages .02 5 T01 133 pet (*average rate. Lee than 14 of 1 N. TABLE 15.-BLUE CROSS AND BLUE SHI ELD PLAN FOR FEDERAL EMPLOYEES, HIGH OPTION4973; BASIC SURGICAL- MEDICAL BENEFITS FOR-MENTAL DISORDERS, BY AGE AND SEX , ' Male v . Footsie Totil ° ae Under 19 hi 34 45 54 3510 44 y -c 55 to to 64 g.N'66 and over AU ages - 1nhospilal medical daims.pei1,000 1.3 1.5 rib 11.4 7.7 9.7, 8.8 3.3 r 11.8 11.4 7. 9.4 7. 2 4.3 3 3. & 4.2 6.2 5.2 1 Visit days per 1.000. _, -C thoder 19 24.5 26.2 25.4= 19 to 34 103.7 123.9 gib 91.15. r, s 35 to 44 . ?o. 4 .. -`s 131.4 1101-:: W2.40 45 to 54. , 711..: 125.7 101.5 3.7 94.4 82.2. 551064 51.8 44. 1 r. 662,11.01yr am_ 52.7 - 76.1 6416 19 to.34 112 11:781 .gLos 15.45 Under 19 t ... 35 to 44_ _ 8. 78 , 10.77 9.82 45 1p 54z 4.14 .6.83 5. 49 . 55 W64 , 2. 33 " 3.91 3.10 65 and over ... 1.42 . .130. 1.88 s An ages. __a . . ..4. 90 5.93 ' 5.42 Ago Males Females Physicians' services--C111011 per 1.000 population Total 48 59..1 44.0 26.3 13.7 5.7 Hospilal casei per 1,000 population Under HI.. . , 0.8 - 0.6 ' 0.7 19 to 34 4 2.9. 2.4 2.6 35 to 44.: - I rte___ 1.2 2.1 1.7 4510.54_ *-- L2 , 2.2 1.7 55 to 64 1.1 1.5 1.9 , 65 and over . 8 .1.0 .9 Hospilal casei per 1,000 population . AU ages _Under 19 19 lo 34- 35 44 45 to 10 54 55 to 64 65 ago over rAU afrIP Hader 19 19 to 3% . 350'44 45 to 54 7 55 to 64 AN ages - Wider 19 "19 to 44 35 to 44- ', ... 9,38 lUIL 30.04 45 Id 54 -3. 78 4.65 55 to 64 . 1.62 . Mr 2.15 65 and over_ * .37 .53' - 46 . AU ages s 4.26 5.27 f.4.77 Physicians' charges per person covernd . 1.2 1:4 1.3 Total Physicians' services--C111011 per 1.000 population Under HI.. . , 0.8 - 0.6 ' 0.7 19 to 34 4 2.9. 2.4 2.6 35 to 44.: - I rte___ 1.2 2.1 1.7 4510.54_ *-- L2 , 2.2 1.7 55 to 64 1.1 1.5 1.9 , 65 and over . 8 .1.0 .9 7.1' 41.9 32.7 178.7 . 3 3.2 Males Females 48 59..1 44.0 26.3 13.7 5.7 8 Jto 52. 21.1.1 11.1 4.5 1.2 1:4 1.3 A.. 16.1 7.1' 41.9 32.7 178.7 . 3 3.2 2L$ . 19.0 8 Jto 52. 21.1.1 11.1 4.5 Hbspltil charges.per person coverodi.",. 16.1 ..86.90 $0, 74 s 10:17 .3. 75 2. 28 2:12 . 92 L 55 1. IS 1.02' 1.92 1,47 11.0Z' . i 1,6o . 1.30 1.02 1.29 . 1,16 Hbspltil charges.per person coverodi.",. 1.34 ..86.90 $0, 74 s 10:17 .3. 75 2. 28 2:12 . 92 L 55 1. IS 1.02' 1.92 1,47 11.0Z' . i 1,6o . 1.30 1.02 1.29 . 1,16 1.36 1.35 2L$ . 19.0 Physicians' charges per person covernd . 1.34 fit§15.-95 15.02 Wider 19 "19 to 44 35 to 44- ', ... 9,38 lUIL 30.04 45 Id 54 -3. 78 4.65 55 to 64 . 1.62 . Mr 2.15 65 and over_ * .37 .53' - 46 . AU ages s 4.26 5.27 f.4.77 Total supplemental bine& paid by program 2 per person covered fit§15.-95 15.02 19 to.34 112 11:781 .gLos 15.45 Under 19 t ... 35 to 44_ _ 8. 78 , 10.77 9.82 45 1p 54z 4.14 .6.83 5. 49 . 55 W64 , 2. 33 " 3.91 3.10 65 and over ... 1.42 . .130. 1.88 s An ages. __a . . ..4. 90 5.93 ' 5.42 Total supplemental bine& paid by program 2 per person covered 54 percent of average. percent of average. 38 percent of average. 1.36 1.35 1 - TABLE 17.-BLUE CI(OSS ND BLUE SHIEkl) PLAN FOR FEDERAL EMPLOYEES, HIGH OPTION, 1173: ALL BENEFITS- ,. PAID FOI MENTAL DISORDERS PER PERSON COVERED, BY AGE AND'SEX 04C L=. A r. ; rItadar 19 :I21(875...063219 44 -r -121 to 54./. ..12 -73 - 55 b:464 - 10.60 , 65 and over -4.59 -Male 4 10.91 . 4041- 4. FeMale - (fetal $4.67 - 29.96 24.99 20.87 14.95 5.79 .,34.98 28.93 20. 7/ 16.82 12.73 5.22 14.37 20 Behest of nveratm safanceSeltrceysn: Losoustsuu8S. "Ativ;eircaagne..._sgst Utiilciiamition04:71f4i'oC.ezre19%.11onfrl Conditions Undo. rsmoiliw TABLE V-NUMBAHD COSY OF PSYCHIATRIC SERVICES PER 1,900 BENEFICIARIES, BY AGE A to fps Quebec- Health Insurance Boni( Age Mal; , . Female Number Numbera Number 1 Cost a- _0 to 1_ _... .. __ ________ ____ 4 $45 3 10 120 6 1 to C.__ ___________ ......_____s__.... -.' 5 to 9....7 27 . 396 17 10 to 14 .r.,g, g 36 551 25 1, 435 15 to 24 " , 96 154 25 to 34_ 190 3, 160 373 U ' 35 to 180 2, 871 361 ;' 45 to 54 . 184 2, 446 285 55 to 64.. 144 -;--2,..048 215 127 ... 65 and over_ .- ________ --__-- -._ 83 1, 092. 110 1 ;700 , 191 , Total . r $45 3a zis I "72 373 30 2, 549 125 6,379 281 5,834 0 - 270- 4, 207 226 2, 957 1 633 181 108 103 313 464 1, 987. 4, 770 4, 352 3, 345. 2, 521 1,401 3,030 151 2,310` Average: Ages 0 to 14.46; nes 0 to 2438. 2 Avert's: Ages 0 to 14-$231; ate! 0 to 24 -1512. . 4 ' TABLE 7.-AVERAGE COST OF PSYCHIATRIC SERVICE (COST PER SERVICE), BY AGEAND SEX,,1973 .A/19 ttale Female Tate I Oho $16.57 $10.99 1* 1 to 4 .* 11. 85 -- 13.31 $13.17 -4i, 114Z:0391 10 to 14 .15.27 15.12 14.53. 5 WV 1 14. 94 ., 11..9121 7 .,- 16.63 I 17.12 .. 16.53 16.95'- 4 ..1281 tow 3424 / 15.92 ,,. 16.17 -. 16.09 35 to 44... 55116 64 4 " 14,-87 ' '. 14. 77 't 14. 81 14.23 ...45 to 64 ,-/ - ' 1123..9943 65 and over - 13.16 m13.8375 4. Total -dr 15.39 15.83 7 15.67 140111--.Airolo: Ala 0 to 14, $14.70; age 0 to 24. 514.14. . , . Source: Louis S. Reed; rai). Coverage and Utilizationof Care for Mental-Health Conditions under Health Insurance- Various Studies, 1973,-*,' Americo. Psychiatric Association, 1975. - , . `' . I. Soares: Draft of paver by Herbert Francisco, Calif., Feb. 10, 1977. p ; . ClIAMPU . - . (4) Lb. than 2-pezdent utilization ot mental healtiiservices for,..past 3 Years: (1.S2 percent in fiscalyPt 1975) (2) Per 'weeper year cost for mental health services, in -fts.cal.yeal equalst$1,181 less coinsurance and deductible. . -Omer capital basis.: maital.health Seri-ices/person equals $20.90. i f.; -(3'). Mental health. serviceidiised 17.7 percent of total ealth benefit fund. Aivrtge duration of hospital stay (all conditicins) equals 8.08ays. . Childhood behavior disorder ; average duvation equals 47.4 days:- : Personality-disorders : all age ave.igge duration equals 20.4 days. 9, Ay Age 5 to 1 verage duration equals 53 days. v..' .. a 4 \ Diagn .phrenia end aged 1 to 14: --, 18 all admissions in diagnosis. ast .., hosPit41 (Ilya (58 daYs-average 1 ).;.(12.1.clays-avera..e all ages): I; 47 " . . : _ . PERSONAlITY DfS01,D1.11.. 1. . AP . lo 14 71, Atrodulons klosnitetdays (P14,400 (Paroo.4) . . Avenge .datrz 12 31.. 100. 100.; 53: 0 20.4 P. D., Langley Porter Institute,' University of Calliorpia, son r O 4 : . ' 0 I, ':' ' r .10 1,--71--------.-0-0,-0.--,----.`-.-------,.,-..--a-----.-A -,--.+--4-'-. ) f h-,--- ,....,,... -..--.,04.,,,,... 4 .., 4 i .. I' I . ' ' 0 I . , 0. P ' f. ?ARE 11;-.101(11ERAND ?flag DIST1181111011 V TOTAL PiTIEIIT CARE EPISO,DES; AND NUMaf PERCENT DISTINUTION, AND PERCENT CRAtIN PATIENT ME EPISODESAM,. OS OF AG, II TYPE Of PSYCINAIRiC*1) UNITED STATES 1166, 19( AND 194, ,4 .4; 4 TypialtOritimici:. 1911 Mg ,T0'01041 PtierlutiOadisuoir 11 ipiodu-0101 Tolg 01101 ail PiIieol OJAIoil 18 "PriNdli-111 ;.,,,.14114ilit Nuaiberol prithiittic Punt ;0 . 1911 NNW loot Tod Pool episodes. 007000101.0;100m001 4=04101.06410000100=m70100= Prig dill: Noir I Paid labor Pot Opt, , 4,053 3;161;31371 MD 111,@14,1..1N,0' .10,0 3134$3 ;1010 111;490 100,0 19,1 L,.... ...,...~.....~PO.1=o00106'....pw.,;................r.........z. 0 a. , 1 4 , 1114-1,1411,519, 40 1391151 11.1 9:0 1102 :, 4,0 10(85 13 , 1,1 dmimmmPPI.d.0....r.appkc.....,...r........r..........:.....:.........;. Stiiillin riiilf10101i 324 1151219 1913, AIN 5.! 5.3'?, 161,11$ 11,1 At 5.1 . 6 '' Gool'hospilt,I* ,, , will s 633 511, 612 1k1 SSA to, AI' 25,493 161 :4. t 3, 6.9. 124 91M3 /4,5. 1A1 1.0 1.1 Km I.f 1.I" Priv* olli 4 f 1 s n isiOlticfroclobn orimolookilishrbidthildria: 311 : *EV , 3 2031. 3,1 , 1.100,0 NA , .1; 310 3,3 so Corommilymotilholicetio i . 85 .110,00 54 RN; : 14;7' 13. 9 15,103 19 ,i,', 41115 ,l ;I 7,5 0101Pi** /11411' I., ' I I i CommilltriirtaNN,mil 4. MI iiioulitk mditlic ilivicti 11 11,11,4.,51 56,Q If, ai a! Kos 16, 91,677 '1,3 1904 i11 111, 'a MIjr6480 13:9 4. '))1P139', 1561 451 1,113,13. ,11.1 Xvi .11,9 ' .4 I 1'; t.) 19663 . . Total petient carp ages Patient are episodes under 18 years tut ' Percent chino in number of pied are episodes under 18 year! ofogo, . Oumber Percent Number Perift 1914. 1969-71 19E01 g fi Total --el! pnyclOric lu 1,1649,030 ., 100,0 415,700 100,0 Illa 33,3 ., 19,2 58.9' 1001 pOintric urvicti IP l'i463,0i ---755/r 86,700 L'7,8, / !Al' , I, 21,8 32, 27-64, Slikand county mental hosp 4Is hut, mental hipitth , t: General hospital inpu nt pnchintric unit: , ,. esidentii1 4o culeinior.imotionillythirbid children_ . Cothmunity m ill health centers ' 802,000 ,10.3 361900 1,m 74,4 101,000 3.9 1,800 11 J-6,7 '549,000 20,1 34, COO 1.0. 1,3 1663 NA NA NA . A It .v. thdpilient 4 1,186:00 44.8. 399,000 -142 35.8 J 0 niptental help centers NA a NA NA All othroutullent psychiatric scabs '1,186,000 44,8 399,000 82.2 I IncludenOpitiint i3Ichilitic services of Votonos.Administrotion hopillls, ) .. 1 Data oro,fOr under 20.yr 'age 'rook j E : triialogshor for 1%6 represent luisioniof the 1%6 dell as shown in elk NIMN publications, NAPO ipplicialtoply a few ollheso facilities begin fundionint in thisyear and roporling was natfoqoak / I ? 4 1 e a 155.5 16,7. 6;1 Source: Statistical note,tio, 11, DN JPubl llllsSerrices, A0AMHAJNIMNI Divisioulof Di- ometry and epidemiology Survey and Recatniefuh, Rockville, Md,, July 1973, ONDI publiu..! lion No. (ADM) 73-158, 0 - r. a . OUNBERI,PERCITISIIIIIIION, RITE FOR 11.101,1141ION, AND PERCEN1 CHANGE IN RATE Of ATIE1IT tog EPISODESIN1SYclIIATRICSERYICRT 0 TYPE OF PSIC110111C DICE,. BY AGE; CITED STATES, 191 AN11 .) 3776 1911 1966 1911, u x1986 .-111-717166 Number 05 to 64 65 ilk* 19111 761 an Is' Tablillitychiibilimicsi,... 441143 2,'11 711 814 485319 ; 6811641 331,0 1,433..E 951,951 ,8 ,231 611,* '8' 24264 313,014 ..... 11111,.382 1151r4 13,658 ilitudounilidis..- 1450 259 .31196 361932 Pri hsidrtiil 91,613 , 1,668 1,7pi tratmmulmil. dm 28,637 3,637' 8,000 0001 Hospitl lrams. 5421642. 451065 341 033 941569 1761g1 20967 130,111 .P1 18t092 , NA 118,190 2, AN 1 86174 2451106 13.084, 61421 561,825 512,19 51 II 91,285 118 11.,331 2391060 1105 114 151 IL253 11;61, 23111 5,968 23,4" 216,124 1 L214 511 63, 580 NA 53,191 NA 9 .3 133 11.02 13 163 ,16.12 5(1211 '1051 16,110 el' 1413 NA 1 id NM . 62.216 3991000 436,535 2 31 399, loll 919 21143 , EX 'A 119077 12,0 NA V1,1$ AI Other tea. 1,1Ik 437,339 399,000 313,93 1331 596.439 Ps* disttibuir 1004' 100.0 100.0 So / 95,412' 7399,1, 01,# ,./ 14A0 110 3,212 NA 10 Alt 2t13 rf ; . IOU s. ,18.5 2.4 4 , 573 , 76,1 ' 49.5 ,....:............. 5.1 ': 1 14.3 1.1 , 24.9 9 , 4.8 51,1, 1.0 1.6 . 2.1 13 4.3-'., , 3 . 4.5 4.1 . I. t' 17 ; 1.6 . , . ..t 6.0 7.0 ill ?Li ,' 153 226 ..... ..:,..... 3.0 6.6 ,',1), 0 5.1 i, 3 2.1 ..7.,4....,. .1 .......-...1 ', 15 .'...'....,... r 8L9 82,1 3.45 ..., miNMe,. 10.7 59.9 11.6 31,6 0 / 6.9 24.0 13.6 7.1 , hilit,A0P0011203 loalitsipil,u 1;96117 .',116, 2,8iLl 1JN.1 2,184,* 1,46 zteia 1,1181 1,3101 :ED 0204 197.3 ' )244. 1,0314 651 1,212.0 Mao 414.1 w' 55.4 ' 52.9, , 40.6. Z14.1 . 481,9 5E9 556,1, InvolumilisiiiL40.. '."' St 8 . 10 8 : 111 .51.0 ' 10,9 I1, 3 1 0 110104, Will ,..,- - -,...,-... 141i. 4.:1 , ' 40.5 . . 11 5 . . ; , ...,.. 4 . qqqqq .. . ........ ...._ ______. 'iiIN IIIIMIAlfelINIMInti.. 4,, 264As 'ill' , 65.1 , 411 1 , 311:2 342;3 . CU 1.3 314.9 42LS. 1181.4011._,.. .,,L____.......; . '; LI 131 ., ..... ..,,...,..... J., . 1.1: '11.3` . la& 1116---.. . .4. ......ri ,.. , .63,t ....,-., ..v.... 15. /6,t.,........ ,.., r 7E4 ......., .. , , tt , _-.....f_.....-____r_z_---J--L------.-----=--- -------- 4 veslitiv ,___.. ..... 1; MI 7 i 641 f 8983 ..1 .... tiff, _ , rtI1R-r...1"7.'.. 7. ' .."Pf' ..4 a.' ' .....,-'- tAlliiirlat.*---,AL- 815:i; 613.2 , ) t , ,4 T winos 7' t 56t8, 61.5 . 22.5 -21 .6 61'4 *di x'188.0 111 189:3 ES 3a1 120.9 1p0.0: 74,4 15,9. e, 343.0 511; 1,1133.4 1,0219. 1,6E7 60,1 412A 268,3 110.7 45117.,_ 1163 11.0. , 570 4.40 144: 1,233.I 64.6 1 .!: 130.i Per4ntchange in rata It* 11 33.1 679:6 5.3 79.'1 o 1 ..... 1,A. . .01, 8.1 411 141/41 3E0 " 4 r ' 111011161130111., . . . : ' 7 6 5E9 51.6 19 -1.0 -32,4 10, t 4.1 48;1. -21:1 -33,9 . t 3;9 21_5, -9. 3.' 12.1 1 , A 252.2 '7"/"`' . 111 4 VA IOC - 41109r. ... listiOrito fonvfotrid timintede Inpoopt isvisickef liJodif 210, 4. '&21 346. -25.4 .64 ..... Hos.. '116,3 , -3343 ................. ..... '31.3 0 115.8 105,3 1 ' Cass,. "Currot Popt)alicelip solo' N,o' 413; 1971t-LS, el of the Illfi r glint IatientPopulton, Report 'Mind Ntiliple 110,3). Ur u CifiS NA4ot ipplictift-onlrafew ciatalad begun functioning minis year intreporling was not Mold, ' . ofigiroitans raid to.dmpo ialgs offk 1916U,S (eau of Um I g CrOltitip4ITY Pk o#19 atckfrit rfg=etit Of, total population: to 8S catchment areas-are under 20 years. -- 00(tOna ti4e4:20.00,28.1 Percent of total additions. 0.61 percent of total popUlarroit'aiider 20 are additidas. 010pereetteafptidOoptaatiortalkige8 arie-Oditions. ;13tO 19' All ages -Number Percent Number ?orient . ...... ,...--f7,3,601, 047 : da. 4 9,_388, 619 '. rulditione. . ''' . : 21,129 . 26.1 84, 192; r .94ii oenters.7/97i. , ' Age group undiet 20 form 27.4percent of total- 'additions (118J48/4i2,040). 100.0 0 to 19 All ;gee' !lumber Percent Number r.. ' Percent NI services__ .,, 118, 748 100.0 432, 640. . -100.0 patient tient 10,413 Ja4669 8.8 86.4 79,100 335,648 : 17.3 77: 6 5, 666 4, 8 21, 092 ; 4.9 i970'(261 center;): ..,.. .. . .. ,... I. !;.Population under 15 is 28.6 percent totaltchmept nonsiation and forms . . r .,.- 16.7 percent of patient additionw. .' --"--- li t population " . . i 'population under 25 is 46.8 percent of catemen and fOrms 43.7,, - - ' percent of patient additions.: Catch PcDuta 39. 172, 4. - Addition as CMHC cent to total / additions population 419, 107 70,004 182, 985 // 1.07 .62 00 _,....., ,NUMBEIRAliti PENCENT.1)11TIOISITIOH_OF PATIENT tARE- EPISODES UNDER 18-111181 OF MENTAL - DISORDER, BY -TYPE-Of PSYCHIATRIC SEIDOCE, UNITPD:STalBX IV/ - --'.-- . -Total-,alt - Total psyrJuatrie, . inpatient . rudlg __ services 1 Percent services l Peceinpty Total -all mW disorders .J.743;237: 100.0 111, on' OA ., . -2.. Mental rtardation '- 55, 254 - 7.4 5, 835. vs 7.3 .Orgarsic.brain syndromes (excluding alcohol , '.>" and drug) 19, 121 2.6 3, 649 t5, 01'4 2.4 Schigephrenia 42;035 ' 5:7 23./341 Depressive disorders (psychotic and neurotic). .. 24:250 3.3 11, 657, ilk 2i sat 3-3 .7..-'arli 2.5 Other psychotic disorders ' -1, 408 . 3 1,1!3 l I .111; Alcohol disorder* *. 2, 373 . 3 870 8 .313 . ' Disorders associated with druLabuse____ -1 13 072 L8 i 7,157" c, 5 s lie 4 All other disorders_ 584, 707 70.6 ' /62: Tn 55.9 lin_las 82, - lyr . e of mental:diem defy finraim gib 100.0 411--- , Indulge Slats sod county MH:- PM14. GHIPO. excludes VA hospitals et herwilimuw ...!.':nsierreeeters for imotramIllty disturbed children_ . I. NUM_M111.10t0 PERCENT DISTRIBUTPOM OF DISCHARGESIINDE41- 11_ YEARS 8r,441F . OF MIONTAL 011811111ER; BY TYPE OF iPSYONIATRIC SERVICE, stanNtarare. Txype of mental disorder Teti r -Minselieeterds' hen _ Or rani syndromes (excluding airman' and drug) g I . .., 4, 427 Persomirty disorders , : 2 Other meeroses Otheriencbeels 4 Depreiseve rhsordirs (psychotic and nautastic) ,.,. Akolocl disorders_ ' ' . , i 750 Disorders associated with drug abuse... .L743 :Triamenbsituatiostal disturbance _192E ; . All other disorders 7froptiont *whist:tic =charges ingimar * Patent 70, 085 15,4110. 0 . ., 14, 324 -4.; . Source: Statistical' note No. 90, .DHEW /Public Health ServicelADJ8torksvm- .:..mirof sot Bemetn Survey.. and ,,. Reports Breath. Rockville, Md., July 1973, DHEW publication He (A111.473-158. a, rsr- 8. 1 6.820 2.3 8,5 _ _2.9 5,84 2.0 la .1 2..881 3. 0 7r., s. 1 275 . 1 . 7 ,13°92r 30.5 I, I I I ( I I, 1.0 11 ' . NON 11 SICTE40110:11 NEA1111 CENT, BY C0101 AN P $ 1(1"BNIN STATE tifirit Ill 11.4 Its I I .....4.1.11..1.....1.......... ' ' ' , , , d ', I et 'ro 11,633 /L 2,14' tf 4;15. 1 N lit ,,I,.4. .101' la, Co,. 114 :., A 4 03 ii.3 'kill ',Ili 1101 Ili. 11,,.Ila 15. it V1, .1.2 10 11, tie, II ftli : 43 3 " Poi Pe it , Fu. ;quad St 11 , to. 151).1 101 10 1111 1111.11014111.1*INIM*0401.r.n11&. Poe p. (Sod al pp Ito Of Ail 113 kit ftt Li Phi Irak Li 41 1(CATCINENT 431 4:111 11.1 Isil , .411. l'Y'',D111111NITif MENIAL 8E14 CENTERS BY ACE, CQU)1 AND 119 STES, 1110 t I =1!144,,,, I 4,1 .! 5t14 15(1019 110D bit 45i61 65iiUt if - _, f.P,..1,... .... r .... 100 11114saiw -fri OfOkt . 0110:1 IA t ZI 1 CI d guis' zit*, ;i1olp :hi 4.., ....... . . .... ........ , 1,to 0 Pai IV 1111111 'AP , Am s , . 4'4 ..0444, 4 4 41 .4 "0"1149"...r.. ' 1/1 Di 11 11,3 IN KS hr i ki 1 0 :It II I* ,Ops.,..,,,4 nfdC....,91 * *IN I 131,911 1N1 4,116 AB Id INIL.:......,., ..... .. ,..4 girl '. , il,r6 . MA 11,101 v Souro:StglitifOloigt01100ilith *a, 1104N110,,Qtaion,of Mir!, Sum Juo131,.001,111141i00 k ON)* ' .4 ' 1916 ale' , ......,,..- 4 .,, , ,if-4,,,, , II , 114 1.0 , 11.4'. , 'girl '' 'ail( --36.6* 11; *0 . 100.0' -1 1.3' , 1&0 . ., :10 . 13.,3 344 ,.' 19,1 3,5' -eittfonalr " - . ,...,... , v.'. itif .8 '. 1.1 I, 13,z ,7-111 .It fir 15. IAale. .........L. ....... ...,4..." s .3,0 1,2 16.1 ',, . , 104 11.3 31:0 11.4 .4.0 . I 0 Bliitaa...... , . 6 , I " if I 4 '`t ,' " ' 3.0 , .7 4 10.0 14.$ . 16,4 4.3 i k. 13,8 03,8 ! . $leir)bh *to:4100m due t Aset error,: 4" .1 ' 0 .1. n. I 1 ,,d P i 4.11, 6 MISR Of PATIENT AilTINSIENE-oh. MIt 59 SELECTED C01111$119111MAL iliAtiliCUSERSBY AGE,'IJNIIID STATES, 1111r c ` .. i II \ i i 0 a , fielder -----.(. ; 1111 - low ., 4101(1%4 . 1:810 IA , '. ileck fails ,4, , ,. _ , 4,4 . i r 6 . , , ; .% : ,!..69 .. 69 All kisle0 it altcled AI 41 , SOW All Sided , Selekt ° 1 4 . *NS canters cillt alto writs , itatem, ceeteri "Nlers centers "cptes men _:17._ ..........- _...;,"..4.......7-t-0,, ,....-,..,..-,.:-,--:51.7. . 41149 84t192 11'1 101.0 - lici art .10a0 ,, to' 100.0 .. 1018 il Igo 'law , ...__,.......,_______ I- .. ... 6, - .. 155 ... _ 54,931 10,411 /53,60 10,663 63,314 12,16 '151,105 30 16 ...... 69,011 r 1o91? 14.40 1,359 1.0 ), 1.0 0.1,3". 11;4_2 Iva 6i0 12'7 31 1 It' r £.3 316.; !Are pet ents de not add up total ihoin, discrepancies are due imolai error. 'I 416 ti 4.1 , .8 1.5 , 1.2 , 10, .1 49 , 163- 11.8 10.0 11.1 13,3 6 10.5 13,4 1 ,15.6 115d " 16,5 16.1 4,1. 3,5f 4.1 , ,' '2.1 4 4,0 3.1 1,13' 4114 )4 4,' 8 I - 0 1, 4 ''' 'I. , I . II 4/ . I /4 I,' , 'I W ° 4 I a ' , . / 'I %,," ti Ji- 1. .4 1 I. DIS11181,11101 OF MOILS TO MEOW FUNSED comer! NEPAL HEALTH CENTERS BY ACE AND DIAGNOSIS, WED STATES, 19/0 Not Pitt ApodmiisiN Im 4 b 11 510 19 3 la AI 25 to 44 45 10 61 °loll TAI 0 II 4 5 to 11 to1159 20 25 4 ES end 10 21 to 14 to 61 mart 1)1 31 3143 4,201 105 1k9t 121,116 ;,51,655 13,128 MO 110 110 11 11 11 0 11 1 100.0 01* . Ow utildlq O*910 ( 91 54111 Mk& kin (Wok pha llic Omaitirol 52.* Otlpr char g*lism ;if; ;MI WI orpik $1, 21;(,; pm8shm(iu itimp-4J , . 4,10 odixiitiot iadw kin *AI 4 di litmcy, 060 01 sitoro) NI* MI Mom comiimimial oilioutitielest tic dixdo sad ao mat ilodo ......... 506 1,035 136 911 92 1100 1 1,011 1 145 ii :114 It 181 ,11,303 , 6,811 4 wl 15,362 Ilile 7! -.1,111 J im 1,671 111$ 1,811, 693 74 410 11 Li 1,5 1,2 Ll 1,183 1,154 1 2,9 4,0 L0 1,3 L5 11 /5 on $s NA/. 11419 1,331 15.1 1,1 Ll 111 19.9 191:1,10.1. 313 1,32 221 696 13, 196 L'261 15,1 1,1 1,1' 1 9 11, j1,1 23,9 21,1 5% IE. 1,331 1,650 316 1.1 (9 .3 1.4 1,8 1,9 L9 29 9 9,143 1,209 ,661 5,9 .3 .2 1,1 3,2 10 f12,5 5,0: ZOt 3,18 3,118 636' 109 3.1 ,1 .4 £1 6.9 'Li 3.1 11091. 1,431 1,581 44 119 9.9 29,1 1,111 11,7/5 24,613 63 "4 11128 110 11.1 11.3 1,931 91 335 23,351 10141 ,110 049 210 33,1 '31.9 I 0 1412 1,614 5,281 ljl ,113t .R6 L3 3,3' 2,9 1.3 ,8 20,4 15.0 111 21,1 1 v11.3 11,1, 15,6' 2,1 3,1 5.3 LO 1.9 4 a I din 0,05, . Rale*: ufinimili Ned 11011O Ciro 10 to 1100 Stift" [MR Publication Na (NSN) 134111' pri#119/1; *a; Rodeo ill to billm 101' 01 4d0r14 Node Comity 11110t01 ' 11w0 5014" 1301111 Immh, Netiaasl edam o1 abl Null& I I '101 . . s &UTZ AND COUNTY Ilizsmst. Hoserrem-1972 Additions , 6.1 percent of all additions are-under 18 years old. ; ' C16-3/100,000 population under 18 are additions. .. 97.2/100,000 general populations are additions ( under 18 rate is 822 percent of regular rate). 4 Resident population Rate per 100,000 for resident population decreased each year from '1969 to 1973 for under 18 age group : from 18.4 in 1969 to 15.:5- in 1973. o I , 1 I ; . . 4 r ! 11 -'_ i I TAW-RIMIER AND PERCENT pirivtiTioq Of ADDITION:SJiNDER a YEARS Of AGE,T(STTE AND.COUNTY ilUITAI, 1105PITLS BY AGE,SEX, AND DIAGNOSIS, UNITED STATES, 1973 1., di *. s , t' . TO, oda 18 '. '111nrief 5 5 to 9 '10 b A 15 b 11 .1 ....7- e ,`" \ . ' ..a...---. ...... ..... So mid dime ' Number : Poe , NMI* Nat Number Pe;cent Number Pe cent Humber Pod : ,. .. 6- , I A:s 11 I . 1 Boa mum .. '25,11 . . 11 0 !Slit' 10010: V96 100.0 7,695 Jon 0 , 16,13i. , MO , T. . . ,,........, ' , 413 26.3 . 955.; 1 1Z 4 1,328 I.2 1 .1 28 .( , 341, L I .135 . 7-1 353:7----4;6-----560 .- 1 44 II W*tin , 2111: 11.1 122 58.6 1, 1 0 ..., itiereffs. . 1, DO 41 7 I 1 fei i 3,996 15,5 , ' 25 120 141 11,0 Dormsin herders. I, 045w Pert:city dimrirs a T 2, 104 8.1 4 1,9 , 15 : :.8 Drug *Wel 1,413 5.6 '0 1 , i MO& radio , ' 6,123 ',-. 26.0 16 1,1 ' 318 19.4 .. Oat WO diatom. , , 3,861 . 15,0 26 4 Ili . ''' li 254' 2,12 9t1 1 , 3,4 nxittoi with drug ebussi $ NI I I 201 94 1,258 1, 708 867 i 11.8 2, 830 5.1 6.2 1 10.0 1,,609 119 8,4 29.3 41,101 25.4 22.2 1,618' 10,4 9.1 1,418 9.2 , ) 0 TABLE 5.N11111ER AND PERCENT BUTION Of RESIDENT PATIENTS UNDER 18 YEARS OF AGE IN STATE AND COO MENTAL NOSPItALS Bf AGE, SEX, AND DIAGNOSIS, UNITED STATES 1 19131 Total under 18 Under 5 .5 to9 , a 10 to 14 15 to Six Ind diicrais Number Percent dumber Percept Haider percent Number Pout !lumber Piglet a 8OM Semi. ry 10, 516 ' X00,0 - 11. ti: 0 I,.136 100,0 1,141 110 , 51121, igo in ritirdioi..:.. ..... .............. ,..?, 494 ', ' 23.6 48 \ . 64.9 3i4 31,7 ; 861 20,8. 1,225 a 215 .4 Orpnic Wirt slidrome.. , ...... . ..... 112 1, 1 1 9,5 113 , 10,8 . 358 8.6. 334 6,4 Schirophrenie L 386 /2, i 11 14.9 203 Ili -. f 872 21,0 1, 300 .24.9 Pereonelitl disorders... 611 5.8 0 6 5 .1 203 4.9 402 73 Adjeive ruction Id, 101 16.1 2 41 ' 153 13.5 61 16,8 " ', 850 16.3 Behavioral disorders , 1,175 16.8 $ 6,1 216 11.6 921 , 22.5 s 591, , 11.4' Other ,4 ... 181 1, i 1 1 ' 1.3 ii I, Eit 228 4 5.5 513 % 9,8 . I 4 Sow St stied note number 115, DNEWIPublic Helilh Service, ADAMNAININM, Division 1)1 Ilion;etry, Eti'deesioloo Survey, Ind Reports 8Inch, Rockville, Md, April 1915, DHEW Publicilion Number (ADM) 15158 / p 1 97 V 'r Yur both sera f I ADMISSIONS TO'STATE AND,C0IINTY 11ENTAL NOS a Total oreier II 1 ALS, UNITED,STATES, 19443 Wet 5 , 5 tol 4 101)14, 15 lo 17 mbar. *I Per* Number Rate! P* Number Rite 1 Pend Number Rotel Pod Nurhbo 1410 1961.:. 1970 21411 88A 9 IN 41185 ,1,49 1,56 111,685 a. ',86 21, le 39.0 153 1911 . 28, OM 10,3 1N 268 14 , L 0 1, 116 9,2 19n . 171133 1 3 1CO 215 1,1 ,9 1,633 . 8,1 1973. . 25, 130 31.9 100 3 11 .8 i 196k 19, 9 1.1 11 , 2 11 .1 1 3 , ,7, 643 .3 '6, 0 " .11914 380, 6.9 °?,695.4 11$ 11 14132 111 vst. 11,341f i5L I I 4 17,211 440, I 3,71 23.11 16,131 IR 1 5 Nr4Pro#14.=4Irs I Rote pir 100,001 popOion . , . , . 6 :4,, 1 0 I . I I V I A i 4' . III . RESIDENT PATIENTS IN STATE AND COUNTY R1131., HOSPITALS, UNITED STATES, 1 13 , I . e 1 au r g . . \ . I d a Vald 0 a a I 2.r.,..... , TM under 18' , Uuder 5 s. " 5 'lo 9 '4. . 10 to 14 15 to j1 , . 6 1 i......... '......1..=.1....... 41#141#44m.:04~Ml= 41.4., ... .... , bier Mei! Peat Norio( Role I' Percent -Number Me I fob* Number Rie 1 Pot ,flumber fteh I i Pool .__,_:___,_t_ il .1 , Yurbth 1113 12,811 111 1DO 14 .0115 0,1 1;600 1.9 lZ S, 067 1971 H91 111 10 100 15383 1: 41 11, 4508 81 11: 83 11 '1 185321 1910 1912 11,39 163 100 , 85 .5 .1 1,284 6.9 , 4,391 1919 10,516 15.5 100' 14 i ,, 1 (1,136 0 6.3 103 1,115 2124:59 311 23.0 16 61,14 51.2 21,0 10 5,501 44,9 1&8 19,9 39.2 5,211 11,9 49.4 I Rote per hundred thousand populliool a ' 1 1 sod Eodemiolery Survey end Reports Drench, Raiville, Ild,, April 19751 DHEW publibetion No, (ADM) . Source; Slitistid flotilla. 115, DNEtPublic Huh St4ice, ANNA ,N1111, Division ofBiomet 11 7$451' I rI If a a 11 1 ' a I a 104 , REBIDE1c7liT. TRE&THENT CENTERS FOR CHILDREN. (3974) As of January 1974 c .. . . There were .340RTC's w/19,023 beds,. .. .. 27.9 f(TC bed$ per.190,000 poPplation under 18. - 1973 . , . , '29-,726 Children reeceived Care, amounting:to 6,337,926 days. . . 5 Average residence/day=17,624, 4 t end of 1973, 17,697 in residence. ° 12,929 alscontinuations, 12,179,additions. . Average of92.6percent beds occupied daily. . .10xpenditures: total : 242,348,00 (approx.') ; $38 per patient day; and $20,389 °I per discontinuatidn., - t 1 t . ..' 0 0 4, . . . . TABLE 1..7COMPARliONS OF SELECTED DATA ON kESIOENTIAL TREATMOT CENTERS AND PSYCHJATRIC , . , HOSPf'ALS FOR CHILDREN: UNITED sTKTES,1973 4, . t * . Selected niyiurei for 1973 . - Predominant tyPirtof Ownershit . Average (mean) site (in beds) Most.frequent minimum admission age (years) Most frequent maximum admission age (years) Average - caseload par facility: . Annual additions ; ,. Aqndal discontinuations Resident patients as of Dec. 31, 1973 ,.. Addition Indices: Additions per 100 beds ... , Additions per '100 average residential.ftalienls - "731'1/4 Additions per 100 discontinuations Additions. per 100,000 U.S. resident poPufition under 10 yi Residential , Psychiatric treatment hospitals for centers children . l ) N (340 . (N-26) 4 ull-time equivalent Ltaff per 100 residents: Total patient ciretaff .. Professional.' Othey Expenditdres: a. Annuli total expenditures pet facility $712, 788 $2, 208, 724 Annual salary expenditures per facility . $425, 847 $1, 870,902 "Percent salaries pie of total. Average total expenditure per patient day ' Average total expenditures per discontinuation 0 . V 1 t 6 . 6 .18 18 36 84 . 35 85 52 79 6649 107 s4 101 I. 99 18 3 . 143 50 67 . 27 76 $38,,c $82 . $20,389:' ; `$25,561 I Private nonprofit,. . 2 State and county. Source: Sbtistlial Note number 130, DREW /Public Health Service, ADAMHA/4161H; Division of Biometry and Epidemi- tlogy . . Survey and Reports Branch, Rockville, Md., April 1976, DHEW Pub number (ADM) 76-158 TABLE 2.comPARISoNS:4F SELECTED DATA ON RESIDENTIAL TREATMENT cENTEBs: UNITED STATES, 1971. AND 1973 .' . Selected measures 1971 1973 Number of facilities 344 . 340 -" Average (mean) sizq (in beds) Average caseload per facility: 57 k 56 Annual addition; ,, 32 36 Annual discontinuations.. 29 35 Resident patients at end of year 51 52 Additions Indices: : Additions per 100 beds., 56. 64 Additions per 100 resident patients , 63 69 Additions per 100 discontinuations 110 . 101 Additionsger 10,000 U.S. civilian population under 18 yr 16 18 Full-time equiValent Staff pe(100 average daily residents: . Total patient care staff 77 Professional . 38 50 Other 26 27 Percent change 1973 versus 1971 1.2 -1. 8 +12. 5 +20. 7 +2.0 . +14. 3 , +9. 5 8.2 +12. 5 +31. 6 +3. 8 105 , , TABLE 2.-4(IMPARIS9N'S OF SELECTED DATA ON RESIDENTIALIREATMENT CENTERS:. UNITED STATES, 1971 AND 1973Continued Selected measures 1971 1973 Percent change 1973 verYtis 1971 Expenditure: . Annual total expenditures per facility Annual salary expenditures per facility Percent salaries are of total . Average total oependitures per patient day Average total expenditures per discontinuation $573,006 $348, 000 81 $31 $19, 654 7 . 012, 788 1425, 847 60 $20, 389 +24.4 . +22.4 . +LA ++231. 76 Source: Statistical Note No. 134 DHEW/Public Health Services, ADAMHA/NIMH, Division of Biometry and Ephlemi- . Wog Survey and Reports.Branch, Rockville, Md.,April 1976, DHEW Pub. No. (ADM)'76-158. TABLE 3.--NUMBER AND PERCENT DISTRIBUTION OF RESIDENTIAL TREATMENT CENTERk AVERItGE NUMBER OF BEDS PER GROUP AND BEDS PER 100,000 RESIDENT POPULATION OF THE UNITED STiff ES UNDER 18 YEARS, BY SELECTESJAC1LIR CHARACTERISTICS: UNITED STATES, .1974 ^ - 7 Resiaential ( Beds per treatment centers I npltieni berjs 100 000 - b.s. . Average .resident number population Selected facilibp.characteristies Number .,;eicent' Number Percent per group under 18 ' Alt residential treatment centers _____ ___ 340 lob. 0 19, 023 100.0 56 27.9 SizeLbased on number of beds): . . . Under 25 beds . s 88 .. 25.8 : 1, 472 7.7 17 2.2 25 to 49 beds 129 38.2 4;588 24.1 36 6. 7 . 50 to 74 beds 69 20.4 4, 033 21.2 58 5.9 , 75 to 99 beds ,. 26 7.5 2,251 11.8 ' 87 3.3 ',. .100 heds and over 28 8.1 5, 679 35.2 239 '9.8 Ownership: Private/nonprofit.. _ 330 -97.1 '18, 543 97.'5 56 27.2 State and county goveinment 10 2.9 480 2.5 48 0.7 Geographic region : . . . 'Region I , 41 12.1 1, 719 9.4 43 . '''' '''46. 4 . Region II .. 36 10.6 3, 039 16.0. 84 38.3' Region III' ,. 24 7.1 2,291 .' 12. 0 95 30.3 Region IV. 15 .. 4.4 I, 022 5.4 68 9.3 Region V ' 104 - 30. 5 '4.447 p. 3 43.. 29. 7 Region VI. 22 6.5 1,840 '9.7 . 84 25. 3 Region VII 20 5. 9 759 4.0 38 .. 20. 7 Region VIII 15 4. 4 534' 2.8 36 :1.0 '027. 1 Region IX 47 13. 8 2,645 13.9 56 34. 6' Region X ' 16 4.1. .667 3. 5 42 '30. 4 . TABLE, 6.PATIENT MOV,EMENT AND ANNUAL VOLUME OF SERViCES IN piPATIENT SERVIC'E OF RESIDENTIAL TREATMENT CENTERS BY SIZE (BASED ON NUMBER. OF BEDS) AND GEOGRAPHIC REGION: UNITED STATES, . 1973 . . . . .. .Patient movemr during year S Annual volume of service , v Residents . iinua oiscon- 7. Size (based on number at Additions tiona Residents Patients . Average Numbers! at end under resident . .,- patient of beds) and beginning during geographic region . of year care patients days. during nagr Year of year liv, , ,. . All residential r I .1- . . (treatment centers 17,547 12, 179 12, 023. 17, 6971 29, 726 17, 624' 6, 337, 926 , . Size (based on number of beds): .2, 499 - Under 25 beds .1,205 '' 1,294 1,324 "457, 836 25 to 49 beds. 41, 233541 31, 11.5455 , ' 3, 142 . . 3, 691 41,288 7, Mil ' 4, 260: 1;514, 614 50 to 74 beds '3, 079 . , 2, 989 3,781 3, 736, 1,333, 683 75 to 99 beds . 2, 084 . 1, 874 1,$77 2,081 3, 958 2, 083 : - 739, 866 100 beds and over __ 6, 181 2,882 2,816 6,253 . 9, 069 6, 220' .' 2,291,927 . . . z .:. .. Geographic region : . ,.' . Region I 1, 617 958 307. 1, 668 2, 575 1, 643 580, 907 Region II 7+820'.. 1,576 1,589 2, 901 .4, 496 .. 2,864 1, 012, 828 .3;28d1 i 2 3i? 1(111476 Region III,... 2, 331 850 . 866 Region IV 800 685 4, 004 .563 4, 093421285 1, flz.' 4,1026 1336, 597 Region V - 1, 826 3, 420 1, 683 2, 893 . . 1; 755 642,283 Region VI 1, 067 1, Region VII 661 668 lie . 680 1, 329 671 240, 812 Region VIII 445 422 342 625 867 - 485 163,095 Region IX 2, 439 2, 203 ' 2, 295 2, 347. 4 ;642. 2, 393 ' 875, 120 Region X ,,A04 -5.30 : 532 . 602 ,1; 134 603 212, 011 5TAEllif .15.1NUMBER AN9 PERCENT DISTRIBUTION OF EXPENOITURES, RESIOENTIAL TREATMENT CENTERS BY TYPE OF EXPENDITURE AND SIZE (BASED ON NUMBER OF BEDS): UNITED STATV, 1973 , . V .1 ()Pleating expenditures ' 44 ...- 1. - Total . Other . , Total operating operating Capital Vbased on npmber of beds) expenditures expenditures Salaries expenditures expenditures ... t All sizes m. Less than 25 tied 25 to 49 beds. . solo 74 beds a ' 75 to 99 bild5,- 100 beds and ov;lr.4.-- AnnUal expenditures inlhOusands of dollars Alf 341117' 242, 348 222, 550 144,788 77, 762 19, 798 .. '. ' Use than 25 beds 21, 366 20,862 ,. 13, 801 7, 061 500 , 25 to 49 beds 57, 349 . 52, 549 35, 730 16, 819 4, 804 50 tp 74 bed} 52, 067 50, 094 . 32, 415 . 17, 679 , 1, 973'. 75.* 99 beds 24; 812 23, 707 ' 14, 726 8, 981 48, 116 1, /155 LBO bids and Ali . 11, 415 86,754 ' 75, 338 27, 222 100.0 91'8 100.0 '97.6 100.0 91.6 100.0 96.2 100.0 95.5 109.0 86.8 Percent distribstion of expenditures . 59. 7 .64.6 62. 3 62. 2 59.3' 55.4 32.1 . 8. 2 33.0 2.4 29.3 8.4 34.0 3.8 36.2 4.- .. 3L 4 ,13.2 TABLE 16.--LAVERAGE EXPENDITURES PER PATIENT DAY. AND PER DISCHARGE -IN RESIDENTIAL TREATMENT, CENTERS, BY TYPE OF EXPENDITURE AND.SIZE.(BASED ON NUMBER DF BEDS): AINITED STATES, 1973.ip Operating expenditures Sin (based bnnumber of beds) ,. 1$ sizes 4 4 $38 Less than_25 beds 46 % , 26 to 49. beds 39 50 to 74 beds.... 39 75 to 99 beds 34 100 beds and over . 38 Total Other Total operating ' - operating Capital . expenditures expenditures Salaries expenditures expenditures Average axpenditures per patient (Lay , . ,./ 1 Average expenditures per discontinuation . . 'All sizes 520, 389 $18, 795 $12, 198 $6, 50 51, 594 Less than 25 beds $ 18, 341 17, 932 11, 834 6, 098 409 . 25 to 49 beds 4 18, 922 17, 420 `. 11, 817 5, 603 1;502 50 to 74 beds 17, 08_8 16, 476 1Q, 634.. 5;842 - 612 75 to 99 beds 13, 437 12, 872 . 7, 974 4, 898 565 100 bedtand over 31, 133 -, 27, 239 17, 351 9, 888 ` 3, 894 $35 .. $23 . .$12 45 15 36 ' 24 12 3 37 ' 24 13 2 32 20 12 2 -33 21 . 5 $3 fi /, , 107 ".1 ' . `TALE 17.-DISTRIBUTION OF RESIDENTIAL TREAYMEiff CENTERS (RTC'S)" BY RESPONSE TO SPECIFIC ITEMS ON THE 1973 INVENTORY OF MENTAL' HEALTH FACILITIES Data item and 'poop . Response Non response'" Number , . of RTC 's !timber Number surveyed of RTC's Percent of RTC's Percent Numbes.of bids '''' .'': 4 , 340. , 314 26 ' 1.6, 340 . 314 92. 4 RTC:31w jpgra 26. 77.. 66 -Type of sWaersh 340: . 314 92.4 Type of service 92.4 By bed sizet.-.: .. 92.4 ' 26 , . 7.6 By geographid r4 is 4 . 340 314 92.4 . 26 Region II,' .. 340 314 37 90.2 .34 , 897.1386 Region Li : 41 Region III 36 \33 91. 7 Region fr , 24 24 100. 0 , egion I 14 15 100.0' - Region V 104 97 93.3 .7 6.7 Neon e. 22 20 90.9 2 9.1 Region 18 90. O. 20 2 10 Reid Y 1 15 15 100.0 Regio t 47 41 , 87.2 6 12.8 Roil n " s. , -... Patient move e t and volume of ser7ice: . 16. 14 87. 5 2 It. 5 By bed iz 340 't 292 85.9 ., . 48, By goo re hie region .14.1, R eon I 340 32 78.0 .292' 85, 9 48 014. 1 gion II 41 9 22. 0 egion III . 36 29 80. 6 f 19. 4 24 egion IV 15 ' 21 87.5 . 1 12. 5 , 100.0 Region V 104 Region VI . 92 88.5 12 11.5 22 20 .. 90. 9 Region VII 1 ,2 9.1 Region VIII Region IX .20 .15 13 17 85.0 86.1 323 11113486.... 7309 Region X 47 '.- 40 85.1 7 Num rof staff and hours w rked by Ind size...,.._ 16 312 , 91.8 13 81. 3 . 28 : 8.2 Ex ndi ures: 340 Bi geograpffic region_ 340 83. 8 Byl bed size_ , .285 55 16.2 340 . 297 87.4 43 12.6 Region I 41 36 87.8 5'. . 12.2 Region II 36 31 86.1 5 ' 13. 9 Region III Region IV.- 24 24 4z 100.0 l 15 14 93.3 1 6. 7 Region V Region VI 104 92 88.5 12 1181. 26 Region VII 22 18 81. 8 90. 0 2 Region VIII 20 18 10. 0 15 14 93.3 Region IX e *Region X 47 16 ' 13 81.3 37 78.7 1301 21861...737 patient day and per discontinuation 340 285 83.8 55 16.2' I RIF; TO.11101411111 ,011 inciontspitasivim BE NET IN RELATION TO' O '410US MSULIPTIONS if NEED: ASSUIlit371 USE RA 'ONLY,,BT tilE, ORM STATES, 4915 AND 1980 I WNW number al pros nollniork v assuming NolOr In PP not roollicimouni14 Print vial Cusp 11% 10 In: 4fniticals1 2pereset ::'1:1i0= . lint;"! (4) (5) (6)f a 0 0 40) Homing I I I S TAO III44,914041 Otteaf110 3, .r , IS 1 444 it4/ Iii.532;10) 4,3,(41,80) itiqps jogna 0 211. 481.3 1,502 1t362,180'. 1,110,90 13,621,808' 618 1611131'398 121914298 90,5 51010 55160) Vika ION 'I', .114"") 1203,411 1,016,7N .5,14k0 10,1 1000 .,115591 i2450:131544 4111311461.'' ii132T01 31,AW 013A :14.1 90,1 82.8 .% 20 r, 3,600,215. X513,522 ,N1,600 451,11;40 1,030,028 19,2671125 44015 681,653 al LAIN 61061,600 13,929,200. ,.61 131241,547 558 641,146 511120/ '21915,61 5,831,200 Q 2,3011154 'a1,754 621 1,2111N1 4214 I§ 61/131200 12141 2N_ ; 0 1 951,113 , 11,1113,4 016 71061 11011N 4,341,900 1,611,1r 77 119 3;55i 839 7,9051739 mosa, 321018 ,;14 0000 .247;012 4111,2N 4,51615N1 11 22.5 813 50,6' 911 .00,,0 111 0 19,5 , 19 81,8 51,4 13 project on d e ILS. 'population ("Onrront Phpulition , 2: coda oNinti bighilniirtloesint rill per HI ppeerr lo1410141id19151111110 U.& potion, All dIstribu ins IsoOer *el brilphilni 1971 pulp sail 1910 1 1eb1 arto ieaeeb ostiskid plot artillido number porsonigiunlIng for Li obi* it multi kill. we 'Op* tent al SO. This was dorlvid from 41h, PIO Co blink( Iwiy pan In Ind rillitirhidinivings, dliploSdimpur, 4 111. Prw 4 tooraza wa5mcol, icii 10, coul I 1 Colima 4CoL 3 (Nolo: For Ns oiumn ImitIon ulna woke assumed to be Oro, 11,1 the n for orifices would *met, An Mil MI lite oil top pirtt) , WAN r 5-U1,3, IColliii 16-41.3, 4,10Co1,741,1 U11000;8+1 5. Cci,12iti9+C(16, r I. 'I Fiscal vean1976:..48 pe f, medicaid eligibleit wider 21;, 18.4 percent' , diiiires for iiervices to i's,* . " .', , . tak #eaitliliprvices, / f. 28 iStateis Iburren cover ch tinder 21 ftr-iniis.fient pyychiatrIc.cara 24. / de other servi , 0,g-, clinicooutpatient,.evaluations. - . A `. : . 2.. In fiscal year 6; 11.1 million children under 21 received' services under, Medicaid. It is ted that only 70 01 received cov red'-setbices *in mental hospitals. (.063 pe t received services I .imentai hospi s.) .. 8. Children *lag inpatient .psychiatric care in ate I hospitals accounted forgin estimated 6.4 percent of all recipients di mental hospital cU under Medi, caid in fiscal yjAir 1976. ' .. ., . , , - 4. In fisca//year 1976, $503 million were expended fqr mentalhosPi4t,care; it is estimated that .$45.8 million (roughly 9 percent) *as 'expended oircliildren under 2 - . . '. -., . 74-.484 0 79 - 8 V/ DEVELOPMENTAL REVIEW IN THE- EPSDT PROGRAM Prepared by U.S. Departmentof Health, Education, and Welfare HEALTH CARE FINANCING ADMINISTRATION in cooperatipnwith THE AMERICAN. ASSOCIATION OF PSYCHIATRIC SERVICES FOR CHILDREN, INC. DEVELOPMENTAL REVIEW in the ,EARLY and PERIODIC SCREENING, DIAGNOSIS and TREATMENTpROGRAM PUNA REPORT April 1977 IF `This report is made pursuant to HEW contract SRS Phpared by !. The American Association of ,Psychiatric ServicOs for Children, Int "!' -U.S. DEPARTMENT. OF HEALTH, EDUCATION, AND WELFARE Health Care Financing Administration The Medicaid Bureau (HCFA) .77 -24537 112' ACKNOWLEDGEMENTS This report wa,s prepared 13,, It represents a :synthesis o position papers, coriferet gestions made by those w of the report. .The Americ ices for (thildren. wishes those who are listed on tl* gaveof their timand coup t Dorothy S. Huntingtot, Ph.D. at ial supplied by various Atillings. and helpful sug-' ded t the initial' draft on cr'r Psychiatric Serv- its gratithde lo all of g page who. generousli We must be held solely'. res le for all errors . of omis- . . sicfn .or commission.. NeverthelesS this project could never , have-been-accomplished without the tireless and. invaluable-, . ',participation of. Dorothy $. Huntington, Ph.D., Chief, Child and .- KFernily Services, Cominunity..Mental Health Center, Penihsula Hospital and MediCal Center, Burlingarrie, California, who parliolPiledin the .original planning for the project, synthe- sized one of the original working papers, chaired the confer- ...ence itself, and prepared. all versions of this .report. ,Special \. thanks. also. !mist go to the following people who authored.* the original working papers: Allan G. Barclay, .Ph.D.,; IMMO'. :Coleman, .M.D., Anne-Marie Foltz, M.P.H., M. Phil:, Frances: -Dagen Horowitz, Ph.D.. L. Wendell Rivers, Ph.D., and to Jane R: Mercer, Ph.D., from whose research and publications thd sixth working {gaper was synthesized. 1 +. 113 . American Association,of Psychiatric Services for --Children Conference on Developmental Screening and Assessment Santiago, California February 10-12, 197.7 Conference Participants pobert-S; Adams, M.D. Allan G. Barclay, Ph.D. Thomas J.. Boll, Ph:D. Harold bovermari, M.D. Richard. J. Bonnie, LL.B. Thomai Coleman, M.D. Marcene Erickson, R.N. Anne-Marie Foltz, M.P.H., M.Phil. Martin E. Glasser, M.D. Fernando A. Guerra; M.D. Frances Degan Horowitz, Ph.D. Dorothy.S. Huntington, Ph.D. Conference Chairman Harold Upton; Ph.D. Sydney Koret, Ph:D: LuVerne A. Kunze, Ph.D. Harriette B. Matthews, R.N. Jane R. Mercer, Ph.D. L. Wen fell Rivers, Ph.D. Carlos J. Sanchez, M.D. Henry R. Shinefield, M.D; Sheila Swaiman Judith Humphreys Weitz I Observers Karl. Banks Rudolf Ionnuth, M.S.W. BentriceD. Moore, M.W. Laurence J. Platt, M.D. Linda Randolph, M.D. Robert S. Thompson, M.D. Elsie M. Tytla, M.D. Charles Wilkinson M.D. Conference Staff Debora D. Kramer. Ruth Ann McGrail Monica G. Noether Marietha J. Slade .114 CONTENTS Conference Participants Executive Summary RATIONALE AND ELABORATION 1. Whatis_Developmental Review? 2. Some Considerations in Developmental Screen- ing, Diagnosis and Treatment: Strengths versus! Weaknesses 5 3. Aii.Approacly to Developmental Review, 4. The,Role of the. Parent ... . ......... ... -'21- 5. The. Delivery System 24 31 7. Ethibal and Legil Considerations 32 8. Evaluation 41 9. Cost Effectiveness 42 10. Training, Research and, emonstration Proj- ects Bibliography, t 48 Page O. Payments and Eligibility 1I '115 EXECUTIVE. SuMMARY. 7. ...PROLOGUE. Developmental 'assessment is an extraordinarily ':complex .topic, but one which holds enormous promise for.allchildren.:11. Attempting to make recommendations about developmental assessment' perhaps approaches the level of a Herculean task In ,view of the work ahead of this group I am_rdminded of a storywhich appeared in the Washington Post sup- plement. -The story was set /on an, ancient Roman galley and the Hortator,lhe one who bangs on, the drum to keip oarsmen in cadence, says"I got somegood news and sarne bad news! You all get steaks tonight!" "Yea!" "YearfrOrn the rowing benches., "And now thd badthe Captain wants to go water skiirig ,tomorrow!" .1 get the feeling that the organizers of this conference are avid water skiers 11-lurt 1974) The Early and Periodic Screening, iagnosi,s and Treatment PrograM '(EPSDT) becime a. mandated service under the Medic4id Program through an amendment in 1967 to the Social Security Act, Title XIX,.Section 1905 (a) (4) (B). Effec- tive July 1,-1969, it required . . such early and periodic, screening and diagnosis of individuals who.are eligible under the plan or are under the age of. 21 to ascertain their physical and mental ,defects, and such ::health care, treatment,. and other measures .to .Correct jig ameliorate defects and chronic conditions discovered thereby as may be provided in regulations of the Secretary. We recommend that a major shift in emphasis and con- ceptualization be made with reference to EPSDT and de- velopmental issues. These recommendationi flow from a , . vii J, 116 consideration of A/wide variety of salient points, the most .bisiC of which is:that'development As 'not a disease which yields a judgment of present or absent. We are basically :eon- (berned with the concept of.coMpetencehow well hasa child met, and how well does he now meet, the expectations, im- plicitly and explicitly set by hig society for an individual of his /her bge and sex group. The legislation authorizing EPSbT makesvit national policy that the development of our children, our future citizens, be- safeguarded ,so as to inst./re that each child reaches maturity. functioning at a maximum level of clevelopment. This gab, is more than the finding, the study, and the treatment of disease. The guardianship o the health of children is in the national interest as well as, in the interest of the indliiiduals; this is the essence of EPSDT. ta. Parents must befeccepted ,as full partners with the pi-ofes- sionals who pJan and staff the services 'provided for children. if responsible parehthoodis td be encouraged: then parental involvement must be fostered. No single department or unit of the. Federal government nor of local governments, and no single profesSion, has "the key" alone to proMoting childrens' development. Only through coordinated service delivery as proposed herein is this possible. We must develop a systerr of. health' care that treats the -person rather than the disease or dysfunction. We are urging the deimlppment of a system for the protection of child de- velnprrent, a system' of derelopmental review. 111/ No single test or instrument is recommended because none could possibly be used for the adequate accomplish- ment of a developmental review for all ages and functions. Each review must ipclude multiple assessment pltocedures tied to the age of the child and the dimensions to be asSessed.. Any system of review must be predicated upon parental aid 'child involverrtent in the review. Any review must be oriented to the discovery of develop- mental, strengths as well as weaknesses, not to' the exclusive search to rule in or rule out pathology. . Every attempt must be made to voluntarily engage and utilize parents in the entire process of continuity of care'and developmental review. viii 117 . We recommend this system fall rim child citizens. We encourage the recognition that the currentslaw as specifically writfen is inadequate, undesirable and almost impossible to implement, but if the welfare of children is the goal, this proposed system-lhould be set in its place. There must be an integration into the EPSDT program of payment for all services which are needed by,a child or family as a result of developmental review, including special edUca- '-: tion costa. . . Our basic message is that developmental review is much r, more complicated than' it appears when it is labeled "develop- /. mental screening" but yet the system of-developmental review . holds out enormous promise. We -are, in this program, 'at a point of _crisis; it is instructive to note that the word Crisis in Chinese calligraphy is the blending of-the-two symbols for clinger and opportunity. 'National and individual interests may or may not coincide in a screening Aheration; indeePthey may sometimes be in conflict, but they will -always coincide with regard to .the guardianship of the-development of our future citizens. Thus the issues are more complicated..and more relevant to both national and individual interests than the critical incident style of assaying or analyzing for speCific fixable defects. The issues are more in the realm of a periodic review of a, process, that of development. They are releyant to all children. Further, they are more relevant to .a synthesis of function, supports, and developmental needs than to analysis and fragmentatiOn. Once this departure from the fortter conceptual model is 1.41* accepted, we'can go on-to the details. 'To state it most con- cretely, we believe with reference- to 'developmental and psychological' issues, that the national mandate for' EPSDT may better be stated by a change in name to EPRDT;, the "R" . representing a 'developmental review rather than a: screen. The function Of the review is to assess the ways in which de- velopment is occuring, the form that it is taking. It then follows that national and individual needs and pri- orities will determine the prpcesses to be used*forthe ,review and the resources available. The proceis and the resources will in turn'determine the level of review, theages served, and the backUp treatments to be made available. It is at this final revel' of conceptualization, where specific methods of ,review 4/ ix r ; A., ,f.;, ,,' , may be sutgested,'-and speCific ways of delivering services 4sinvolveriin:this ie* may be proposed.. 4 11 is' apparent hat the present legislative-language, wifich states that there hall be .screening *1'.. . . for _mental de- fect . .-.",.is .clearly inappropriate. The proper emphasis, in our opinion, is upon a process of developmental review, with 4 the object being -to identify strengths and competencies as well as weaknesses and defects. ° It is assumed that the legislative intent of the EPSDT Pro- graM was to establish a;natiorial policy such that the develop- , ment of, the, child be safeguarded in order to insure that, as with other national. resource, the resource is available . to the natkin;:jathit end, it is assumed that -tne raison d' etre for:the prograiMiluit.be the husbanding of our child resources, front both a humanitarian and an economic point of viewand that the. EPSDT Program. mutt not have, a narrow focus upon defect, but must look as!Well toward The optimization of the development of the child. The policy surrounding. the fuller implementation and de- velopment of the Earliand.periodic SCreening, piagnosis and Treatment Program should, be' based on three principles: - 7 .. 1.. a national commitment to Vie W11-being o '9 dren 2. a fostering of parental involvement a pooling of professional and parental knowledge: :A policy for children must give practical recognition to the fact that they are the citizens ot the future. Their develop- ment determines the fapriC 'of-tomorrow's society. At a time when resources are lined, there is a case for concentrating them Where they'can do the most good, in the area of well- being ofchildren and.farnilies.: II, RECOMMENDATIONS A. .,0ur first recommendation is that the EPSDT mandate be broadened to apply to all children in this country- so that a x 7 system of developrnental: review and .protection..tnight be planned for compreheniiVe irriplementation: It is also urged that funds be made available for the development of health care resources, including manpower, facilfties, and research and development. . , B.. In theinterest of pooling resources, consolidating efforts, alid effecting maximum impact, we recommend that the 'cur- rently existing,. extensive oveilap in functions .and goals of existing Federal programs be eliminated. The Maternal and . Child Health program, the Education-for All Handicapped . Children Act (PI_ 94,112),, and other programs sponsored by . NIMH, NICCHD, BEHancii0CD/Children's Bureau have sikni- .ficant dupliCation of effort, with-EPSDT; a thorough review_of., existing programs and agencies serving children should be undertaken, with the goal of effectingsuch mergers as would improve our services to children and reduce duplication. C. The establishment of an'EPSDT Coordinating Office at the local level is recommended; the function of this local coordi- nator will be to insure that the revie5v,- referral, treatment, information dissemination and follow -up resources of the community be Utilized. in carrying' out the -goals of the "merged", coordinated EPS,DT program. Also recommended is the establishment of EPSDT,Community Coordinating Councils to inclUde the schools and all service agencies, as well aS representatives of parents and service providers. D. These support systems are being recommended in order to enable and ficilitate planning on the local level; identifica- tion of gaps and needs in the service resources; coordination and stimulation of services relevant to achieying goals of EPSDT, and. cooperation and contribution to the external- .--iye,luatiori of EPSDT. We clearly are recommending Multiplg 4,tt.77.--,,.,,,-:-..!,,:nroaels'ofTservice delivery depending on the cfafacteriAlc6.\ -1ICF7.01:Triditrrduals and agencies eyelet:4C as sappprt systems. E; We recommend a new apprOath lo:.the discovery of "handicapping conditions" Or "mental .defeCts"., Develop- review is seen as the first step in engaging 'children and' parents inan ongoing concern with theirhealtti and well- C, being. We see it as a way of promoting strengths,`asa way of ., engaging parents with their children,. of strengthening these parent/child ties, and of reducing the anxiety so prevalent in ,our society today regarding issues4:in parenting and child . rearing: This is a true system of health care versus specific . rnediCal 'care. 120 $ F. As the trlividual with priMary.responsibility for the care of the child and for the facilitation of development, it is yital that the parent or other caregiver be meaningfully involved in the process of. developmental. review. G. Stich developmental review Should, to the maximum ex-. tent possible, avoid coercion such as mandating that the de velopmental review be a condition for a survival need such as a welfare payment. Vigorous. efforts should be made to insure voluntary participation by the parent in the developmental review. . . H. Such developmental review should, to the maximum -ex- tent poisible; provide significant_ benefit from participation, in the form of a better understanding of the child, with the aim ,being to provide assistance to the parent in coping with developmental issues, ancrfacilitating future development. I. Stich developmental- revie tent.possible, recognize, r tura!, social and linguistic d and culturally and ethnicall States. In a free, pluralistic society, there are clear boundaries. on the 'scope of legitimate inquiry into personal and familial. concerns. Therefore a mass government financed screening program should be limited to 1) those. of organic functioning and basic, adaptiVe coping. skills which enjoy a high degree of consensus within the health professions and effected communitieS,.and should, to the maximum ex- land;incbrPorate ethnic, cul- ces that exist in a pluralistic erse nation such as the United . 2) those. behavioral factors especially associated with learning,4anguage and. speech development, motor skills and perceptual abilities. Specific assessment of emotional and behayioral adjustment and parent/child ifiteractions.should be left to parental initiat tive and sensitive clinical observation (Stage three :as herein proposed.) . - . As an integral part of the initial outreach phase of a de- velopmental review effort, parents should be provided in the language' most appropriate- to them, a written description of the nature and purpose of the proposed procedures, including adequate ,assurances of its quality, confidentiality and bene- xii 121 -its to the child and family. At the time the parent personally appears, he.or she should be verbally informed of the nature end purpose of all developmental review procedures, land ' should be notified that selective participation is possible. A refusal to atithorize any given procedure must not jeopardiie the child's access to any other aspects of the program. Parent- al consent should then.be obtained for each procedure and for any proPosed transfer of records or information upon comple- tion of the developmental review. Each child being served should be informed of the nature and purposes of :the pro- cedures and their results to the maximum extent possible con- sistent with his or her level of intellectual and emotional. maturity. Any. transfer of developmental information between.. and among systemi is recommended, only when the information would be helpful in identifying those conditions under which a .child. functions best, so as to enable, for example, optiMal school placement., 1t is our recommendations that only diag- nostic (Stage Three) information that is pertinent to educa- tional prescription for the child be Pcommullicated to the schools, subject always to informed parental consent. J. it is strongly recommended that no single, instrument for development assessment be mandated nationally. There is no one single instrument, inventory or assessment tool that is totally satisfactory. Anjr instruments, materials and methods for developmental 40Po review within the SDT program niust be normed for the minority group wi m they are ,to bb used. They must also be interpreted y persons who are familiar with the economic and cultural background of the populations being assessed. K. The system -for developmental review must be clearly , recognized as a system, not a piecemeal approach. We recommend research and development or demOnsfra7.. tion projects to develop measurement.and eValuation standards` appropriate to the assessment of children and their environ- ments. There should also be research into the methodology of developmental review with emphasis on a variety of assump- tions and theories related to age and ethnicity. There must be the development of strategies for the simultaneous selection of measurement variabes and the 122 identification of program needs, for the establishment of research, development and evaluation priorities. There must * be an emphasis on -the overlap between research and con- Sumer priorities. In.addition, there must be provision for taking into ac.bountfamily needs and values in the.conceptualization of measurement related probleMs, and in the develoPment, selection and application of any measurement-or other instru- ments:parents and those directly responsible for the welfare of the children must be involved in -all decision making processes .in this area". The focus in interpretations of assessment. must always be on individual differences that will lead to appropriate inter- ,- vention for each specific child, as opposed to a focus on group difference and comparisons. s-- :There should. be a 'collection of multi-measure, multi -do- main, mufti- function measures from which:instruments may be selected at a local by local *ion for Stage Two and Stage Three reviews.. L. Adequate development5I review would include factors from these areas: 1) biological dimensions 2) psychological: dimensions 3) family di6ensions 4) ,environmental/social/cultural elements M. The review should, be' carred'eut in three gaies: 1) Stage 04. a. The biological dimensions would be reviewed within the:framework of the pediatric physical exam- ination, which, would be expanded to include an O.Pddriuni-ty' foi. the child and family to discust, if ,:theY..eso wish', any stresses or problems with which Y.;ifopid ;PRO. he!P;M:4,to identify strengths and syspgrili.haf7pPia roe engaged to provide fOr4jiiner*;#061opitient: n assessment -off the child's functioning would he- -:biied uPon the parents' report in the of ileVOIOpmerit of skills and emotional and iOral status. xiv J _Stage Two `.Direct observation Of !the child's furfctioning, utiliz- ing a variety of broader developmental screening in verrtories or instruments. 3) Stage Three This stage of developmental seview,would include detailed aspects ts of the four domaihS: biologic:al, p.wcpological, family, and environmental/social cul- tural, The psychological deMain would include a wide variety of functions-Lcognitive development, coping strategies, social development, emotional develop- ment, language and speech development; auditory perception, vigual peiception and physical func- tions. This extensive review of a child's development at Stage Three, this clinical assessment, must be done with great clinical sensitivity by people. highly skilled both child de-: velopment and in, working with parents.. N. It iscla early necessary that we deVelop appropriateinstru- ments' in. order that all stages of developMental review be carried out most adequately. There'is not at the present time a single, universally acceptable tool for developmental review although there is a multiplicity of such instruments appropri- ate in differing situations and for differing developmental problems. ft is strongly recommended that the Medical Services Ad- .ministrationtake a leadership role in establishing task forces _ and demonstration projects to deyelop 'further review pro- cedures relative to acceptability, standardization norms, instru- ment reliability, instrument validity, concurrent validity; use by paraprofessionals, cost effectiveness and availability. In develOping parent questionnaires,cOncerning their child's de- velopment, it is obvious that the questionnaires must not be trivial, must have developmentil implications, and must have cross-cultural validity. ." 0. It is also recommendeOthat a.separate task force be hp- pointed to supply a list of tests currently available, with in- formation on how well they meet these criteria isection14. above) of appropriateness,. and in what areas of psychological, family and environmental review. 124 In connection with this, it is strongly recommended that there be constructive use made of data already available from past. projects such as the,collaborative studies, in order That we may become much more sophisticated about issues,Of longitudinal prediction. . After two years, no standardized procedure should be utilizedin the, program until it has been approved pursuant to- :- regulations adopted by the Secretary. In the interim period, this - Task Force shall review standardizecLprocedures currently. in use to determine theirldompliance with these above mentioned criteria, and shall recommend appropriate regulations to the Secretary. . . P. is recommended that a separate task force be.developed that would collate and make available to local communities the varying models of parent based "treatment" programs that have been developed, and also make available .the wealth of parent education materials that current& exist in many scattered places. This particular use of parent educe- . tion materials holds within it a truly exciting and innovative approach to health carein this country. Q. Any developmental revievesystem initiated under' EPSDT should clearly reflect 'the 'important distinction' between the disease recognition and prevention model, and the cultural . divertity model. Screening may legitimately utilize the "disease. model" during the years of infanby and early child- hood development when the child's primary social group, is the' family; in doing so, however, developinental review must focus primarily on the child's "physiological" deiropMent. Conversely,' as children enter the mandated schoff system,' when their behavior is evaluated with reference to the expecta- tions of, the social group"developmentat assessment neces- sarily encompasses behavioral measures, and policies must therefore be formulated within- the normative framework ,of the "cultural diversity" model. ) R. It is recommended that specific 'guidelines concerning program evaluation be5developed by, a task fosce of experts who have specific competency in,this area. We caution that this,must be done quite soon; so that 'elements considered es- sential to proper program evaluation be included in 'those prograrns now in the process of implementation. Evaluation 9f EPSDT should be done in relation to specific, predetermined process and outcome measurements. xvi 125 One of the most important' issues in evaluation must be the inclusion of a search for possible positive and negative side effects of any system of developmental review on chil- dren and their families. this would incltide an investigation of any ploblerris associated with potential "labelling" as a consequence of the . administration .and implementation of any of the 'aspects of developmental review hirein recom- mended. Research must be set up to answers to cost issues, . and to develop appropriate systems for collection of data to ," estimate costs and benefits of publicly financed child health programs. S. The proper implementation of EPSDT across the country will require the development of ,raining programs in order to increase the sophistication of professionals in the area of normal.developmentedevelopmental review, and opportunities -for the developmental protection of children' Therefore, We recommend that there be an. expansion of existing sources of funding so that training programs,necessary for existing pro- fessionals who will contribute to the-achievement of the goals of EPSDT be made available. We include in the group of eligible professionals: physicians, nurses, teachers, psycholo- gists, social workers,' school counselors, and speech path- . ologists and audiologists. Training programs .should be car-. ried out by existing acCredited training resources and institu- tions '(for example, universities, state colleges, community colleges). Training could be offered in the form of workcshops, courses, seminars, and inservice training programs. We also recommend that training funds for .paraprofessional person- nel be made available on the, assumption that Stage One and perhaps Stage Two of the developmental review process will be carried out by such personnel, and on the assumption that a great deal of the paren,Lsupport WOO< will also be carried out ultimately by Paraprofessionals.. We urge ineggased effort to sensitize health professionals to the problems of parents, to the issues of ethnid diversity. within /his pluralistic,socety, and-we urge that health profes- .: sionals be trained to offer increased support and counseling to all.families. In order to achieve- the goals of EPSDT, special resources for developmental review need to be created to supplement the kinds of assessments typically'done by physicians. The xvii 34.484:0 7 79 9.. 130 4 126 nature of these special resources are largelyspecially trained personnel. Such personnel should have extensive skills in using developmental evaluation techniques, should know something about the arena in which physicians operate and similarly should have some familiarity with the nature and requirements .of effective educational settings. They rnust also know about parents, about families, their ethnic and economic diVersity and the realities in which they live in our society. xviii . 4 -RATIONALE AND ELABORATION What is Developliktal Review? It is evident that.the development of a child is a process, requiring periodic review to insure that development is pro- ceeding adequately. thutthe term "screening", with. its con- notation of searching for a defect, is less appropriate than is the term "developmental review" which irtiplies a process orientation rather than a simple cross-sectional view:4Stritg" it may be difficult to change the present legislative language, it is urged that the process of developmental' review be strongly 'encouraged, arrd that concept of deVelopmental screening; which is more appropriate to medical. or disease oriented conceptual models, be avoided: De'velopmen'tal review in the context of a health program has three goals: 1; - The promotion of strengths of a child and family to cope. With the.various tasks of living; . .2. The prevention of specific developrrtntal disabilities; 3. Early case finding; At this time we are recommending an entire reconceptu- alization of 'developmental' assessment within the EPSDT - program. The elements of "Operation Rethink".iovolve a reas- sessment of what "mental defects" are; what. mental health and development are; the role of the family in child develop-. Tent; the orientation of a screening, diagnosis and treatment program around the integratioh of the family within the sys- tem; -and finally, how one produces develOpmenial gains via variouia.tupport systems. 'Under the proposed systeffi:of concepitializatiOn, there is 'n,o,,Aai this field.to identiiy.precise tests to distingiiiSh tween "normal" and- "abnormal" children; there are dozens of . 1 128 . crucial functions subsumed. under the concept of develop- Ment, .since development is not one/ thing.. Developmental review would thus consist of an assessment of these functions rather than the specific diagnosis of a condition. A functional assesiment, a profile of strengths and, weaknesses, or assets and liabilities, describes the transactions between the 'child and the world around ;him An terms of the ta'sks asked of him and the people, significant to this life, in the context of the partipular setting in which the child is-found and at the particular time of every deVelopmental .review. The outline of :assets and: liabilities, strengths and weaknesses, is clearly not related solely to the functioning of the child but is defined specifically in relation to the expectations of the important people and institutions in a child's life: family, school, friends, Whatever is uniqueJy' and individually, impcirtant to any one particular child. . The effects of early life experienceS as well as the effectsof recent experiences such as a divorce in the family, the loss-of a parent or other significant _person via death, situational issues such as a fear of the procedures, all have a powerful effect on the ability qt a child to demonstrate the quality of his functioning during, any specific review. Developmental re- view would thUs assume that the child and his environment' (including significant caregivers) are a unit and are not divisi- ble. One does not eidst withOut the other. One cannot be re- viewed adequately without consideration of the other. De- velopmental review, cdhcerns itself with what goes on between the child and this environment on the biological, psychological, ,' social and cultural levels. It is just as foolish to search for a single method of ob- serving a child's development is it is to tell a physician that he must' use only one method (using'a stethoscope versus using a theimometerversus visual inSpectionfor example) to com- , plete,an entire physical examination. Hiaither, it iS'db;y04. :thaf a CornbinitiorN meGlods Will.allbw the obtervation era set of significant functionS. It must be stressed repeatedly that development is not a disease which yields a judgment present or absent. We are basically concerned with the con cept of competencehow well has this child met, and how well does he now meet, the expectation's- implicitly and ex- olio* set by his society for an individual of his/her age and . sex group? 2' 133 `This approaCh raises a host of questions-and issues. To be- are such considerations as the difference between Medical and psychological screening, diagnosis and treatment; the difference between' an individual problem of a child and the matrix of social problemS_ that might be reflected in a child. AlSo to be addreSsed are issues such _as primary pre-: venticm as the detection of disease in non- symptomatic persons versus the newer concept of promoting strengths and:- promoting health. Ode must also consider health: care in gen- eral versus medical, care; this is a parficulaAY prominent is- sue since EPSDT is essentially a medical,,care system. With all the foregoing in Mind, we recommend a new ap proach to the discovery of "handicap.pilig conditions" or "mental defects". We do not see developmental screening only as a quick, simPle procedure to identify those in need - of further study but rather we see it as the, first step in a way of engaging children and parents,in an ongoing concern with their health and -well being. We see it as a way of promoting strengths, as a way of engaging parents with their children, of strengthening these parent/child ties and Df reducing the anxiety. so prevalent in our Society today regarding issues of . parenting arid :child rearing. This is a true system 9f health dire versus specific medical care. We run ,the danger within developmental review of the fallacy bf misplaced concreteness: There has been in the past _ an almost obsessive concern with the numberof false positives and false negative's that each specific test yields. This is not _truly the issue; the issue is what a, parent thinks of his child, how he perceives the child, and how the child thinks of. him- self/herself, In addition it must be noted that this obsessive concern makes it'sound as if there were a magical treatment available once the case is "diagnosed" according to this single all powerful inStrument.hat this is not the case will be reviewed in the follbwing section.,Again, we see the screening process and 'the diagnostic proceSs themselveai' the' first order "treatment"; through the engagement process by. helping a parent think about the child's emotional developMental, status in a new way, in 'the context of a relationship with a helping person, a health professional in the broadest sense who is.interested, who cares, is supportive and listens. 1 3 4, Engaging tire Posnb. In order" to accomplish the goal of 'assessing a child's growth, strengths and weakneSsei, one must as a prerequi- site engage the.xooperation of his 'parent or caregiver. Al- though logical, thisixocess is at times ignored. This leaves the parent non-engaged, virtually iabotaging any ctirative effort on thepprt of en "outsider" to assess the functi of a child. In actual practice this also leads to a Very low number of return visits for diagnosis and treatment, v4hen referral is made without parental engagement. The parent is the only, observer of, a child's rate of growth from birth until school age. Health professionals are not predibtably, involvdd in any consistent manner. When the child enters school, a new observer is identified, the teacher. Therefore, the parent must be engaged early in the infant's life in order to utilize his observational skills in developmental review. The teacher likewise can be a valuable adejunet yeah parental approval to give information about tie rate of growth of the child:The-exclusion, however, of theparent when 'the' teacher's observations are sought, can lead once again into a sabotage of future attempts to assess the child. . All parents, whether single or "coupled", have some fears about outsiders observing their child-, and indirectly their "parenting*. These fears can be stated as a "fear of labeling: good parentbad parent" with a further extension of such, "good, childbad, defective child". Since parenting is fre- quently filled with ambivalent feelings of whether or not the "effort is enough", the fear of intrusion froth an outside.is,- . . constant. On the other hand, ,the assistance and clarification of areas of concern are greatly welcomed and invited. . A further fear is that if any defectis discovered, there will be fact no assistance or .treatment for the `co rrection of dhch. With these considerations in mind. the following sug- gestipns for engagement are made: - - 1. Every attempt should be made to voluntarily engage the parents and the child. Coercibn by mandating an exam or by attaching the exam to a survival need (money from welfare), immediately raises resistance and anger. 4 1 t.J t- ') 131 2^ In order to have the parehts cooperate, they must understand the _benefits of ,participation: A model allowitigfor parerrtd to evaluate the child first (Parent- . -.al' inventory) with the opportunity to discuss areas of *\oricems as well,. as .strengths, allowS parents to .took forward -to assistance, rather than to fear "ciriti- .cism". .. . .3. The process of engagement should frillow the stages df the parents'_ assessment bf their. 'child's 1, development, and the parents' participatiotiwith:a health. worker to talk about areas of concern. (This also offers the opportynity for direct observation.) It would, in addition; be important at this stage to have a health,worker who is bicultural and bilingual' 4. Although there may be a period of- time from the initial contact to the defihitive "diagnosis", the process of eriagement with parents will enable the review to proceed..T.be failure to follow this engage- ment procest could negate the opbortunity to pro- ceed to the desirable goals of treatment, remedia- ": tion -and facilitation of growth -anti .devfrlopment. /6, The, definitive diagnosiS, even though confii-med by - criteria and norms, must be shared with the parents by. a health profession'al' with high sensitivity, exper- tise and knowledge of the parents. 6. -The earlier the engagement process takes place,,,the easier It will be to have .an accurate assessment Of the child. Once rapport has been-establtshed at an. early age, ideally birth, the review can take place with ease. zz . x .. 2. Some Considerations iD Sireening, Diaghosis and Xreatment: Strengths versus Weak. asses We 'must think very "clearly about the implications of the' difference in concept between screening oriented to promotion of strengths and prevention of disorders; and screening ori- ented to defects, damage; disfunction, illnesses and weak- . 5. 132. tresses. We select tests _partially on the 'basis a what use is going to be made at the results. The emphasis on defects and. weaknesses leads to many ethical, social and psychological ,problems: In order to be concerned with success rather than failure, 'we need to establish a non Pathological model. As Brazelton (1976) has said, A new model is needed irr pediatricsa nOn-pathological -model_ With such a model that identifies the strengths of parents and children, the pediatrician would present him- self as an advobate rather than ailabeler. The. Hawthorn effect would be greatexpectations thatthey would suc- ceed might reinforce theirsense of dignity, of their own coping capacities, instead of the kind\ of expectancy to_ fail whicli, too often, they find_now.' This viewpoint is. especially important if we are to screen for mental retardation where, without ignoring pathology, we must be concernedwith' positive adaptiye, coping capacitiet and not just with "defective" scoresor failures-on formal I.Q. testing. The Natureof Intelligence and the bonceet.of Development The traditional assumption is that mental retardation is a chronic handicap that exists, in a person as an individual characteristic, unrelated to the circumstances of that indi- ,,vidual's life. There are two models, theri,.of retardation: the pathologiCal and the statistical. The pathological ,model is based on a disease model that views mental retardation as a' biological dysfunction typified by parlicular biological symp- toms. The statistical models states that a person is abnormal if he falls. into the tails of the statistical distributiOn of the population on whatever measure is being used for diagnosis. Both models imply a relatively simple conception of a develop- mentally constant and pervasive fadtor of general intelligerisce, , yet this conception is no longer tenable as a model for . "ment4to development.. 4 Intellige e is clearly a matter of basic endowment, health status, enviro ental expectations and experience, learning and definition. pathological model fails when .one refers to p chologicai functions: development is not .a disease that .1 '' 6 yields;a judgmerd Of preseht or absent. There is an enormously wide range of what is "normal" or uziyeage". in developmental professes, and an equally wide rariggln the variant rates at which different functions,,develop in different Otlildren. ane ,frequently wisbes that this were not so, but it,must be stressed that "development. is not a single Unfolding.of:more compli- cated behavior' froql infancy to4rmaturity, but a process of ;. learning and interaction." (BoelsAle, 1969) . The Model of Medical Screening versus Devopmental Assessment . Thee nature of developmental phenomena diSc sed above ,leads to very different model's of screening and a. sessmOt. Medical screening is a soOtticateci concept; such screening is-usually simple, quick, capable of "pass or fail" _interpretation; it is applied once to each subject to minimize nog-cooperation, and lends itself to evaluation in toms of sensitivity, specificity and repeatability. . Developmental assessment of psychological fbnctions on the other hand, is a clinical procedure to which "pass Or fail" interpretation should not be applied, repeated examinations are essefl'tial and it is not amenable to detailed quantitative evaluation. (Rbgers, 1971). The essentially clinical nature of developmental asses-sment must never be overlooked; screw- ing cannot be a "one-shot" attempt on a parameter that is developMerital. . Developmental assessment involves a description of the child's adaptive.functioning in the major areas of development of skills (motor, language, self-help, etc.) and adjustment, including behavioral and emotional characteristics. Such description of deireloOment and adjustment may be based on parental report, clinical observation and possibly direct testing of the child. . _ Preliminary interpretation of functi;oning in elation to the expectable range for children of the same age,' ex and cultural group then defines a developmental profile of the child's strengths and weaknesses. This developmental profile niay be used to define needs for further evaluation or other inter- vention., 134 There are marked differences in 441e. personnel required also, for medical and deVelopmenfal screening: for medical screening tests, suitable training in procedure is necessary ,,.but no previous clinical experience .is necessary or even de- sirable. Developmental assessment, on the Other hand, should only be performed by personnel having broad experience in the children of the age being ass'essed, and having specific training and experience iR the, field. If pne uses the analogy of screening oranges.for size as an appropriate one for medical screening, then it is easy to see that the appropriate method for screening is the use of some sort of size sorting quipmentscreens with . progressively . finer mesh. .0f course there may be numerous other standard charaq- teristics against which any given orange Must. be-as- sessed, such as duiciness, sweetness, resistanCe to bruising, color, thickness of skin,: peeling ease, general esthetic appearance, etc. Some of these characteristics are more difficult to mechanically screen and assess than others, thus requiring the informed, relatively subjective assessment. of trained interpreters to differentiate 'and classify them. (Meier, 1973) This seems an appropriate-analogy to developmental screen- ing and assessment. Because we use the same word "screening"we seem to have confused the concepts of medical screening for the presence or absence of disease with developmental screening, which, might more appropriately be called review of developmental status. The distinctions, between the two models complicate the generationbf a comprehensive, nation-wide screening systr. The dangers of over-generalizing a model which may be, relatively satisfactory in one realm Iv other, inappropriate realms cannot be' overstressed. State Behavior The physiological and psychological state of the infant and child at the Mme of testing, that is, the degree of wakefulness, alertness, anxiety and attention is an important confounding' factor in all screening and assessment efforts and frequently has been overlooked. -thus it is possible that a low score on !' 15 some screening or 'assessment procedures may hot be a junction of some deficiency, but rather a function of the child 'being in a state inappropriate for that assessment at the time. The issue of the strange surroundings must also be care- fully considered in relation to the child's degree of comfort, and therefore test-taking ability. Developmental Issues Screening cannot be a one-shot testing session on parameter that is developmental. There is a great deal of misunderstanding about developmental issues in children,. and about the constant change in their developmental capac- ities. In addition, infants and very young children are difficult . to screen and assess definitively because of the wide range Of normal inter-and. intra-individual variations as they rapidly grow and develop. Lack of Predictive Validity. Developmental screening in the traditional sense cannot be used to predict future potential, because of the nature of "intelligence", because, of the limited number of item' on such screening devices, and because of theidifficulty of standardization using different ethnic', socio-eponomic: and educational backgrounds of children and families. Such pro- cedures should be used only as observational. descriptions, by thoroughly trained examiners, which would then lead to plans for educational and remedial intervention for each child. Stability of intellectual furictions is very probably in large part a function of environmental stability, and in no way may one predict how an individual might do when the. environment is radically modified toward greater enrichment or deprivation. The predictive validity of developmental screening devices is thus very poor, based on issues of environmental stimulation. or interference. Problems ,of Personnel Since children of pre-school age are frequently shy with strangers, in a new setting and withistrange tasks, the skill of 9 136 the examiners is an especially important issueiln many cases, bilingual competence will be crucial, as will be a thorough knowledge of the expectations of each ethnic group for .their children.. Programs,to.develop ipersonnel with such skills, and to'train, re-train, do- periodic,, roficiency checks and constant sitpervision are extremely costly. The "Treatment" /intervention System ti The- basic question of having a, detection system when no "treatment" is available Must be faced. If screening and then' full scale asseslment.do not guide some form of "teaching" process or intervention system, why do it? Improvement inthe health status of poor children requires meeting-a-farg.volume of unmet need for health care as well as changes in environ- mental, social and other factors that affect.health status, but are outside the scope of a reimbursement and. support system related solely to health services delivery. This is a crucial point, particularly in the area of "mental defects". Many de- . velopmental "defects" are social, educational or nutritional. Unfortunately the required services are not eligible for'reim- . bursement under the current Medicaid system. The Federal appropriation for Medicaid does not include, and State Medi- caid.agencies do not have, funds that.can be directed.toward devglopment of health care resources, whether, manpower, facilities, or equipment, or toward research and demonstra- tion efforts, specifically for the purposes of EPSDT. When a satisfactory comprehensive developmental screen- ing system has been field tested and thoroughly debugged. it is only useful. if it plugs into practical intervention programs.' The implementation of early childhood intervention through EPSDT has enormous potential for impact on the health, mental health and welfare of the entire country. 3. An Approachlo Developmental Review Given that the Tirocess of developmental review is more appropriate than that of screening, it becomes apparent that such developmental reviewers must, of necessity, engage the 10 137 parent or other caregiver as a significant aspeet of the review process: Thus, in.order to accomplish the goal of reviewing the development of the child and the concomitant strengths and weaknesses, the .assi ance ofAhe parent, or other caregiver . . be engaged.. An such review process must make vigor- . ous efforts not only o engage k the caregiver in the review process, but must also be alert to thepiychological diriamics of the review process such as the natural ambivalence to intrusion into the family and consequent concern about ade- quacy .as a parent orFaregiver. Any such developmental re-. view processshould, tg the maximum extent possible: 1: Avoid coercion, such as mandating.that the develop- mental reiiew.Pe a condition for a survival need such as a welfare paym'ent. t .1 2. Provide for significant benefit participation in the form of a better pnderstanding of the child, with the aim being to 'provide assistance to the parent in coping with deVelopmentarproblems, rather than the, . anticipatidh of criticism for inadequate parenting. 3. Recognize the ethnic, cultural, social, and linguistic differences that exist in a ,pluralistic and culturally and ethnically diverse nation such as the United States..The developmental review process especially the interpretation of the findings of .sOch a. review, must make a vigoroui effort to insure that such differ- ences are recognized, respected and incorporated appropriately. 4. Insure' that there is adequate provision for an inter- pretation and review of the findings with the parent, N taking into account the strength as welt as the weak- nesses of the child, and insuring that the interpre- tation'is, to the maximum extent possible, of practical benefit, to the child and parent in the facilitation of future development. rhus, the process of parent. "engagement" is viewed as a primary :prerequisite for any adequate developmental review, and as a sine' qua non of the adequate implementation of such a program. Developmental Review Given an extensive review of currently available.materials, it is strongly recommended that no single instrument for de- . .138 . velopmental assessment be mandated nationally. There is no one single instrument, inventory, or assessment tool that totally satisfactory. Any instruments used must meet the criteria discussed below. At the current time there is no one instrument that meets such criteria. There are a number of assessment tools that might serve as prototypes of approaches to, the adequate conduct of a 'developmental review, and the criteria for such exemplars are discussed yin the following section. It is also' strongly recommended that the system of developmental review herein discussed be clearly recognized as a system for developmental review, not simply 0 piecemeal approach. We strongly urge that this system of review be adopted and implemented, and that appropriate guidelines and regulations be developed for its implementation. In essence, the system of developmental reviei proposes that an adequate review would include factors' for these areas:. I: biological dimensions 2. psychological dimensions 3. family dimensions 4. environmental social 'cultural elements. The teview should be' carried out in three stages: Stage One The biologiCal dimensions would be reviewed within the frame- work of the pediatric physical examination. The basic Sampling from the biological domain would be conducted as set forth in' the guidelines for the pediatric examination of the Arnerican Academy of Pediatrics. It is further proposed, how- ever, that the pediatric examination be slightly expanded to include an:opportunity for the child and family to discuss, if they so wish, any characteristics of the family situation that they identify as causing stress and problems; as well as to identify strengths and support syste'rns that assist the family in its coping behaviors. Some sample questions that might be added in the coursebf the pediatric examination and health history are: Who is.in the family unit? 12 1.13 139 How are the key relationships, functioning (parent/child, Cou child/Child)? Are there health and/or social .0 emotional problems that are of concern to the fam,ily? This opening of an opportunity to review problems and assess streNrths and .support. systems with the health personnel al- ldws for further engagement and child/family development. The second area to be covered in Stage One review is an assessment of the child's functioning based upon the parent's -report. This would provide an opportunity for the 'parent, alone or in interaction with the health personnel, to comment on the child's developmental progress and on issues relating- fd behavioral adjustment, temperamerit, 'coping capacities and the like. This would involve t)vo sub-sections: 1. s parent report (interview or inventory) of the child's developmental skills. /motor,--lan-guage, etc.) that would provide a dekelopmental profile of the child's functioning. 2. , A parental report (interview or inventory) of the child's adjustment and emotional and behavioral status. Both of iese reports may, according to local 'option, be de- veloped as's uctured inventories which would permit review of changes over time as the child is followed ih the health care system. The use of structured inventories would also al- low paraprofessionals a key role in gathering this information. Stage Two On. the basis of the informal observations of the person doing the health examination, and on the inatefia) from the parent questions, the parent inventosk, covering developmental area and the parent inventory ,cogeFing behavior, it would be de- cided if there were a need to refer a specific child to Stage Two. In Stage Two there would be direct structured observa- tion of the child'sjunctioning. This might be ,accomplished usjng a variety of broader developmental'screening inventories or instruments that are currently available. Paraprofessionals might then be trained to t dminister these screening inven-' 140 tories, if. interpretation of results and constant monitoring of, . reliability were the responsibility of ,more highly ,trained pro- fessionals. .4 Stage Three Based on the findings from Stage Two a child might be re- ferred to a Stage Three assessment of functioning. This stage of the developmental review would include aspects of the --for domains- listed above: -biological; psychological, fainily and environmental /social /cultural. Irr the biological domain, one might envision a'child being referred for careful neurologic assessment, or for an extensive physical examination and review of health history. The health. history; as specified in the guidelines of the American Acade4., my of Pediatrics will also yield a great' deal of pertinent in- formation on development. In the psycholebical domain, the recommendation is that an adequate developmental review cover behavior rpresenta- tive of a wide variety of functions: . Cognitive Development Cognitive Bkills. 'Judgment and reasoning' processes (as opposed to out- come) Memory Interest and skill at gaining information Information about theworld Integration and organization Attention, persistence Coping Strategies Characteristic patterns of dealing with tasks Motivation 14 4 141 Social Deireloptiient Relation to adults -Relation to children Self-help and adaptive skills Concepts' of responsibility and moral dictates, Emotional Development .1 , Affect expression and, ontrol Self-concept: self eSteyOM Body image Individuation Concept of competence Language and Speech Development . Receptive language; language comprehension Expressive language Articulation Fluency' Auditory Perception Discrimination' , Auditory memory Vistial,Perception Visual Visual motor Visual memory Visual integration Visual sequenceing and reasoning 15 14;964 0 79 - $0 1 46 Physical Functions Moyement,,, mobility "aross motor Fine motor. In the farily.domain, one might use any number of cur-. rently available family stress inventory outlines. One would, in addition, be investigating the issue of what familial factors are available to support the healthy development of the child. One .would like to know about parenting issues such as:: do the parents feel they understand the child, do they accept the child as. he is, do the parents feel ih control of the child or is he "beyond" their control, and do they essentially trust the child. A variety of economic, histor;ic, and human relation- 'ship issues might be reviewed for their strength-giving aspects in child developmeh t. It must be emphasized that the identification of -emotional, and behavioral difficulties, and problems with social develop- ment or parent/child interaction, should be left to parental or child-initiative and sensitive clinical observation. Clinical in- quiry as it is normally carried out with parents and children by a skilled professional must be employed it this stage.. The use of a systematized itandardized procedure inquiring into these issues is ethically unacceptable. In the environmental /social /cultural area, one is essentially again looking for the factors to support the healthy develop- ment of a child and family. Particularly pertinent. here would be the support of community institutions such as schools, hospitals, churches, recreational facilities, and the entire child- care/day care system.. IAt should. be emphasized that at every pbint in the develop- mental review, the orientation is toward the child's compe- tericies and forces which are facilitating or could 'facilitate the child's development. Is Intervention Necessary? The final question, of courser is "is intervention neces- sary?" The entire developmental review is a process of at- 16 14 . , 143 tempting to understand in successively finer terms the situation of the, child and family that would lead, to pdsitive aclion. Numerical results of test items are only one very small part of the picture: -The process by which a child arrives at a result is'Crucial. One must observe with all clinical skill issues such as work- ing method, attitude, motility, interest span, curiosity, how a Child understands his environment, those around him and his own 'relationships to them. The ethical dilemma of reviewing a child's development, without reviewing the parent/child-totality when this is intrusive, but crucial to adequate investigation, must always be raised. It is in this area that some of the basic disagreements of the group were raised. What is clear is that this clinical assessmept must be allocated to people highly skilled both in child development and in working with parents, having a very high senstyity to ¶vhat to appropriate and what is inappropriate with an r specific person. It is for this reason that any extensive review of a child's development must be done by sorneone with. great clinical sensitivity. A true comprehension of what the clinical process is must be conveyed to all people involved in developmental review so that a very clear understanding of the difference be, ween Stage One and Stage Two material as contrasted with tage Three, the usual diagnostic state, is available. "Screenin " is not just faster and simpler; it involves an entirely different process of understanding. As will be noted, no specific list of tests, instrument or observation schema have been, included. It was the feeling of the group that no such list should be made available since* it would automatically signify to people seeing the report that these instruments were "acceptable". Two points needito be made: first, that one of the basic areas of disagreement covered the use of instrumentsacknowledged to be inade- quate, simply to have an instrument, and second, that it is clearly necessary that we do develop instruments in -order that The developmental review may be carried out most adequately. The recurrent theme in reports and discussions is that whjle it is earnestly desired that there be a uniformly acceptable set of\ review procedures, relative to psychoMetric validity, norms, eultural ethnic validity, etc., there simply is no such set of procedures currently available, It is the hope . that, such a set of procedures might be developed, and it is strongly urged that the Medical Services Administration taka 17 7 1 '1 leadefshlp role in establishing task forces and demonstration projects todo just that: It has been noted earlier that while there is not, at the present time, one single fully acceptable tool for develop- mental review of the psychological domains of cognition, emotion, perceptual-motor functions, or -lagguage, there are proceduies that have reasonable utility to selected aspe'cts of the developmental review process and are acceptable. in certain situations. Any tool must meet acceptable criteria for use. The following criteria are proposed for instruments to be used in the different stages of the developmental review process, whether the review is direct, with .the child, or in- direct, through the parent or caregiver:.,. 1 Acceptability of the instrument, and its content, to parent, child and professionals; 2. Standardization norms appropriate to the population to be reviewed; to include at -least the following: age, sex, race, socio-sccinomic status, and geographic, area; 3. Dembnstrated instrument reliability; 4. Demonstrated instrument validity, through standard correlation techniques; 5. Demonstrated concurrent validity; 6. Amenability of the instrument to administration and scoring'by trained paraprofessionals, if it is to be used in Stage One or Two; 7. Cost effectivetessi 8. Instrument moist be published, and widely available. Given that the instruments to be used are in conformity with these criteria, and, with appropriate consideration for cultural; ethnic, racial, and 'socio-economic factors that may influence.. interpretation 'of the.findings from the developmental review process, this proposed system of developmental review has the following desirable characteristics: 1. It does not attach a label, or categorize, 'a child prior to a much more extended review, referred to as a Stage Three developmentakreview; It makes a dedicated effort to engage the primary 18 145 tie caregiver,, the parent,: as a collaborator in the de- velopmental' review process, and attempts to insure that the interpretation elthe finding's of the develop-* 4 mental review are culturally, relevant, as well as psychologically sound; It At ablithes definitive criteria for any deva.I pmental review instrument to be used .recognizing hat the present state of the art does not admit of a single universallyacceptable instrument that is applicable to all of the culturally diver* and .pluralistic, popu6- .tions involved Intlae EPSDT program, some twelve million American Children; . . It attempts to establisfi a b f, workableSystem of 'developmental review, that is functionally effective, both in terms, of cost and benefits, with; hopefully; a reasonable guarantee of acceptability to both parents ..and professionals; and 5. It recognizes that there is not, at the present time, a single, universally acceptable tool for develop-, mental review, while at the same time pointing out that there are a multiplicity of such instruments that have practical -utility in differing situations, oriented toward'. review of individual and specific develop- , mental functions. It should be constantly emphasizedthat everyone is Strongly opposed to any effort to attach "labels", or to. make a diagnoSis of tha,child during the first two stages of.developmental re- view. The purposes of the 'initial review are to engage the parents in a collaborative effort to assess the process of the child, and to identify areas in whidh process has been perhaps problematic or, alternatively to identify areas of special gifts that-might be enhanced .through facilitative efforts. The first two stages of review would not attempt to categorize or "label': children; rather, the systgrrf of developmental review would be devoted primarily to determining'-whether, in fact.,. there is cause for concern and if so, what further efforts must be made to detefmine whether,the concern' is -valid or merely reflects transient annot continuing problems. Given this orientation,. 1. the question of false positives negatives is moot. The rplevant question might be posed as follows: 'Is there sufficient consensus between the developmental reviewer, the 19 MB, 0 146 parent, and-the. child (in the-case of older children),that there is need for further review ?'" Tf 'the Answer is affirmative, then the recommendation wotild.be that of referral -for Stage Three. . .ie;iew. It is to Qoted that the assumption is that Stage One review (other than the health examination in some loCa- -"bons) will .be., done by paraprofessionals, while Stage. Two .1* most likely a combination' of professional/pkapro- festio41 efforts, i.e. the administration but not the interPte- tationOf the developMental review instruments will be 'conduC, Jed. by .paraprofessipnal personnel. at this_ stage. Stage Three must be carried out by. experienced, and skilled professional clinicians: on a concrete level, it is recommended that when:1 . ever-the performance of A given child at Stage Two-deviates by.mOre than.20% either above-or below what would be ex- pected fOrAtironological 6g,.q norms for that particular develop- mental review instrument then: the 'findings. from the devaloP- Mental review' for that child shoUld be assessed- to determine whether a Stage Three refeeral should be made, or in the case of a- .child 4tIo has special gifts, to make special efforts to assist parents in seeking out means to.facilitate the speCial talents. It is to be stressed that this proposed method of identification of children who maybe at risk for developinental. difficulties is both empirical and objective, and does, not "label " or diagnoses a child. Rather, -it simply indicates that . optimum developrn.enfal prcigeiss is either not occuring or is occuring -at. an accelerated eate."Thus, the system pf develop- .. menial review as proposed recognizes that there errail be strengths :as well as weaknesses, and moderates the seit4h for patholOgy that.is the .411mark..Of other systems.of cleVelopLA mental assessment: j .. *--"1: It:thou 1441e pointed ouf that the aeeas orbasic: disagree- ment we four; . 1. Ariy review of the,adequacy Of Orenting IvskilISas an anxiety provOking area fdr .Many. This i'discussed in fuller detail in the section on legal apd ethical Con- siderations. Using instruments that a ackhowleclge'd to be 'in- adequate; simply to Kaye an instrument, was a further-. area of disagreement. r The absolute need not to make up lists of "approved".- tests was felt strongly bOnany. It is suggested; hoW- ever,lhat it would be pbssible!to supply a list of tests currently available with' information an hoW they meet the:.;.criteria of appropriateness reviewed above. A separate task force could dothis,in a brief time, mak- ing.;tpe pointoalways that the situation is much more corniolicafed than many people believe. 4. In terms-of the content Ascreening instruments, the . .-truestion of whether we.are ready to move from small scale to country-wide on any available instruments was an issue. The vast social implications of what we do were constantly before Ait.. 4; The Role of,the Parent Clearly underlying t e approach. to developmental :review tio suggested here] th premise. that .a child's cognitive and .emotional fun dO not develop in vacuo:Althaugh this appears to be a truism,' it .is unfortunately also true that this "truism" rarely informs the development of programs. Health: care is often ... ,,..delivered .without the . involvement of the- parent. Our belief in the .importance of the "engagement"- 6f the-parent in the system, in.the'use of information from the :. parent in .the developmental review, and in the involvement of .. - the parent in the full-scale treatment programs. should be stressed. . . .. . Relationships between parent charactefistics and child health and child deVefopment and the greater long-term effectiveness of parent centered as contrasted to Child- Centered early. education programs suggests that. child 'health progriMs should have a major goal of supporting ;if family care of the .child. A comparison of m3, jot. charac- teristics 'of parentris contrasted to proional inter- .action with the childpribrity, duration, continuity,. amount, -extensity, intensify, pervasiveness, consistency, responsibility, an& interfamily var'ftilitysuggests the - need for a Major focus on the role of the parent in the EPSDT program..Traditionally. parents have, had primary responsibility for the integration of screening, diagnosis, an treatment services for their children: Parental .ao- - operation with health workers is essential in order to ,make EPSDT services available to their Ellildren.'There- ...., 15'21'4 r 148 fore, a major component in 'planning State and local EPSOT programs will be to develop communication and collaboration with parents and With parent eoups. To achieve..the needed colldboration between health and 'welfare professionals and. require training of both parents and professioqals. Health and welfare pth- feisfonals should' understand the role of the family jn child health and should have skiffs- in strengthening and supporting as well as supplementing family* care of the child. Workshops and inservice training programs for health and,- welfare workers on the conceptualization of family,care, on variables that' influence family care, on the relationships of parental care to child health and child development; and on new methods by which professionals and paraprofessionals can strengthen and support parerit- al care of the -child are needed. The. programs should motivate increased collaboration with parents in provid- ing for-the needs of children. Programs that train and motivate -parents to become involved with review 'of de- velopmental progress and with diagnosiS -and treatment through outreach programs, followup programs and con- , tinuing' home visitors programs are essential to insure early and continuing care of the-child. (Schaefer, 1974) In developing a parent questionnaire, it is, obvious that the questionnaire must not be trivial, must have .developmental implications, but most importantly, .must have roilitultural validity.. There are in the United States a, number of such parent questionnaires currently, being. used.' A second area of important contributionof parents to de-, velopmental review is thp review of the family envir nmPlAt. The purpose of -this is to describe the characteristic of the family, and the social and ecohomic circumstances in hich it finds itself, in -order to identify the stresses and the strengths 4PN and support systems available to the child. Some questions which might be added to the physical exarninatjamilbave been discusied in Stage One screening. In addition to this there is the possibility that, with parental approval, a local group - might choose'add considerations of a more extensive sort in understanding the family support system. Under these cir- , cumstances, an approach such as that suggested by Mercer. in discus ng measures of sociocatural Modality might be accepted: 149 . family structure 2. Anglization 3. occupation -of head-of-household . 4. family size 5. parent /child relationship 6.. sense of efficaci 7. source' of income 8. urbanization 9. community. participation.. t Some idcal areas may choose! to focus on a "problem list" . such-as economic stress, marital discord, parent depression, and the 'like. There are several family stress questionnaires currently available. , It iS.-cleirly essential that parents understand their 'chil-: dren's ibillties and assets as well as their disabilities' and .deficiencies. What'a can do Is far more important than. what a child cannot do,. The dialogue which brings parents and children into a true health care system is,,,,vital,.3Ne4AUst. ralso think seriously about developing parent-i#seil :treatment- - models .right at. the beginning of the prograrns.°This-truciat aspect of health care is frequently ignored. Treatment in this area of development frequently involves eduCationakprograrns for parents on hOw to 'work with their children, ;:aliclo tional materials about life styletlwand health impact. on family organilation.'"Treatment" may-be education of the 'parent. toy support the child's strengths. -.o A recently published review of intervention strategies for high risk infants and young children (Tjossem, 1976) reviews an entire seriesof parent projects. In assessing the availability of treatthent resources in-local communities, most frequently the most obvious resource is omittedthe parents. It pos- sidle to help parents learn to work with their own children in,a way that has been highly productive not only for the children but also for the parents themselves. It is recommended that a ' separate task force be develdped that wouldeollate and then make available to local communities" the Aarying,models of parlint based "treatment" programs that have been'developed, and'lso make available to these local communities the wealth 23 150 of parent eclucatiop material that currently exists in many scat-- tered places. Thit particular use of parent education materials NW within it a truly exciting and innovative approach to heallh care. in this country. 5. The Delivery System Our first recommendation is that the EPSDT mandate be broadened to apply to all children in this country so that a system of developmental rekew and of developmental pro- tection might be ilanned for comprehensive implementation. This will. undoubtedly require the establishrnent of guidelines. for eligibility of families who will qualify to receive these serv- ices paid for by Federal funds and for.sla,ding fee scales for other families, but we believe that the service delivery systems contributing to the goals of EPSDT ought to"serve 'the needs of all children in our society. Primary prevention and early intervention .programs should be available to all children and youth. The identification of EPSDT as being available only- to = 'poor children is detrimental to the poor and nonpoor.alike, as well as. to the long-term Viability of ,the program. It also de- tracts from the potential of our efforts to conserve our most valuable resources for the future -our children. There is extensive overlap.in functions and goals of several. existing Federal programs. In the interest of pooling resources, consolidating efforts, and effecting maximum impact, we recommend that Such overlap be eliminated, possibly through mandated merger. . . It. is premdture to say whether actually merging. programs is possible or desirable, or whether EPSDT should have the key coordinating role, described below. We 'need to know a great deal more about 'how each Of these programs operates, how they are administered, °what services they can provide, to whoin, and in what kind of setting, which are f\nost acceptable to families and can best reach them, etc., before any decision. can be Made :regarding the most reasonable and effective relationship of each to the other. Nonetheless,.intensive efforts . at coordination, collaboration and linkageS must be continued and strengthened immediately. 24 Specifically, the Atiternal and Child Health prograM arid the Edutation Mr All Handicapped Children Act (PL 94-142) are programs having significant duplication of effort with EPSDT-: A thorough review of existing prograrns and agencies serving children should be undertaken; with a goal of effecting such ) mergers as would improve our services to cihildren arereduce - dupliCation. Added to such a review should be program sponsored by 'NIMH, NICCHD, BEH and OCD /Children's' Bureau. Care must be taken, however, that existing services provided by. current Federal prograrni must not be lost if and when a consolidation of effort should occyr. -03r example, it would be'unfortunate if the services. now funded by Crippled Children's-Services were lost in the "merger". Interface of Mgdical and Educational Settings fin. Achieving the Goals of EMT jhereafter EPSDT refers to a merged program) In order to facilitate the interface of medical and educational settings and, as well, social. service delivery systemS.forthe purpose of achieving the goals of EPSDT, we are ,recommend- -ing the establishment of an EPSDT Coordinating Office at the local level to be staffed by,an EPSDT local Coordinator and supporting personnel: It will be the functiOn of the Coordi- nator to insure that.the screening, diagnosis, referral, treat- -ment, information dissemination, and follow-up resources of the community be brought to bear upon carrying,out the goals of EPSDT. It will be the function of the Coordinator to relate to the medical; educational,and pervice agency setting so that each contributes its competence in providing developmental review and protection for all children in the community and for individual children who 'need special services. CID Developmental review and protection of the child begins during the prenatal period. Pregnant teenager,s and. pregnant non-teenagers need to be provided with a health delivery sys7 tern that offers both 'medical and 'educational services. hrouto.Anformation -disgerninatibn and by- relating to the clinids, county health offices, welfare- - --agencies; and individual families, the EPSDT .local coordi- nator should work to insure that every pregnant woman is entered into the health delivery System as soon aftecthe on set of pregnancy as possible. Initial developmental review becomes possible. in.tie' first few days Of life in the hospital setting on the, basis of present- ._ - ing conditions, some infants will be classified as high risk for normal development,*some will be classified as suspected risk, and some as-normal:Later developmental delay and dis- order may be expected from all of these groups, .in differing percentages. The normal pediatric exam needs to be supple- . !Dented by an additional screening instrument. None present- ly exists that can be convert" ritly implemented. However, we are.recommending that, su ect to parental consent, each newborn infant in a cOrraEnu or designated EPSDTdistrict be entered in a birth registry and slated for periodic home visits by an EPSDT home visitor. The home visitor would' be expected to make contact 4-,,th the parents prior to the infant's dismissal from the hospital, to condOct or arrange for sub- seqUent metabolic and/or blood screens thatoican be done in the home at 10-14 days and to offer the parents pertinent inforMation concerning early child development and resources ,available in the community including clarification of the full °range of services available from the EPSDT Program. If de- velopmental problems are observed by the home visitor (as qv result of general observations, parental concerns, or the application of a Stage Two developmental screening test) re- ferral to appropriate medical or developmental services for. Stage Three. evaluation would be made if the parents are 'agreeable. With parental consent the home visitor would facilitate communication with the child's physician if the child is being served by a physician or would refer the child and his/her family to appropriate serv,ices. Home -visitor's work shoUld be under the supervision of the EPSDT Coordi- nator and be assigned in accordance with neighborhood or community EPSDT districts. However, flexibility in program - requirements should be maintained; if lodging the home visitors, with an existing community service rather than in the office of the Coon,nator makes more sense for a particular community or neighborhood, such arrangements, should be permitted. The frequency of, visits would be _determined by a needs assessment by the, home visitor. Visits to the home will con- 'tinue.until the child has been engaged in a system that pro- vides health care 'overtime. The home visitor's; role would , .serve educational goals, permitting developmentai review-to take place and -would,,facielitate referral and.follow-up. At any time, upon parental request, the home visits Would be clis-; continued. -26 153 Public. health nurses, pediatric' nurse assistants, 'develop- mental- psychologists, and other . professionalS with special training might serve as home visitors for.the purpose of pro- ' iding special services to the family (e.g., hoMe based devel0P- programs for young infants). At the ePd /Of the'preschool.period and just prior toentrance . ..into the public:school, the 'question of the interface with the publiO schools for purposes.Of information transfer will need to be faced. Children 'identified by, the EPSDT program. as' haying been recipients of seryicesinay or may not be served by having information communicated to the puBlic schools. It will be the responsibility of the EPSDT Coordinator to'ar- range for service agency personhel providing services to the child to Meetlyvith'the parents of the child for the purpose of making a decision concerning, information transfer. Such de- velopmental icformation transfer is recommended only when the information would be helpful in identifying the conditions uncteY which a child frictions best, so as to enable optimal, school placement. It is our recommendation that only diag- .. nostic information that is pertinent to educational prescription for the child be communicated to the schools, subject, always, to informed parental consent. We are assuming that normal. medical information typically required by school systems at the time ,of" public school" entrance for all chiliken would continue; As the child. moves across systems .or within sys- tems; information transfer should only occur when the parent Ind service prOvider agree that it ip the best interests of the child. With due consideration of age Ind maturity the child's consent should be included as a condition for information transfer. . During the'years in which the child'is enrolled in the public school, the teacher and parent are always the first line of in- formation for developmental review. Special trainineprograms will 'be recommended which- will enhance the 'developmental' surveillance and protection role of the teacher. It is in relation to the entrance intoopublto school that the recommendation , for the clOse collaboration or merger 'of PL 94 -1w and EPSDT is,most relevant. This "merger." of the mandates orPL 94-142, . Maternal and Child Health and EPSDT will maximize the re- sources -available for developmental protection of children , during the school years. We recommend leaVini to each State the irrl'plementation, of goals of these "merged" mandates via .. interagency agreements and local coordination of services and I 154 agencies. Identification of individual educational needs should be part of an ongoing program, to be followed up by thepro- vision of relevant services. Wring the adolescent years, edu- cationhl or direct experience which contribute to develop mental readiness for parenthood and aduttliTod should be made available. In an attempt to insure that services are made available, statesshould be required to outline a phasing plan for EPSDT implementation beginning with outreach and covering start up and activation of the full range of EPSDT services and Providing fore multiple entry points. Local EPSDTCoordinating Councils should be' established with representation from the schools, health services and other appropriate agencies; parental representatives must also be included. Recommendations Concerning Support Systems for EPSDT o major support systems were mentioned in the preced- ing section. Recommended is the creation of an EPSDT Co- ordinator, and EPSDT office and support personnel for EPSDT districts. Where feasible, these districts should be formed to be coincident with local school districts, or to be larger or smaller than existing school ,disfricts depending upon population density. Also recommended is the establisfr- ment of EPSDT Community Coordinating 0ouncps (as noted abave), to include the schools and all service agencies as-40 as including representatives of parents and service providers. These support systems are being recommended .in order to enable ant facilitate 1) planning on the local level; 2) cation of 'gaps and needs in the service resources; 3) coordi-. ation and stimulation 'of services relevant to achieving goals of EPSDT; and 4) cooperation and contribution to the extern_al evaluation' of EPSDT. k As is obvious from the foregoing recommendations, there.is an absolute necessity fo.examlne any 1091 situation prior to initiating a program. Questions involved' in .a health. _needs .assessment of a community ould give answers to "who is . there to do it", "what are t e supportive institutions", and "whit facilities are available work with parents in develop- ling the fullest treatment programs." 1t5 The manpower issues involved in training, consultation,\and technical assistance are primary. To be careftilly reviewed, again in each locale situation,. are issues of qualifications of personnel involved in each stage of developmental review, cultural appropriateness of these personnel, and their training and education. Each natural system on a local level, would ,_include not only the professional system but the highli'valu- able, and indeed critical, sources of information and support, the parenti. The characteristics of each natural system need r to be defined for each locality. We clearly are recommending multiple models of service delivery depending on the char- acteristics of individuals and agencies available as support systems. The local coordinating councils may decide on re- source centers with transportation to these centers, on the Use of 'mobile units, on the use of community college person- nel, on a.. multitude of other mechanisms for obtaining serv- ices. Again, improvement in *the health status of chldren requires meeting a large volume of unmet needs for health care as well as for changes in environmental, social and other factors that clearly affect 'health status but4are outside the scope of a reimburseMent and support system related only to health services delivery. For this reason our emphasis on coordination of -program and payment mechanism must be taken sdriousiy. Existing programs which hold enormous potential are not adequately meeting the needs of America's children and families: Federal programs are scattered among dozens of departments and agencies. This fragmentation creates problems of coordination at best and conflict among.programs at worst. At the state and local level the situation is even more confused. A wide range of services i2"..families and children is cur- . rently being provided in an essentally 'haphazard fashion from many different government agencies and private organiZayons. Despite the sporadic attem011ik com- munity ,and regional planning and coordination,rthe re- ..sult has been inadequate coverage in /many localities -and duplication of effort in others. - Categorical, single strategy programs, while effective in meeting some of the specific needs of many families have failed to ?provide the support-required by many families with multiklepeeds. In addition- to programs specifically 156 directedloward families and children, public policiei in many areas have effects, both positive and negative, on the welfare of families. Despite this 'fact, little explicit attention is given to the impact on families and thildien of welfare, health, housing; transportation, environmental regulation, criminal justice, recreation, consumer pro-- tection, and other programs, both old and new. (Toward a National Policy -for. Children and "Families, 1976) , The Parent and 'Support Systems . . To be emphasized repeatedly in this approach toward co- °reflation of services at a Federal and local level is the role of the parent. - Support not intervention for parents of ioung risk chil- dren has emerged as. the most promising available ap- proach for producing developmental gains. Findings show that parents are effective teachers of risk children if given' appropriate support. Their success in ,ennancing thgr child's development rests largely Upon their moti- yaw, inVolvement and acceptance of responsibility. The early relationship established between mother and . infant is given as a fugdamental determinant of the child's later course. With acceptance of, these principles and the family as. the object for support, communities can organize supportive services that enable families to en- hance their risked child's development. , Ideally; the approach. beaks In tlhe newbont nursery. Here, both physicians arJ nurses are alert to sounds of early risk and show conce'?n for the child's developmental well-being as well as health. Ir6 theirappraisal, signs of risk in the early mother-infant relationship are not ignored. With evidence of risk and need fqr support, mother and child are ditchargad with an accompanying referral to. be community health services for nurse sup- port and-obse?vatiOns in the home. In her home visit, the nurse first gives expression of the community's interest and support for the' future.- well 'being of the risk infant and family.' While observant of total family needs as well as the health of both.mother and child, the .nurse is supportive of the mother's ben- 4 .30 . C 157 eficial chile pare hehaliiois. She continues her .periodic visits until, after exchanges with the' child's physician, determination,is made thfit no risk or continded risk is priasent With this determinkion, she maintains her visits and relaticins ith the 'risk child and family and terminates service child and family that are doing well In the continuing supportive relationship, the nurse ex- tends her knowledge of child care and training to the child. through the mother.. For family and child require- ments beirond her Command, she draws upon her-knowl- edge of community or area ,resources to bring them into family .Service. In this manner, refirral..of the family is made to the community's educational resource upori evi- dence of the risk child's needs for educational assistance in fnastering the developmental- tasks of childhood. The transition from nurse and physician to education services brings with it k-comprehensive understanding of the child's health and developmental status' and the family's needs and strengths. Upon educational evalua- tion and acceptance for service, the child and family enter into the home-based training prograrn offered by the educational resource. The individualized training program is implemented by the .parents with the guidance and support of the educator. Continuing; as needed, ito the preschool. years, the,educator, monitors the.family's and child's needs for adjunctive community services and assists In:bringing their support to the family:, The parent approlcn outlined in the foregoing is but one of thy many models a community might develop- to pro- vide vices to risk children. To the extent that other models capture the baSic principles involved, they should be effective programs:These principles restated are: 1. supportive services are initiated early 2. are offered on the basis of perceived risk and . need, not diagnosis 3. are family oriented 4. support and enhance the mother-child interaction system, and 5. are, sustained. 31 74-404 0 - 70 - 11 71)e. requirements of the :basic program are modest' and can be met. They exist as medical, nursing, and early , educational services provided in most communities, or, in their absence, can be developed. througn existing agency organizations. the resources and technology. are, lir can be, available. The task, now, is to make the.m. work (Tjossem; 1976, pp: 2425) 6. Paymentsand Eligibility . . The coordination of seiyiees and programs disct&edin the preceding section obviopsly dictates toordinapon of payment and eligibility issues. It is a strong recommendatibn of this group. that the "merged" EPSDT Program be available to all children and families in thea'Unitdd States. It is also urged that tunds be made available for development of health care. resources, including_ considerations of manpower, facilities, and research and development. In the Cugent situation, EPSDT turnover in eligibility ne- gates the periodic aspect of EPSDT and may deny treatment found necessary as a result of developmental review. There( are lapses in eligibility and these lapses are a clearly demon-' sirated. problem.. Patients may not be eligible for services long enough to receiive treatment for identified developmental problems, or their treatment may be interrupted on the basis of eligibility issues. .Currently, eligibility for EPSDT depends in most states on eligibility for welfare services, and ihesalth care. needs do nbt necessarily correspond to welfare status. EPSDT reconfirms thelimitation of "means-tested medicine", and. the heed for a mdreIrcontinuous and comprehensive' method of assuring Ilid-Sright to treatment for people whose incomes often vary wielY. from month to month. 7. Ethical and Legal;Consideratio o 1 .General Ethical/Lejpemises , . . . In developmental review, ethical evaluations must be viewed against the back010 of two different nonnative models: 1) i 0 11'') (4 32 159 the disease tecognition and prevention Model and 2) the 'cul- tUral diversity model- The, former emphasizes' identifiable organic pathologies ich. imply some type of medical treat- ment. Within this .d yh1,1he basic assumption is ttiat-false positives carry no risk aside from th`ose. associated with fur-:. ther diagosticrproppdures, ohile failing to detect- pathology could lead tpserious-and possible irreversible consequences. On the other hand, the "cultural diversity" normative model :focuses on behaviors which deviate from the expectations of the socialgroup. in this casClithe basic assumption is that false positives are more setioulthan false negatives in screen- ing becistse labeling 'a child as deviant tends to trigger social responses such' as labeling, tracking into special'programs, institutionalization,, changeti perceptions and expectations, etc., which in themselves may have irreversible consequences. For this reason, emerging laW in the area of mental retarda- tion and juvenile justice _Clearly rests on tbis assumption. Thui, any developmentat review system initiated tinder EPSDT should clearly.reflect this important distinction. In our view, screening may legitimately utilize the 'disease model" during theyears of infancy and early childhood:development when the ehild's primary social group is the family. In doing - so, however, developmental review must focus primarily on the 'child's "physiological" development.'Qonversely, as chil- dren enter the mandated school system, when-their behavior is evaluated with reference to the expectations of the.social 4 group, developmental assessment ,necessarily encompassea' behavioral metrires. and policies must therefore be-formu- lated within the normative framework of the "cultural diver-1. sity" model.- The Scope of Developmeritallteyiew a In a free, pluralistiVsociety, there are clear boundaries on, °Ihescope of legitirbate inquir'y' into personal and familial con- cerns. Therefore a mass] government financed screening program' should be limited to 1) those measures of organic functioning and basic, adaptive coping skills which' enjoy 'high degree of consensus within the healtffiRrofessions and-0 affected communities, and 2) those behavioral factb-is espe- 33 164 cially associated with learning, language' and speech develop, rrient, motor. skills and perceptual abilities: Specific assess- : rrient of emotonal and behavioral adjustment and parent/ child interactions should be let. to parental initiative and sensitive clinical' observations (Stage Three as herein pro, pd,sed). Relationship Between Developmental Review :mainders of the Health Care Delfvery System and the Re- 1. Programs should rice be instituted wittiout careful attention° to their place in the full service delivery system: coordi.natiori of services as recommended in Section E is Vital. , 2. A top priority is the identification of gaps in diag- nostic.and treatment services in -each,,community as an integral pert of health services needs assessment. .3.; there must be some mechanism for ?swing the qtlality..and equivalen6; of al) developmental' review and treatment services in the community. Relation'ship Between Developmental Revi:w and Unavail- . :ability of F011ow-up Serviads It Is not ethically' mandatory to limit the scope of review by precluding a specific review procedure because .treatment is unavailable for the identified 'cotdition. This is trUe whether, or not there' be known treatMent at all, or treatment is not available 'in the community, or if available, is too costly. Reasons offered for this position include: 1. without such data, the need for the development., of treatment capabilitiet may never become apparent; 2. :the information may be useful to the provider in coun- seling the parent about managing the probkin, and in developing parent oriented treati-nent.'prArarns; J. treatment may, laterbecome available. 34 4 However, in many individual cases; it is like* that the csost of Stage Three review would be unjustified by its likely, benefits to the child. Informing l'ants of Results of Screening 4 If the developmental review Prografb suggesfs that the child. I, is in developmental difficulty, the .health .professional shad inform the parent of the general area of concern, being care- ful to avoid arousing undue parental anxiety, before recoiri- Mending referral for. diagnostic (Stage Three) evaluation. If the diagnosis is Positive the clinician should inform the pArent.fully" of the child's cievelopmenta status and discuss the treatment alternatives. If treatment (or perhaps even diag= ' nostic) services are not available in the community, then the diagnosing clinician should.counsel the parent, .utilying-his/ her own clinical judgment in detrkmining.what information to disclose. It is, of course, also important inform Parepts when no, indications of difficulty are foundsd ing any Of the stages. of deVelopmental review. Criteria Governing use of StanRardized Precedmes 1. We accept the view'that American society is hetercir. geneous. Therefore, standardization of all procedures used in screening or diagnosis which are correlated with sociocultural factors must be done with appro7 priate sociocultural noims, and all testing must be _administered in langua.geappropriate to the pnguage spoken by that. child. Further criteria fmiappropriate- mess of instruments are spelled out in Section 3. ' 'After twe.yearS, no standardized procedure should be utilized in the program until t has been approved pur- suant to regulations adOptpd by the Secretary. In the interim .periodo task force appointed by the Medical SerVite$ Adrnibistration shall review standardized. procedures currently in use, With the advice of apPro- . -priate professional and consumer groups, to deter-4.: %mine' whether they are correlated factor's, 35 2.. Each standardized prOcedure.should,have predictive validity for the betiavior or conditiorrs which they put:- port to Theatre: They Must hak predictive validity . for children of each of the socioCultural groups with , whom the prdoedure is to bq used After two years, no standaPdized-.procadure .should.be utilized in tthe prograM until ithasbeen approved pursuant to regii. lations adopted by the -Secrethrylr`n the interim, the task force appointed by 'the 'Medical ServiCes Admin- istratioh shall review the predictive validity of stand irdized procedures currently in use foi compliance with this standard. .if. 162 The Ethical Relevance Of Cost. . . Cost becomes an ethical issue when4overnment,--with limited resources, must finance services for-large numbers of children and must 'choose to what extent which Children can i. and will be.served. ce t, -,- 4. . . Although:reliable cost. estimates are presently not available for Screening, 'diagnosis and. treatment for EPS'DT children, it is clear that such procedures should be as low -cost as pos- sible witOthe highgstireturn. 'Considering theSe preinises, we suggest the follow42g guide- lines for.priorities for the PSDT program: 1. Priority for care should be- targeted 'to the pren tal, infancy. and clearly Periods- until the hild reaches the mandated school entry au.:. 4b) 2. Stage One and Stage 1wb review' procedures should ,be as quick, brief and si le as pos'S.ible without sacrificing quality so that s high .a proportion of 'funds as possible can be toward treatment. .A.% lriformati Consent 1. Parents 1, I a.' As an integral part of the initial outreach phbse of a. developmental review effort, pArents should be 36 4 .163 . . . . provided with a written description. of the nature and purpose of the proposed procedures, includ- 'ingadequate assurances of quality, confidential- ity and benefitS to the child arid. fanii.ly. Any. Writ- - ten, notification sfibuld . include jnformation; .a . lacgbaire appropriate for that particular fain4.; 13: At the time the parent personally 'appears`,,-he or :-: she should.beyerba informed:of the .nature. and ..purpose. of all developMental review proceqUreS, . and .should be notified.that selective participation is possible. A refusal toaulhorize any-given pro- ' cedure must not jeopardize the child'saccess to any other aspects. of the program. Parental' con- sent should then be obtained for each procedure and for any proposed transfer of records or infor- mation upon completion of the developmental reidew. 2. Informing the Child A, Each child being served s uld be informed' of the nature and purposes of the p ocedures and their re- sults 'to the maximum extent possible: consistent with his or her level .of intellectualiand emotional maturity. . Records and Confidentiality All patient records should be created and maintained in accordance with the customaryANctices of the health pro- fessions. Confidentiality should be carefully preserved and no information should,be released without parental consent. Atgthe time of the mandated school entry scfeening, all records of earlier developmental review at time of birth,dur- .ing infancy, or at time of pre-school entry would be canton- dated by the EPSDT Coordinator. It will be the responsibility of this Coordinator to arrange for-service agenci personnel providing services to the child .to meet with the parents of the, child for the purpose of making a aeciiion concerning infor- Ihation transfer. Sath developmental informafios transfer is - recommended only, ,when the information would behetpful in 37 j identi the coeions under which a child funct1o9s best ;sous enable .optimal school placement. It is our recom- mendatron that only diagnostic infbrrhation that is pertinent to educationat prescription Ifor the child be communicated to' . ---,,ibe schools, sybject 'always to informed parental consent. 1.':Vnitleczo circurnstantesphould Stagelne and Stage. Z.Two'infOIMati--.4;. orte transferrecNo the choOl system. - - - 2. "Medical" informat am these records may be '.'"U/IPLI'r disclosed to authorized Pei.Sons4hthe educational system with parental consent in no-Tv:1:00h usual 4. ° procedures. -- . "Screening information" per se should not be dis- closed at all. _ 4. Additional information from the records may be dis- ,closed to authorized perSons with parental consent only after the EPSDT Coordinator has consulted with the parent and the have made an Independent de- t/ termination tria t e disclosure is in the child's best interest. With due consideration of age and maturity, the child's consent should be included as a condition- of information transfer. 164 Ethical Aspects of DeielOpmental Review and Assessment After Mandated School' Entry Many of these ethical and legal concerns about the purpose and scope of developmental assessment; informed consent, parental and child roles sand confidentiality of records are espeCiallyacute after the child has entered the school sys- tem. This committee recognizes the-school as a major point of impact on the child'sdevelopment at this stage of his life. We also recognise our mqual concern with, the critical aspects , of a child's development at this point, since much of this de- velopment affects school adjustment and learning ability. There are some safeguards ,ioto the education system4 to address our concerns for safeguarding the child'S rights (such as the Buckley amendment) and. more will doubtless _come with implementation of PL 94-142. Nonetheless, the EPSDT Program should not abdicate nor delegate its respon- .1 J r .165 . sibirityfoY,the children beeause they have. ntered the educa- tional system. It requires instead that the criteria outlined interface with the safeguards in the education system, and buttress it when there are gaps. In fact, the "merged" EPSDT with its concern for the overran hdalth and well-being of the child, should feel that its 'responsiblies' may supersede the requirements of the education syste whenever safeguards 'for the 'child'S rights in these processes are conOerned... The Dangers of Labeling "It would be -unconscionably myopic to entirely overlook Some of.the larger societal issues inherent in' any national massive screening system. The legal ethical and ethnib ramifiCations of labeling humans are to be carefully con- sidered and respected, .etpeciall% in light of 'the recom- mendatioris forthcoming from the 1971 President's 'Come, mission on Mental Retardation in Monte Corona, Cali- fornia which severely criticized-current labelinvractices and their subsequent dehumanizing efforts. ,Kr example, the determination of cutoff points separating normal odevelopment from abnormal development is extremely controversial and the Boston conference focused much discussion ,and debate, on this crucial issue (PCMR, ,1973.)". (Meier, 1973) In a *working =paper .prepared for, the National Adyisw Committee on Classification of ExceptiOhal Children, Merl& addresses this normality issue: - "The classification of exceptlerral children has become a critical social problem beciAdYhoSe ethnic and cultural groups disadvantaged by present 'classification systems' arerotecting the taken-fqpgranted value frame withino which psychologists, .educAlis, and .test makers have been operating. The classification, of exceptional children did not become an issue becausepsychologists, educators and medical practitioners were dissatisfied with the present system. This fact has great importance to the deliberations of this committee. It signifies that the cen- tral issues are conceptual' Ind ethical rather than tech- nical and empirical. It meaKs that basic assumptions are 39 170 166 ., k. . being challenged.': enged!: The committee Must be willing to examine basic assumptkons -and to. address the funda- mental value of questior0 being raised by thosd who take issue with present polities and procedures. If, instead, the committee treats its task as merely setting guidelines for establishing the reliability and validity of measure- ment techniques.in their traditional sense, its work will have little relevance to the current controversy because it will,have misunderstood the nature of the controversy. The value issues must first bp clarifiedd the implica- tions of adopting a particular value fame explored." Alercer, 1972b) . 4. 4. , We would caN attention to fhq, crucial nature of this State - .meat for implerrienti glhe provisions:of EPSDT, for beyond-the. .ethical issues lie tie dang2rs of legal actioil.Test results a3e used for.makin_gfar-realling decisions about children. In recent vars, a growing controversy regarding the use of tests has.blosNned. It haS become in reasingly apparent that the . , large scale use'of tests for plac g persons in. social, edu- cational ancl\ economic niches has serious social conse- squenCes,.particular19in lie of the .growing. realization that standardized tests am unfaiY not only &Abe culturally ,. different and the socio-economically disadvantaged, but also to th brighf 'Unorthodox 'person and the naive individual who lacks experience in taking them. There .are potentially bias g.effects of. ethhicity; language, socio-economic 'level, and conditions of test administration. on test performance. "Increashg social demands seek to ',modify existing uses of tests that are inappropria te and unfair, particularly with minority group children:Social pressure in this regard takes various form;_aIrd, principally includes litigation, action -I;)y professional arid'other types of organizations, and legislation." ...., (Laosaaeid Oakland, 1974) '. .- The messages"that achild receives about fi=ifnSelf from his environmenrdetermine to a great extent his feelings about who .he is, what _he can do, and how he shoUld. behave. <Thus, ,if arents or teachers perceive children as differen n some Way; they will treat the child differently and ay thereby encour him to become as he is perceived. Te chers giVe the least acceptance and support to .children they perceive as. having the least promiseand the least backing firm parents. Teacher contacts with "low assessment".children tend td..be.7,,' significantly more dir4ctive and discouraging of initiative iii-d' Y 171 167. spo taneity. When adults -believe a child to. be .incOmpetent, they ay protect him from exposure to experienpesfrorii which he hi y learn greater 'competence, Learning is heavily in- volved with the expectation that one is able to learn. Specific Mineriti. issues There is a 'prevailing attitude, based bn ecdnomic ,con- . ,siderations in many minority groups, that one ignores-41 conditiont which do not cause pain. One of the major issuel in arcomprehensive system of developmental review is: , what Mrn of outreach must be designed and employed which will impact .upon the pattern of health facility non-utilize- . tion Which is so firmly established within poor minority families, and which interferes with. the ealy deteetion of factors which may potentially lead to poor. intellectual and emotional functioning. Why (lui Fears Will Not Be Stilled The erhaps repetitious insistence on the appropriateness truments and the inappropriatness of labels comes from the experience throughout the country of harm that has been done to children -under the guise of "doing good." Children have been tracked and labeled, exclUded from school, on the asis of the use of psychological instruments. In addition to is, the issue of parer( al and teacher expectations is a, dai consideration.Children aunt each other, and guilt and an'xie y are easily ,aroused in oth children atvd families. The basic rights .of children m t be consideT6d in' any program of developmental review. he 'motto must always be ".'first do no' harm ". In the -EPSDT system,:there is the potential for enorm- .pus good. 0.. Evaluatioq Prograrrrevaluation is a highly Specialized field; it is recom- mended that specifiwidelrnes concerning program evalua- 41 <!" 1106 172 J 4. 168 .4 tion be developed by a task forceof experts who have specific competency in this area. We caution that this must be done 6, quite soon; to that elements considered .essential to [rope?, program evaluation be included in those programs now in.the proCess of implement ion. Ir to of EPS sho be done in relation to specific, pr etermined roc s and-outcome measurements. An effort should.be made, h ver; to insure that the evaluation' of the develoPmental reVievksegments of EPSDT does not itself be- come the Controlling factor 'in the operation of the EPSDT - program where,-such cctritrol"would deflect the program from s . achieving its goals. Ally evaluation program to be implemented must ,be Vona io with a minimum of paperwork andeith the least distortion,or interference in the ciperation of the program.' Pro,cess evaluation would be relatiVely eas y' to implement since it involves such matters as utilization, Cost issues, vol- ume of service and so forth. Outcome evaluation is much more difficult and more demanding, but must bereosffice the issue of lorig-term predictability of any aspectlirdevelopment- al review is oie that is crucial for the future orthe children.. 9. Cost Effectiveness * ny publicly financed health program begins with the as- sumption that it .provides 'benefits which are an adequate return on the investment of eublic funds. Otherimise; the government need not institute a progrith at all. It could let the market, place regulate health care , without interference. During the past forty, years in the United States the government hag grAidually Increased its share of payment for personal k health services. In child health, the:government paid out 3.5" 'bill' dollars in 1973 for welfare recipients and the medically need wNIch has thereby become the major gOv mental child eialth program :_'both numbers of recipients dollars nded. J he history of the federally and state firvnced. Early and --,,Periodic Screening, Diagnosis, and. Treatment. Program indi- , 4. This section hps been adapted directly from the working paper writte_V- for-the conference by Anne-Marie Foltz, "The policy dilemma: screenig and cost effectiveness ". cats that it. was established on the overall assumption that early detection and treatment of disease will save lives, save suffering and save the costs of life-long crippling conditions. Further, Rivas assumed that screening and early detection of disease can.alter the natural history and courseof a disease and that' the benefits of this. alteration can be quantified in. 44dotlar amounts. These cost-benefits assumptions were never fully ddcumented go it's difficult to know precisely what were Congress's expectations when it passed the law in .1967 (P.L1 90-248)..Thus, evaluation of the 'progrark based on con- gressional goals is not possible simply* because these goals - were never clear. In actual fact, despite the grandiose title of the prograM, it was plapned and implemerrted in such a way that preven- tion and screening have been the focus, while. diagnosis and treatment have been secondary if not neglected..0ontiouity. Of care has remained-a' distantly hoped 'for goal. It was hoped that the burden of handicapping conditions wowid be removed by providing preventive care services for children. The Department of Health, Educa4n and Welfare ,- thereby thrust itself in the midst f a Major`debale 'in the field of pedicine and public health which has been "described as medicine's great schism: prevention versus cure. Not only has there been no discussion of exactly what was # to be prevented through the new program, there was no com- mentary on how effective a- preventivp program might be. Giyen this imprecision of purpose, it is no wonder that costs d of these programs' were even less eafly stated. . One way of controlling costs in implementatiOn is to limit the extent of services that states are required to provide: In monitoring the prog-rams in the states,,HEW.decided to focus its attentions. on EPSDT1and hot to IciCk at the overall care rendered under Medicaid to welfare Sand Q;jeditelly needy children. . . The efficacy of:-disease management t `rough screening rests on three necessaryconditions: a knowledgeof the nat- ural history of the disease; the efficacy or 'efficiency o'f the treatment; and agreement o large number of "social and individual 'benefits which r accrue from the screening procedures.. For sc Frig to e efficaciouS; there must be a ,?+5 nsensus on social and individual benefits of the treat- 43 / ) 170 ment procedures,' and it Is here that the developmental screen- ing aspects are most vulnerable. ' Few cost estimates have been made of. the developmental screening components of. the EPSDT program, 'particularly in relation to benefit.i. In the past, the issue of quality of care as measured by appropiiate utilization has been constantly con- fused with the issue of costs. Sometimes costs are evaluated; -*,, ..sometimes.costs are noted only in terms of the substitution of expensive'services for less'expensive services itito contrasting nizatioris of health ea're. Costing out the EPSDT program assessing cost effectiveness has received far less. atten- tion thin studies for the Medicaid_ population as a whole. As in the case of de mental screening, the sta of the art of .cost effectivegesVnot far advanced. Alm no work has -been done on cost effectiveness for' any sy em of develop- mental -review; cost effectiveness itself may not be highly relevant if the goal if to provide children with, relevant and promotive agcess to health care. A "merged" EPSDT, seen asa comprehensive care program, . provides a basic pacicage of health services. whichrsbould be available to any Child in the United StateS regardless of his economic status. One does not need cost benefit anaiyseto prove that poor children -.should have access, to the same - health benefits as rich ones,:Nordoes or should one'need cast benefit analyses to decide That-children With Crippling conditions deserve care. The analyses become useful, however, when,fgiven limited re- sources, policy makers. must decide how much of what sort of care can be given 'to how many people. ' EPSDT's significant contribution to the field of child health . . has been to uncover the present health system's inability to provide comprehensive and continuous health services for poor children, evens given a financing mechanism. The reasons for this failure are diverse: ^1.. 'The state of the art of preventive health services, part ticularly with reference to developmental review: agreement among health professideals as to what is" required and what is .needed. . 2. "ie irbility of okanized systems (state health pr welfare departments) tO monitor and folloW 'all Oil- __ r--,dren under their care: ttie lack of case Management. .)sNsZems. 4 A 171 3. The iiitWillingness of private health professionals to participate in a public health system unless adequate ' financial .incentives are provided and bureaucratic dis-incentives are removed. 4. Contusion among federal and state agencies as to which group' is responsible fo'r-Thild health (for ex- ample, Maternal and Child'hlealth, Medical Services, Administ ion, the Office of Child Developrent, etc.). Research must be continued to provide answers to cost issues, nand t9 develop appropriate systems for collection of data to estimate costs and benefits 'of publicly firianced child health-programs. The goat is, obtsiously, to determine the most econarnically feasible methods to deliver services without sacrificing qualify. 4 - The field 9! policy is extraordinarily impoi-lanh If Congress meant What' *jai stated in the E(?SDT legislation,. ter mak comprefrensiv4 care , available for every poor child, ithen must folloW 'through on its promises and abandon cost elf tiVe-approacheS' which subvert the:lintent of the policy, 10. ; Training, Research and Verionstration Projects The:prow implementatibn of EPSOT acros411 the country wilt YeqUire the development of training progrems in order to increase the sophistication of Orofessionals in the area of normal development, developmental review, and o,pportuni- ties for t4e developmental protection of children. Therefore, we recommend that there be an expansion of'existing sources - of .-funding so that training programs _necessary. for existing N professionals conttibure to the achievement of the goals of EPSDT. wfay be made available. We include in the gradp' of eligible rrofessibnais: physicians, nurses, teachers, yeholopsts.ksocv,y0W7,F*01eVcounselors, and speech athdlogisii and. aCid1Ologists. Training programs ,should be arried out by existing accredited training resources and in- stit _ns'yor'example, universities, state colleges, community ges). Training could be offered in the form .of workshOps,. -courses, seipinars, and inser*ice training programs. We also recommend That training funds for paraprofessional persOnnel be:Made available on the apsumption that.Stage One and per- . - 45 .1.7 172 ,haps Stage Two f9/ the developmental review procesi 'will be . - carried out by such personnel, and on the assumptiorighat a great deal of the parent support work wilffalsd be carried out 'ultimately y- paraprofessionals. - L We urge ncreased effort to sensitize physicians and other health profeisionals to the problerni of parents and to the problemsof $ethnic diversity within this pluralistic society. We'also urge that health professionals be trained to offer in- &ease& support and counseling to all families! . . It is crucial that members of difkerent professional groups, be sensitized to the wayi that their colleagues iri othenpro.- fessions-vieW the Werfd.'Ttie training of any "bridge" Orson Must include knowledge not only of the procedures used in the various pfefessions that are being bridged, lout also the insti- tution,s in which .they are embedded and the professional culture that them. Some of f-thii can be acquired, by exppsure to other professionals but the understandirigoof it that is essential to effective colldboration probably depends' on a more explicit e'Xamination anit during training.' . , r . 'We will gain little if we establish new bureaucratic struc- - . tures without careful consideration of the .quakties oft:the 'people who Will make- up that. structure. In order -to achieve thefgoats of EPSpT, special resources for developmental review need to ,be created tbAt.ipplement the kin of assessments _typically done by, physicians. The uresof these special resoUrces _primarily are trained 'per- 4," sonnel. Such personnel should have a very firm grounding in normal child development, should have extensive 'skills in using developmental evaluation, techniques, should knoW . something about the arena in which physicians operat$1 an similarly. should have some 'familiarity with the, nature and . requirernents of effective educational settings. They must also know about pal.ents, abch It families, their ethnic and economic diversity, and the, alitieS in whibhotheylive currently -iii our , ;. a society. . r. 0 Data Available It is stronglyArkommended thdt there be Constructive u 'maple of data already available fro.rnopast projects such as the . . 46 7.7 collaborative. studies, in-.01`der that we may beCome. much, more sophisticated but ut issues of longitudinal tiorr As has been noted repeatedly in this report/ we recorrimend 4tresearch and dexelerpenf or demonstration projects tci,de- .velop measurement standards approprilte to:the assessment of young.chil4ren. There should alsobe research' into method- bfogy of developmental review of young ohildren with empha- sis. on the variety of assumptions and theories related to age and ethnicity. .,. 4 There must be the developMent of siratdgies for the. sienul- ,taneoris selection of measurement variables and the idenli- fication of program needs, for the establishment of research,' development devaluation prioritieS There must be an em- phasis on ;overlap between researcband consumer priori- ties. In' tion,. there, must be provisio'for taking into ac- count .family needs and values in the,`Co.nceptiralizatien of measurement relatedkroblerras, and.in the development, selec- tion and application of any meastir,ement'or, other instruments. :Parents and those directly responsible for the vrelfare of the children must be involved in all dedisiorl making proc- esses in this area.. . The focus in interpretations of assessment must always be on individual differences that lead to appl'oprial inter- vention for each-specific child, as Opposed to a focufliTntgroup differences and comparisOns. Any instruments that are deVeloped.muSt describe cfiaabili- ties and limitations for which some form: of° intervention, including parent education, may be prescribed, as -opposed to tests or instruments that are interpreted only in 4emmative 'terms! 4 There should.be develope.a multi measure, multi domain, multi - function collection of Measures from which'instrunieos' may be selected at a local level, by local *io', b'ne of the most important issues in evaluation must be the .inclusion of a search for possible,,pczsitive and negativp side effects of any system of developmental review on children and their families: This-, would include an. investigation of any problems associated with potential"' "labeling:: as a Conse- quence of the adrnnii'tratibn of any of the aspects of deverop-' menial review 'hereinJecommended. , \.. 34-04'0 - 79 - 12 . 47 174 References . A Armistead, LIM. and 1E.E. Orawford, An, easy developmental .sdeening test for pu.blic.-health use Amer. J. Public Health, 1914.1. 241-244. Boelsche, A. Symposium'on mental retardation. Early'identi- fication land differenlial meaning to the child, farnklyind,phySician: Texas Medicine. 1969, 65% 42t49. EduCational, Testing Service. Prioritiei and directions for re- search and ;developrIent related to measurement of young children. Princeton, New.-)ersei,EdUcational 'Testing Service, Report on Task 2 under OCD Graht t H-2993 A, H). PR-72-22, October 1972. furuno; S. and A. Connor: Use of non - professional personnel . for health screening of Head -Start children. Paper: pidented at the annual meeting of the American Orthopsychiatric Asso- ciation. Ban FranciscO; March, 1970. ,;:- ar . Hurt, Madre. A problemLciriented apprAtch to EPSDT in dev_e1-1 opmental asessgneni in Hersth and,Rojcewicz.(Ed§.), Heiith .care screening and - developmental assessment: DHEW Publi7 catkin No. (ADM)24-115, 1974' p*: 12., cr1/41. and T.D.0akiand,,Sotial control in mental health: -,psychological assessment and the schools: PaPer presented at the meeting of the American Orthopsychiitric Association, San Francisco, 'AOril, 1974. : . ; Meier, J. Screening and Assessment ofrIoung Children at De- 4 :velopmental Risk. The Preg-idetcht's Commission on Mental Retardation,-Washington. D.C. 20201, 'March, 1973 DHEW Pub- licatio.*;10S)73-90. Mercer Discussion Of Alteinative Value Frames for Clas- 'Siffcatiani of ExteptionS1 Children.' Uniyersity of :California, RiOerside,4932b, . -43Ogersk The early ,recognition of handicapping dis-° 'order in ctijldhood. DevelopmerUal Medicine and Child Neurology.. 1971, 13, 88-101.. ° _ , Schae*:E'irt S. A perspective on developmental assessment . under Ent:ff.-In Hersh and Rojeewiz---(Eds-.-) -Health-care screen and developmental assessment. DHEW Publication No. ( 4- 15,, 1974, pp. 3637::. Tjossern, f: 0 Ed.) Intervention strategies for: high risk .. , ;infants an children. Baltimore: Unversity perk Press, 1976. Toward a ill Policy for Children and Families. Advisory 'T 4 Committee on C 1d- Development, Asembly of Behavioral and Social Science, National Research" Council. Washington, D.C.: e National Academy of)Science;, 1976 pp. 3 -4. Wetnei, E. Review of the Denver Developmental Screening j Test: In Buros' Seventh Mental MoasurementscitearboOk. Gryphon-. Press: Highland Park, New Jersey, 1972, pp. 734-736. Narrow; Leon; Robert: Klein, Salvatore Lomonaco and George A. Morgan:Cogriitive and motivational developirientIti early 9 hiraood: Jn Friedlander, Sterritt and Kirk (Eds.) Ex- .Optional Infant,A7o1.1. New York: Brunner/ Maiel,.1975. 4 --4' 44 4 176 EXAMPLED OP DEVELOPMENTAL REVIEW IN EPSDI Szfrtsfos. As component of the total ' EPSDI assessment, the developmental rerig* __wlli-tags-place -in-the-variety-of:settings-in whicii-EPS services-are-con-duetaff.-- These can be basically described as: (1)- freestanding EPSDT screening 'sites, (2) private physicians' offices, and (3) comprehensive health care centers such as community health centers. The procedures recommended in "Developmental . Review inthe EPSDT .program" lend themselves to each of these program designs. The brief sketches which follow are examples of how the process would flow in each setting. , . . , . . . .. . In this setting, Stage I may typically be accomplished when the child. and the accompanying responsible adult (hopefully' a parent) are seen by a finit linastaff person,.perhaps a nurse Or apqraprofessional, tyho takes a health and .developmental history. In this interview, the worker also -uses the opportunity to reemphasize -the goals of the prOgram in terana of preventive health care and., strives to allay any anxiety on the part of child or yarent as to what is to f01- low and to. create a supportive atmosRhere in which there is-a- clear opportunity to fully shale impressions about the child's groWth and development: In . the conrse of this interview, the worker should utilize a brief check list (parental - inventory) to gain the parent's assessment of the child's deyelopment, both'. ' strengths and weaknesses. For some parents this may also serve as an opportunity. to raise questions about their perceptions of this child and of their own responses to him, . . . In the case ofsnolder child, obviously for an adolescent, a brief interview with . . . the child'is a part of the history taking. (The child should, also be encouraged to discuss his interests; as he sees the need, during Ihe physical examination which follows.); . The material then acco panies the parent and child into the physical exami- ,nation where more highl trainedifersonnel such as a physician or a nurse prao- .titioner can use the results of the parent inventory, the history; and the findings of the physical assessment to compile a total overview 'fit the child. .This full assessment of the child's development should be discussed with the parent in whatever terms the outcomes. suggest as follow -up for continued good health . or the need for further assessment.. If further assessment is indicated (Stage II y it may be. done by professionals . (or paraprofessionals under professional supervision) in this setting. /- . . . . .. _ . . . MODEL 2; THE PRIVATE PHYSICIAN'S OFFICE . .. . . . . 1na private practice where- there is appropriate s port staff, ft procedure similar to the screening site model can be followed. ere the physician works alone, the bistoty taking should include a discussion with the parent (and the . child, as, appropriate) about the, child's general growth and development. This discussion, the history, the assessment of the biological dimensions during the pediatric exAmination, and the litryAcian's overall impressions become, deter- minants, forillarther assessment (Stage II) in the office or through referral. . 7 . - MODEL 8.,A A. COMPREHENSIVE . HEALTH CARE' SETTING - e; .. .., t In the comprehenaltre-health care center there would be a wider eomple ent of available staff on hand, including paraprofessionals, nurses, physicians, and perhaps in more fortunate locales, meltai health specialists. In such a setting, inktiple serviceScan be.oftercki, and Stagg II-(and possibly Stage'III) evaluations may be available Within 'the same setting. ', The -flow.' of the proces'a4emains . thasame, hownwer, and the same combination of information becomes Vie basis'. . for adecision on the need for a referral from Stagal It should also be stated that case management isaii important feature .ofAtv-' ices delivery in all three-models. Case management assuresfollOw-through, 'either' to a determination that the child is no longer considered at risk or to the completion0proper,diagnostic and.t sea trnent services. ' Private ' tioner ' lode' 2) ropy feel confident that they Cap. complete '` the .first tw e..review themselves,.but they should be Prepated to enlisrqutAide r rces or more thorough evaluations when suSpecteffproblem. , 'areaadre,not-within their immediate area of exPertise. Such areasinightyude . speech &and language development, cognitive development, and learnin din-. Norderii. 4. MODEL 1. PREESTA.NDING EPSDT SCREENING SITE 1_6 . , Comprehentive Ilea Ith Gore .enters .(Model 3) sloulday definition; serve as a_renttjaxesouree4o'r guaranteeitig_a_eomplete_andibroad spectrum of-evaluation services, whether within their immediate Confines or through referral. The. foregoing. examples nre intended to illustrate that the developmental review may be adaptedto the normal format of EPSDT examinations with no _increase in staff..In fact, in those settings now using a structures assessment; Will be freed by the detelopmental review, since each child will not require a Tull assessment. . . Senator RIBIPaF. Wedwill t,ake'a 5- minute recess. briefireceas was taken:.] . . for Rico The comiaittee willhe in order.- Mr. Secretaryao -may. proctid. . `STATEMENT OF HON. JO,§EPH A. CALLFANO, JR:, SECRETARY OF HEALTH, EDUCATION AND WELFARE 'e . . SeCretaryCALIYANo. Mr. Chairman; I would like to read much of statement, but not all of it, andI would ask Senator RIBICOFF. Without objection, your entire statement will go into the record as if read. Secretary CALIFANO. Mr. Chairman, it is a pleasUre to be here this .morning to. testify before this subcoiYimittee. and before you. For years, you nave been . strongly. committed to the goals of this legislationin providing healt)r ;ate for 'poor children, i)1 hnding ways to deriver that health tare, :And in _Making sure that poor children . receive needed health services. Xour.SpOnsorshie of, the adniipistration s bill reflects "a, long and deeply held concern for the health and well-being of America's-poor children: That. concern dates back' many year to. your -days 44. Secre- tary as well as to your early Senate cafeer. There are, iiideed, in the Medicaid progranfrit group of childaen called he Ribicoff children who,a.re covered. only because of yourinsist- ence on including this.proVision inearlier legislation. , Mr. ChairlriazIt we believe that the CHAP legislation represents a single .opportunity ;for prodUctive cooperation between. tlie.xecu- tive,and.,,tite Congress. There is widespread agreement- on rhoSt:Of this. regislation. I think it can be, 'without question, the most significallit piece of cloniestic social legislation and health legislatiorr to..be en- acted by the Congress and signed by the President this year With it, every poor child in this Nation, as defined by-State income standard, would be eligible to receive; basic health services for the . first time in the history 'of this country. 7 The Child Health Assessment Progiam will incrcise healthServie for thoge- who presently: have, inadeqiiate'coVeriige,, reachufg1.7, lion children iniamilies with incomes below the poverty line who either have no health insurance or. are inadequately' protected. It 'eliminate aspects of the current sypten that Often cau the poor to receive substandard care, and it will put renewed: em asiS on our efforts to prevent, not ti-.) just treat, disease. The CHAP 'program, together: with our propos41. mendments, would: extend medical benefits to all low-income childrentinuler the age Of .21:Aneeting State income standards, and would previcje Medicaid coverifie al low-income pregnant:49mm : meeting State income °Standirdsr 178 1 might note that the number of women involved is 94,000, these women are m eligible because they are categorically ineligible.-80,000----- Of these women are married, living in two-parent families and ineli- gible simply because of that fact. -.' An important .goal of this legislationfis that every child should be able to develop his or her talents to the greatest extent possible. Every child should receive continuous comprehensive health services, includ- iiiii the preventive care thais necesary if childven are to grow into healthy productive adults. No pregnant woman should be denied the prenatalcare heribaby needs for a-healthy:, start in life. . These goals are too often;far tooroften, not fulfilled under current 'leant programs and praCtices. Millions of _poor children and preg- nantlkomen in this countryiack even basic health care coverage. . "rsidaf, I would like briefly to summarize. our knowledge of chil- dreo_s he 4th problems,kspecially the problems of poor children. Then I iffil review the achieVgments of the 4p8DT program and the short- coinings we believe thaf"the CHAP program will help to correct:. In Decent years, as you well know, we have made great strides in. . improving the health of childten'in this cottntry. Death rates due to I ° early childhood diseases have dropped dramatically. ' For.examtile, the death- .for children from influe '114 and pneu- monia declined from 150 0,000 in 1925 to 6 per 100,000 in 1973.4 Despite such gains, mil id . of children still fail to receive adequate health care. The rate at which infants die in the first yearlpf life in, this Nation is higher than that of 11 other nations. AP; . -,. When children enter. sehool, 17 percent have defective vision and 27 percent have defective vision by age 11. . . Many children receive treatment only. in times of emergency acci- dent or injury.. Nearily 6 million children over the age of lrhave no . .. -regular source of hea th tare. c . ,. . ,. -Eder} those able, to ttbiain caw may not receive' the full range of iervices apprakriat* for proper development- It is estimated that nearly 24 mWn children under the age of 17 have not hid a routine physical eictoninfttion in the last,2-years. Ten percent of children 6 through 16 HO& never been tb a dentist. . .. The burden of .these troblmslalls disproportionately on the chil- . dren 9f the 'poor..TWice as- many children in familie§ earning under . $5.000' have 4,histnry of chronic kidney disease as in, families earning $10,000 or more. Poor children 'are bedridden 25 percent more than ' nonboor children. 9 - ViliCknow that prenatal care pllys .an important role .in influenc- 'ing the hpalth of both the mother and the-uribofri-thild. Inadequate. prenatal,care increases theiikelfhoo4-1 than infant will,be barn pre,* in qtpre. sii tier disability, or evendeath. :-----,.".. . - . As in the case of iiealth problems amonglitiqdren. the lack of timely and adequate prenatal care falls mciSteheavilv Itpilm the poor and upon minorities. are Babies in black families a-twicenalikely as babies in white families to die before their first birth' it. Death, rates di ; o it the first' 5 months oflife are four times io.' eattiong infants in low- income families than these in high-i,pcom ies. More than ,1 out M.: V of every 8 black mothers aged 20 to 34 do not receive prenatal care -Auringthe-first-trimester-of-pregnaney . ..- grams The Department of HEW currently administers-a variety of pro- . :aimed at improving health' care for children. In fact, mare . than $2 billion a year under medicaid alone is spent directly on the health problems of America's children. v . We are committed to upgradiflg the- quality and availability of healthcare in all existing programs: -- . ' Last year for. example, the President launched an unprecedented ' initiative toiiiitriunize an additional 20 Million children under the age of 15 against- childhood diseases, such as polio, measles,. rubella, diph- theria, tetanus, and whooping cough.. . Senator RIBICOFF. What have the results been of that?. Secretary CALI:FANO.. Mr. Chairman, the results are quite good, although they. are still .'somewhat erratic. OUr objeetiVe IS to immunize are . . more than 90.percent of the e lildren by:October 1, 1979, in many Suites, .. wethive. inereased.#enani r of children- immunized substantially; 30Obt- the 50 States now rt levels of protection against measles ariil polio. above the 99-pe .greater in children enteringg school. 'Several States 'have ..begun force laws that Were not. enforced 4efore.' There has..been a sharp rop in the incidence. of childhood dis- ::: #ase4t swth. as nleasles;during Ale first 6 months of this.year. .-Th. pSetlittol ItiattOri:Where..tliere nyq.frires M- redchi,4 your objec- tives, wliat-are.the..etrises? ..-`- . SeeretarV:C.&&:&SI:-'-I-.061ik..fliat most .young. parents today-have 'rawerSe eit;12.--ese''.diSea4S._ ;and-doanot preciate the importance of im- inunizio6-..A.fir, childrvenjairainst -- They have never seen. polio, -.. -v and whykit-ethi...do, for:example: j.-'1'...1,411-,, . :.. . SecoMI thinkthat some. -doCt4r.S,-'ancl..perhapgnii rses, have not been as.atten.tiVe.aS.they . might have`lOkn tti the immunization recordS of childrefi.. , '---. v. (..' '. -.--. - Tliird,' while many States have laws, many .of these laws have hot been en-fcireed in the .pasr. and sonic. are just. begiihningto- be enforced. In COnnectibte, for instance, the Governor has undertaken a vigorous erTfotceinebt drive in which, the .,State /aW has recently been clan ed. tie panic childhood diseases until this -year. We' would expect.. ig , MamefOr example; never had immunizationVrequirements' f 11 change theri0 think that those arethe Alain reasons. Mr. ,c hmtlefitn, the .current EPSDT program ..works-as'Wirealth..:. status monitoring progarli. Under it. the States --- are required to.-,make. a positit-e effort to inform parents' that their .... children are eligibleilfor-this service, to o er the, serv140..to them. at appropriate intervals, to .regularly assess th alth-stafilS' -of eligible children diwnOse theitl.healtly- problenis, and ,. sure. that -needed and avoue-sted lollowip treatment; is provided. 14' Bufthere'have'been at..nuniber of serious problems. All poor children gre.not..eligible fOr EPSDT. Many children whose fainiiy income is the Taleral., poverty level do not qualift because the prograni .t.o.'Fttife, in ice standardsand many children, who meet -.their .',..0*.Kafttite's:poVerty eligible because they live in two- rent fairillii*"..0f.over-12 mil i& children aetuallyenrolled in lqed- tad. receive ..up-fb,d110e assessments - 180 z a, Even among children reached by the program, many do not receive needed f011owup-eare; 28 percent of-all conditions -found go untreated. State assistance to improin this aspect of the progra. have not been .adequat* developed. t Penalties against States failing to reach eligible children have been too.rigid and unenforceable. Finally, many pooropregnant women are not eligible for medicaid beCausethey are-not yet mothers, or because their husbands live with them. Thus, their children are denied the healthy start in life that good preventive care provides. The CHAP proposal,.as amended by bur submission to you earlier this year,.seeks to assist States to rectify these deficiencies in a number of wa s. We would require States to cover all children Mider.the age of income ncome meets AFDC eligilility standards for both se = a<nd treatment; regardleSs of whether they are categorically ble under AFDC for medicaid. . In ether . words, CH .wiigld seism_ poor, chlld-re- in two-parent famihes. Qui. lecrislation wouldrcOvefan add41 ition7 Million children \under Medicaid'. \ More children-would. be assessed. We liniTid Provide assistance and incentives to States to reach and assess more eligible children. We will pa the States a higher Federal match, a -mininfum, of 75 percent, ins ad of the current average of 57 percent for all screening doneN....- unde the prograin. We\will also pay a higher match for all ambulatory folldwup medi- cal care to assess children including care in physiciaffices,'clinics, and outpatient care in hospitals. We would not pay NW higher match for dental services as the'CHAP legislation coming out of the House would. We would pay a higher Federal match for general 'administrative costs, 75 percent rather than 56 percent based on measures of perform- ance by the State. We would expect, under oul' legislation, that by 1983, 9 million, instead of 3 million children, will be receiving regular preventive exams. CHAP will require'States to be responsible for managing all medical ca' e.of each assessed child. Together with a higher match for ambula- tory\ eare, we believe this will assure followup and continuous care for a mach greater proportion -of all those assessed. We. would also guar- antee,:even if the child became ineligible after assessment, that the chile rented for up to0 months thereafter. We: Id change the penalty structure. Currently, any failure what-. *Bowyer y a. State, no matter how minor or temporary, can makela State liable for p, penalty of 1 percent of all Voderal AFDC funds. The pen- altris so severe, Mr. Chairman, it is unenforceable, as you are aware: We have.bee (wired by the General Accounting Office to impose it, nd c 11.$ effectively delayed, as I think they should. Ern AP, *e would provift much more flexibility in establish- ing an breing criteria. Statesiwould be given an opportunity, and 'enconr ent to correct deficiencie's. The measure of deficiency would provide secretary with flexibility to impose a -penalty of up to 20 percent of the administrative cost of the medicaid program. . e 1/4 ar a : 181 PRENATAL OAR,E. .0. CHAP extend medicaid coverage to all low-income pregnant women in that meet State income and resource standards; This would make financing fOr prenatal care delivery and trostnatal careavaila-ble to an additional'94,000 women annually, 80,000 of whom are married and living withtheir husbands. Mr. Chairman; we would urge that the Senate act quickly on the administration's proposal. We believe that if the Senate acts quickly we can enact this legislation this year. - .We believe that preventive care pays off. There is phenomenal costs benefit ratio. it' For example, we know that weekly mouth rinses with fluoride can . . result in, 35-per ent "reduction in tooth decay. recent study indicates thab our measl vaccination program in the iod fiom 1963. to 1972 &as saved about 3 billion at a cost of about $ 00 inillion. Mr. Chairm I think I will submit the-rest of the statement for the record. b Senator Rtinconr. A few questions, Mr. Secretary. . What ari3 the implications for the future health of the country of 'failing to take care of the health needs of children? Secretary CALEFANO. Mr. Chairman. I think they are a shameful commentary on a natipri as affluent as this Nation is in terms of social justice and social need'. In financial terms, these are unquestionably the' most cost-effective pfograms we can provide. We now, for example, that one of the things the CHAPoprogram would Oa is provide for an , effectivaiminftization of every child, in the program. The cost- benefit ratio in -immunization is tremendous. Iii the measles program, -a,- investment of almost $100 million over a 10-year period has saved billion-ht medical costs. Senator Rn3icom,Evervbody talks about cost. but the cost of hea care for the individuals, for, the State, for the Federici Government; in this Nation are magnified greatly by failing to take care of the health needs of children when you could ea11y improve it. That an impaCt for their entire lives: _ Is thatapt correct ? . Secret. CALrFANo. That is correct, Mr. Cliairmitn. , . Senator RIBICOFF. Let ate ask you, do `you think t t the State medicaid offices.are capable of liandling the administr tive changes proposed in this bill? Do you have any evidence one way r the other? Secretary CALEFANO: Mr.' Chairman, 1;e can submit solne detailed analyses for,the record, if eve have not already given them to the staff, that we made in retponse to questions of the House.' . i is i I think the record of the State medicaid agences s mxed. The issue is, why is it inixid ? We believe.that in large part, we lutes not provided tlie kinds of financial incentives for these agencies to go out 04 find /s these childtoen financially. I do. believe tlint they provide the best' statewide organizatiisn'that can be provided. It is an interesting question; I think partly as a result of the concern implicit in thequestion you have juSt asked, the }14se Comrnittee 1;d11 Changes some of the RrovisiOns in th adininistrattpn It expands the number. of providers eligible for thednaximilm match of CHAP funds so that, in States where medicaid:agencies are .2 See D. Se5. .0 1.86, a. not perhaps ,ad aggressivalas they might be,=- we attract a reeve .Of. Lprovideres: - fr Beiliatcir Riiicort. In ether Words,L You wOild be willing to have agencies other tlian the medicaid agencies' handle these. programs, . especially With maternal health and child health prO ? y Secretary Camiraiio. The maternal health and 'c d health aggeencies are, I think-, on the whole not likely to do a better job tha . aid program agencies. They are grant-inraid programs. They are not. focused. on poor children, and their whole tradition and method of operation is somewhat different. . However, I think- that the medicaid agencies sh d be free to Select providers to use granteed under those programs ell and that, in part; is what the House did in its Changes to our pro d legislation. It would provide the maximum match for all kinds of providers that we did not include in onr original proposal. N Senitdr RIBICO" Dojou approve of the House provisons I Secretary CALnkipro. We have no objectiona. Senator RMICOM We heard testimony today that S. 1392 repreSerifs a step backward in terms of'health and psychiatric services. This is not :may intent, and I am sure it is not yours. Is this problem adequately addressed by the amendments that Sena- tor Cranston introduced at your suggestion? Is the administration committed to Assuring that each State maintains coverage of at least those services which children can currently receive through EPSDT . and medicaid : Secretary- CALWANO. Yes, Mr. Chairman:IthirtkietiOgislation was =intentionally ambiguous, when we first sent it forwaraand that is why .we did send° forward amendments in this particular area. These amendments clarify coverage of mental -health services at we orig-. inally intended. . There is nointention to reduce the mental health services covered. deed,I was informed coming in from the airport this morning, that. Mrs.- Carter called my office to make sure -that appropriat mental health services would bejovered in this legislation, and I indicated. or desire to do that. . . We ire.very much in support of covering mental health services; as indicated in Sena* Cranston's bill. T.1,4 House legislation went even beyond that, and it was only budgetary Considerations that prevented us from going as far as the House legislation. . Senator Riercoiy. In dental seryices, how do yawthink havirrgrocir children frnm the ghetto areas get this pieventilve dental care in a - dentist'Sioffice, many of them downtown or scattered in the suburbs,' comps with hadg.this care in. Clinics ettablished in the schools oeStafanalth offiteSor.#ity -Ilealth offices, in clinics arbund Where the peo le ire? Secretary' I think tfutt.the reality that at least at this point Kiline, through .the latter way, we will provide dental health services. for poor children. Anyone who tries to make an appointment with adentist knoWs liqw long it takes. . I think that dentists have been far ahead of physicians in terms of using para-dental personnel, nurses to 'clean teeth. and perform other functions a dentist once performed. I thialsthat We should ,looleittn4e0 methods of delivering dental _services to poor 'children particietly' . under: thisprogram. V 11 1, , .... 1. 4 as ., Ypi; suggest clinics; I think that is rightlin r'the mark from my experience. Senat?r RIBICOPF. W1i4rewe.are -reaching out to try' to give new Ai health services, Department your .De rtment or -Vo ur represent ivt sit .down.5.- ''.:4Eith. thakeprettintitives of the organized dental and me ica agencies` 1' and. org anizations to try to work out an' isl a nding with them' ' Secr6tary CaLTraxo. We do; Mr. Chairinifn'778o es we are able . work out an understanding. For example .. Inainunization. p r o g t a m , . we have complete cooperation in wor vit kiilt AMA ;: in our oking program, complete cooperation: tither areas, par- ticularl w,e move into the areas that. affect perCeite d financial and econornmintereSts, it becomes more dilficult, when Wet View those in- terests somewhat differently than those in the profASions. But they have .all been helpful in terms.oftelling us whether they. . think something will ,work or not, elen when they do not agree with it. v. . Senator RIBICOFF. Let me ask you, you are alvare of the history. of EPSDT. Great hopes for results, b;olten promises. This is not your fault, but it took the Department 4 years to issue regulations for the program- What kind "of implementation Schedule do ydu have in mind to -prevent CHAP -from going the'same way ?, tp Secretary C.trarxxo. Mr. Chairman, I think the delay in putting . the regulations in this program was inexcusable. I would expect to hive all regulations. out within 4 months and atthe outside, no longer thait6 months, but I believe we can dolt- in 4 months. i Pthink that our record in the past year. With respect to regulations is muchimproved. We have written most of the Medicare. and Medicaid Fraud regulations.. We issued the. rural clinic regulations,. I believe,. within 60 days of enactment. We are moving much better in the regu- latory process. I think that we can deliver. Senator Rinicorr..Do you think that you dim institutionalize this without your taking your personal attention and your persOnal com-* mitrient and your personal time ? Secretary CALIFASTO. Well, Mr. Chairman, you have been Secretary of *HEW. I think that bare institutionalized theregulation writing . process and it is much better than it was. But I think undoubtedly it will take time; some of my .personal time, to move things out 'on that ; kind of a sektedule, but it is time well invested. Senator Runctiri. In all of these programs, it will take your per-. sonal interest to make sure that it works. Secretary CALIFANO. In some of them, Mr. Chairman. ,* Senator RIBICOFF. We recently. enacted a rural clinics bill mandat- ing medicaid coverage' in those clinics. To *hat extent would CHAP, 'or the present EPSDT program, use those clinics for scre,ening and followup in. the rural areas ? . Secretary. CALtrallo. We would use those clinics. energetically. .We would want the States to use those clinics energetically. I just saw a, rural clinic. when .1. was up. in Ifaine. with Senator Hathaway on Friday. It was wonderful to see one of these clinics devel- o ped *in 'a distant area called Abbey, Maine, northwest for Bahgor.-. What it meant to the people in that hey, themselves put.'" $47,000 into putting this clinic together.. BE?. . SenatO:ritnalcorr. If the clinics work in t13.6 rural areas, why could .4msriceJ . Secretau ..CALIFANO. Mr. 1Chairman, we did have I *believe' We. .ofigin*PY recommended be, °permitted to reitabtirsg .nurse ' rural areas. The, . -46:Tided 'tAr let use just danorkritte in thecj prasititipners au* je clinks in dieneI7city, areits as well as in urban areas bdt we, went forward full blastnt theruital areas.., I.eite_t;01 as in exanipk. of our general beliet that Clinicg like thiS iVorkThthe inner-ants* AL. ,../ Senator extlensive:tas the demCmstratiernt- SemeikaY Ivo: We have just begun :.We just got the authority artbe erid.of last year. Wware just-beginning to dew] p .demonstra- dons now. Senator Ittatcoer.. I am curious---where are they ? Secretary CAL o nut Imow the extent of. progress but provide that for tTie r,e 'Senator RIBICOFi.. think this is a very iniportant demonitration program to be -monfto 'mil would hope that you would:expend- one of your key pedple onitor these, because I think that is very, verY. . I rettiv-:-. (egy,chfrguittOlitqieOple'ffom the innercities and-the ghettos -1O go downiiiwr-toallelmstigious private medical buildings. They just will not do it.. ikriel,,K4Au say, the dentist is busy, the Aoctor is busy it takes a long time to be able to get an appointment with them-7weeks, months sometimes. And yet there must be millions of people who do not get this care because of nonaccessibility. I can understand that. The doctors go where it is more convenient, they like the atmosphere, but there is a need elsewhere. I think the dental societies and the medical societies could work ther, in having the various doctorsvolunteer a certain amount of th it time every month to staff theseIclinics.,The ..ean do it 1 And I think there is a willingness; there t it on their own.' Secretary CALTFANO. Mr. Chairman, I think they can do it and I think also, as was thecase in is Maine situation, we can also get a- a national health svices corps of, doctors to staff these clinics. T particular clinic is staffed by two national health service corps doctors. Senator Rtsicorr. I Understand that your Department, is giving serious study to revisions in other child health/programs in the. De- partment, dspecially the title e maternal and child .health pro- ' gram under thSocial What effect do you believe that this study should Ave on our. constderation of this bill ? . . SfrrObilry CALIFANOr Mn Chairinan, I thi committee can go ferwagi. inconsidering this bill regardless of t at study. We are look- ing afillitle V. I do not know WhaCchanges, if any, .we will propose. If we propose them, we will propose them sometime next spring. It would take at least a couple of years before they would become-law, and we Would like to have this legislation effective by *Rt. Jr4,14)/9. That is what we have been shooting for-g-April' 1;"of next year. I do not think that should effect broad consideration at all. also think it is,possible' that, especially in a situation in which liSdget restraints are so tight, that we would havApo recommendations. hs 169 A 4 . p. : 185 .7 . 4 --Senater--Rwcpri:-1-w-011.1115ay we are All pleased_to have your,tom-, -. '''' . ? ulitinentmore lmportant, Mrs. Carter's commitment I hai-e.alwaS7s :found that a fresicUn03..wife lean _act ,as aygreater goad :than the President oi' the Secretary in mar of these'vlograms. .. -. -t - I would-hope tiiata-ey and Srourstaff would study all of these'various -..phigratinstihat you'urcworkiugon laol:wftli the viewpoint of.present7". tnget the beginzung.of nest5earit series of-suggested pirot or'demOn. stration projeate and rivould consider it a privilege to introduce stich'a nieluniuse...We can look at, sonie `of .these thoughts and iclei-s and your . ; deep concern. Where there is either a budget' plloblem or a qUestion, we-can try to see would they work, how they work, can it be done...We (Tan try these ideas out in selected places around the country. And -I think you would find sympathy in the - committ®e and sympathy in the Congress to try these ideae out. There must be man f them that concern all of-you,Ahat you arejliscussing constantly. ill . . You have another 4, 5, or 6 months into nest year .You are not going to ge..it this year ; 'Congress les going hoine some time in October. However, it is something that I think we ought to litive; a broad-stale series of demonstrations to try to solve some df these prof ems. secretary CAL.nosko. I would be delighted to do that, Mr:Thairman. Senator litfecoF1-. I i'ould commend to you consultation with- mem- bers of the committee staff, Mr. Constantine, and Susan Irving of my own staff to try' to work these oirf nith you, so we would have a cooperative effort. Secretary CALIFANO. Good. .. Senator Roncot-T. There may be some otherqizestions.lir. Secretary. Again, my commendation to you for going very well on a very, very tough job. GI . ) . I think the country is fortunate to have-you heading HEW. Ili , Secretary CALIF0. Mr: Chairman, thank you very much. I think the country is fKtimate to have you Se :kg on this subcommittee. 118enator Rrsicorr. Thank you vary m 1, ,- FThe'l)repaied statement of Seereta 'Califano llows]; --- , 4.'4 STITEiiiiir OF $EORETARY. JOSEPH A. CALIFANO, JR., D AarSiE:cr OF HEALTIE, EDUCATION, AND WELFARE l. # . , . 7 Mr, Chairman and members of the subcommittee Lis with great:pleasure that I appear before you to toiptify in favor of 8 1392, the Adminilintron's Child Health Assessment ProgItm (CHAP). I know that you a., rongly committed to the goals of this-vital legislation, which addresses o. r nation's most important problemsproviding ade . quate healt re to children and.pregnantew.omen. There, can'hk; no. - more importanitt mpassionate society. than elasuring that those most a1 poor e el filidrenreceire those services which can mean the duff c mothers and young children, sespeciallye e between r mothers in need of.care .a full, productive life and a life impeded or retarded by mineceisarkillness. Senator gibicoff,*your sponsorship of this bill reflects a long and deeply held concern for the health and well being of. America's pOor children. That concern dates back many yearsto your days as HEW.Secretary,as w6g1 as to the early s --- days of your Senate career. Your early and enthusiastic efforfs 'to enhance the ' health care of poor children is refiveted in ' ur proposal to permit States, at their option, to cover otherwise ineligible categ of poor children under Medicaid. This proposal became law, abbe man& y Statecoverage.of these'lltibicoff 'cliflilren" is one cornerstone upon which we constructed the CHAP proposal that - is before you today. . . . -.. Mr. Chairman, theCS! legislation represents a signal opportunity forpro- ,....dfictive cooperation bet the Executive and the Congress. There is widespread 4 ___aireanient-bOtiiiinattse and the' filenate that the bill is necessary. And . -. together `Vatican attain a httmaffe and noteworthy objective the passage - of CHAP, ev poor child in this nationas defined by Stale Income standards wtH' be ellglh receive basic health services. Your cons! ration of this leglelation id especially sionHicant In light of the of principles for national health insurance. ' President's Although CHAP' is not, offirse, a formal part of the President's forthcoming ' proposal,Ittepresehta minritital stepa separate legislative step that it not part -of, but leads to, cemprebensive reformthat can -be taken now to remedy, some of the Probleinn that.the Lamle sendi to the Congress ne,xt year will address.. Like the. National $Calm Plan; CHAP will increase health servi ; those _ who ptesently bavelnadeqinite eoverage, reaching 1.7 million children es with liseomec Mow the poverty line. It will help eliminate aspects of t -" --' spiels that often came' the poor to receive substandard care. And it will put renewed ortonr eglii;ts to predent, not justr to cure, d Mr. the'VHAP pram--fegether with our p dments - that would, . its benefits Too all low-income children under or 21 meeting *tate standards- and would" provide' Medicaid for all- . low-income 0 wonigp meeting State income Standards -1s . : . founded .on several essential Ali ofillound maternal and 'Child...health Care r . Every child in gatien shon14.be able to develop his or her talents to the greatest extent Possible. -' . .. ' -- Every cWdohofild receive- continuous, comprehensi'vliiirrlott services,' including the preventife dire that is necessary if children are. ip into healthy, pro, ductive adults. : , .. No pregnant wpmen should be denied the prenatal care her body needs for a health,y start In life. 1. / 0:Yet, these goals tob tOtten,-far too often are not fulfilled under current health, programs and. practices. Millions of poor children and millions of poor pregnant 'women In this connfrk lack even basic health care coverage, tinder Medicaid or ' ank- other program, and suffer sextons health consequences as'a result. This shameful national fallurembst be remedied. Today, I would like briefly to snnimarize out knoivledge of children's health . _ . problemsbspecially problem's of poor children. Then. I would like to review . the achievements, and the shortcomings, of Federal child health programs... - Finally, I wish,to explain why CHAP will correct some serious weaknesses in: -the way we dIscoveriand care for the health problems of poor children under .. HEALTH STATUE) OF CHILDEDS . " l o o;. In recent. years, we have made great strides in improving the health. of chil- , dien in this country. Death totes duet.to early ellildhood disease hfie dropped . . 'f dramatically. For example,:thedeath rate foighilaren from influenza and pneu- monia declined from 150'per 100,000-in.f925.. 8 pFr 100,000 In 1973. Yet, ditspite such gains, millions of children, still fail to receive adequate health , care. -i - .. The rate at .which infants die within the 'first year.fif life in. -this country is higher than that of_11,, other nations. .. n When childre enfer school, 17 permit haye defective 'vision, often not cot- '. reefed:. By age. eleven,' 27 Percent have defective vision. Man/ children receive treatment onil irtimes of emergency, accident or injury. Nearly. $ million children under the age .of 17 have no regular Source of. health care. - - Even'those able-to obtain sale may not receive the full 'range of services ap- pi.,. vhPriate foriproper development. It is estimated that nearly 24 million children i under thstage of, 7 have not hold a routine 'physical examination In the past -c', nears, 10 percet of children 6- through 18 have never been to a dentiat. '-' The burden of ese propIem9 falls dispropoilronately on- the children of the' poor: . . Twice Ete many children in .lemilialsOiriiing under $5,000, have a history of - chronic kidney disease as in familiedlearning $10,1300 or,more. 4 Children in fOnities earning -less than $3,000 are .four time more likely tahe , reported In poor or fair health than children in families with intemes of $15,000 or more. ' , .. . ilk , Poor chilffen ere bedridden 25.,perce more than nonpoor childrenan av- .. erage of 5.4 pays pet year, while the minpoor child 'spends 4.2 dais in. bed annually. .. s V ..0. ., t- ; ID,. tuc0.. .0,,,,, 187 . z . . We kuow.that prenataLeare playa an iniPortaid,Xole in influencing the health. - of both the mother ifarthh-tinWit, chltdr.-rundequare prelistalT-careZere-ases-the likelihOod that eh-infantwill be born premature, anger di.iability.,,oir even deal.- ..,, ha laillhe ase of hirt problems among ehildren.-the lack a timely and ode=. quate Prenatal care most heavily _upon the poor and-tiptinninorities. `. .Babies in g 'cu lack families are twice as likely as babies whife families to e .". befOre their tirst.hirthdaYA -- - . . . : . Petah rates du.ring the arst 5 months of life, are 4 tittles higher. amoligintenti. S. trflow-Inconie families thilithose in high income families.. ....._ , --Aritre than one out of every 3 black mothers aged 20 tb2.4 do not receive pre--,. ---. natal care during the first trimester of pnegnaney: , - . . . " - ..-4. . . % cruitater FEDI:ALL Et/FORTS r & -. . - The eat of Health. Education, and W Turrent,ly adfni . tars a variety o ms aimed at imp-riming health cfor, children : ough re- , 7 search, eduelition.and treviiiitionand through the ,previsiOn and fi acing of ih -health care services in community health centers, aternaland child eadh Pro- .. -gninisand niedipaitL:In fact, more_than't1 billion a year *icier ti.ledicaid atone is spent disetitly on the health prOblenis of America'a children,. .. We are ebtamitted to upgrad the quality and availability. of health care in all- existing.-progranfs. Last y or example, the_President lafinched an un-, preeetfentedinitiatite to immatii .111 additional 20 Million children under the , age of 15 against childhood disease s Polio. m isles. nu:twilit. diphtheria. tetanus and-whooping h. Retently re rted data owslhat we have made . considerable progress t d achieving our goal : 30.of t 50 States report levels of protection-against measles and polio of .90 percent or greater for- thildren -.Mitering sehot . W e arellisknfincouraged about the decline in the incidence of iimaples. mum and ru li frellWfdriling -the first. 26 weeks of this year; cases of vieastes were' own by 50 perenf, mumps by.16 percent .add rubella by 1,1 percent over the saute perlodlast year. .. 4 . ' . - . 120BilMil OF MEDICAID AND EPEIDT 4 . Etta' despite existing child health, programs .anti services.we are here today because we perceive serious shortcomings in our health 'tal'e system for children. Aud. the most basic shortcoming,is tlte; lack of adequate heath care services for poor children and pregnantrwointn Undo- Medaraid. . The medicaid pm/gram 1 primarilr a payment' plogramit assures eligible . persons thatwhen -they need health cafe. -the bill will be paid. A different focus, 4owever, underlies a part of thcs-Mediceid program which Is designed to.meet-the health needs *tbf children. .The ,Early 'iind Periodic Screening. . Diagnosis and ..Treatment programthe EPS.DrT programoperates asea" health outreach and health status Monitoring,system; &, ". . - Weer EPSD', the States are- required to maker ffsm ye effe t nform ; parents that their children. are eligible for,this service; to; offer the fee to them tet appropriate intervals; to regularly assess the health status o eligible chitelren. and. diagnose' their particular health problems : and to a w m t ssure . that. needed and requested folloup treatenfoie provided. Hut there hare !wog a number of serious problems with El'SDT : All paw children are not, elit,rible for Ntslicitid and EPSDT. , . , Of over 12 million' childl-en ac.tually 'enrolled it Medicaid, only 3 million enii- dreikiveeive,up to date assessments. E`Yen amopx children reached' by the program, manjilliclio not receive needed follow-hp rare024s percent of all condition* found go untreated. State systems t improve this ditpecLof the program haVs not been adeqUately developed., renalt1411 !against State] to reach.eilgible children have been too rigid . . and unenforceable. . .7* Finally. many poor pregnant women are not eligible for Medicaid because they .a re not yet mothers orlecauseltheir husbands live with _them. Thus, their c_ hildren , are denied the healthrstarti in life that good preventive care provides. - -- - TheAdministration's CHAP propottel, as amended by our submission to you. ;" earlier. this yeaeseeloi to aitsist Stakes to rectify here deficiedcies in a Number Of ways: Expanded Bligibiiity.,CHAP will:require States- to ,coysr 1111 children finder k the age lot Cl whoge twin Income meets AFDC Oigibilit, stiindleids, for bi:fth , 4 screening and "treatment, regardless or, whether they are categorically eligible . 1 0 im is. under AFDC for ,MediealtlAtratlier 'words, CHAP would also serve poor children "in..twO Parent 'families.. Thus,:an 'additidmil 1.7 'million poor children would be . eligible fOr health services linden' Medicaid.- . More OM ldren ilasessed.4,CHAP will provide assistance and incentives fOr states tO reach and assess more. eligible children.Ore will pay States a higher .-Eederatmateha minimum of 75' .percent instead of the.current average of 57 Pereent-1-:for allstreening under' the:program. Wa.will also pay the higher match ' for ,alt ambulatory, f011ownp`medical care to assessed children,. including care in physicians' ofilees, ellnies,and. outpatient care in hospitals. Artil we will 'also, pay a State a higher Federal match for general administrative costs-75 percent rather than q) percentif the State niOets 'certain standards ofgood performance. . Thus, we eipect that b7 1983. 9 milliod, instead of. 3 millien;children will be recteiving regular preventive exams. . = Better. Folloactsa.CHAP will require' States. to be responsible for, managing all medical care of 'efigh assessecl_:child-Togetiler-with-the-higher-mateh-for-anr-, bOatory tare, we believe this 'will assure followup and continuous care for 'a much greater proportion of those assessed:The program willablo guarantee' 6 nitonths of-. continued eligibility for followili care for children who, have been . assessed, even.if their eligibility for assistance otherwise terminates.,, ' Sensible, Enforceable Penalties.Currently, any failure whatsoever by a'State, no matter how minor or temporary, can make .the State liable fora penalty of one.percent of all Federal AFDC funds. Under CHAP, there Will-be considerably g performance criteria. States will ptVO correct their deficiencies before g ss- tO repeal the current penalty clause retroactively when the changes pra used in HAP are enaeted, so that penalties asSesseil under current law beed not be co lected, Prenatal .:Core.Plnally, CHAP willrextend icaid` coverage lb all low income, pregbani women in families that meet.Stat 'income and resource stand- ards. This will make. financing for prenatal care, delivery and.pOstnatal care available to an_additional 94.000 women annually.. Mr. Chairinan, 7 strongly hope the, Senate can act .quickly in the Administra- tion's CHAP proposal. We mpst move to assure that poor children have access to the same preventive and treatment services enjoyed-by more affluent Children. Preventive early and continuing care can -produce significant improvement in the health_of our children. By emphasizing regular, preventive care, we can deteet problems at an- early stage which can be corrected arid treated before they reach crisis proportionS.: Investing preventive, ongoing care also reduces the need f more sophisticated ang costly services which are needed .to treat more advitneed condition's: weekly mouth rinses with_ fluoride can result in an average-'34percent reduc- tion in tooth decay. -. ... A recent study estimates that .$1.3 billion' was saved'in- mediefa cost§ `hver 10-Year period (1903-72) through measles immunizations. Where coimprehertsive care- became availdble to women who -had formerly, lacked access to such care: infant mortality rates can be cut in half.. In some child care centers,- hospital, days decreased up to 40 percent Its prehensive preventive and follospop care was delivered to children. . We estimate that the first full year Federal' cost of 'CHAP:iin- fiscal year 1980, will 'be $592 milliOn. Because of the .financial incentives contained in the bill, .anumber of States will experience .cost savings during the first full opera -' tional year. By $iscal 1983, we estimate States wiltsave a total of $27 !million. As you know, Mr. Chairman. the House Commerce Committee hasIfVed :a number of amendments to the hill 'which greatly increase the tota1111r§r year costs, of, the Administration's.,proposal. And we estimate that ate Federal costs J. of these amendments will add another $347 million to the Administratton's CHAP the current fiscal and economin Oblate: Mr. Chairman, we oppose these add -ens to the 1979 budget: The Administration's. CHAP proposal. is a sound and realistic reform of 'the current EPSDT program. CHAP will7enable,us to render ongoing health services to children more effectively:. It will expand available benefits and provide :incen- tives under the higher Federal -Matching rate. and performance. bonus. We are .confident that the improvements we nre proposing, will give the. Federal govern- . ment, the Stites, the .consumeraand providess of health care a significant oppor- ! trinity to reach out to more needy children and pregnant women. more fieiribility in establishing and enforc _ be given ample opportunity and encourage a penalty is- assessed. I have also asked C 7: 189 , . ' , , . - _ - I hope the Senate will plies tbe Adtninistration's CHAP proposal as quickly as . possible. The current /IPSDT Ares- is badly in need of overhaul, and we are -shortchanging one of the weakest, most vulnerable .groups in our society until .. ss'e make these imptovementa. I hope that the President can sign this mach- . needed reform kyto law this year as proposed by the Administration.- We will all ble to tale great pride 11 s: bill that makes many poo llj dren th semi /' -eligible for ba Thank you. a - . . {Thereupon, at 11:03 a ., the sohConithittee. recessed, to reconvene at the call of the Chair.] [By direction of the chili madealiart, of the record :1 tan the follOwinp. comniunications ..were STATEMENT. or Hoyt. Roc DE LEGO Mr. Chairman and honornble members of the Senate Finance. Subcommittee-on riealth. Lam gratetui for this opportunity to testify hi support of 'H.R. 9434. legislation I have co-snongered to eliminate discriminatory treatment of the Vir. girl Islands under the Medicaid prorisions of the Social Security Act. The purpose , of this legislation. which was reported by an overwhelming margin by the Howie Committee on Interstate and Foreign Commerceand passed by the full Home, is to guarantee equal protection nnder the la yV by extending to residents of the United Stites Virgin Islands the salmi rights and benefits already enjoyed by residents of the several states and the laistriCt of Columbia. Section 1108 of the neial Security Act Sets ahsplute ceilings on -Federal funding 'for the Medicaid programs in the Virgin Islands. Guam and Puerto Rich. Federal financial parSicipation with respect to the Virgin Islands is subject to a 50/50 matching rate. whereas- the. Territory would qualify for 75 percent Federal match- ')ing if it were entitled to a full state-like treatment:.The net effect -of these pro- visions is to reduce the level of health care-services available to low income per- sonVn the Virgin Islands.. as well as to p on the fiscally strapped local governmen that of individual states. 1 should like to Point out that the h Islands Government are expected to finer The aggregate ease load for governme from 25.000 in 1972 to. 34:090 in 1976. tinne aslarge numbers of non-resident year to permanent resident status and are expected to increase.na the Meal G health care inodernizatiorr and' const eral ceiling altogether and allowing state formula would enable the Vir nients in its health care system. th that full state-like treatment would gear 1979. rising to.an additional $ The principle instification for di. under the Social, Security -Aet has b of 1976. th;AIEW Under Secretary the Virgin. Islands issued a report ment of Puertq Rico and the tern thscriminatorysand undesirably re their public assistance needs." Th treatment ,for the. off -shore areas. .of Puerto Rico and the territories should_ be considered within the. with the Federal. Gdverhment, the within the-context of the Social S . This conclusion, fig accord present Administratihn hag mad President Carter recently stated: distinguish ,between first Lind s. Rather. the :Constitution spec law to all United States.citizens. 34-4a4-29---11 ace an ever increasing financial burden that is disproportionately .higher than altli rave respensibilities of the Virgin ace significantly exer the next few Years. -sponsored healt*Wirfees has increased nd additional .growth is expected to cob- aliens in the Territory are adjusted every r Federal law. Moreoer. operational costs vernment moves ahead with its $52 million ction program. While eliminating the 'Fed- e matching rate to rise under.the.varltble n Islands to help finance' needed improve- "Congressional Budget Office has estimated barely cost an additional $730.090 in.fiscal .2 million in fiscal year 1952. _riminatory treatment of the Virgin Islands en its special tax status. However. in Octo'ber Advisory Group on Puerto Rico. Guam. and hick concluded that "the current froral treat"- ries under the SoCial Security Arc sr unduly. Jets the ability of these jurisdictima- to meet report went on to recommend Till sgate41ke nruintcthat "while the legitimale,thulizations to contribute to general Federal, ta3-. rwrennes context of their overall political eionship e is little justification for addressi %as issue urity Act." nee with statements of general policy the with respect to the off-shore territories. As 'The Constitution of the UnitedStates does not nd class cifizens. &ally guarantees, equal protection under the regardless of where they may live: The logic of r. 190 . r ''. the. coustituttonad estranneat, nioreover_ is strettgthefied- hy,the fact that hilei the people of! the y ingin Islands do ucittiontediute tothe Federal Treasury. i r- . ilkmilliens etiimeriosno who are =Bible to pax .t.iiies beetrusglof eo e sir'- o -ctupstibiggs. hti the final analysis, neither rit these circutlistonces relieves:the ' Fedefal Government of its responsibilitiee'toithese citizens:" While the Linder Secretary's- Rep : . tronsil Obove*Itiso recommended ./tall. state -like tseannetst,,,At-tlid suggest a of ways in which to- do-it,'Incladieg - t phasing in refornswever a three :yes 'owl:. The Houtie Ways and Means Coln- ' to extend the S tuittew took a step in this.dlirtrAiah last May when it voted unanimous mental Secirrity -income .Program. gliulimite the Federal ceilings of ish. tussistallek IVittirl"i turd revise administrative procedures ;_forithe Tide XX Ssehil Services Il'rroiittlni for the 'benefit of United States citi- zed; in the.ilVirght Islands. Guam woe Puerpi Rico. In its Report on H.R. 72b0. the Ways- anilikotsus Ci-s.ainittee .1-7 a ts atitcon-;was-a---'2=necet3 i Th- portant step" -in the direction of , ,, siet,.! equity between the States and the . - . . Territories." .. I More vrintulicattly.. President. r hes included the Virgin Islands.. and the other [713:Ted Stitt-s Territories ii-i tappreliensive welfaie reform proposa:. on a funned ernitek basls".w-ith. the PralStntes and thg District f Columbia. To accept cautioned discriminot , , ti :hi. NIedlcaiil program. thou, Would run .connter to 7lie trend toward .eqii --clluntent Under the law for I7Iii-r,1 States citizens in 'ore-Or-shore tireas.. L 710 restteetfully urge. therefor- that the -.Members tit the :timer. Finxtrace CA;..,1 ..tee 4upport,11.1t. 9434 as ststd:lo-' the Idolise: _ so.v.tw 11111t Intratt-;;ilbevimmi pieta; Off re B war? i Washut I4" ".N - YE }/test u stile '04;4C" to/ -NGIZESS nF TIM STATES. HorsE OF ligeat:sts.yr.trms. TheiNfiingt , //rigor 15, 19";.S. . ; : t.nirian itiztaisiof Guam, It respectfrill Cr 9431. 14-.4slation -rvitirh proposes 711 m'iwntflIS in i;cini, the 7116 . Mo1,1:41 th...". -41.tect prn-rrnitl_ ,-4.1114)ogr- tho trn Ifte rai Dorian" -if ',sir -1*.S7 pe +"- 'tug rat -:e, Hoe- 4." .("Q1'r:el" 411 19!),1-rantlipg :netirity el with suiNtlinitinly loss fetteniC 4.4 .resfilent,5 of the 50 _A, a 1,.tatii are trgable- to er the 17111- 51` coiling. of:only $900,0"' ,r0 subri'itiimittee. the c -4.117611241 evactly.ilonlihr the present i rnis the feildral match! I. in11.4 extnintled in thg. rt4Itorles. i 11(TP:1,40. WhiC11 is preillccfteit.on. states. tcoIIL1 again belief:- re.i nit Foreign' Own nrm on the IIIIIMST:7;. (N:111)1111`. unable to tat cif t. .77 rat assis-anoe ;Ind -- tt 'td bee:rise :they cannot rat- - loge mat , would urge ivlopt-:,n ifieltuleil by. flit- .FFiolgw-whi. lice- - 01.,4;tses in the annu:11 :V- . -nit] ecilintr.nr.all, trriteri, th t ring- Indxos. f that This.for.;tutti Procratn. I .sitreKs tint: rinsoulligqof living'ittiThant is f2si...hightilestste in r I 1:111d. A,...rordtrur to re(lorar.thritr,s r)n: 44//2.71,145. 10114 141 pirecnt hir_thc, than in tit.-- District of Ciillimbitt...Thuszliw- :tiff 0 rates oolii proyidi- n M.` oh -needed eeiinntinie.I.Mffei2-0-it (1?-7 )""fe"11,141. -witlf the trrigeo..- otnyjng-, , M' Alands ready to assist. :von in answerlitganYciiieSti Pie --.nract Mr. Roger 'Stillwell of this office :Sot' rthe - fours, 0 H 1111 . f. , $?ATtk.NT4.J Aua5xN 105 T.ASOCWrXoN ier.tcn Hil*L Adat, whkb represelits over 6 4(iO ner --- and baalthcai jnatf6ocq. as well as more than 27 O4O peiu4 aprecIatethI clppo.1n1t% to prseflt ts s ie S on S 134Z the CAThF -1t.t ./ imprO? tie health afatus pver12.nrll1inn WbOstanie6r suthans hive Ios* 1hi uie by provng fofu.. pro- .ttas regular 11iui a esY.mt,Its arid fnllon np trustnient 'ihe AHA n.'lile- J, support orts t &ucouthge preventv.e care and egily meSDm1 of children who süfler fr?w..dIsease. Our, membership bas * o g1iftct'efforts tu de p.riiwir5' din- in .4ppriipriate setrgs C xpal1i n of utpatti&iit 'uid anithil ItorY ilinit progrini. Tlir ro- Ii e-aeeess--te--etizuprel*ttt'i tre cons?nnZ with our pokcieb and goai / t.eye that anyprrarn.attew.pting to.a&tress ti sulij,torclilid b+*lth s rns1der the'ft1 range of i.ss s iich will confront the pt1ents anet th Ins o1!Ø 1tbjs ren& we s uld (oflInit nIl to Committee . a en II.'- mcentstuth nude.ider a I,rnnt troth ffl' nne darie PWt; Lnc-Intiea of i C11d Bealth Poli,ie IUipi To states (a I1u enter 1r e Ii Srv-jeeq Rese ireli pizI lt)7S) Tb andingit4 th study nitlicate that pu iou federal effrts to inwve Ith often sufferel froui pi-oblcui. in unplementatlon which e tte orJi 'ilitent' of legisLators. Arudr these prob&ms are: FaThire ! specific powAsatIons ?rngmentation of .ini eon1IIit btween dierent u rJurfsdlctfons 'ihre tto proidt .tiThqent nnancial Ict-ntives rr en- F flfl.N.ç)ygj(1 parvj',on :ti fefIlraj pr)l.. racic nf: ad'éiutere-n tie geAerate iirupriate assessmnt"data f progràms In tku- eon extof nr iddreirigtte lull s1jectiim of cànsera-' mIii ri.iated. ttl ih1l I th.egisjation. wonii& Iik to , offer rhe' fOli."w-ing I& ebminents -airi - edttiorji. ., I - !Rit.sMTJi)NCLRNS f; Cônceb.cflRipe S'r-. '----The AlAstri.ng sviports the pirivis1ou.of "fli.-'.p('( legis1ation- "j'rnrture the screening of IitiWecmthfrei in settings whic :pni-n-tde the ran i oriiprei nsive .bealth sei'.-teistir-- to ntnr ttdt.i1tUii Lfl(I J[Iproprt U . 'I tiuv if diii glItetI .- .ii(li i.,,,Ls. lI!1i.g Orllii4 -. ire. if I-' ":11111- Wy: .- .' r.retii,n 'k' so - .. E:ir r'rtnierit 7"1 111e,4 ti 0 .fltf ii' '' 110111 fL1R',.ttI;r1 '''': jyh I5fODIFi re- ,ur'v,wh.elI. 5'fl54-y4 ri-.- ?'.lYt (rallY. W tl'iro.i .:+' 1-. fO.M9 1iU"Ile Of c it at ixrshca! 'are tUIStS OTer (h- ung Nh. '4ti,g.:1i..w ,.- i '' i I iii I ra 1rr I ri )stet nil trea tnt. servk-ei' Iii- ,i.cOml ebensiri' nJtti t.eiiteI. (S1,0cialIY ill v -se-1-c'poJulst.d nzii1 tretc. e : eref-oro 5lj+- :-' a:IllIlliIilt ,ju the Pr1*m.d act. such os that. intrtLily.eiiutiir. 'UuI1I.Iy1I0fl1Nl. 10i)t. w-'- i-ould a.11osv a 'ite to Clllh . oci -('!Iditii,- i. wIi-ii ppio(riite .eei't' indi'iduI 'proviiers' .' for &Lrt .,fl iItiwy rt-d hr colitraci t'i (1erI '-- a. netwur for (lie pr y.ri s.*f hill health _--n'!lr services. '1 tIlls ren1. - '-, riy-,j-tft!f YjYI."yieey IfitIiUt:' of (I, ir.'.-' 'VOII1II ].iI1it. jiiii-rflt,-i4ii retitic,r'--'- ititOtiii'd r:t,1'-' of refe s1 d folio" up se--- I 'edectktn 1l2i3 wdpexnit the treat awlr fif iiitrricesed in 1initiatscre#ng. A literal inter- pr..!: nf this .'etU)IL .....:tIil () .Itl(ie Oonfbtihns iiucOvc-'t ,during the. c.rie ii! rot. #'iY- or .fI1 c- where thattliieetf.e: should be ainend.-.l i.i f. to inude tin r'entiue& of enntlIo nco-er t av prnnF In the ,ab$l1.a.'rt jjli ii I tic I. tipla,,ybi it.. p p aiMbi. to o I4I tiii . ny -'--"tive tren5ta(u (:e. n-ei1'r ykIR'IJ'tlil'IO'(OIl -....n0 iIsessiiwi:t prio- fl'1l1I(t iri,srOVekt d'.tii,foltlw-np fr. II'(1t .. t,id )tje!t hi not jtI.le d'*uIv\ front th P' tici 11Th 1t IIIIIIIc I i_ri In Iji ith '.!9 iLl! fo fIiTh.i" lIiJ) fyi I itfi I .Ioiy 1(I( 'iiii Ii thy, lit - I ...-Ita4)4r woziId)I. 01iso' w ifli Ib' iiytut of ii I I to rirol tile I tnt ,,r-- '. oil at he e$r,t t p.i F IL( f.y t Ili1JirelI a I it ii i Pit 11)1111 r w= 7roLafli o1.:l " ('r: 'rho stir ps of OYI flT;I1i) -to iniir.ire- 1thl I c'Itli siLhezreaty deJ*d at o tl aleguncy f orts tO ensuthroper 4 / " 4 - -- .. 192 4 prentaI and pb.tnat1 etire Jbi expectant mothers with loW throme' Fpr too lonx fbJacuntry has been coneerned about a bI Intant mortality r'ite Iv iatliid g ,reen}pgandappropr4zte follow-hp. care !or',exeetant mothrs in p Co will be ta necs,ars- steps ta*ard the goat of Lm'prov- Ip the health) 'tafuis f eh,ildren In the target populatto grou. .'t1lth.'lJDWfl tht maui env1rtirnentttl and socj,aI factors sueh' as puor.h1tTh a1id te lack of .prsper nutrition. preva!ent. nqng low income g'roup iredIrectiv I'jtked to a .blah lnience pf rAivcical ipd meatsi thssthxlitfeb in chflden- !* addtioa the fi4queny of a1coho1isi and rug luse In Low Income IrInpe mske It Imperathe that expectant motbts In t'hesj groups be sc?een!d n that hjeh link p najujei an he ideitlfied 'promptly Thus A1A rernztmitnds that cilgilile expectant rnothrs he corere4 under' the program ..JbetaewthIs-lëa1sjntion. andth.at e1in1bilIy for such vumezib ut'ninei1;.. foTujto tceomoths.followIn déLivery Further, I.t Is ou, understanding. that this blU 'wpti!d prolde-everag.for infnts at birth, In contrast to semé current stat e41eiul progrirn1 that be In. -coveralte ftt sty minth of age s. T)tij r'._.-Pijp AFLk Ielleves that adeqtia- dental carg Is an important. onpent-of child health. The 7wobleni .°f dental nerloct among low-[jt'ome I: ..grcups(cnnziht he overestImated,. If the Comrrijtee .deterxiiInsthat sufficient *naut'ial respurees.would bea,yailahie, Wé would s'npgyrtnp amefidznent. to the NU. siith s that proposed by Senator Chles cndniept No; O31 L t Include dental re a'nan'r.cemprnhle to other medigal servaes. . L #f-dlni. 'uotiJsW believe that public atarprjes isan essential ele mêzrt,Izi tte uceess of the' ('UAPeffort hnd siigpst tlit the bill 'b expanded toprs*Ide,fnnds fort both n.tInal aUd Ics-il .prornotiono'L public hea1thednca- ¶ion lit a,]dItfeii to traditional he1th educuti.oii funr'rhrns 'ns crivity .could;rëtliThe thé'liirlen on provhler resources by ihstructin parejsts. in the apIrprhl to of. servlees1 e.g; 'telephone enniiltati's, appintiiieljt proce- . - dnn's,nrid u-'e.ofs)qck s'riodc of elective deiutnJs. 1ADuXs'ry CONCERNS 1. Fi;iinrinp 'ond Paynie; I $;/.LIeI1i E,perience wi4h the tinnncingand pay- riu'ot 'y.stem utilk,zed by the 3ledieaid progranI ha'poiiited up a niiiiiber of s"rious- - .eioe'ernfoni the point of flew of hgptale. WbLle th.entttlenient to health 1euetlts foi th iñdlrent and tr persons with low-incomes has resultecj in im- - reourit in'theIr :iec*'ss tneecled hasith care sèrviQes theuneve iess'of f'Jj gfhHit,v reqijiremçnts and varii1on'. in payment methodoloak's amonj thi.' states often hau led to a fallureof tile prokram 0) i-fleet the full Cotq of prording hi 'utli'y health care. /: ' . -, - .. . - !sa ('onsequen,ce of MelicnhI rate freezes. berifit lainitatioris. aipf vafti1 Páynients-under sern-'tate plans. otberhotpital patients end third-pa,rtyjRlyers ,are.in edpet. sirbsilizing'the 'o'ts oferv1cenrendered.to Medicaid heneficiiries, Such 1nquitahle rlreumanees could make it difficuultfhr pruviers to.pTIrti'1ete in the propoed-ehiMnith asessnient program. oreer. in some sltes the problems nut he e'acerhatejl by the prbgram s ,otentl for Micreasng the .rollinip of ervice. nUlich would ho an InevjtahIe/resuilf eS' thlo broad Serfdning port. -ieunt6r Thh-ieoff pointed out In hIs rehuk-s aeotnying the. introdnc- tion of tl1iy JeJslation 'tlint'only about .q)nO,six,frh of tI or 12 millIon children pit lelorscreeninc selces,nader tlp qrren'EPST 'rogrm actually have ..' been scre'iIé4: this -proposed net' apsi éxpaijifed program must, th 9readllress tbeflnanClal'and payn'ient I s.a /rom,.thelnereus'sI demand generhted be a igntflnr t lie rene In tIe lLatrf-e'se load of behare.Provdjrc . 'I'he 1ncresed ace .loadwo1ilt 'c°re from . three coirces 'Ii pntients not piplousJy. lIgflde for; or takipg.ct in..the exhting se Oin progrt%m; (,2 ; pntle3s zeferred to Qu tfied4roydlers wilfi the r1eessarv dlaaThtic and treat mont qer%Icento meet thetr npds and ('I) the prevIsion of additisnal servicec -wlthIn pyuting ene lond%cr,eSult of moi-e thorough and compreherf4tse 'creen ing and follow-up srst/' .' ' :: ' : : We are peased Ye that the bill in sPtat.reas.reeqfiniz?t the ,need ri pr(u ;(l idequnt' a1uL& resources nr the program _iec1flcsl?v' te lull wou;hl nuthorlear -crezlseln flue federal rnafrhing rale fhrrequlr1'd amhtilattr rare serviçIt. .j57nlso would 'SfltfldlflNljZe 1fgThiUiy r Irementcamcing.th. ' vtwte ntbat4hIldrt'n of intact fam11Its as ve1l'a srnwie pa1un ho,eholds; tonkl cnt(red under the prptrram "evefiDt4ecs the bill do'notprovideforany-modflI,;t on efjbe pfs'set Mesh -"eaId paent system to luistlfutional provh.krs inc1uud.t fretandrng cjiutcc - ///' J9v\ ' iNj 153 ,Which Itas perniitted Sate idittatta pay less than the:titil 004 -ertig services. The AllAte-urges the Conisnittee"to.iieItprw Ittm::1-age in .'t-hb legislation, wider "theproputteil section .14103(a (G ut ra-,;.411.7i.liat for services delive&cl pnEsztaxit to the.sereening prom,. be ou the reason-- attitiodirect ings: of such preside*: 2: Allied .ifisallh Profek4ional8.4-In carder toeneouni, ami (laumnical Pro'013.` Joh of services under the progqsm. ,-the AHA F 0; tint. Specifically reftoglize the role that-Wane practition P4.11. piny in siiide screening and follaw-up. hemvitiesaiggs- .. oat prnlinsed Section 19021a)(37) -her amended; require a ste0`3,,:c.oeffn, -13T, 1- that the Stnte will encourage:participation hr irtaith cat cediL teraand ,to the.extemt pe-aalssuble under -.State all"..ed to, n--eitern!..-- in seetiati191.2 of this Act -:. _ , . . .. : ::. .C'rmrdinaAion: with, Other . Prfrwaspng.A nctur.-t. a - rxi..- ret.-iviaig federal siipport provide related seri-'_.ces for 41 ildrzt_ a::,1' 1 i ,: ,Vii,,,,,,, zu::-Lous Im-tualt, ;:( : audit ion.. and social services. t..11t- AID: believes um-- !,,e. I. n .4.-'41:q. proviti;: -fOr4 the administrative anal clinieal, covallimuskipf of 1 char..; RE:liza Asses..-zaeift 1:_Pgrain-tled other .federal Programs forli4e di- tirocrision ,..r !iealtI.L..a.-nd related social services .1o, children.-,StuM coordinar -,,-) !rim niiitiam.....,,, inertsase the:combined. impact of . the services- an the targe iv.........iinti, , ! i tar It;,171,41S,.. ad-- .ministrative costs. _ . . Aloreovier, 'we.su.ppon-t the. concept (17:_- 31 'iilead moron, ,i,,, it :t - .,slant t... propose d OF -Sesator Chilo, tmtais amendment tassieudmonn i ;r.:-..- , tri surirdinate for each ',county ikr health; service area all riprograans all- tirb.,Liai s-:attis of :mothers, and:children_ whether proV,:iileastlirop .1(, .e fist -. pti.W4.:.11ealtit--.- agencies, schpol healtiti agencies: miumcrrr healUf C or Maressual 'arid. Chdld health centeri.. . , , ". t Wea'ppreciate che-coppbrtiinit.0 pr,int Mir Ties% III" -hilt: .:-:lentIth Assess- ment Act AIIA.suppesets the intent of rAislegislat we- :Atili.:44e plea'sell to , ' .1! . provide any additional information or as-,istull.,-a i_-..:se-m:.1.,,, repa-si. . -: - ._. . , s STAT.E.YIENT OF THE,ASSOCIA'il(IN OF STATE.ANI1 TE;1.:1.1Tote,L3.1. 417,,, AI, AND'1.1.11.LIf - IIE41TF AND CRIPPLED. 0111-141:' ' 11',1_".ttu11.. .(Presented. By .Indson-Fbrce.. l'.I)Dilltil /.thr..c,-.-: 'i i niel li., _ . servic..-. De- . . / .. pertinent of HeuIth and 3deto.4,1 iiiiil)--tite) _ . .1 "ACtiNOWLF110E1=IPS Thia stlitement ias been. prepared b, a Task ther -prbfesSiorials wdrkhi In all Stare, ann t sents.shrae.nlnety,sec'z -'( 9T-t' physician i. y.' Health and Crippled ChililretaS Services prog,r::.:: ' lactil and reaional'areits ell states :tad "1:- 'sents'an additional and rttitisCit\tP11 eh s pf ti.:411011 Stare and Inca staff !windy_ itooldie if h , clans; dentists., cal sotal ognsrs, speech pa oglsts; Ite..ponsibilitie4 arses ch'thali most tat emNi an l direct patiertfcirtiervIcis. , ; The,ref(Ire,:iiisuppropriateto ackno)vred.te,i this sta .erment,retleets the coneern.pf perNons .wholot is Act; is latentlefl... - Ssociattim ,o4.31atettral aUd.C1041 F tors of 'Eine V I'rogranis SOlpt: t,t. tnr tallrDom- 1 modifyi EPSIIT and ,bronyle rokram-,elig)In recogn{ zed that if fipeciak pill olic yt nt=4.hble Cit1411t, ,inoe,eca :nnik ap .onably.gxpected of most- 1.6w tfoome fatniit. opportunity tO;rjoitiforce PA.Sious (Muresaid Law90-248 andthe Ou 7 allr of tim4.Selnia4.4eCullithreila.ws. %Ad titit-1;a 11(1 t t 1,r caref ,considera tioti as ;the lan,==" ire 44, went c I , whiciv'7 - estimanTitl LINO/ :Iiiik:Yenial and ; s.taff Inca te(1:ln r "err. iCLe repre- pr.t.i.t I !inners,' I tm.9 tpana theta plats. ,4 adniiiiistrative is' pres011,-41 -o Or tre0111' tnildren'S, 14irec- to!,-.antingtheu and tr e i 1 rkie "past_ has trokzr.t dependent and ors than ran he I ("1111 p'roride a needod and commitments rimier o ti-le and title XIX (1 1-,mtittitiandates need es further rievelpp- ;(0 4.. 't i is - prj .. ./.'..-1 , ' a ... _ , ., :. ..- - The Child Health Aseessleiit Act Is an Initiative diet shotild promote healthy cInVdren and prevent -,sua-oeceittary ,diseese., disability, and hasMitaliza ti on by ,,Insproviing. the opporMutitles for more needy children to he Identified and pro- ...Tidled witli a co-Jo:Mahn sourcelf quality medical care. A major gal of this Act musabe to emphasize the neeetandenSure the availability of necessary -primary: secondary and tertiay prermativeeare services tbrough a coanprehensive 'and coeyrdi rtted network of p ers. The Association vigoroteily ,-.supports e ....- iniorit. to have every n ci tom/sir/iced and-assured a- medical prog wkike'lieelth seeds .111roukl periutlically /assessed. 1 prevention orientedreare pits., developed And rsees. . diagnostic, treatment and itteweare services -iro- vialeel In accordance wzdi Ian. .. . . a , . Mae foll6witag stafesoestatriamd recornmendstiOns 'are made-. then,-,in keeping *- .. Waft want wenetrve rn se tosictLealtben.re.provisionalittar f"ongress intends . E11:-41T serrri and es under title V. an title XIX II.rd 0706. . ... . A: eiressrmtxr ,ERAGE In taxis 4..puirray the pit., --- of 0-, handicapping conditions: is greatest 2431.sui those children ..,..-i-Ieft thle 1 title XIX prograrns.1-4ection 1905 now titres title Xli reyiraianeco .,;or EPSDT services of all -*Haile . ,lie under twenty-oise yealirs?-itif dlesa_.of diagnostic category. It. is ctif ',Area cern, therretoo' rant.` uld !amend this section whereby Stan, ':-I.1,e X progrn1 in, .v1.1-1.,! zto l',1111 tared to provide appropriate fare ancrAeltvIces handlcapoed liildreit -.,*-zh mental illness, mental retardation, or dersicostuenta ,dissibilitie. 'Purls exclusion-is COntrmr7 h. li., fy hvent of sec.-1001' which states that title. .--''.",,X appropriartiont? /t.- 1,- iiir?- .-- ,1* enabling stat,..is to furnish (1)' medic,' : assistance in -beii:i.- ,d vi-Olfs -.....11 -dept;othint-cbildireit, and disabled indIvidivaLs and. (2) relishiFirrt. , ,T ott-. ,..rvices to help such" families and lord c. ,iutils attain or rersiiii iry. ..1- , ,.ii,,etultinee of self - -are., Some of the most urgent MIlittir ', -%.11;111).,!;(' nail treatment rueethp and 'opportn- nifics orseconolary and rerraa ., -it. it thi.sii .4nitift.idas,Or categories ,.which sre'not to be manalar d .ippr- .rte care and services. To exerude these ,,nitlitions or to litrat t 0'. 1,1.: , ro is:,:i re..a.,()11:1:-1.e-.expectation of evenrasilly attaining or r it IA, ,.!.:.li.,...,:.ility for at least intlepernlience' of self.care May tout -be in a state's ,;est fis- Ay -:::-..rest Manly states .are r.riesently investing -. substaintial amounts of liinited i'SYSirtiul fir ds itrdeveloping heiti'27h care resources andsevices to reduCe the need -sr costly in-;titiitional care. , . Alsii to be excluded irntleri(r!AP .-, ner-itaFtreatarent unless the need .is dis- covered during an assesmnrie ., -inee a .-.rge percentage of diental.'defeets can -''. only h.- detected after a t6 ..*-o:',C1 di::gri. --ie tr!xiitnination. it is. imperative that children peeie tiiagno.itii ,I., al car. , I I aat: ongoing regidi pr#ventive and eitilitii-e.,hasis. Furthernuire H. vast ti!- iorirty of needy clindreit are Already Inowl; ohave "dereittarCouiiit ., rplinir;:.., di:lcroisis and treii- merit, Assessment' for'tliase in this reutirrixit-:; kiwi OA', : il b cast effective. .. ,We also recommend that: ntal trea 'Inept services not heNiexelnded from the increased Federal htedies.' assistance 7elinIllttr§enient:as described .in sec. -- 'Ambulatory dental Cnrelts,l.r po:fti and itoildiapped children 1, limited and i-...- adequaite financial incenftwes WO:I/nly mato. It more difficult f4hr states to 'maim these needed services avilliathle. .' .., . . . . . ,/ PROVIDES PAI:TICIPATIO; JP . Ilk for chihdren and to he further slatenditel Tt Is believed that netion proizram direction and! efeRitable reim- ,-ItirSensent provisions the greater--: influene- on EPSDT provider participat- On and practice putt rt.i. %Aso or inu-,rtaneei thematient and - provider is the/ organizational sttucttik .erting and iiinoiiplif.re in, which health care services -are to be delivered: TIJelerrrire a diversity of choices in deliiery systeins and binding arrangement slio.4M he mandatell by stai tire to allow for differences in personal prefererIces Mr-egoist among patients and providers. We fully suPport e CRAP invent as expressed in, sec. 1912 to require the responsible state ad inhales:rive unit to provide greater access to programs and proeiders whfeh,tan inner tuotimlv -periodic asseisnullits lint also the neeessary. 4reatme0 and eon nninr 'ollowup care needs. However, the Association is greatly eoneeinect tinimuirenients tinder'Section 1912- coutd interfere with . . a ability to deliv.-r- :r:PSDT :service thrdu4h 'title V ,progrants. Under . . States, . - (;) title IrlocikatiniMabity providers, includiingthealth art-roasts, provide-services to senaraiMpiell Children antestily. "cular. ( reit and nullities served_ by heeltheillillartment programeataaldeme isely alfeeted-by this ..cation. of 17haft departments coplianels- jut resource of almrcaul. spear-dm 1-1 specialties amd iiiiseiPlintes tmdker-served areas Ilm.'ionglictut the country. r outreach capability in nee metatty is comiderab4D4pending -on locarn care available through It natty programs , .Nary from .asseassnent attires to comprehensive olltis.ed in primary car;'-'contrunnit' hospital, university medical elm -...t.L'oikals. Most local pr *CralliS 114(Ve,, however_ itilifitionally focused on well Ali* an..i primary prevent iwe fare: diag- .nostie consultation, treatment and 011e011.11 lirrztageMent- services taFre been pro- videfir ost. leerier .extent and.mainly den "or handicapped children folloWed through State title V crippled childretf ,ervices. ArrailWinenns daveTheen workestesut ewer the years to coordinate sainimmatent services with neressarrdlag. .nostie:.7eatanent and foiter-up care to a. _ raprebenniveriessand continuity.. It ism" pastille that local programs wi. ;!tra. have been developed are "con hum meet community expectatfons aule.teeds not be disrupted /but hopefully r and strengthened under this astrion. If This sectioit issieet changed, health rtatendi could only continue motia1019anent services in th geographic areas watere it has been determined thar:liet.Atate has Made- r ble efforts to assume provider pairticipalitin hut' the n=ntaRpof enlisted previd 4itisttfficient' to serve the member of eligible Childre. ''[ire is great reser about the effIcactotof thbsprovision as preseptly deseeeestm. . Three is the potential for incareuhtbleammintiv_hand dainating rifles viz lOcal health departments. (That is. possibi--idunnatiorn of many heal'. health programs and a decrease in available .isweesment Itealth serriiit-,- tartierliarly at at lime when there Is expected to be an ini,,teaseti demand for snits services as a result of Public' Law 94-142, the Edto.c otion. for the IlanadicappecJAct,'which is to be implemented soon by local edumnitioppagenciesr. . At beat it lafelt. that the proVider regW nment under sec. lin.. wonid'haide . very IFefle beneficial effect on the further (hevelopment and strew:linen-lig of lures, . eat delivery systems for the health heeds "1 ).,or ibilthren. Most Starter naaild need total Federal funding to epnbre exist inm, heaiti deportment assessment programs, to add the required level of diagnostic :to, q-entment services. It is conceivable that some health: departments might he mappeopriately rarced t expand into primary rare delivery programs.; there isn't any 7.-uvision rhat world Prohibit a local program, from taking this course of action even if located in an area where there wen already a sufficient number of diagnoestiand t.atment pro- viders lastly. the sAlectiok of appropriate eTiteria to be used:for -.-nelia deter- lo urination would appear formidable siltifi,,' ..,irt...iid?ring the many geographic,' pro- vider and cons titer variations that exist o7.-. a 'nationwide basis. A.(!ordingly, the Association recommends that section 1942(1i i ,(2) :(A), (B) amid 14.-71 be del ted.r.,ecept for time statemen, tha,tbiti lien thereof "a Shiremay eo ter hit, an agreeme with any. health earn provider who liras written ar- rangements for the referral of such individuals to appropriate.pahviders,for. such diagnostic and treatment services." This change shonikl not have any significant adverse effect on the overall intent 'if the section, ta, reset; inicreangly more title XIX,chiOren with a full -range if approPriate and oligningnteventive health services. Theiciiange would eliminate, inucti.earfier than (Ahern...we: those asess- merit providqrS who cannot tessure a minimum covcfaae of diaimostic and treat- ment services, or who have not been sacce-:fill in affiliation wir.-. in appropriate .=. health care provider. 14 addition. it is belleved that theInnistics :net-dyed in .ad- ministering the compliance asfects of se -ion 1912 over a 3,yea-r -Imase-in-period , I--mtild lie nidnumental. i . . C. PROGRkM AT-T110RITY . Enah:Jah,legislation for title V. programs 1F4 for time express.plispose of Wend- inn and iarprovi ng health care services to children filrotighOut Sttates. espeeial- ly in uncles- served and economically depressed areas. Title V agencies have been directed b lrederal and State statutes to administer or supervise the adminis: tration of the State plan tor identifying health needs of children and develop- ling stint -es for meeting those needs including the provision of direct. service by the agency when neeeslary. Maier Public Law 90-24S Congress fnrthe?` speified and attempted to"strengthen title V authority to p ovide:for ongoing continuoas programs of preventive care, by amending title V tate plan require- ments toeprovide specifically for EPSDT services ; Section 50. in r (7) was added which provides. for the earlriaentifIcation oil children in need of .health care . ... \ . . - . 2 ,..,(7) 196 and.service% amd.for bralth care and treatment neai l to correct or ameliorate defects or chromic casalitioaa discovered thereby. *through provision of such, periodic sereenfing and diagstailtic services, and Aueti treatment, care and other measures to Correct ormaiellielate defects (or ?I/twine conditions. - - ,. Also, under Publie craw 1110-248,. conforming monadnuents were added to. title ." 'XIX. These adall 'were seemingly intended _o provide the neeessur3l fund-. ing mecisaniams for 'In services wluich were to Ile developed and made' .available under sect: Ma (a) (7) of tithe V. Seel:ion 1903(a) (4) (11) defines EPSD7-for the purposes o meat and sectioc. I10-.2in) (11) (B) requires the title XIX agency to starter reimbursement cpeeinent,i with providerS re- ceiving payments for Dirt of of the cost of plans mr projects under title V. -- _.TheXasQCitillton snamits that most of the shurretamings: of El'SDT can be 'attributed to the ver.v, low priori this program has repeivat The Stafe-Tvel subsequent to,tisese.1:11.1PSDT : .. endments. Part-of the failure of title Vaud . title XIX agenelies ne witiaclish D'ikas; it priority'prog-rani is believed related to; the diticulties anti. seLays whi r surmunded rile developthent of regulations and guidelines.. In uorrlition, whe reuaatincis end guidance nnuerial finally became availablie in 1141: away S tes ware is,:: !an!. maj.(r .eff.r..f, 14i eot*..i..,..1- title XIX ,costs: and U.161.Vrti out' rtieula_rly int,e,-,---4:d hi providing funds for EPSDT program: dere:wawa= I fact, as of flt,,-- ,eter.IQ13, 6 itionths after the . date for full inool y about 'half .of ..,- Sliites had some services available on a suiszewksie . Much of the Mit! oil most of the teeani-.:1 expertise _for developing , EPSDT standards.a.mi saigessuntalit schedules has be,aprovitfed by title .V..agen- . vies. However, the a Mistratzve fesponsibilir: fi ,4verall EPSDT program di7. \- reelkmrontinuesito witn_ titre XIX ageneiet-. . nee title NIX is a .roderal- ,State,grant-In-aide p in. a serious constraint In ng theEPSD,T map dottellics existed - wh y. sr.ates have ,i.lpted it) .itIlit eligibility. the scope of services.. and in some :a.stances have even dr;c1:1:14s1 the opportunity to participate. . Interagency inrietw.er..:.s. be-F:iveen ID: V ;J: Al Title XIX: agenCies thfVe been -tried as a'neans O4 iiev:rove EPSDT.,rerforrinartee but have :getieriilly proved inadequate for the needs. If is believed :hat this adthinistrative mechanism will . fall,shfort of well intreci:lionsie hopes :111(1 prodigal-Ie.:4 Is -cause Of ipliefent .differ- ences Itn agency f.t!:? wkiti,:t44 Itniri goals. {Title :lox-. being administered by Wel- fare, It primarily: .' arr. neoine iiinintertniice for families. the aged and ,. db.,....d.ohIldren'a b -needs are of only secondary importance as n factor , in supporting the olers xtrfiNility! and 'fifnef ,ming of the family unit. Title V orientartion. as preireusf7 elted. t for th'e ex-nress pnrpoe of imprnving health service's for childre- and in particular those (-.%lielre.n from low income families. Cost.myntainmerft orrder this, XIX is strewed primarily as iessincome maintenance. for needy families, not Ssapossibly denying. , -1111d the opportunity far a fair start in life. .. -. The Association --esp.ect!'-ally .es-melii.des that .:f the desire and*intent of Con- ,. .gress is to meet crlitcmi health reeeis of asedienId ebildren,..tben the respore.' . sibilio- for CII.sP gra= authority must rie!(1( in Federal anal State aueneles thnt,have as their ar objectives the pre..-ctiort and promotion of ebildren'sr. healt.!1. These ageezeie r,r1St bAZe the npe-z-viry professional. capabilities and inoentvea to devillop an( -,nanir-e the'availalellity of a eomprehrtisive. interkrated and eontittning'sia.ftenf-ce, .oild health servie.- It is with regard to the issaeof program aiithoilt-- -hat r-,,,,isions of the exis!- in 2: title V child health and EPRIYI. statutes must -be .'greciffitiLv a ddressed and retntena'cs amide in H.R. 671/6. It is essential that (-HAP hillent- and lanai age reflect an untlerstunding: of both . title V and title XIX cbd(rVieslth mind. .and-afrivities . .1 * . . .... - a -- , , ,: 4.. . ,.... .. s: . . . :STATEMENT OF THE FIPTLEr''''IrO,l'N11.A.TTOSr 0 A MTAIIC.A. TITE NATIONAL ASSOCIATION FOR.P.ETARDEO CrTTZEN=. TTIF NATTONAT, Si' , rp7.ry FOR A rTISTIC CITILDREN AND UNITFTA CEREBRAL PALST .:114S0eTATIONS. INC. - : . I .. ST" NI MARY STATEMENT The four volnntary agenefes serving mentall:v retarded and develomentally disabled perstins are profoundly itoeked nt the de facto exelnsion trf children - with these disabilities from treatment and referral services under the Child ' Health Aasessment 2Progratn (CHAP). Permitting. such children to receive ., services at the optical of the state is tatitarnonnt to insuring their being barred from 'any but the most skeletal screening services required by law, 197 twit HPADICATED ON THE FOLLOWING REALITIES 1. Treatment and referral services under CHAP are routinely- available to all other qualifying lone- income- children, rvices to which many .mentally. re- .. Carded and developmesitsPy -disabled children would otherwise be *entitled on the basin of their fastily's financial status. 2. Mentally retarded and developmentally disabled children are particularly- , in need of early intervention if lifelong disabling conditions are to be ameliorated to the greatest extent possible or prevented altogether. . - 3. Excluding mentally retarded and develotanentally disabled children from care will only exacerbate chronic problems already experienced by low-income tadivMUals itratteraptingtoacceszehealtir-seta it-es. 4. CHAP was designed to expand, not restrict, thealltope and availability' of health care for poor children. Ity excluding mentally retarded and develop- mentally disabled children from all but screening services, the program is clearly not,meeting its intent. THE RATIONALE FOR. SUCH AN EXCLUSIoN IS BASED IEPA.,ASSL'MPTIONS WHICH ARE FUN DA ?.4..N TALL L NsuL. D. 1. Contrary to prevailing opinion, the majority of mentally retarded and developmentally disabled children do not require costly longsternt institutional care ;and their inelusion In the CHAP pr am would not represent a substantial additional commitment of resources. / 4 2. As mentally retarded and deVelopnientally disabled children will auto- matically becoine recipients of Medicaid benefits once they attain their majoritys it would be both practical and cost-effective to reduce their later cost to the system by prOViding early intervention In order to significantly lessen or even eliminate the tong-term effects of such. disabilities. .° 3. While 'mans individuals erroneously assume thab mentally. retarded and developmentally disabled children can receive treatment services tinder the Developmental Disabilities At (Public Lair 94-403; HI fact that legislation facilitates planning and .coordination of services only, and is not equipped either financially or administratively to deliver direct care. . . ran CONSEQUENCES 'OF EXCLUDING MENTALLY RETARDED AND DEVELOPMENTALLY DISABLED CHILDREN FROM CHAP ARE POTENTIALLY VERY GROVE 1. By providing an incentive to states to classify more children as.mentally re- larded or developmentally disabled in order to foregh the full extent of their nancial liability undetyHAP. the net is virtually assuring that many children who most.need the benefits of early intervention Ivill reeeive delayed treatment. or will be,d6nied treatment altogether. 2. AItegorical exclusionindeed. a eatecorial,approneh of any kindruns counter to the recent trend toward providing: fun,,tional assessment and individ- ualized treatment for all children ill health. education. and other social service programming: 3. The.eXtinsion of mentally retarded and developmentally disabled children contravenes Meilleahrs historical refusal. to deny services on the basis of diagnosis. .- . STATEMENT ON THE CHILD HEALTH .1-;m1.:ssN6-:NT CENTI-.1{ . INTRonrcrioN lithe four national vpfuntary vtncles representing persons %vitt' developmental disabilities have been bistoricaliy supportive of efompreltensive:IlenIth loo_ grjrnif4 for children as a primary mechanism for preventing and reducing the in- clencerof these handicapping- conditions. Programs ,iter/ a.: the iiitriy find P odie Sereening.Dlagnosis arid 'rrea t nom t (F.Pslt initin rive provided tinder Medicaid have been welcomed by our organizations -as major Federal oommit- nts to fissuring and increasing tile aonfinuity, gun lity. and availability or si:i11 orts. Child health Assessment Program (Cum') k another such potentially valnable toolifer implementing na t iong 1 strategy of health promotion and pre- vention for low-intome children, A population statistically at (high risk for long- term. permanently disabling conditions. For this reason (our are particularly distressed by the flagrantly discriminatory categorical exception I sr 194" . . .. - - . e- , 4 . . . .--') . ' made in prOviding tfinitqfent cervices to mentally retarded anddeyeloprementinetrainli; disabled children under section 3(G). of the proposed.legialation. By the provisien Of care and treatment ser to Mentally. retarded and Alevelpp- mentally disabled children optional u r eh steel Medicaid program, section 3(G) effectively excludes.stich children fro receiving those same health serices 'available on a routine basis to their nond sabled,peers. services which they uti:. - questionably require and to which they uld otherwise be entitled by vistue.of their financial status.: . . - . NEED FOB EARLY INTERirbiTION . . - 01._alLefliaieptilation grouPs. low-income children are at greatest risk of ex-r. periencing developmental disabl tliy-Thi delay as7flie-resuit-ofinntlequatettrettatai _ . care, poor nutrition, environmental hazairls felt as lead-based paint poisoning and mercury toxicity, and, above all. lack early .diagnosis and treatment of various sorders due teeinsufflcient utilize on or availability of health se vies. In his a reps to the White House Conference ongthe liandicaeped on Slay of this year (dent Carter enunciated his administration's eedimitmeet to In-* . miring the health of financially disadvantaged children : A.s' I lqok across" this tremendous auditorium with many" different kinds of . handicaps represented here, I know. that many of them could heve been prevented in your early life . . .. within just a few years we will multiPly five timet-the number of poor, young children who lia,ve a .chance to see.a doctor early in their. lives -so their potential handicap or affliction might be presented or corrected .1 .This.prevent,ive emphasis has alreddyipeem endorsed by this committee and-by . :the Congress as a whole in such legislatien as the Health Promotion and Disease l'revention Act of 1976 (Public Law 94-31T1 and the Health Prdtessionals Edu- cational' Assistance Act (Public Law 9-1-1144 ). which seek to insure'the adequacy . Jantlavailabilify of preventive services and primary cane profesionals to deliver - them. We are..thus particularly dismayed at the exclusion from such services of precisely that population which has a t4encinstrable need for them: mentally -... setarded and developmentally dis'abled loW--inconic children. ... ft has keen abundantly dcamented that disabling renditions Neir with greater frequency among the low-income population which Medicaid is designed to serve.* - ... These disabling physical and 'mental conditionthieh are not the result of pre- natal' proldems often first manifest themselves during infancy or the preschool years. Acithout immedikle and ongoing therjoetitic interyitntion these conditions ran beemee permanent16- ibiabling..,With litany low-income children tin need of . treatment for medical conditiOns related specifically to problems of growth and development.' Trbeemnes. particularly essential that individuals so identified be eligible to receite the full range of .referral, treatment and follow-up services available under -Medic auseice4. so as to .1 nsure,_ the amelioration of their. condition brfq'e damage o degettera Hon bicomesirreversible. . . - ;:`rtinwent regulations undo F.PSI.T r quire (-4*tes to arrange for treatment 'of conditions discovered during routine sc eenin either by providing such services themselves or by referring childned aPprepriately. There is. little doubt that the de facto excit:fon under CHAP of mentally., milli-tied and tfevelopmentally dis- aided children from even this bashc referral funetio M4 11,n.te.direu more function severe impediments to attaining appropriate services than these fihildren ni ready face as . the result 'of- inadequate parental information or preveptiveAdaenticwand the inherent difficulties which lay consumers- -and particularly eto potireontintially; experience in attempting to access health services! 'r ,. k I Moreover. the few Federal programs proyiding some medical or health- related services to children With misfitsl retardation and developmental disabilities ore so frligmented, condltioffl/region specific. and hedged with varying eligibility reqnire- inents and application procedures that tracking iipproPriate services within' such a "non-system" becomes a confusing and frustrating pro-eess: and it goes almost without saying that under these cenditions toutinnity of services is impossible to guarantee. . t. . A . . 1"Fresident Carter Gtve, Hope to Handicapped Individuals," CongrPssional Record, Vol. 123. No 99. June 9. 1977. pp ming/1-115691. . 2 For PUIMPilf. National Center for Health Statistics. IlitA/PItst/Inte.W. Selected Vital and Health Stntlmtles In. Poverty :end Nonposcrtv Arens of 19 Large 'Cities; United States. 1909-71. (PHEW Pub. No. IIIRA1 70 mu! The Children's Defense Fund. EPSDT : Does It Spell Health Care for Poor Children? (.AVashington, .D.C.: The Washington Research Project, Inc.. June. 19771. 3 ChIldren's Defense Fund. op. cit., p. 109. . p. 199 ft 4 In short, it Sad been cur underst,anding that the Child Flea 1W Assessment Pro- gram was deaigned to:wand. not restrict, the scope Of the EPSDT mandate. Clearly the new program as drafted contravenes that golil as articulated in section 2 of the proposed legislation (Appelix)4 . 1 EXCLUSIONARY RATIONALE: FACT AND FALL,FY r - Cost.-,The Acintinistration's /allure to require follow-up treatment services for mental retarded and develoPnientalIv disabled children appears to buiorivated primarily by a concern that the cost of prnviding such services will be prohibitive Jo. statflt An unstateci-but-imPlicit--asslimptirA-appears, to be thnt naerytstlly_re tarded and developmentally.disabled children are at high risk for- long-term insti- 6iiional care. Such- an- assumption is' not °Warranted. The overwhelming number; of mentally retard441 and developmentally disabled children do not reqUire institutional Even among tine more severely involved institutional care is only rarely for and need net be long-term. Equally important ks the thaVe rly intervention anti fellowup can preVent the dev'elopnurnt-of sume rins of deyetop- mentally disability (Such as mental' retardation caused. by nbcorn errors of . inetabolisM) ; fn dramatically.reduee the.severity of the d pity (Ifs in many aseizure disorders Which; if untreated, can significantly inere in ;requency and intensity of occurrence) ; can compensate for disability-prod ceti impairments (as . in the, case of-children with cerebral palsy who. with ap ropriate theragy, can he helped to reduce or compensate for communication and otordifliculties) ; and can reierse *yet toms (akin. the case crfsthose autistic ehildren whose cognitive ." and behavioral etioning has- improvedsAnitieantly s a result of neurolokical intervention). .arly intervention,: in other words is iguiliaant teeter in reduc- ing the neeil for long-term institational care atuoul the mentally retarded arid lleketopmentally disabled child papulation; and fy legislation inhibiting the provision of such care as early as possible not (ally ails to save money. lAtt ally -asst es additional piddle expose throughout the life of the child, expense,- wide T ight otherwise have been avoided. . Ic asse,ssing.cost it nlifsf also be reinenil.ered the ve.rely mentally retarded or . developmentally disabled children eligible for-Medie as SSI 'recipients or as., A.IPDC children will in most cases_become eligible for dicaid as adults on the toksis .-of their disapility. Nondisablet1 AF'D(' ehildren in. contrast. will generally lose eligVAlity "for Medicaid when thy reach their maj(ority. Thin: the disabled I Sredicaid.child will also be ie(lietii(l's responsibility ifs an adult. If the children are not reacted iii-ehIldhoodwhen the possibility of reversing or reducing dis- , ability is greatestthe long-term cost to 3Iedieaid will be dramatically increased. 6 - The 114.-e1opmental Art. A--second :Intl equally specious rationale for excluding Mentally retarded and develomnentally 3lis bled children from the program is the phtattive availability if tr(Nit mentservi s tgr. tit and tl)e Developmental Disal(ilities Act 4Pobli( 11/11 1 gi latft a'SdAte of Public Law 9.1-.103 is that of 14anni igairdcoora 'n. servi and not . sat vieerdelivery.-Pnblic I.aw..0-14 -103 is .unipped to prgyide neither t efamding . nor tie ndminiatrative apparatus necessary to deliverervices. except as e prnvitlgr of last resort in certain limited instances: current appropri tibias ($30 could not wssrl.ly (absorb the loirdem of providing in full those rfgeral and treatment services currently available to mentally retarded and developmentally disabled children limier the EPSDT mandate. dearly it is un-.. realistic to expect. that. givepi its enrrent structure and funding, levels. Public r.:N 94-103 could provide the scope and volume of services whit the Aledicafd apparatus is already organized to deliver. . 7 CONSEQ11.3:CES OF ExcLust)x Perhaps the gravest datiger inherent in the ex(71usion of mentally retarded and developmentally disabled children frMn services under, ClIAP is the very r eal likelihood of its acting as An' incentive to states to reclassify many faherwise eligible aildren as mentally retarded or developmentally disabled in order to lessen state financial involvement in the provision of screening. referral and treatment. Such a response an the plot of the states will delay or deny treatment to puny, children far wit° immediate therapentle attention is Critical if per- manent damage to be avoided. Yet-it is evidentbfrein the preliminary response by many. states t ,pregrams such as Public Law 94-:142,the "Education for All 20t) Handicapped Children Act," that a4ditiOnal state administrative and/or fiscal Oommitm06ts to comPrehens ve (leis. programs, even 'with the incentive of a II:l . matching provision, tend otte to be 'viewed in terms the mosrexpedient rather . than. thaa most equitable .impl Mentation route: , the. case.pf t,13e CHAP p gram categoriepl exclutu is regressive as well as -obstractiVe. During the p few stars Cougrks,shas b n'MovOig away from' de- . - fining-ba'silc Soda n s such as Idealth in categorical terms, preferring to em- .phallze fimetfonal abilities and the specific. types of services an- individual might requrt In order tpApti.inize hisTher]physleal and mental competencies. At the same UM there has been.atrend toward' the individualizatlan.ot tervices-pro-' Vided under in nY federal prograuls,'and a concentration upon,ideveloping.prri. . Igra.nia whoSe a ance components reflects each person's uniqub needs. In this context"it beconi s readily apparent that a policy of blanket -categorical exclu- slot] is at best, out a..4ed. at. worst insensitive,. and,in any event contradictory to theillealth needs.% f low-inCome. mentally retarded and deVelopmen'fally dis- 'Alfred chlidr n. . . Finally, su a poll y is clearly incompatible with Medicitid'slong-standing re- hictance to nut riz more.eirentriscribed set of services to one group of ell- ateipients than to nother nil flie-hamis of diagnosis..t Section 1902(a) (10).) 116EPgDT system was originally conceived as it meChanisin for eoordinating- - .referr41 and tteatment services fee-all...eligible children under-a centralized ad- ; ministrative rubric. *By providing clients with a central roots through which' they could be assured of 'receiving treatment, the .progr.anywas'tn minimize the .....haplitiard and discontinuous service delivery which gene?ally characterizes an individual's attempts to receive health'eare from mare than. one agency or pro- gram. The EPSDT model is. of course, only n model : 'and many flaws exist' in theway,the systern.ctirre.ntly operates.,But despit%4Igany failures of ample: mentation. we hlieve that the-philoSophleal.linderpi s df the program the provision of centralized. compreliensiYe heklil'eare to all low-income- children, including those m tally retarded and .developmentally.disabledremain sound . and ought to he pftetuated. We therefore urge you to remove froth the CliAP proposal as drafted. -that. language which denies to mentally retarded- and developmentally disabled-chil-- dren their right to receive the health care necessary to insure' their maximum partielphtion as,adifits. in American' society. To this end werespeetfully suggest.% the' following reVisb;m4itlection 3 . -" "effective October 1, 1977. An the case indirfilind under the :ice of twenty-one who :has 'received his jleriodic assessmenLpursuent to netion i 912 ( h 1( 1 ). for the 1110ln:ion of al!. C.ir(, and services appropriate . for in- (11,vidnals. rnder'llge twenty-one for- whieh payment' is available- under' this title, whether or not tinder the State plan for the State suelfcare and sere- ` . lees are prodded. to individuals who have Apt been periodically assessed pursuant to.seetiOn-19120) (11 ::" Mt The TIouse Committee on intcrstate..:111PriiFeign Commeree has recently re- portedofnvorahly RIZ. 13611: a-elean:propo41(4mbody.ingoiir recommendations. In doing so,thcy have, palahly acknewlegic:;(lethsb, wisdom. in both humane and cost:beneficial terms. (ifeneouraging preventive and ameliorative-care. for Medic- mentally.retaded and .deVelopitolitally disablisl children :, We. tirge you tOlftnrind likewise.. ...Thank Mi. permitting es this opp,wtitnity to express our .c.olIMPs l'i'e look .formi rd to the (ri when we itnreserc edly expresi.: our Support 'for te,,,...t-eVised and ..'extanded rtrngram of compi.ehensivehcalth care' for all low-income children. To - '.that end we -will be liappY to cooperate°.with your staff in, providing ;any further infomatiOn-o a,sistanee the Subcommittee may require.- APPFS'Ill . 5. 1392-111.:cr ARATION OF PVRPOSF. See. 2. The purpose of ,this net 14 to modify the early and periodic screening. dlognosis. and treatment program and-brtiadeo medicaid eligibility (1) to continue and' expand the availability of health ar' to children whose,' families. do ,not have adequate resources to coviv the ,cost df such care and -to Strengthen efforts to assure mbletiate child health assessnients. diagnosis, treat-h, nient. hnd periodic reassessment of all eligible children ; (2) to increase the number of children eligible for such care; 201 , . . II. (3) to mature the continuitY of care for a period aft& a child would on account of income become ineligible for Inedical care under title XIX of the Social-Se-. curttY A . (4).to increase immunization lever of children': and ,i5) to provide further incentives tp_ States to arrange for and encourage qual- ity ity health care for children. A . / A MEBICAN. Pusrac .HEALTH AssodiAncs, . . . Washington,D.C., A agast.21; 1978. .. . ROM RUSSELL B. Lorin, ./ chairperson. Senate Finance ommittre,, Dirksen Banat Offlae Bull ing, Washington, .0. .. . . . Dui Settkr a LONG: The American Public Itb Association wishei to sub- mit a statement for the hearing'.record on S. 392; Child Health Assessthent Program.' Alaiough EPSDT has been a .mush criticized program, we believe neverthe7 itselhat it is a most. useful and important prOgram. We believe that the-CHAP- legislation with modifications can. strengthen the EPSIYr program and correct its .failings. , 4 . . ... Attached is a copy of our previous comments on this legislation presented by . Dr...C. Arden Miller before the Subcommittee on Health.and the Environment of the Committee on interstate and Foreign Coninferge, We wish to reaffirm our commitment, to the proposals contained in this testimony and to urge their .00n- -4. 'Additionally, we are support, several changes to the CHAP proposal which sideratiomas you review.the .. . have been made by the TIODSe, of .I epresentalives and encourage you to include' Bar language In your markup of S. 139'2. These are :. '.'r Langlitage Which allows finnlified health care providers, including public alth deghrtments to perform health assessmentu: . . . .. 2_._; An increase of up to a maximum, of lal.percent ill the Federal matching rate" ...: fOr -health assessments. . .. .. .., . ',3.:.The inclusion of: basic dental care as a required service under the program. ' , 4: Pzision bf Medicaid eligibility lor'individuals under'IS years of agcy who tare flnauciallypligible finder the State welfare. or MedicaidAtlindard,-nr-who have , . inciane of less than $4.200 a yelf for a Ninny y offour. . 7 -=-" 'f;::.. 5. Eligibility of pregnant women and children if they meet the State welfare . or Medicaid standard ortiivf? incomes Cttiess.tban $3,900 a year. . ..Tn lightef.the current controversy surrounding national health insurance, and the distppointment we feel with the President:a National -health. Insurance ini- tiatives. there is an (Wen greatPr Ruse for prompt action o this legislation to address the health needs of children. Poor children are the most vulnerable and perhaps the most neglected people in our society. Their rights' to health care . cAtipue to be: largely unfulfilled. CHAP. with suggested naodifications. rep- . . resent+th best juitiative now on the piddle agenda to meet ;these unfulfilled healthAleeds. . : -. . We tirge you to carefully consider the legislation before you and to work towards strengthening its proviSions to assure that the children of ,our Nation -may participate, under public Auspices to 'the extent necessary. in a program of health pare that emphasizes primary and preventive services 'and access to ac- curate diagnosis and trentimait :1 s individua ily. required. Very truly. .E.FiANk Ems, M.D , M.P.H.. . . .., . President: STATEMENT OF THE AMERICAN PUBLIC 11F.ALTH A FISOCIATION BY C7 SARD.E15, MILLER, PROFESSOR, :WATER rs-A r. AND CHILD HEATH, UNIVERSITY OF NORTH' CAROLINA SCHOOL OF PUBLIC PIEALTIT . This testimony is,pt'esented on behalf, of the American Puhlic.ltealth AssociV. non. I 'am Dr. C. Arden Miller, n Pediatrician..and professor of Maternal. and Child Health at the Sihool of Piiiilie I lealtiO flniv'ersitY of. North Carblina ; I speak for the association foist president, ''lie Association, with affiliates In all no States. comprises a total iii4nbership thrOugh the National Association and its affiliates of about i(1.000 people. Most of .there ere health professionals-:- , 202 . nurses, physician-a, social workers ,envirenm taists, adminLtratOrs, tYutrition- 1sts, ljetilth eduCators, potliatrists,technicia and a numbei* of new,.profesionals * such Its health aides and community 'outre ch workers. Consume?s'are welcome members of the Association. . . ,Although I take responsibility for the contents of this testimony, I wish to .atlt4Ww.ledgeiinportant assistance from statements that were prepared. by 'the :t7hitdren's Defense Fund, !the Coalition for.Chddren and south. the American AcIdgmy of Pediatrics, and colleagues in t he Ailierican Public Health Association. 4#Ince.November of1970'a strong theme for our Nation has emerged in ; defense t.hurrian rights. The American I'iddic 'Health Association applauds that mu- .,4:phasis , find invokes it today in consideration of the.Child Health Assessment Act of 11477 (,}1.R. 6706/S. 1392). . ".!;PrOglams that address the needs of poor people are predotniiiantly addressing needs of children. The majority, of poor peoPle in the United States are chil- Alien, and there are' moreof them raised in poVerty today than in 1970, [1] About. folitY:pettent of all minority children and about fifteen percent of 1{11 white chi!- , dietlare refired in poverty,..Their rights to liealtir serViees 'have been well defined fiCr'nearly (1.(iCealiP finder the entitlements of.the Early Periodic Screening Diag-: noSis and Nentinene,,Prograin of the ..letlicaid amendtatmlA. Medicaid' eligible cdildren arrstifitled to services thiit screen for he alth. problems. and are further entititd to aZcurtite diagnoses and treatment of any problem's that are identified. T/icse.entitlemesesthese human rightshave been uplieltUrepeatedly in litiga- Hon hn.s attcnejeti iniplemehtation ofEPSHT. -.Tile need Youstill,rfunAgrttm is great. More than half of thechildren who have . Preen sciveuelputv-heen..found to suffer otre..or more health problems. Only abbot forty percent of thagerrobleins have been treated even though. the most con- spicuous of them--dental disease. nutritional anemia. lieaing disorder and isbailefe'etare readily. correctible. This circumstance is especially tragic be- .cause without treatment all of these-conditions atebe.expeeted to lead to lifelong. At: disabilities. But, most tragic of .101. about three nut M every four children who. are entitled to the seryices of EPSI)T have. not. been reached by it. Poor children are the most vulnerable and perhaps the most nvgleeted People In our society. Their rights to health care contintn, to ..be largely tlitifitlfilled The full scope of children's health problems is superbly doeinnepted in the first twenty pages of. "A Proposal for New Federal Leader:4101M Nlatimuil and in .the United States". Office of Child Heirlth ,tflairs, Office Of Assistant .Secre- "fa ry for Health. DIIEW. 'November 1. 31)76. . The probable advent of *naliimar-bealth instirtini.0 in the. years immediately alieml requires that...prior. attention lie given to strengthening health. services for ciiihfrtil Unless speCial provision is maids fin children. they 4ill get-'pnsited. to the mid of the (pious Wiico-they are itieorflorated into service 'or 'financing systems along with their elders. But nihre..tlinn delay is involved: The nature and scope of health services that children '''s'u're are different fnan what thiir elders expect and require.[2] The experiene..of other nations is-..releVant. When :universal health insurance' --was introduced in4Quebec, the untidier of phySician visits per person each year -remained constanfeia,were shifted from Mos. iii dgit.to.those in lower inmate . Biltdistiirbing,ly etiongli,tbere was decline of about seven per .coin for,ages.muider 17 yonits..Eiii(.111no' concludes that time decline - "May reflect inability, of the age gl'ou.p 1.0 compete for servic,,,.;"Xvi children in another province' f Canada (Newfootulla Lobradorl Were protected, from such -.crowding ont... A children's:- liptilt 'service was established. there .11405S: La ter When a henith. insitra nee program was' established.for alt ages. sPeelalVene-, ' tits-tor clithlren'were retaine(14.41 . itepent experience Britain is even more compelling. When the National Health Service was enacted in' 1111. preventive consisting most,. con-. spiuonsiy of prinza- livalthe:/ re tic 111,.1;111'!-: :1111) wire septlyittely /nine() Juicier the Local Health Authority. .uffinired feature ,M..this serv-- ire was the 'Work of speciall trained 111:/:Se.S. 111.1'XII is llealth visitors. In 197.1 all health services were merged initlei.8 unified authority for the Sake ofinte-. :grating preventive-atid curative Medicine and proViding.a .sitif.:11-..door of access .lIiiougli the offices. of general, 'practitioners.. A, report blished in Deeember. 1.97(1. by a govertuni;nt committee Health Services stafeS Hint since ma-. farniliestrifh rnnng children lave than their previous share of-the health- visitOr' HMO. :did this is a develOpnwnt.we should like to see re- . versed".[:'] Special proV4ion forbionith servieesAh-childrert; the report . urges that those provisions be inade.once again in Britain. 2 In this country wt. derive out of. Amerit.iin takes of others not of 0 services to children. The CHAP program c health problems of childre e 'ohll tit t the most timely avenue . extending and improvin drew. Its fad aires of 7m port, tech'' III Assista (1-1AP . ti 1r (*ate ment ; it s Lo - ' k system-4i ''...,4 t I health care,aakPat health services as CHAP eases children under..* Lion and fails t tied tolbeltItic .requit.fintents or ci conti4falls w thin. t . state Welfar refit I least tAelv 'mon )'h WIRY is serious million childre of poverty levels towards thel. over f'tri yea r under Itttli should be in The ben of trynt.411 namely in inept for, t les? dis Including, n.efenti provided. Efforts rentions in sorri impOse ixpensiy /children wiltsti 'istratit u of C childr li to he libtrt ized, th. , Th re slum not: ;.uppOrt 11111 rre Tit or ho EPS], lementa ce, sta explicit 0 intro cess 1-(7 ay he r quire me eli ibility a yetis a age. .cover edictal% ill chi d en and assisft levels r men[s-. After' imited ring 1 And ,V% age.! egall ess of their economic resources, were addressed ehil reit .are the next population group whose health needs bite resitonsibility: . d under CHAP, as it is now propoSed, exclude certain kinds uilvde entre fur chPtIrtal 'suffering from certain diagnoses..- 2Q3 d tOdevelop oils: but we mt. It;pecial ly .prop APHA si SI stems of care that legitimately re not obliged to,repeat .fhe mis- trovision must he/Made for health Is not an adequate response to time ports the concept/ underlying.CHAP ealtlm services tt/children rests with a powerful entitlement for chil- table Annie'. stronger. ederal sup- d enforcethent. OsP i$ str0100.1' (11110 health into a roninninity based health care e eouthinhig prithary amid preventive diagnostic, curative and rehabilitative. emir ments now existing under EPSDT for nut di. 1.lininates against tilt. sChobl age popula- wetly children. We urge that eligibility lie moth- tits to '1. years of age who meet the financial C f wel heal plan. land n all c troving v. It rei esents ion ar 'corre s:. dug a y that ti put y 001 tat wi provi full rt ge Of t ildreim ire eligibi ity.otice ac fere(' should be continued for at I assessment. Even with these revisions eligi- should be lath to expand eligibility, to the 23 es that are supported at less than 150 percent step should be regarded as an interim measure ildren and ontlf. The healths needs of all people onhl not be excluded if,family imm- at.v even if they fail to meet other. 'mien)) fit ;riciVid .i am] 1, al illiie s, mental retardation. at d developmental ditabilities. Treat- rders.. as weltas all apt Itpriate preventive health services of dental cartes.should lie restored. Dental care shout 'be 0 disqualify certain conditions or diseases will fosler ciren it- Instances. and 'discriminatory practices in others, and w and unnecessarily complicated a dmjnistrative conditions. Many er.needless neglect. Unsatisfacttiry- early experience with admin. pilled Children's .services in .same state, that required .eligible. of .1).111111.111ind" is relevant. \Vhen eligibility 'requirement-S. were tl be I 6 lintil. on iltt nutubt'....tt!' town .v indicated .visits: data do "ad lust titent;" of i.ti. s:t.ort,s 110.111nO I.,S urgent, . an expectation that children will vi-it health. service .providers iV.SSil ri . . . .-. T iliffirm viler:11 standards' of care should he adopted. similar to thane whIcli- lut -e IVeen t.cottinfended by the Sznerican ..1cti'dottly of Pediatrics. Performance -.. S inda ids should be adetpted to assure that a reasonable proportion of eligible t. dhlten i I each state are reached by services that conform to defined Standards. . state's, failure 'to meet (tandards. of rerforina nue with minimally acceptable nicomes should be penalized not as now nrOpospil. riy Withholding fonds that are sPecilltally identified .with services to poor people. but by withholding.a porfien of the state's revenue sharing funds. Ittittnale can be der/gored for this it el jon on i hi. basis thiit 11.'1111'111,er of federally, financed pro:rt.:11ns, !nary of them-targeted as health st.rvices for. poor pettpli. wereetirttriled in favor of revenue .slia ring in expeeta (inn -that states would a ssittne.and extend services that had Previously been sponsored by federal goveritnient. Where health services are detnonstrably deficient the states may fight fully he 44.ni:idoroil to have failed an obligation that was ininlieit'in the principle of revenue sbaring. .. . .CII.1P Should provide 90 Percent Federal l'eittibursement of state.expendititrest. for.services. Precedeht, for this level of matching derives front some other aspects. If Medaaid. ,kddi Hotta] fetter.] ..funds ,..,1.1041-.1.e. made a'railable to develop . resgirees that are retbuired to.firtiolVinent;(1(tp. ..- , - . I' ho . merle:in Piddie Health Assnplati,)ti's zrynt-t..emplinFis with regard to CHAT, O,Iirdrips resource developMent. especially in the atrenoies of government' at the total level flint tarry greatest responsihility.l'or init.lementing the Progriiin. ,L) , . ly60.*Ircent of all 'health, assessments that were perfOimed'Iffider :ZPSrlt read9red by -local !math departments. Those states, 25 ..of . there' in,1975,, ProPo' l' of eligible children' hose stet s that relied On qiultiPle,.provIdere . ich.,re ed exchistvely on hettiligepartmTs for screenng reachid 'higher .;. 16.1 k,childree.,,Who were !mutat° have health problems by-kT§DTrvtgling'S wer vtot:mibsequelhtly ems:Flied. in programs of adequate diagnoSikand, ed ent. E Once,,hai, pot been presented to Suggest that these failingsOccurred ahrMOre c only after sereeningin health departments than in privatethYalaans' offices r111 hospital clinics. , / . - . ; /Certainly an child wiwreeeives health care from a q:uglified'Proviaerhe it / peighhorhood. health teeter. physician, or.seecial project of 'title V- -:should not ../ have the care intevriipted. in order to participrite.in the service's. of a health /./.department clinic vilierre there has been ,126 ineevtOus 'contact,But. large numbers :,./d.;;,nf poor children receive no services; mid their care, ultimately faints a tesponsi-. y.: .1)1111-y of.-the local health department- Itegtila tory landela sitnply db' net exlpt to assure tkat private, and voluntary providetti can he made equiltably,402kenon the . ''; 'ocutitleniehts of all children' tn. health services. The fulfillment of th entitle- tneatsthe guarantee that huMan rights will . he honoredfalls filtimatelY as :.i gn,,nbligation of government. In matters of health service that nbligation is hest fulfilled by the public health service; agencjitha t functions closest, to most people-- : local .health departments: ., . . At least three times within recent years federal government has attemfited to .1riplement massive programa:or personal health Serviee.WIthont deyelopi»gthe',.° .', resources of implementation FR/1111Y Planning, immunization' against. infiffenpf. pi,rofir.ate and extersive use (Aped- ntid.health screening- for children' alhmade.a I Via teand.volnntarylvroviders. But ultimately theguarantar for those serrices-, . "; . the Amur/knee thatererynae would he reached.,--reated with 1000 health ,depart- ments:.In all of Ifiese ptogratus health denartments carried the greatest Burden of serviee. Jp.S.Ofrfr aS1.11.7. programs s-failed the .failures shonld 1w nttrilmted to a . false expectation. that Ineril.hegIth departMerita can'etpand perfortrience witbnur . . expanding fheilltieS and staff. VI eggregnte health departments reprilsent the ; potential fora effeetive health setviceinfrastrnetnrethat'enn assure that 0-very Person fa rearlied with essential primary cafe. . In: an'exeellent 'recently Published. hook nn primary 'health care (Lewis. Me-' ehanie Ind Feint the statemen't 1,...;niade that iideqnste first contact.ea re requires '. at a minimum : insuring. necessary Immunization. providing. preen tal and child ' carte nd monitreing orefali tednith needg,.. These. rentarernents4fre Well.wi thin. the .: . enxiability 9f at least otuffnilith of this nation's 1.700 local healtjr dePartmentk. fr. CHAP should he used as ri:deviee for resource development.thnt Would otrIlle: 'other heplth departments to develop such a capability-wherevertbereare children -who are .not adequately served by ,existing health care providers,. s"orne data on health services forrhildren is timely. .. '. .__, In 1915 one out ofevery four AmeriCrins received some personnl liCaltii serl..ice : ..._ 'from !nerd ealth departments. By -far' the largest population served was chi], dren..[8], . , -in some ceases tracts as many Ss 80 pereetat.nf nil children rier. Sonfilhealth'en re from well child stations or sehnel health clinics that finietion as . programellfInettl 'health departments. [t)1 TS at least one state., 5c1 pere,,nt of all children receive whateverhealth care they get, .excent attimes of hospitall7a.tion whichis rare among children. at the clinics of local bealthdepn rttnents. fun' Although the ftvailahilitY 'of ,Meillenid reduced the economic barriers between poor. people rad healthcare and increased the numher of their visits*, 'health Care providersit clidnotsubstantially- alter the sniff-cps of health ettre.'for children. 03 T' . . Only abonr:10Tereent_of practicing 'physicians Will .see Medicaid patients Ini : u. in at least one state for which a reeenfrenert is available il0 pe'reent ofiletliatri- ciana refuse to see ii.licald enrolled children. r 1 2-.1 -. .. The.Mnat effective public.InItirdiveFf during the past two deimiTes ferthproving health services to' children Were included In the Neighborhood Crimprebeesfve Health Centers and In the Children and Youth. and .Maternal and Totatit Care projects of title V. The Department of .HEW has ciirtailed the growth of the neighborhood health eenters and has reassigned the Child and Youth' and Mater- nal and infant Care projects to the states for inclusion in. their ,Programs of Special Projects. 'By all available .measure? these programs have affirmed their effectiveness 16 maintaining health and in reducing unnecesentry hospitalization,-7 I . n. . 205, . /:. .sdrgary,laborntory t N trild,'Critys: The per capita cost corapiehenidie hare, !iding all Administrative costs, is s more traditional frafirtented forms of 1.1eLlIth 14e-twice, These more than tolen demonstrations of what might be dotte.tO to -Children: li.1974 an estimated 550,000 children were se and, ilrouth prof and an estimated 7.000,000.additimuti qualified for such oniprehenaive care. [1] Similarly iu, 1 1450300 out of needof 5001000 were served in the'Mat projectM,'[1-] T constraints werefizedny policy and fundi ..of government. . Fonziostofithitt century. the pieval ilng public policylot sericripes has been to develop at publicexgense the resource. at private and voluntary .health service systems; These .pitals. technological devebainieni, training of manpoWer In direhrreimbtirsement for services. benefits of- this em mous;,It represents commitment that needs,to cont -.tune our nation needs to 'strengthen and eXpanii those ag that Performin the public sector and ,whidt'are obligat piece -meal laissez -faire syRtem of heitith care. :Proriders,df pens:mai hearth services Under public :At' children and are 'important for the whole spectrum of in setvices. The intpottance is most criticarsfor eliildrett greatest need : minority groups and poverty level fund whom public. providers render extentliv.i.services presen den of diseases,. disability and neglect. . AsSumption-thar all health care now provided 'under transferred to private. providers is not justified..1Siddels f vd?nntary providers are not available to reassure. tha corrected; sr that entitlements will ..be equitably hono health- care under ,public authttrity are not tral.lg Fer.example.the.valuable work of !ley professionals veloped* in .public agencies. SUpPort systenik suet', as o dolt and transportation more readily 'characterize ,1)1.1 - privatetinek.Efforts to force all poor people into pri cafe systems, while. retaining public *responsibility f retch; will result in even greater fragmentation' ro burdens on child-roil and \all.healtli care agencies an pr ("rides bfipuhlic pros-4km brim:0th services son, morfolithi public 'proerani..We run a contrary ki well-beingof children to a monolithlehealth service - professional prerogittatikt. So -long as. a substantial lives in poverty, I stihinit that we must provide t that impoverished, people require. Arguments f health care.--a subsidized priVate, one which, minim systenismonopolizes tesources, favors a special' pri concept of health'care. - The Credentials of private and .volunfary health . sfrortig la. the interest Of. children's health. They de:: ened, but if concurrent efforts are not made to stret are .rendered by official agenvies of government, childten will suffer. blighted health:. . It ikergent that CRAP be strengthened as a dev fac dillies. technical assistance, and standards to of limited services ill order that they may do a mor diagnosis and treatment of allichildren. Locai:h cal greatest need and greatest potential for expansion . tin:behalf of children. (711..t.1' should incoris)rate pro ,.-4-.)ng of federal money for local- health departments sary te-implement. HAP '11 'chording to uniform; funds that Bass through state and local goverimte :departments shouldnot subStitute for present fund these provisions total health departments would -authority ; they would be strengthened in order national health goals :!i, d objectives. These recommendauutis should not invite Critic inentS. or it public system of care, will 'supplant lz 16 4 0 - 74 - 14 r stet, programs '4 tanfially iess thad rojects ressrain,littic toee'health cervices I Ved by the Children children, wonlii 5 only an estimated lei and 1Wfant Care g federalleyel t- proienient of health tIlaeare.itieorporated sources ,include ,110ti uding physicians; and hash; haVe been error -, ued.*Ipt, at the same nhiea of health service SO fill the gaps fin our rity arelmportant ternal and child health d families who are es. The popttlationador a disproportionate bur- ; public authority can't* r regulating private and daldistribution -will d. Many, advantages ble to private systems.. s most conspicuously de- Mich, 'couaselingieduca. lie. systems of care 4th tte and voluntary' he transportation and nuns and will place u riders. '.1 Imes .raise the si er d of -risk--sacri tigr. steni that assur p, sirtion. of ;our "Potai e' special sup t stents',: or of n sing' 3y em , zes pultille rockier lege, and fost. rsianarfelw , / ry ice delivtiry. siistelaS are rve to be ftirth r'itrength- thedi healtieservices: ;Whey }fermi-mother generation' of ! // tl armed providers .. e to pnitdefeem unds, assist m adequate job of- assessinent. departments represent the of health provider systeMs iSiimfor Pass tlikough fund- ) devidop the. services :teces- atimial standards. 'Federal t 'forISpiamrt,sif local health ng fruntbwat sources. 'Under. raliced tinder . federal" nimbly to achieve specified sun .that local health depart- ,rivate providerst or compete unfairly with .thent,;. 'Where. children are adequately" served by qualified ,pro- viders,--or where that p9tential existscOntracts .shOuld be written as now recommended by CHAP to continue andexteltdthat citre. But greatest concern at- taches to the'many children where there are no koviders, or where there are' felm whocrill see poor children. For those children.,Onr public systeko of primary ..health care needs to be improved and expanded, CHAP should provide the facilities.ktaff :support, and technical- aesistanceifor that. important .ptirpose.4 In locales Where. population groupings and other circumstances;;-afire' cOndheive, provision should be made to expand-a state's Program of SpecialMtOjects accord- . hag to well.known models of comffirehenalve health service (conileehensive neigh-; borhood health tenters,.and,special projects -oktitie . 4f ;14;rictal 'Security Act). .. We urge that administration of CH.AP be estabilshediii. Wie. Health Depart- Monts. Although eligibility for the ,prograni*/tied to eligibility f?r ,welfare ...support the program is in fact health se'ice, predoraiditatly implemented -bye') now through health deOartnients. d, Title V ,of, the Sociat'Secur_itylAct provided authorizatipn fq,r government to .respond to the unmet4ealtk needs of chilflieo. In the Intervening forty sears many chIldiett benefited- from this authority' but *many were nagged, due-largely ta. Dfi ..the.wide discretion allowed states in tmplementation of Title VI..EPS in part -corrected this circumstance by uniformly -providing poqi childrekwith a strong entitlement-to health services. CHAP should now fulfill that entitlement by ,prii siding the-,mandate and the resaufees to assuie that every in thiscount7 partleipates, under public auspices to tha;extent that may be,necessary, -in a program of health care-that emphakiteS primary and Preventive:services and access to accurate diagnosis and treatment as individually requirAd.. . r , . REFERENCES 1. America's Children. ABicentennial Assessment. National Council of Orgfini- . zations for Children and Youth. WaShington. D.C., 1976. :' . 'g. Doctors and Dollars are not Enough. The .Children's Defense Fund. Wash- ington, D.C. -1976. .. ,, -. , . 3. Qnoteci,t4 Weber, G. I.-An Evaluation of an Ntpanded Public Role in the Financingief health Care Services for Children : An OptiLn. Background.paper for Sun - Valley Conference on, Children- and National Health Insurance,. Sun Valley, 1975. . -. 1 ' . . . , . 1 4 .1 MateriaTh provided. by Departinent..of Health PrOVince of Newfoundland, :- ):9751.3-.Fit for the Future. Report of the Committee on Child Health Servicei.,.Her . . r, Majesty's Stationery Office. London, 1976. 1. --. 6. EPSDT. Does it Spell Health Care -for poor. Children? Children's Defense Fund. Washington. D.C.. 1977. 11 : ''- ,.. .. .. .I .7..Miller. C. A., et al:LoCal Health Departments and Their Directors.- n Press. . ... America-nJOurnal of public Health, October, 1977:.:.; . . . . . . 8. Comprehensive 'HPRS Report. Services, Expenditures, and Programs of.: State and Teri-Racial Health Agencies, fiscal year 1975. Health Program. Re:. 2 . portin g System, ASTHO,. Washington. 1977. . 9. Lan, S-P. M.- Loewenstein. R.: Sinette, C.: Rogers. C. and Novick, b.. Screening and Referral Outcome of School-based Health Services in a- Low , Income NeighborhOod. Public Health Reports,. 97:51-1. 1976... . i 10. Personal communication. Dr. Jimmie Rhyne. State Health Department, Raleigh, N.C. c 11. oghman, et al. "Anticipated and Actual Effects of Medicaid on the Medical Care Pattern of Children." New England Journal' of Medicine 285: 1053, 1971. - 12. Verbal Report by Dr. 'David Simon. Presi nt-Elect, Misipouri Pediatric So- ciety. Pediatric Grand Rounds, Cardinal. nnon Hospital. St. Louis: Mo., t.' NATIONAL HEALTH LAW PROGRAM, Washington. D.C., August 21, 1978. Re S. 1392,..the Child Health Assessment Act. MICHAEL STERN, Staff Director, Senate Committee on Finance. Dirksen Senate Office Building. Washington, D.C. DEAR Ms. STERN : The National Health Law Program is a support center flinded by the Legal Services Corporation to provide technical assistance to focal Iegal 9 ... 7 : . 1' '20 . ,., , Services Prograin -reiiretiehling loW income clients in health laW matters. In '' -.that capacity, the National Health Law Prbgram has been extensively involved in litigation, legislative advocacy, and administrative advocacy regarding the .in- - adequacies of the present EPSDT Program. While NHeLP supports-Ale views.! expressed by the Children's Defense Fund I,n their testimony, /we believe that., lbreepoiats needIo be further highlighted.. .-, , 0, I. Problem. The proposed legislation 'would still,exclude 'mini children Whbse families do not have adequate resources to cover the costs -cit health'-care. Recommendation. Establish federal resources and income levels to assure that all financially-keedy children will have "access to' 'needed health, Care. .. Disositsfon..-Ry- eliminating the requirement of categorical linking, many aci- ditionalehildien are.now for health. assessments -and necessary services. However,.:Use of state 4.FDc..income and resonrces standards will necessarily "exclude many needy children from coverage. The House of Representatives has taken. an important stap" in establishing a federal income llhor-of $4,200 for a familY of fout. This federal income fiair would supplant AFDC.Income le is in those.states'whlch provide less than $4,24for. a family of Mai. In this way, a Minimum 'nationwide federal program would be established. States would still be able ton utilize higher income levels, similar tq the Supplemental. Security Income Program. Unfortunately, a federal income Boor addresses only half the prohlem. Uti-,. living state AFpc resources standards will insure, that tho ds of financially '13.eedir children will be excluded from CHAP eligibility in ntravehtion of the Stated ,goals. of the-legislation. The children in.a...tvorkin family Arkansas awning a home,Worth$10,000 would' be ineligihle forthe, am. Similar- ly, a child living in California would be ineligible if her parents owned a $350 r refrige,rator.. In other states, the ownership of a car worth $1,000 woulkdeprive ' needy childien. of CHAP eligibility. While controls could be estatillshect to bar . eligibility for applicants owning giansions; luxurz cars,. or home entertainment systems, such basic resources as a mocieratpiy price home, car, or a major Sppli- ante, sbonld mot, deprive an.otherwise needy child from eligibility.. - _ This problem' could. be easily. reepnciled with the need' to protect state fiscal l . . integrity by establishing a federal resources Shot. using SSI'standards. These standards have proven workable. the SSI program, and were supported .in Con- gress as the appropriate guidelines 'Or eligibility: under the Administration's Welfare reform program. This approach would realize the goals of a minimum na- tionwideprograin based on rational guidelines... II. Problem.The proposed legislation does not, provide CHAP eligibility for families with substantial work expenses or high medical expenses. Recommendation. Require the use of applicable AFDC income disregards and, require states to implement a spend-down program for CHAP eligibility. Discussion.The purpose of theCHAP legislation is to provide health care services to children in families whhse income is insufficient to meet medical el- penses. The pro 1: s legislation, h&wever, does not consider the actual income available in the fa 1 ly to meet medictli expenses. Working families marhave substantial Work-related expenses which reduce the it/1101113t of money actually available to meet the lb sts of health care. Income dis- regards forAluch work-relate(bexpenses as child rare and transportation should be applied, 'Since these expenses reduce the income available to meet present needs. Similarly, a family may be medically indigent. despite a seemingly %Osten- 'tial income, if the family has medical expenses which. significantly deplete this `income. Such families should be allowed to spend-down their income when incur- ring.medical expenses. This spend-down program is already a feature of man, - state's Medicaid programs. III. . Problem.the proposed -legislation does not specifically proVide for the full. - range of Medicaid reimbursable services. Reoommendation.---States should be required to provid. :, full range of Medicaid services for which reimbursement -is available -a,s.ction 1906(a) of the Social Security Act. , 2 208 111acussion.Slany states have cut pack their Medicaid progras by imposing limitations on the amount, scope, and, duration of services availhble under state - plans. .Often these limitations conflict with medical necessity, and frustrate or even prevent the delivery of necessary therapeutic care., . By overriding state limitations in..the'CHAT legislatibn, services can. be-prO- vided in the moat 'cost-effective manner.'.Often, stateeilminate or limit jervices which, may reduce the need for more rostly'servieeS later.A prohibition on suet' limitations in the CHAP legislation would. Help realize the goal of initiroving the health,-of .the nation's children t e most cost-effective way possible. The EPSDTProgram has long Iron need of major overhaul.. We look forward with 'anticipation IT the rapid and implementation of the'CHA.P appretTate the op tielpate in this process. Please do not hesitate toicontact me if I can be rs truly, DAVID C/IAVKIN, Sfn i or S t °V A t torney., a Ala:aft:AN CO TETILICIANS AND OYNECOLOGISTS, . 11-08hvigi071, D1C., August 21, 1918:: HON. FURMAN E. TALmAnak. Chaff n, Subcommittee on milfee on 1'ittACC:._. ' 17.s. SOutio, Wmthington, D.C. . DEAR CHAIRMAN TAX-MADGE :The. AmeriMist.college of Obstetricians and Gyne- et/insists is pleased to comment on the content and interest of S. 1392, the "Child, ..i ,Health Atmessment Act,", now before your Subcommittee on Heal*of the Com- -- mittee on Finance.. . The members of the (7ollege--iotaling nearly, 20,00() obatetricians and gynecol- ogists in the United States and NOrth Americaapplaud your efforts to con- Unite and expand the health benefits under. the early and periodic screening. diagnosis.. and treatment program ( EPSDT 1. We feel that the EPSDT program has made a positive contribution to the .health and well-being of the-children served hy acknowledging the importance of preventive and comprehensive health care. ,By broadening the definition of eligibility. thereby inelWing,additional. children for participation in the Cliild Ikealth Assessment Prom authorized . by. the provgions of S. 1392,..the Subconnattee has, moved toward 'achievement of the goals. . W further support provisions .similar to those .included in the 'amendments to 5 139'1 submitted on Ailgust 15. lias: by Senator Cranston on behalf ,of the ad nistration. These amendments would open eligibility for participation in CH P-to individuals bei iw-the age of 21-who are financially eligible under the State welfare or Medicaid standard. The present bill only extends eligibility based on income apart from categorical definitions for those under the. age of six/ Adolesence is a time ,,f great importance, not only to the health. of the young person, but to the health , :' babies born to adolescents. n addition:the College strongly supports provision .of Medicaid eligibility II to all pregnapt women who otherwise would' otialif7.;, for Medicaid assistance if th y had a dependent child.... By including those women. who are pregnant for t first Hine, we will be. able to serve a critically needy population who other- s se would have no assured prenatal care and thus jedlairdize their health ... a d the healthy delivery of their children. These women 'would, in any case. ome eligible within six to eight months: but It is a critical six to eight months .for the health of mother and child. in light of the serious rise in our country of the incidence of adolescent ptegnany and the need for assuring these young 'others .of good health care, it bt essential for the Committee to incorporate hese amendments into the Senate legislation. We look forward to the expanded rovision of these, needed services and implementation of the programs with the nactment of legislation currently under your. consideration. Our members practicing obstetrics and gyneetdogy recognize the importance of, and contribute to the good health care of participating families by serving as providers according to agreement with the appropriate State agency. We do have concerti. however. with 'the language of the bill with respect to this agree- mtnt. Specifically, our eoncern lies %vitt the providers responsibility to "follow-up to assure the provision of such treatment" and "to assure ... that reasSessments are performed as required" (section 1912(b) (3) and (4)). As physicians. we question the feasibility of mandating thiscrespo nstbility to the provider. In . essence, continuation of proper health care can be assured only if the individual 'being sensed shares responsibility for his -own health. The provider 'certainly' - can facilinste this action by malting his services easily accessible and providing mechanisms to encourage continued participation in the program. In this regard. we urge further consideration of this provision within the bill and suggest that any neW language incorirated into S. 1392 should reflect our concerti for this folloWup activity. Again, we commend you for your efforts with respect to maternarand child health care and would bpheased to provide any assistance to the Committee as this legislation moves forward in the Senate. With best wishes, Sincerely, BRUN E. NicHoLa M.D. FACOG, Director, Practice Activities. AMERICAN AcADEMY of, CHILD PSYCHIATRY, Washington, D.C., August 17, 1978. 1r Hon. ABRAHAM RIBICOFF.. Committee on Finance, U.S.Benate, Dirksen Senate Office Building, Washington, D.C. DEAR SENATOR RIBICOM The American Academy of Child- Psychiatry, the . American Asaociatiou of Psychiatric Services for Childn the American Psy- ,chiatric Association, the Association for the Advancement of Psychblogy, the Mental Health. Association, and the National Association of Private Psychiatric Hospitals appreciated the opportunity 'to Testify before the Seinde Finance. , Health Subcommittee on August 14 on S. 1392. We wish to expand and clarify the responses made to you by Dr. Joseph Noglipitz regarding an acceptable' alternative which our organizations Would. Consider' in order to reduce the costs incurred if all treatment for mental illness, _mental retardation; and developmental disability were made mandatory in the Child Health Assessment Program (-CHAP). Our organizations strongly believe that It is cost effective to include coverage for mental illness in the same manner as physical illnesswithourexclunlon by diagnosis. Studies, such as those indicated in the enclosed summary, shoW*loAer costs for the treatment of phyAcaf illness when adequate mental health services are available.. _ The House Committee on Injerstate and Foreign Conanerce has taken a first' Major step in its legislation : it fins mandated ,treatment for children screened and diagnosed with mental illness, mental retardation, or developmental disability for all but inpatient treatnient in psychiatric hospitals. We hope that the Senate Finance Committee will go beyond this to instil. that all treatment modalities are available on, a mandarory basis[and that exclusion by diagnosis or type of treat- ment will be eliminated from S. 1392. However. as, you recommended in the course of the hearing. representatives from our organizations wouldshe pleased 1, meet with roar staff and the staff of :HEW to further discuss mental health provisions in Hi:: CHAP legislation. ` Sincerely, *IRGINIA Q. BAUSCH, Executive Director, A in n Academy of Child Psychiatry. COVERAGE OF ,MENTAL HEALTH IN NATIONAL HEALTH INSURANCE CAN BE COEc EFFEcTivF . Early studies, such as t;oldherg; Krantz and Imeke's, conducted is 1965, have located a significant factor in the cost of comprehensive health coverage. The results of their pilot study clearly indicate that. "the short-term out- patient' psychiatric benefit at G.H.A. ((,rolip Health Association) was associated with a decrease in the utilization of physician anti ancillary services under the plan. Not only was therein decreased utilize: ion following psychiatric referral for the study group as a whole, both with restsI r the number of persons seen and the number, of visits made. but this decreased otilisation heldto a greater or lesser degreefor all sur.segments of the population studied. . . . There was no 2 _ 210 attempt to do any cost-benisitt analysis in this study, the primary purpose of which was directed at..-ettlizetten without regard to costs: However, an inference could be made that tbeveostlawings due to reduced utilization would be reflected in thontire benefit stroctureirlthout setting forth.doilar amounts." [1] Otbei studies at Katev-Persaanente [2), and at. the Departthent of Research and Statistics, Health Insurance. Plan of-Greater, New 'York [31, strengthen, the hypotheids. that reduced utilization of medical services is a result of short-term outpatient mental heal benefit)), in prepaid health plan settings. , Mary Ellen Olbrisch; in "American Psychologist" [4] has prepared an overview ...- of the literature oh the effects of psychotherapeutic treatment on physical health. Shesays, "A question of centralimportatice in policy decisions regarding national health insurance isivhethervtr will be economically femiible to cover the cos of psychotherapy." In reporting the effects of psychotherapeutic programs on arco- hut abuse, she notes that, "Persons with alcohol problems constitute a. group whose medietil costs are very high. In addition totheir high utilization of medical services, these individuals coal their employers a gipat deal in absenteeism sail. lost productibn, Some interesting research only been conducted which suggests . that activeintervention programs not only reduce medical care utilization by troubled persons, but actually result in a proklt to the employer funding the inter vention program." The Kennecott Copper CorporatiOn has estimated a return of "$5.83 per $1.00 cost per year for its psychotherapy program. Impact is noted in reduced absentee- ism, redUced hospital, medical and surgical coats, and reduced costs of non-occu- . pational accidenttufd [4] [5) . . More recently, December 1976, a study sponsored by Blue Cross of. Western Penhsylvania. reports that "overall medical/surgical utilization is reduced for that 'subgroup 'of subscribers whb use the ouThatient psychotherapy be efit. Fur- ther, this phenomenon of reduced medical/surgical utilization wi exImsure to outpatient psychotherapy. was found to be independent of age, sex, or mplbyment level (salary versus hourly employee groups 1. The study findings at consistent with the results of two previous studies. . ." [8] . The Western Pennsylvania study estimates the resultant cost savings relative to the cost of'providing the benefit. "Since 195N. this population has had access to outpatient psychotherapy services through a community .mental health .clinic. However, Blue Cross coverage,for these serVices did not become available until January, 1968. The outpatient coverage provided for this population includes only those serv- ices obtained through the local mentaftygiehe clinic or a similar. 'approved com- prehensive ecimunity mental health center.' The outpatient services covered neluded : 'a lit Group therapy up to 50 sessions duringally 12-ihonth period ; 2. Collateral visits with members of tile patient's ftrmity 3. Professional services 11-) to 50 visits durlug any 12-month period ; 4. Psychoactive drugs. .. Inpatient coverage, which wa Iot limited to the .linic. provided for up to 00 days of inpatient care p0 year. : Emphasis was on early, referral and short-term intensive therapy,. Services of all mental health disciplines were covered; including those of psychiatrists, clinical psychologists, psychiatric social' workers" and psychiatric nurses. The first 15 visits for any of these. services were covered - in full. Thereafter the subscriber was required to make a co-payment of one-third of the cost of covered services. The coverage was designed to discourage long-term psychotherapy by stipulating that any treatmen7 given more than 15 days following the date of the first covered service would be covered only if a psychiatrist certified that continuing treatment was required. Thereafter. this certification had to be renewed every.30 days." These benefits closely resemble those:advocated by the Mental -Health Associa- tion for inclusion in National,HeaIth Insurance. Findings of the*tudy report that "The average adult total monthly costs after initiating outpatient psychotherapy are $8.52 less than they were before first outpatient psychiatric eosmact I even with the cost of that therapy included), . . ." name I compares the ire-contact and post-contact expefience of adult males with that a adult. females. "Of particular knierest is the indication that adult males have the highest pre-contact use of Medical services of any sub-group in the sample (costs of $21.00 per month), the greatest post-contact reduction in 2 / 211 use of these strvieeli ($15.72), and the greatest reduction ($11.23) in tltal costs,. . per month after initiitingOutpailent PsyChotherapy." J., - The California X'sychologicafinealthPlan, a statewide, prepaid mental health, plan offered by a public carriet'entitles eligible aubscribers, and their dependenti ' (for a cost of $4.00 per family, per month), to obtain benefits from any paember of a panel ot200 contracted providers located throughbut the state.. . . The plan is based on the concept that the consumer'has the respOnsibility.for his /her own mental health and its maintenance through utilization of insured mental health, benefits. The California PsychOlogical Heklth Plan emphaSizes education of the consumer about mental health needs, and early-intervention.: It offers incentives througha system of total--oupfidentialit3k.no deductible, uo colpay.ment for the first five visits,- quality Control and. the, elimination of claim ... , toms. e . , The C.P.1I.P. was lirst placed in a gmall health and welfare 'trust of 1,000 employees and their families. The trust had been insured for 5 years prior to 'the integration of C.P.H.P.' in the, benefit program. In the year print to the .- institution of the C.P.H.P. (11-74 to 8-75), 95 percent of the total paid premium was paid out by the company for medical claims. In the year followtne(12-75 to.. 9-76), 73.5 percent of the premium was paid out for medical claims; Within one and one-half years, the "loss.ratio" had decreased to 67 percent. These' figures represent an approximate decrease of 27 pepent in medical care utilization costs. it ( 1 FIGURE 'I . . , . 'COMPARISON CIF ADULT MALES AND ADULT FEMALES-4104THLY AVERAGES OF UTILIZATION BEFQRE AND ' _ AFTER FIRST OUTPATIENT PSYCHIATRIC CCINTACT Medic-id-surgical Psychiatric In-, Out -. AVel v, patient &bind Num- eripsoure days/ visits/ be; (months) month month Adult males: Precontact. _ . __ 24 , 21. 74 .198 .139 Postcontact _ _ ?yi 15 .077 .015 Adult females: Precontact 95 .189 .044 Increase or .'(de- 23 .096 .025 p. P , Adult males .... (. 121) (.125)' Adult females_ ....... .. (. 094) (.019) Ratiopost/PIE Adult males 389 - 107 Adult females _ .505 -675 .Cost/ patient/ month .' In- patient days/ Month. . I Out- patient visits/ patient/ month Cost/ month Total . cost/ patient/ month $21.00 .157 721 $27.72 5.28 .154. .715 11. 16.49 '13.22 .205 ..... 7.72 20.94. 8.83 .043 .491 5.95 .14.78 (1(54: 73i)) 4.49 (11.23 (:123) :74;5 1 (1.77) (6.16) . .251 .980 1.669 .595 .668 .210 _ . 771 .706,; The only component in the trust which 'changed, over this period, was the mental health benefit. [7] . Research-findings continue to show the rein tionshikbetween appropriate mental health cnverage and reduction of cost of physietT health coverage. Nicholas Cummings, reflecting on his.studies now in press, says, "We have found not only that psychotherapy can be-eConoinically included as a prepaid Insurance benefit, but also that failure to proVide such a benefit jeoparflizes the effective functioning of the basic medical services, since 60 percent or more of the physician visits are made by Patients who demonstrate on emotional, rather than an organic, etiology for their physical symptoms.'' [8] e REFERE C'EB 1-. Group Health Association. GHA News Annual, Report Issue, vol. 28, no. 1, March 1965; Group-Health ssociation. GHA NewsAnnual Report Issue, vol. 30. no. 2, March 1967. . 2.- Follette, W., and Cummilgs,N.A.; Psychiatric services and medical utiliza- tionin a prepaid health plan setting. Medical Care 5:25. 1967' 3. Department of Research and Statistics. Health Insurance Plan of Greater New York. Psychiatric Treatment and Patterns of Medical. Care. Unpublished final report to the National Institute of Mental Health, Projecehili 02321, July 1969. , 212 Olbrisch, Mary Ellen, Psychotherapeutic Interventions in physical Rea lth,"' 4merican PsYchologist, Sept 1977. . - 4 5. Kenpecott Copper Corporation. Insight, Unpublished report, Utah Copper -1114ision, SaltLake'City, 1975. 627ameson, J., f3hUman, L. J., Youtm,. W. W., The Effects of Outpatknt Psy-. cbiatrig Utilization op' the cOsts of Providing Third-Party Coverage, Research Series 18, Bltie Cross of Western Pennsylvania. 7. California psychological Health Plan, 4401 wiiihixe_slvd., Los Angeles CA 90010. 8. Cummings, N. A., The Anatomy of Psychotherapy Under National Health Insurance, Amerteal Psychologist, Sept. 1977. Prepared by Margot Carper, Staff Intern, November 1977; The Mental-Health.. Association, Arlingtv, Va. ' YALE UNIVERSITY, SCHOOL Or MEDICINE, ltAzt New Haven, Conn., August 14, 1978. Mr. Mxo Staff Direclor, Senate Committee on Finance, Dirkeen Senate Office Building, Washington,D.C. - ,Dzsz Ma. STERN : I would like to submit for the record of the Itearinga on the Child Health Asseasm'Ott Act (S. 1392), the enclosed recently published report of the Tale Health Policy Project on "Uncertainties 401 Federal Child Health Policiek." . Thp findings of tills study relate dirletlyAOtthe CHAP legislation, particularly' . , 'the recommendations on pages 20-21. o iffprove federal child health ,programs, 'we recommend the constilidatiiin of existing agencies or creation of new ones to avoid presentfragroentafion. We also recommend the development of appropriate reporting systeuttf, base management systems, and the incjeaseoin matching rates to provkle states with'greater incentives to carry out programs. 'hank-you for,llie Importunity to. submit tblostatelunt. Sincerely yours, . . AS:4E-MARIE Fourz, Phil., Ri.search .4.08ociate.. O 4./ 213' RESEARCH DIGEST SERIES Uncertainties of Federal Health Polices: Impact in Two States ff ()f PA{OMF f`f If f J, , Aff("4f l L Jiff 41 214 National Center for Health Services Research Research Digest Series, -: . 'he Research Digisi leries . is published the National Center for lipEr . ;Hettlth Services Research (CHSR) to provi overviews o4gnificant research "supported by NCHSR.-The series -desc s either ong mg or completed projects directed toward high priority ealth rvices problems. Issues are .prepared by the principal. vest KatQrs pertorming the research, in collaboration, with NCHSR s f. ;Digests are intended for an interdisciplinary audience of heal i . vices .planners, administrators, legislators, and others who make de ions on research applicatio'ni. . i Abairact , :. e . report'as Sesses the of. federal child health policy, under Titles' V:and -XIX. of the SOcial Security Act upon the states of . COnnecticia 49tVermont for the years 1935 to 1975, and analyzes the reasons for the discrepancy ,between policy intent and state execution. Research inethods-comprised a review of Congressional intent,, HEW regulations, statelegislatton, administrative performance, services with special reference to urban /rural variations, and EPSDT. This study offeis a basis a'methodology for pOlic*.evaluation studies in other states Or.the country as a whole. Findings: federal agencies diversely interpreted federal laws:.states faet1 with uncertain poliCy; start funds, and external pressures failed to comply even with thelifedTri I EPSDT mandate:, Since HEW. failecl to monitor its programs, states faced- no loss..Of funds or penalti6, Recaimeruldlions: that. Congreis rovide .sufficient funding to asskire...sr,3t*,,cooperation, and amonitor state performance reribiiitig.systeins; that Congress be specific as to populations to be served and services to be provided; that .administrative agencies be consolidated to avoid interbureaucratic confusion; and that child health advocacy !groups becoinetitiore involved irr legislation and in monitoring programs. icsuispi Uncertainties of of Federal Chid Health Policies: impact in Twb States by Ame-Marie Foltz April 1978 - .` DHEW Publication N0 (PHS) 78 -3190 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Center-for Health Services Research 216 This Issue of the NCHSK Research DigestStries byAnne-Marie--Foltz-- draws on her work and that of Yale Health Policy Project colleagues,. Christa Altenstetter, James Wart 1r Bjorkman, and Alton Chen under (the leadership of Df. George A'. Silver, principal investigator. The re- search was performed for. NCHSR under Grant HS 00900. Mrs. Foltz is Research Associate and Lecturer at Yale. Dr. Silver is Pro- fessor of 4'ublic Health at Yale. The fatal report of the grant, Impact of Federal Health Policies in the States of Connecticut and Vermont, 397 pages, is for sale to the public from the National Technical Information Service, Springfield, VA 22161 (tel.: 703/557-050), and may be ordered as PB 262 959 in either paper or . microfiche. k The research staff thanks the Commissioner of Health of Connecticut,' Dr, Douglas iloyd, and the former Commissioner of Health of Vermont, Dr. Anthony, Robbins, for their assistance; Dr. Estelle Siker, Director of Community Services, Connecticut, and Mr. Paul Philbrook,. Director of Social Welfare, Vermont,I for providing records and financial information; and the Yale Health Policy Project Advisory Bowl, Drs. Thomas -Dolan, Jack Elinson, James Fesler, Herbert Kaufman, Kenneth. Keniston, Ijgward Newman, Donald Patrick. and David Warner. NCHSR publications are avai on request from NCHSR, Office of Scientific and Technical In ation, room. 7-44, 3700 East-West Highway, Hyattsville, MD-20782 (tel.: 301/436-8970). Current NCHSR publications are listed inside tht back cover. , li- 1, 2t7: . Foreword This report reviews two federally supported child health care programs from the original statement of Congressional intent ro its questionable delivery at the local level in two states. While other stud* have documented the variance between CongresSional intent and local performance, this provides the in-depth analysis necessary to identify and -weigh its causes. The particular value of this study is that its ..Endings and recommendations can be used to assess the prior effects of national health care policy as well as to guide' the formulation of health care legiilation and interest group pariicipation in the .future.- Gerald Rosenthal, Ph.D. Director April. 1978 2)`. 4, The extraordinary interest in health policy during the past decade reflects both public and professional concern. Political scieritists, long preoccupied with purely theoretical formulations, in- creasingly have seized opportunities to test theories in the marketplace. The public, disappointed in political solutions that did not solve social problems, increasingly turned/ to the academic community for answers. Health care, particularly in recent yeari, has been a source of public .discontent and _academic inquiry. However,' evidence of public dissatisfaction and demand for action can be.traced back as far as the Republican the platform of 1912, when national health insurance was ()prof the Bull Moose planks. Academic concern goes back as far as the 1916 reportof Edgar Sydenstricker and Rollo Britten to the Public Health Service designing a National Health Insurance program. But the attack on theprocess of public and private medical care financing and delivery .4!s more recent, and the investigation of the policy process, from program inception through' implementation, -is also relatively new. Many studies have been directed at the policy formation process whereby public concerns are turned into laws. Fewer studies have been directed at,the obstacles, flaws and miscarriages between the passage of a law and 'implementation. Vet it is the visible effects of the law, success and failure in thelight'of the Congressional intent, that ciwout for study. In the case of child care, rwe' wanted to find out why there were few' services, andolagging examinatipnt and immunizations, despite heavy federal investment. The.path.pf study led through many interesting rainifications. Addctssing:ciurselVeyr to the federal/state: interface, the Yale Health .itriject, reviewed the relevant papers and reports affecting ni. t: 41tc , child activity sand, liter, Vermont activities over the 0 years, itd intipyieiied present and former official', ,46:i4c#:' i:44.1e04i:4nd public 'figures along the way. It was a ilcon4inetitatjAisji;;.fiscrniiiiig in the history it revealed and a bit 4.146iltiri.thk jiartitai .social policy it displayed. u nix ., =interested find fested can nd some. explanation of the ii ttadietiOtis`` in )r public posture and program shortfall, 2 . r evidenced in the federal/statepro ms a the conclusions nor recommendan ns can inforination drawn from only a state findings indicate that more fede c ricer and better reporting; would.ieem nee the American people reach some Onsensus way of a child health program; W t [he go be reached, conclusions (draw from p tentative, at best. It seems tha: for the health (and child health) acti. fis will be derived from reasoned coristruchcn ju The-lessoni of these Programs therefore o cll; c generalized, because the In any case, the prOject more federal supervision, . Until the Congress and s to what they want in the is are and flow they might licy studies .can only be resteable future, federal crisis generated and not cious long-term planning. ht to be taken to heart. GOrge A. Silver, M.D. 7' METHODOLOGY .Model and framework Procedures ' 7 -.FINDINGS _ The' states of Connecticut and &Mont 8 ' Intent of federal policy . 9 Were federal policies stimulative? 10 Fiscal.stimulation 11. Impact on services 12 Impact on administration 13 mpact on interest groups 14 Was federal policy redistributive? 15. Reciprocal impact The gap between intent and performance: .policy.,fragmentation 16 'Aibbigbity of intent Intergovernmental problems. 17 Intragovern.mental problems: health and welfare Inadequate information systems 18 'Salience of child health '20 RECOMMENDATIONS 22 REFERENCES 24. TABLES 2tiv vii . 221 Introduction In 1972, the Yale Health Policy Project undertook a study of the impact of federal health policy on the states. Child health policy was chosen as the focus of the study: and two New England states, Connec- ticut andNerrnoni, were chosen as the sites. The purpose was to. analyze the implementation of federal policy to explain thegap, often noted in the literature, between federal intent and state performance. The research. questions were: What was the intent of federal child health policy; did federal programs stimulate states to'carry out federal policies; if not, what were the major causes of this failure: and finally, which of these causes was amenable to:chartge? . , The rationale for this ambitious undertaking was that few studies of this kited had previously:been undertaken and none existed in the field of health even though federal involvement and commitment in health" through grant -in -aid Programsjiad increased notably since the 1960's.. Such a study could:thereby provide valuable information about the operation of federal health programs. This NCHSR Research Digest reviews the methodology and find- ings of the project. The findings have been presented in published pa- . .persproject. working papers.; anthin the fir report, (3) submitted to the National Center for Health)Services Research, which supported the four-year study. Since a report. of thii size cannot do justice to so di- . verse a project, publications and reports are cited to assist the reader in 'finding original sources.. 34-464 0 - 79 15 Model and framework For this study, we adopted a model based on a definitiorr of policy as "a 'projected program of goal values and practices." Policy in our `model is a dynamic process and hence subject to changing or diverse conceptions both within one level of government and also through the -various levels of.government from inception and 'regulation to im- plementation. It is recognized that policy may be formed as much from informal administrative practices as from laws, regulations and rules. 'The flow of policyis not necessarily one way; decision's taken at lower levels of government can affect those at higher levels. Nor can the var- ious levels of government be considered autononious or closed, as the model presupposes permeability of governmental institutions: We pro - posed, then, a project which would follow more closely the format of .implementation studies than program evaluations. To analyze the flow of the policy process requires a detailed. knowledge of shifting events and actors. To make, this' task manage- . able, the scope of the project was limited to cases which would be studied comprehensively. These cases were limited'by: (1) geographic area, (2) target population, (3) policy content; and (4) the way in which impact was assessed. Connecticut, an urban state, was chosen as the original site for the implementation study. As the project progressed, we chose Vermont, a rural state, as a second site to test hypotheses generated by the Connec- ticut study and to verify that we were not dealing with unique relevant characteristics. Any state, in some sense, is unique, and in case studies, generalizations, from a sample. of two, must be made with a certain 'caution. The case studies -prtavided the opportunity for the careful analysis of interrelationships tOiich would not be available in ciOss- . -sectional and .survey-analyses dime. Children were chosen as the target population because the effects would be easier to assess when the federal progrern was aimed at a . particialir populaupn than when ,it.; was more difitse in itiOellt., The study of child health: was partictikrly compelling. We kauspectpd`titat despite° the mythical iiiimacy of the child in the Anierican "child= oriented" society, there was sufficient evidence in terms of the prevail- ing higher healthrisks for poor children, that children, and Partial= larly poor children, were not getting their fair share in American t .3 . . P , society.(I, 27-32) Moreover, health policy toward children constitutes major secial,policy since children comprise 40- percent of the United States population. Public interest, Or at least public rhetorical interest, ' in children is high, exemplified by the White HouseConferencei on Children held every.decade since 1909. Other. studies on child health programs had foc on-surveys, cross-sectional analyses, and inven- tories, but none Ii examined the processes of child health2 policy Many different child health programs were considered, but it was clear we could not study afl federal programs and policies affecting child health. The criteria for inclusion in the study were that the pro- gratnad to be directed mainly toward the health of children, and had - to be broad in scope, affecting as many children as possible. From these criteria, two programs, both legislated under the Social-Security Act, emerged as the logical choices: Title V Maternal and Child Health (1935) Crippled Children's Services (1935) Maternity and Infant Care Projects (1963) Children and Youth Projects (1965) Title XIX: Also known as Medical. Assistance. or Medicaid (1965). q,arly and Periodic Screening Diagnosis and Treatment (EPSDT 1968). . _ These were the major child health programs of DHEW and ac- counted for the greatest proportion of federal fundi expended for. child health and for children served. By 1970, the latecomer, Title XIX, had outstripped even Title V in both dollars and services. (Table I) Both Titles. V and XIX involved grants-in-aid to the states, but they provided also 'a, series of contrasts.. Title V was a. system of fotmula grants: to the states, and 'project grants to localities: Title 'XIX was open -ended reimbursement to the states for medical vendor payments. The formulae used to allocate grants among the states were different. Title V'allotments were deterinined by a ratio to favor poor and rural states with each state required to match federal funds with equal state funds: Title XIX reimbursements were made on the basis' of a match- ing formula intended to favor poorer states. The categorical foilnula . grants of Maternal and Child Health (MCH),and Crippled Children's Services (CCS) could be Considered the forerimners of health revenue stfaiing since their mandates were broad and they rovided wide latitude for the states:. The Title V projects were. so s*cialized and localized that we chose to ConSider theirimpact only in th oritext the larger Tide V formula grants and the 'Title XIX pr ms.vTitle XIX was a system ,of vendor payments for health service wh'ich.reim- bursed the states for certain types of health services for three categories of persons: (1) those eligible for public assistance; (2) those categorically eligible whose incomes made 'them medically needy; and (3) all financially eligible children. (2) 4 In both Titles V.-and XIX; states could choose whether or not to -.participate. In the case of title V,-.within a few years of its -passage, all ;states'eJected to participate. ForTitle'XIX, only two states; Arizona and Alaska. were nqt participating.by,1072; . During.the first' year of our study,,we,spent considerable time de-. fining-qUantifiable indicators of imPact.and -obtaining data bn them. As we learned more about federal-state administration and the service arena; it became clear that the sketchy nature of the, data available would not in most cases provide reliable quantifiable indicators to demonstrate federal. impact. Moreover, any causal. connection between federal policy and' service, or health outcome, could not be presumed from any change that appeared subsequent to federal legislation. Many other factors, perhaps not quantifiable, might intervene. Impact, was -.. not to be demonstrated on the health outcome of children, but to be described through an analysis of the state level and service level changes which took place du ink a period of increasing federal invest- ment in child health programs. . Foul- major areas of research became the focus for the qualitative assessment of impact; (I) administration and relations among and, within different levels of government: (2) healthservices delivered by the federally sponsored programs; (3) expenditure patsprns for child, health, both federal and state; and (4) private interest group. activity in the- states in relation to federal policy. We also expanded our time frame to provide for historical analyses of the Title V 'programs which` date 'back to the 4.g30s. Their implementation provicled the administrative framework within which the developments. of more recent years 'dust be Viewed) . Procedures Given the broad framewinic of the policy -Process model, data' gathering was of necessity eclectic, using techniques mainly from the fields of public health and political science. Two approaches, were used simultaneously: the first was a'cross-sectional perspectivir using data collected from one time segment across different areas; an the second was an historical approach for analysis of the development of policy . and administrative change. Federal, intent for titles V -and XIX was analyzed first through legislative invent by:the study, of Fangresgional. . 'h'earings, and debates the Congressional and j0t4viewS with :i-Aeyant4' actors.' federal executive intent Wasitheri examined through regulations, guidelines, informal Department of Health, Education, and Welfare (HEW) metros and letters, and also through interviews with those in the executive agencies charged with promulgation of regulations (which have the force of law), and. ithplementation. The distribution of Titles V and XIX funds among the states was also collected as well as whatever data were available on services provided by the programs under study. The HEW Region I . office provided data in the form of memos and interview_s:as to its role : in the policy process. . State activities were analyzed Awn legislation, debates, reports, , hearings and newspaper files; from health an$ welfare department reports on services and administration; and from financial.stitistical data from the liscal-office. In addition, deinographic data were calcUlated {Or the states, including derisity of population; proxies for need; such as infint and neo -natal mortality rater,.pOverty levels; and distributions of. health resoUrces.. As for the federal level, relevant actors were interviewed. During two-summers, surveys were held in Connecticut and. Vermont. to assess the iinPact of the. Medicaid-EPSDT program on health providers and.Children's services, and to assess its relation to the earlierestablished Title V,MCH and CCS.services and projects:These surveys included inventories of child health resources in the states and interviews with. providers. The role nlprivate interest groups was examined through studies of voluntary health and advocacy organizations, as' well a4 the professional associations, .with particular attention to the medital ;societies.. These gi-oups were studied through, their publications and interviews. Out of the materials and interviews the staff prepared a chronology of events describing:state activities prior to and follaviag m federal legislatiqn. From 'the descriptive aterial,a series of analytic working .papers was prepared to serve as mutual information soui-ces .. and for testing hypotheses. These papers and additional materials then became the basis for publications and the project reports? . 23 The atlas of. Connecticut and Vendont Connecticut and Vermont were chosen as contrasts for this study: they are respectively high and low income, urban and rural, industrial and agricultural. (Table 2),olitjcally, Connecticut bas seen continuous - changes and competition between' the political parties, while-Vermont remained long a kpublican prongholdi In administrative 'structures the states differ leo: Vermont has fewer autonomous agefcies, and has an.integratec human resources agency, whileConnecticut has maintained separate government agencies for different functionsand even for different populations cutting across functional lines. . However, the two states were markedly similar*.in 'several `surprising respects. Both states have more pliysie.ians per capita than the national average and rank in the top ten states for per capita Medicaid. expenditures. Infant mortality is lower in Connecticut and .. Vermont than in. the nation as a whole,.but Connecticut has a higher non-white population (6 percent) and sharply divergent mortality rates for this latter group. In social policy, at least policy directed toward child health, we found the states differed.markedly. Vermont has tended to apply universalist solutions to its problems, while Connecticut focused.on . , . assistance only to certain selected needy groups. Thus, the Vermont legislature produced more progressive legislation than its Connecticut counterpart although Connecticut's financial resources were greater. When dental services for children were required under the EPS program, the. Vermont legislature initiated a dental itigurance program for ail low to middle intome children while Conifecticut served only ...those required under MediCaid and, in fact, decreased the sertvicesavailable to children. :(4, 17) Administratively, means tests Tor CCSservices were never addpied in Vermont, but were established in Connecticut. It is not clearly evident what.accounts for these divergent social -policies. What accounts for Vermont, a poor state, spending as much per 'capita as. Connecticut? The usual .quantifiable indicators, such as health needs, health resources, or fiscal resources, do not explain the .differences. More likely it stems from a self-selected population whiCh is' more committed to social goals, despite its relative poverty, and . 7 which on ideological. grounds, performs differently from its'equally poor counterpart states,- Intent of federal policy , .1("Ambiguous" was the Word. we used most frequently to .describe feleral intent for child health policy. Some of .the confusion as to intent can be attributed to excesses of rhetoric raising hopes and .expectvions which cannot be .met in the practical implementation of a progi-am. Congtess, in its legislation, was the main creator of 21111 ty, but the problems Were compounded ,as policy moved from the "ve arena to the executive branch and then to the states and. es for interpretation and reinterpretation: The stated Title V,MCH goal of "promoting the heal? of mothers and was broad and clearin intent. However, since 1935, the funds allocated for this purpose by Congress have been so low per capita that no observer realistically can expect the states to initiate major child health programs on the basis of the additional federal funding. Moreover, another goal also underlay the original Title V legislation. The ,prevailing philosophy among health- professionals of the day to build up health sources which were latking in the country as a ivtioleby building up public health ageniies. (3, 33-38; 1, 341-38) Title V required the establiThment of a single-state agency (health department),to administer the federal grant programs. The public health interest groups felt that-only fully formed public health departments could carry, out a 'federal mandate to ptomote the health of mothers and children. Thus, the administrative base would have to precede any federal attempts to provide direct services to children. This philosophy prevailed until the 1960's..when Title V instituted projects in selected localities which would provide direct services, but these Were not of a scope to have.mational impact. Yet, the service orientation of Title V did exist from .the beginning in the Crippled Children's Program, the other ntajOr part of theTitle V legislation. This program required states to identify and treat children, siiffering from handicapping condition%. The potential for conflict and .uncertainty as to.goals-wasbuilt'into the original Title V legfslation. In additioh, the.Chiltiren's Bureu, which administered the program, over the yeirs ,elaborated policy which was not always consonant with the original Congressional goals, imprecise as they !gay have been: (3, 147) Title XIX (M'edicaid) intent was hedged with restrictions. 'As far as practicable under the conditions; ;, in each state, .the states were to furnish medical care, to welfare recipients and the medically needy. As with Title a single state- agency had to be designated to receive funds. Each state' could determine what was practicable for itself. There were no obligations in the law if the states chose not to accept Title XIX. Even if a state chose the program, the procedures spelled out.in the HandboOk Public Assistance (no regulations were 8 published. until late in the 1960s) were Moreover--; the , states quickly learned, as they had with. PUhlic Assistance, that:the federal government would. not enforce its own rules.. In Medicaid's ten-yeat.history, ho state had been found out of co.mp'liance.*The law. and regulations were therefore, unclear since statesthatditi -hot conform, even when the, subject of Medicaid scandals, were 'not penalized. A major confusion of Intent in the Title XIX.-..program arose in 1968 after CcingresS had added a requirement that each state was to provide-its-eligible childre.n under 21 with early and periodic screening, diagnosis, and treatment,(EPSDT). This amendment could be read as a .mandate for r-cornprehensive rare For every Medicaid-eligible child. However; the scope of the screening and care., , and the definition of the children eligible to: receive services were hardly mentioned by Congress in its hearings or debates. Estimates of cost were applied separately for Title XIX and CCS -programs, which were also pareof the amendments, with no, mention of how the two implementing- gencies would carry out these programs Or reimburse one annther, if at all. Another-amendment requiring agreements between,different .agencies did not clarify Matters much. It was not clear whether health, or welfare would be responsible for the program. Moreover,- HEW'sliing delay in issuing regulations confuied matters more because the states began to recognize that 'HEW itself was not much interested in enforcing Congressional intent.. HEW, in iegulaticins 'which finally emerged in late -1971;defined the narrow scope of treatment services follmvin screening. However, the regulations ,did not clarify the_ambiguit in administrative .direction. To, compound matters, in 1972 Cong ss.re-affirrited ,its intent by . requiring states to inform- all eligible perscins of the program and thereby engage in outreach services at the risk of incurring a one-percent penalty against state AFDC funds. (5, 40-64) Again, HEW delayed several years before issuing penalty regulation's. Thus, in the. ...ease of EP§DT HEW and Congress. each were providing different interpretations of Eederal intent to the-states. yurther.confu.sion in intentwas created by frequent HEW reorganizations. The Children's 13ure4u, the' original administrator of the Title V 'programs, was eventually dismembered, while the major expenditures and services for child health sere administered under Title XIX by the Medicl °Services Administration, whose major. concerns were not children but services for the adult poorwhich took- up more than 80 percent of its expenditures. Despite these ambiguities. federal policy intent can be seen as both stimultrtive. and redistributive: The purpose Was-to stimulate.states to spend their own funds on federal goals and to redistribute funds from wealthier to needier areas both within states and among states. The Title V program was to'stimulate the states to increase their eriperlditures for child health through the required matching ( 9 meChanisim, to build health agencies, and to provide services, . particularly forhandicapped children. The Title XIX program wasAck, jstimulate the 'states to pay for medical assistance to all persons &Ole for welfare and for the medicallyi.,n.eedy as well as for financially eligible children if the.states thosefite .option of including these two latter categories...(2, 3-5) In addition, `the EPSDT program was to stimulate stalei to provide for preventiv.e health and treatment services for all children 'eligible under Title kl.X anchtci search out these children. and pringethem in jo care. As with Title V", states would be expected:to increase their ,ex'penditures in order to match federal. grants. . . . Federal policy was also directed.tOward the redistribution of funds among the states. The Title V legiSlation targeted rural and poor areas and the administrators carried out this policy by adopting an allcication . formula iiiliCh would faVor 'states with these characteristics. Tit* XIX' matching grants iise favored ,poor states by adopting a matching formula. which matched federal to state funds on a sliding scale from 50 to 83 Percent, ciependingwn .the state's wealth. " """. Within the states as welLtheipolicy was also redistEkutive.Title.V was targeted to rural and poof,areas W'hile Title XIg, tiliotigh its tie to the welfare programs; directed its seOices to the poor and near poor. ,..,-,:. ,, .:;. i '...' 4c,Vilers federal pollees stimulative? Federal policy intent to stimulate the states could result in four ,possible outcomes: (I2 states could increassgtheir funds allocated .for federal purposes% (2) states could 'provide services required by .the federal polidr; (3) states could build up their administrative capacity to handle the iederal programs; (4)' private interest groups could be . stimulated ;'to participate more in the state-federal policy-making process. - . Fiscal stimulation. The fiscal stimulation was expected to take . . place mainly through the federal matching ratio, although*the fact that the Title XIX funds were open-ended gave the states potential 'for ... limitless funding as long as they 1,1-eret willing to spend some of their uWri funds as well. In the case of Title V, neither Connecticut nor . Vermont appreciably increased its state funds for child health when it began its programs. Sine both states were already supporting child health and, crippled children's services before 1935, these programs were used as the matching funds to 'obtain the additional federal funds. (3, 315-316) Feddal administrators never examined. .closely hr ihe states arrived at their matching fund figures.(6) Today, ithis.pracuce is so ingrained that state matching. in Title V formula funds is only an accounting. procedure. Any persor nel and activities instate and local health departments which are in the field of child care all qualify as matching funds. The minimal stimulation effect of the matching requir,ement may be attributed partially to the fact that -the 10 overall state child health' programs represent only a small fraction of the state budget. (3, 315-317) , In the case of Title XIX, earlier researchers had found -sthat ,no stimulation effect bad taken place. Our study (7, 13) indicated that Medicaid expenditures from state and local sources coiild be explained mostly by fors such as fiscal capacity ancF,urbanization. The federal matching ratio of .between 50 and 83 percent did not praide strong incentives for generating state fiscal effort. Yet, both Connecticut and Vermont, despite this lack of incentive, increased their 'spending for Title XIX. Between 1968 and 197.3; Connecticut's Title XIX expepditures rose from $58 million to $119 million while, Vermorft's rose three-fold from $8.6. million to $24 million. Thus, although the matching ratio did not of itself stimulate spending, the availability of federal funds did stimulate Connecticut and Vermont to increase their expenditures for health services to the poor.- . Impact on services. Table 3 shows that both Connecticut and Vermont -experienced 2 decline from 1940 in the proportion of the population served through well child clinics, and an overall decline.in MCH direct services. (bata were not available for the years prictr to the implementation of Title V :in 1935.) In the CCS program, Vermont consistently provided services for at least that proportion of the population that might he considered poor and near poor while in ConnectiCut the proportion of children 'served declined to far lower than the proportion below the poverty level. (3,220-221) Over the years, both states had been providing fewer direct MCH services and Connecticut alone decreased crippled children's services. If the origiba intent of Title V was mainly to build 'Up' an infrastructure to assist in child health services, then the services should. not have declined, as they did, long,after the structure was in place. We concluded that the goal.of services, although not explicit in the Federal intent, was one that was accepted by the states, at least in their early, implementation. The later movefrom direct services must be explained by shifts in state views of the role of public agencies toward , ,the' private sector and particularly their reluctance to compete with physicians whose numbers greatly increased during the forty-year period tinder. study. In Medicaid and EPSDT programs, the numbers of children served in both states increased over the years. Unforlimately, data were reported separately for the two services so that there may well be duplications. Table 4 shows the growth of these services and the increasing. proportion of the populition covered. Prior to EPSDT, almost,-all. these services were for acute episodic care. FIPSDT was intended to bring the children into regular and periodic care. However, we found in both states, that many of these EPSDT children had been served earlier through free clinics. (4, 8) Moreover, screening , services.were likely to be highest in those two'or three areas where states had established Title V piojects.. 11 44-4 (.../ *231 , . The EPSDT services reported only screenings. Neither state could document whether children who were screened and needed treatment .were- folloWed and received the required- care. Moreover, the:estates reported each screening A 'a separate, child, so that an infant who received several screenings in a year would be counted several times, . inflating the number of children who received care during.the year. In . the case of Medicaid-EPSDT, the program, miller than competing with the private sector, provided reimbursement for it without interfering with prevailing private patterns 9f health care. Nevertheless, for ESPDT. both states exhibited reluctance to proceed with . implementation of the program is evidenced by the low proportion of eligible, children who received services,duaing the first two full years of implementation, fiscal 1974 an 1975. The particular format of the TitleXIX grant System wise weak instrument to stimulate the states to increase services (4. 20-21) Impact on administration. The federal requirement todesignate a single state agency for both Title V and XIX programs' strongly stimulated. the 'development of state administration. This administrative device required.changed in state laws.after 1935.to allow health and welfare departments to accept and administer federal funds under Title V, and the welfare titles of the Social Security Act. Under Title V, Connecticut already had its .Bureau of Child Hygiene which :qualified for MCH funding,' but it had to° create a separate crippled children's division.. Vermont reconstituted an MCH unit and brought in a privately-funded infantile paralysis division as the basis for a state crippled children's division (3, 239-241) Tpe funds were then used to build up personnel in the two divisions. "the single 'state agency requirement had affected welfare agencies in the 1930s and had permitted them'gradually to take over the welfare functions of localities.(9) By 1965, the welfare agencies in both COnnecticut and Vermont had grown considerably. In Connecticut and Vermont, as in most states, the welfare departthent was designated as the single state agency for Title XIX. (A few other states designated health departments.) Then states took on little administrative staff to carry Out Medicaid. By 1973, Vermont had one' staff person' and Connecticut had three staff persons administering a program of $24 million and $119 million, respectively. Thus, even though federal matching funds were available for adrninistration as well as for vendor payments, in contrast to the Title'V programs, state Title XIX programs were, if anything, underadministered. This problem became paiticularly evident when the states were required to carry out .the. EPSDT program. the paperwork of the officials at times seemed to overwhelm them (10, 3-19) Even though federal kinds were available with the usual Matching by the state, states did not take advantage of these funds to build up their managerial capability for these large programs. In this case, the federal stimulative policy did not work. 12 232 The single-state agency requirement turned into its own kind-of s administrative headache for the slates as it developed state agencies with overlapping functions. States were not alloWed to cqnSolidate their MCH and CCS divisions until as late as 1974 even though the divisions' functions overlapped. (3, 239) More confusing was the overlap of functions where the. welfare departments had to provide for services under Medicaid, and then for preventive health services for children. through EPSDT. The.health and 'welfare agencies were asked to "enter into agreements7 but the agency with the service capacity (health) was not the agency with responsibility (welfare). Federal policy stimulated bah health and welfare agencies to develop Overlapping functions within the state.(8) .. Impact on Interest grOupSjThe 'existence of 'federal policy, particerlarlyin crippled children's services and EPSDT, stimulated interest groups which used the federal policy as a focus for their ' activities. In Connecticut, associations were 'formed on behalf of children with cystic fibrosis, cerebral palsy and cardiac disease. Within a few years the state legislature required that these diseases be included in the state's coverage of its crippled children's program -(3, 253). In Vermont, a public interest group lobbied' successfully for a dental insurance program for children at the time that the state became required to provide dental care to Meclicaid-eligibleachildren. .(4, 16-17) : Poverty lawyers working on behalf of Medicaid-eligible clients filed suits to oblige states to implement federal law and provide preventive health services to children under EPSDT. SuCh suits, were filed in Connecticut and Vermont as well as nine other states by the end of 1974. These suits indicated that the existence of the federal law was a , stimulus to the interest group which proVicled a secondary stimulus to the state to comply. The resolution of the suits also showed that cou ts were willing to intervene in issues of positive government programs the state's deviation from the standards set by the statute was sufficiently great. Moreover, state agencies submitted willingly to . judicial orders requiring specific acIminitstrative actions. (11;44-45; 8,, 635) .... , The state medical societies reacte strongly to the implementation ll of Title XIX but .were less of a SCCO ry stimulus to the state than a ii hindiance. Their concerns centered very closely on the question of fees , and reimbursement. In. Vermont, they succeeded in having the'issue settled privately and getting their chosen type of reimburSement. (3,' 381-387) In Connecticut they were obliged to enter the public arena to achieve a usual and customary fee system, only to have it rescinded by the legislature within a year because of its high costs. (3, 391-394) Through their societies physicians were a secondary stimulus to the program by.;41.'iiigating Thes which physiCians would accept. The physicians woUld-'thereby be, more likely to care for Medicaid patients, facilitating i4leinentation of federal policy. However, when 13 I . . . . physicians did-not receive the fee rates they wanted, many particularly in ConneCticut, refused Medicaid patients. ; ,* The stimulative effects of 'federal policy were very different for Title V and Title XIX. Title V did not stimulate the stater to increase. their funds for Child health services, nor to increase substantially those services themselves. The federal policy did stimulate the states to build i adminiitrative capacity in maternal and .chil health. Title XIX, on the other hand, stimulated. state 'funds for me cal vendor payments and services, but did not stimulate states.to build administrative capacity to deal, with these large programs. Botti Title and Title XIX stimulked interest groups acting a3 secondary stimuli particularly to enlOrce the implementation of federal intent. Was federal. policy redistributive?. ., . 'Federal allocation formulae were intended to redistribute federal funds among the states to favor poor and rural states in the case of Title V, and the poor in the case of Title XIX. We analyzed lhis, rtrdistribution, first in terms'of the net inflow or defisitof federal Title V and XIX grants received by each state; in -relation to its tax burden. (Table 5) The redistribbtional patterns ,differed substantially among the different child health grants.. Title IV formula grants tended to equalize interstate distriloutio'n; Title V project grapts favored wealthy and urban states with localities which had the capacity to apply for) project grants; Title XIX open-ended 'funding favored wealthy and . urban states with liberal programs. (3, 310-314) Vermont, although poor and rural, developed a liberal program because of its ideology and therefore deviated from the prevailing pattern of grant distribution. Title V funds could be targeted to rural and poor states, but they did not necessarily distribute equitably' for poor persons. However, as Table 6 shows, the variation in Title XIX expenditures, ranging from $7.54 (Mississippi) to $280:82 (Massachusetts), indicated that the poor in wealthy states with liberal poliCies were favored to the detriment of the poor in other wealthy states and in poor or rural states. (3, 320-32.1) The pattern of redistribution among states was thus inequitable and discriminatory. . Within the states as well, distribution of health resources did not follow the expected pattern ,o1. federal intent. In the case of Connecticut, we. examined the distribution of health resources among . towns in relation to socioeconomic factors and health needs. (12) Private health resources, such as physicians, were concentrated in wealthier towns, Federal policy attempts to equalize access through Title V-grants and EPSDT funds did not have theintended effect. In neither case were public resources such as. Title V services or EPSDT provideis allocated by state administrators to towns where health needs were greatest as measured by poverty levels, Aid for Dependent Children rates and. five-year infant mortality rates. Health ,planners '. 14 were not distributin ,resources to needy areas, even aisuming imperfect information Thus, there was little evidence that a rational planning model was operating in Connectic* in the early 1970s. Rather, .a "bureaucratic politics" model may he more appropriate for explaining the variations in the distribution of- health resources. Planning programs may have improved information available to decision-makers but they did nbt necessarily:change the patterns of decision-making which resulted not from agreed-upon strategies or goals such as equalizing health resources, but from different understandings of What the goals were and from, differing organizational and personal interests. (12) , However, we should note that at least for CCS the redistributiVe, intent for rural services under Title V formula grants was met. Both \ the states of Connecticut and Vermont 'placed CCS clinics in predominantly rural areas. (3, 208-209) , t Reciprocal impatf Since the policy model we employed assumed permeability of institutions, we found that while policy was moving doWnward through federal-regidnal-state levels, other policy was moving upwards. Many such instances of reciprocal impact took place during the period under .study.Under title V-CCS programs in'the early years, states determined that all children under 21 were eligible for services, but federal policies did not formally incorporate this.practice vita 1949, and Congress not until 1968. Although most states by 1939 appointedphysicians as their NICH and CCS program directors, this did not become a federally required practice until 1951. (13, 33) States influenced federal programs which they did not want to implement. The proposed regulations for EPSD1 published in 1970 required states to provide EPSDT regardless of. the limitations of the state- plans. ThuS, states which did not previously pay for certain types or services wouldave to pay.for them under the new rules. The states Objected vigorously and effectively. When HEW published final regulations nearly a year later, the scope of requirements had been considerably decreased to meet state demands. (5, 54) States also influenced the Regional' Offices of HEW.. We had .selecled.two states within the same HEW Region to. mitigate the effects' of differential directives from different regional offices. Instead, we found that the regional office itself reflected More often the opinions of the state rather than the federal policy it was supposed to administer. (14, 4041) The gap between Intent and performance: policy fragmentation Me Federal Title V and XIX programs did not necessarily stimulate the states to spend more for child health programs but merely to take on the federal programs as part of what they had been 15. 2 ) 2 doing earlier. The federal programs, as administered by the states, failed to redistribute services to poor and rural persons. In addition, at least in the case of Title XIX, the funds failed to Be redistributed equitably among the states. What accounts then for these failures? Ambiguity of intent. Cho- first finding about the hypothesized gap between intent and performance is that it was not always as great as purported to be. Close analysis of federal intent revealed ambiguous language and internal conflicts even before the law had left Congress. Congressmen with particularistic interests geared toward election-day success did not: give child health policy, which, was of low political sali- ence, the care which a well thought out policy required. Thus, the orig- inal ambiguity of goals created some of the gap between intent and performance. Federal ambiguity of intent may appear 'as flexibility, but it also left the policy' vulnerable to fragmentation by bureaucraciend private interest groups, among different levels of, and between different aAencies within, government. Thus arose the possibility for different interpretations by bureaucrats and private interests depending upon their own pp-dollar interests and narrower goals. Intergovernmental problems. A first source of fragmentation in federal child health policies came from the multiplicity of interdependent governmental levels. In 1935, the states we studied had maternal and child health programs similar to those, mandated by federal law. Rather than expand their own prograMs, My substituted. This behavior was made possible by the weakness of the federal position and by the flexibility that had been built into the provisions for federal- state. relations. The state legislature of Connecticut, particularly, had never devoted much attention to child health,, so it was not surprising that the state did not seize the opportunity to increase its expenditures for children. States had extraordinary disc tion in how they interpreted Title V formula giants: these funds s ould therefore best be viewhd,as prototypes of revenue s.haring..(15, 217-237) Title XIX:as a' reimbursement grant, prevented,sfates from collecting federal funds, unless they paid out first to health providers. Thus, the Title XIX mechanism theoretically provided .,greater control by the federal government. However, since states still had discretion in Eligibility, scope of services, and payment fees, e program developed more according to what the states wanted than he federal intent. States could refuse,to participate; if they participat , they could refuse to conform even to their own state plan. (3, 197) The states were particularly reluctant to initiate the EPSDT program because of,the increased costs it would engender. The federal government had to proceed by negotiation with the states rather than to order them directly to implement. Even threats bf penalties did not move state officials who believed the penalties would never be applied, just as in 16 24t I . 236 It .. he case of Title XIX. Moreover, the states were right: Although the ftrst penalty for EPSDT were handed down in 1976, no penalties had en applied by 1977. Iniragovernmental problems. Another major care of fragmentation of policy was confused bureaucratic assignment. No one agency wait in a position\-to build burea cratic solidarity behind that policy. This issue was mainly a probl m in the case of Title XIX and sEePr vSiDc eTs . oSince child hh ii m p s provided ewd t he major eonf health eTailttle XIX was a policy diat grew out of welfare legislation, but in fact it was health policy. Health and welfare, agenCies, however, have differing ideologies, professional personnel, clientele, types of services, control over functional areas and'ierarchical relations relative to higher and lower levels of government. (3, 194-1990deologies of welfare agencies prevailed so that discussions of Title XIX more often revolved around issues of fiscal..probity than whether services should be . provided. Welfare it a field in which the government has a virtual A mono!). Oly over its functions and the state welfare agencies have increased their functional control over localities during the,. years. HoWever, only a small propOrtion of the health sector is controlled by the public sector and only a small proportion of these functions are controlled by health departments. Table 7 shows the proportions of state health and welfare functions of Vermont and Connecticut which were actually administered 6y their respective departments. One should also note that during recent years, at least in Connectkut, both The federal requirement of bureaucratic isruiprnealt the health department and health functiOns have received a declining share of the state general fund. (3, 187-190) a single-state agency without control over its runctionil area nrgati ely affected .policy implementation. (3, 196) Although close cooper non between agencies had been mandated.under Title XIX in 1965, alth and welfare agencies were un,able to agree as to who would pay hom for what. Connecticut, for example, resolved the issue by aving neither agency pay for the other and in fact, no contacts or cooperation developed between welfare and the crippled children's program. (2, : 16-19) Inadequate Information systems. Symptomatic. of this fragmentation of policy were the information systems established by federal and state governments to manage the Title V and Title XIX programs. Pederal surveillance of state petformance can at best' be termed inept, (3, 244) and information feedback was poor. (1, 81-83) There were two problems: the types of inforrbation requested by the federal government; and the time lag allowed to states to report. States reported children who received physician's services from Title V-CCS but not those who received CCS care from other persons; they reported well-child services if the state-federal MCH funds paid 17 .237. any part of the services regardless of what other sources provided the services.7matchinefunds did not have to appear as a specific lira-item in the state budgets and states never had to document in detail their matching accounting for ormtila grant funds. Under .Title XIX, states reported financing and s rvices, but no accurate figures were available' on how many children were actually eligible for these services. (10) For Title XIX-EPSDT, the federal' government did not require .siates to report follow-up care of children screened although that should have been the main purpose of screening. Moreover, the state of/Vermont claimed that children Were receiving preventive care from private physiciansthrough regular Medicaid reimbursenient. However, state officials were unable to document this claim because their reporting system was not equip ecl to deliver the information. The federal gotr .nment tolerated long delays by the states in . reporting: nearly two tearSinthe case of mandatory Title V reports (3,,. 242), and similar det4s.in Title XIX, as in Connecticut's failure to submit Title XIX reports for fiscal 1975, even as late as mid-1977. The information system which should haye provided the federal agencies Arith information about state implementation, in fact, tended to obscure activities rather than reveal them. It may be that HEW did not want to know; in that case, the information system was most successful in preventing federal surveillance of the'states. Salience of child health. The final source of fragmentation was the low salience of child health in public policy. For the most 'part; child health was outside the glare of public attention which left both federal and state health and welfare bureaucrats a relatively free hand in the.shapingmf the,policy. Title V had been only a very small section of'the major social.policy of the day, the Social Security Act, and had ,consequently received very little attention; Title XIX had never been intended'as a child health program; the EPSDT provisions of 1967 passed through Congress as a miniscule part of massive revisions in the Social Security Act, receiving very little attention in hearings and debates. (5, 49250, 5940) One could characterize Title V. andaltle XIX as program's without .strong constituencies. (8) Children con liot vote since they were poor, were unlikely to have voting parent:, either. ' . Child health waasalso not of great salience at state levels, asrioted by the low legislative input in the bills related to child health. The interest grciups concerned with child health were themselves fragmented into different aspects of a disease or of the policy itself. Thus, interest groups formed to lobby for children with cystic fibrosis or cerebral palsy, rather than for preventive health services for all children. The only 'exceptions 'were the cases of the poverty lawyers; but even their efforts were limited to those children eligible for Medicaid services in the state in which they were suing. Their categorical concern did not allow them to apply their interests to other .'Poor or needy children. Thus, the lobbies which might have 18 2,1ti 34-484 0 - 79 - 18 counteracted the effects of policy fragmentation were themselves Iragniented or non-existent. In stitnmary; the ambiguity of the original 'federal intent set the 'scene for the further fragmentation of policy. Different federal and state .bureaucracies interpreted the policy according to their own needs; health,and welfare agencies vied with one another' as to Who had the responsibility, for child health. Quarrels at the state level were sent to higher levels for adjudication'with no better results: Thus; those at lower levels made ad hoc decisions to carry. out policy, or as in. the. case of Tide XIX. and EPSDT, when the policy was 'expensive, ancl time-consuming to administer, they made'.policy by avoiding implementation. This became easier because the federal government did not require the management information that would enable it to evaluate the implementation of its own policy. The one force which could. counter the effect of this fragmentary process iias the interest groups which, operating from outside the governinental process, could intervene at whatever level necessary to enforce their own interpretations of child health policy. This process could have-been-.ptarticularly effective if the interest group had been involved in the, policy formation. However, in the, caIrof federal child health policy under Title V and Title XIX, the interest groups theifiselves fragmented. Thus, the one potential cohesive force in federal policy-making was not operating and the policy decisions were controlled by those who held power closest to the delivery points.and who were responsive not to issues of child health but to particularistic bureaucratic and private interests. 41Y 2.1 19 Recommendations These findings on the gaps; failures, and fragmentation of federal chill health policy suggest several recommendations for policy-makers. First,- on the issue of ambiguous policy: given tfiat Congressmen are rewarded not for their attention to detail but for their espousal of popular programs, it is unrealistic, withoutIchanging our electoral %system, to expect Congressmen to change considerably. However; Congress can demonstratg more concern for child liealth policies by assuring, at least, that in hearings and debates, the issues are debated and the intent, even if confli4ng, is Voiced. Moreover, even though the temptation is always to al! the Secretary of 'HEW work out the details, Congress should consider that some of these details will be so i important that they, may change entirely the original intent. Thus, Congress should be more specific in targeting the populations to be served by a particular piece of legislation, the types of services expected, the costs, and the administrative framework. In intra-governmental relationC particularly in the question of health-welfare agencies, we recommend that Congress examine the issues of bureaucratic assignment. If Title XIX is to remain predominantly a welfare program, tied to welfare by eligibility restrictions, the welfare agencies Will have to develop capabilities in case management in health. In`so" doing, they may, in the many states where the -Title XIX agency is not the health agency, be in conflict .with the health agency as to who has jurisdiction over wbat areas. The bureaucratic assignment of a policy to a single-state agency does not make much sense if .that agency has little functional or hierarchical control. (3, 149) Nor is a health department necessarily a solution since these agencies also have little control even over the public funds expended for health.. Thus. the .assignment.of policies by Congress may be .crucial in determining whether that policy can be .implemented. Moreover, interbureaucratic confusion at the federal level spills over into confusion at lower levels of government. We.recommend that Congress consider carefully either creating new agencies for its child, health policies or requiring consolidations of existing ones to assure stronger agencies with capabilities in -their own .fields. This recommendation applies both to federal and state agencies. In inter-governmental relations, we recommend first that Congress maintain a closer watch on theexecutive branch for . enforcing its own policies, and secondly, that the states be given greater ".....eo ND 2.i cm 4 incentives to cooperate with federal policies by increasing the funds available.to them. States, particularly in recent years, have increasingly faced budget cutbacks; to induce states to take on new programs or even to carry out their present programs will require positive incentives, such as considerably higher matching funds with a concomitant requirement of maintenance of effort of present services and expenditures. 'Fourth, DHEW must develop reporting systems which will provide data consonant with intent so that federal officials can know whether a particular program is in fact reaching its goals. Reporting data should be monitored and checked on a random basis. In addition, indiii:ements for improved management should be added for Title XIX's child health programs; otherwise, the present. situation will continue in which even HEW does not know how many children were actually served EPSDT and Medicaid combined. The final and.most impoitant recommendation consists of raising the salience of children and child health as a- political issue. As noted earlier, -the legislation we studied had received, scant attention from advocacy groups. When Title V was, passed, children at least had the remnants of a lobby from the earlier heady days when theChildren's Bureau was formed. However, this influence quickly waned. During the period under study, there was no well organized general, child .health- advocacy group. arhe existence of such a lobby is the one force that can prevent the fragmentationofrpolicy as it moves through the layers of government and among different agencies. The children's advocates, to be effective, however, would have to mobilize for child health in general rather than themselves being fragmented as th'ey were by concerns for specific diseases or particular needy children. Such a lobby would have to oversee policy not only as it were being formed, but also as it were being implemented. The experience of Titles V and XIX indicate that even such major health. policy for children cannot provide, care for the inteylied children unless the. groups which should be looking out foi- their interests are mobilized to supervise that policy every step of the way. Policies,do nor happen just because Congress passes a law. Policies are shaped by the entire implementation' process. Those who would be 4' concerned that children receive the best health care, through' federal assistance, must then supervise that process. 21 2 6. Refereincei .- 1. Silver, G.A.;"Impact of Child Health Le14slation in the State of Connectictu," (19:74),Repory No. 1.* PB 271 055 2.. Foltz, A -M., "fecrei'al Child He- Policy Under. Medicaid: The -Seeds of Failuur. (1 874 ), Wor ng Paper NO:22.* PB 271 036 3. Silver, G.A. C. Altenstetter, J Bjorkman, M. Chen, and A.M.. Foltz, 'Impact o Feclii.ral Health Palicr n the States of Connecticut and Vermolit Final report to Nation 'Comer for Health' Services Research on G ant.tIS 00900, (Nationit Technical Information Service, Spring Id, VA 22161, 1976, PB 262 959):: 4: Foltz, A-M., E : Lessons for Nati,pnal Health Insurance for Children (National echnical Information Service, Springfield, VA 221,61, 1976, FIRP-006848/LL). .5. Foltz,. A-NE, !'The Development of Ambiguous Federal Polic Early-and Periodic Screening, Diiignosis and Treatment." Milbank Memorial Fund .Quarterly 53, 35-64 (Winter 1975). . 6. Foltz, A -M., "Rebuttal to Dr. Shenkin:.The POlitical Environment for Child Health." Medical Care 14, No. 10, 886-88k (14_9ctober 1976). 7. Chen, M.., A...Stoga, and A-M: Foltz, 'The Diffe rential Impact df Medicaid: Inierstate Variation in .Expenditures and Participation Time Lags." (1975). Working Paper No, 29.* PB 271 037 8. Foltz, A-M..,,and D. ,Brown, State Response to 'Federal Policy: Children, EPSDT and the Medicaid Muddle." Medical Care 13, .1\1o. .8, 630-642 (13 August 197.5). "General Assistance in Connecticut," (1973). Working Paper No. 9.* PB 271 038 r, *. 10. Foltz, A-M., -"The Impact of Federal Child health Policy Under EPSDT: The Case of Connecticut.," 41974). Report No. 3* PB 271 039 . 11. Peterson,E., "Legal Challenges to Bureaucratic Discretion: The Influence of Lac;suit's On the Implementation of EPSDT," (1975). Working Paper No. 27* PB 271 040 12. Foltz, .A -M., a Chen, and A. Stoga, vPublic Policy and ,I-J,ealth ResoUrce Distribution." Policy ScienceS (Fall 1977). - 13. Altenstetter, C. and J.W. Bjorn-flan, "The Impact of Federal Child Health Programs on State Health Policy Fortnation and Service . 'Delivery" (1974). Report No..2* PB 271 041 22 2 p; 242 , 14.,Silver, G.A., "The Hands of. Esau." Reflections on Federalism and -Ghild_Health_Senticesinthe U.S.A. Paper presented at the Child Health Conference, Sun Valley; Idaho (August 1-9L5).* PB 271 042 15. Altenstetter, C. and J.W. Bjorknian, "The: Rrttleovery of Federalism: The Impact of Federal Child Health Rrograms on Connecticut State Health P9licy Formation-and Service Delivery:" In Public Policy:Malting in a Federal System, R. Thomas- ancf.C.O. Jones; Eds., 217-237 (Sage Publications, Beverly-Hills, California, 1975). 1: Federal bxpeneiturei for children tier 21, TON Yund-flUe-XIX-Programs,anditurn s served as a percentage of U.S. poptilatIciritinder 21 1040 050 1070 FecNial ErfonftLres 'ns: V e $8,058,000 $22,532.351. $223,504.64r ma XIX 481.063,at OW/in &Aged . . , . The V / 1,898,529 (3.5%r 3,905,857 (6.2% 6,074,675 (7.5%)** ' VIM XIX - -- . 7,1344,000 (9.4%) lri MO* damage. funds of aitiabilmate* $20 fallen as was as du malssrad ind'ihild fain. *Wei childnilf". adiddpadsds. it'd smack kinds. . , . "Passaid111ingsarlialinia mid school fassals asaminalions astir%hot comostabio. fag 'winds &Seas CiAll1 , Source: As) psand (8)031 ir 7 Table 2: Population and health characteristics of Connecticut and Vermont Populadixt, 1973 -.4'-- . 3,980,000 466,000 Rural population; 1970 22.3% 65.2% c' . Per capita personal income: 1972 - $5,931 $4,185 Percent d persons below poverty. 1969 7.2% 12.1% Expenditures for education per capita, 1973 $278 $297 Infant mortality per 1.000 live Wilts, 1973 ' 1 White ,., i :13.3 16.2 24.9 t M.D. Poptiladon/Activephysician per 100000, 1970 ,, .191 187. Hospital beds : . per 100, 1970 . . m' b..34 , 4:51 Medicaid (Title XIX) expenditures per capita, 1p72 $34.67 ' $37.93 Sesecaef3) 121 eni 212 Connecticut *Venom*. Table 3: Children sired by ConhectiCut and Vermont Maternal and child health and crippled children's services Children served by Mate- ' Children stored by sponsored well -child conferences state crippled children's . as a percentage of se ., services g a percentege of 4 . children aged-0-5 - -handlcatiped children' . aged 0-21 C.onnectleut ,---....y Vermont -Connactcut Vermont 1940 8.5 - 7.1 . 1950 2.5 .4 'Sr 8.0 15',8 1980 1.3 11:0 5.5 "22.9 1970 /.° 7.0 3.9 21.8 SfuldiCaPsard childron osematod a savon percent of Ins PoPulanan. .' Data not evaNable. Source: (3) 220424 24 Table 4: Children served by Title XiX and its EPSDT -Sersening-Progrants:Connoctiaut--iferntont-and United-States CY 1968 CY 1970 FY i974 FY 1975 Title xi _ . chairs'? servo . Connecticid .83,594, . 95,617 112,299 Vermont 7,611 43 17,675 . 20,226 24,949 ',Inked States 5,910,000 7,614,000 10,110,317 10,329,000 111k XIX children served as a PoniPtili/8 at tioP1118tion under 21 1 k. .. . 041WISCIbit/t 7.5% . 6.2% 10.1% I Vermont 4.3 . 9.6 11.1 13.8% linked States 7.3 9.5 12.7 13.1 EPSOT percentage otrTidellX. eligible children screened 3.9%; 21.3% Vermont 5.5 8.1 United Matra . 7.7 14.1 . 171* *dwell goverment and the states caudt eagewelely children receiving make Tide XIX union aril those receiving ecnieninge. At preeerik.itere* dOwey*1 knowing whether gie same children we imitated in each count. Dilitanot avellabki &NA* (4) 3.2 25. 245 Table 5: interstate redistribution effect of fedora! health grants to states, FY 1972 (In thousand dollars). .. ro . . Maternal and died health. . loneute ca Matentel and chid . noMa. protest Nob Alaska Atiz Ark Calf' +1,481 . +. 218 + 165 + 933 -4,974 +3,206 - 122 -:. 424 + 497 15317 Cob Conn ON D.C. + -14 -1,158 + 71 - 8 ' +2,748 -1,158' Ag 376. ,W5.601 Fla - 55 +1,817 Ga '. +1,504 + 880 Hama + 83 - + 251 Idaho + 280 , - .5 la -3,170 L:1;096. .. . Ind . + 384 -2,351 i + 411- -1,224;" Kane + 134. - 139 Ky +1:328 g50 . La +1,383 . -1,411 Main +' 334 ,' - 369 mg ' - 307 ' +5.876 -1,444 +2,122 Midi -. .649 + 178 Minn + 340 + 373' Mlas +1,60 +, +, 136 Ai Mo + lel - 29 Mont 4- 214 + 15 Nebr + 158 + 621 Nev '4. 80 -° 276 N.H. + 134 - 272 N.J. -2.082 -4,536 N. mex ' + 337 . + 139 N.Y. -6,065 .+2.493 N.C. +2,195 + 133' . N. Oak + 283 240 ..-- Ohio - 850 + 164 Okla .. + 367 -1,112 . Oreg + 191. 51. Penn' - 521 - 905 R.I. + 65 - 325 S.C. +1,490 . - S. Oak 3. + 278 ..Tenn - +1,230 + 0 Texas + 621 ...4 ,433 Utah + 382 - 203 IA + 214. '- 228 Va -1- 772.: -, 929 'Wash -. 49 207 W: Va. + 737 .- 132 Wiw +, 286 -1.735 WYO. +. 233 103 (3) (4) (5) Oh Maternal Total Medicaid Total and chid tetatth health health. : aseluellna . Including total Afed(c440 . Atodlcsid + 4,687. + 5,415 + 19,329 + 24,744 + 94 + 281 - 6,374 - 6,093 - 259 + 2,223 - 30276 - 28,053 + 1,430 + 2.350 + 548 + 2,896 . -10,291 - 47,790. +181,464 +113.665 +2,762 +11.5E13 1.548 -.4. 10,035 $ - 2.310 -12;.137 - 37,673 - 50.010 . + 305 - 865 - 10.3.18 + 11.183 + 5,595 +23,450 + 3.524 + 26,974 . + 1,562 - 6.866 - 78,903 - 85.739 +' 2,163, + 2.133 +26,902 +29,035 + 334 . + 383 - 4,478. - 4.095 - 4265 -45:572 - '72.692 -118.264 .+ 275 + 1,865 7 243 + 1,622 + 1,96T -. 5,364 - 44,004 - 38,640 813 .1 555 --: .30,722 -- 30.167 - 5' .+ 3,252 - 5,416 - 2;164 + 1,078 + 5,301 + 8,600 + 13,901 - 48 . -1-11,725 + 611 + 12,336. 35 + 899 -4. .4,001 + 4,900" +.5,589 + 6,705 - 25,530 . - 18,825. + 678 +13,194 + 60.97T + 74.165 - .473 -121014 - 14,416 - 26.430 4. + 653. +20.485 + 14.838 + 35.123. +. 1',737 + 4,930 +''21,445 +26,375 .+ 121 + 5,985 48,029 - '42,044 + 229 758 -- 1,968 -;- 2,726 4 779 -+ 4,1,95 - .5;03.10 4-.1 838 - 196 - 4445 -4-.: :.-8,730, ? -, 12,834.... "- 138 - 1411 .-- - 8,200' . - 9.380 ° ; : .-.. 6.618 -30,884 -i: 657428 - - '96:312. . A + 476 ,- 1,510, -;-* 756 7 2.266 - 3,572 -10,986, +417,448.. +406,462 + 2,328 +12,1-72 7; 4,k,. 8,157 +:15,329 4" 43 + 472 4.-, 3.234 .4.',,,3,706.. "2: -- )86 - 3.293 -t17.940 -- 121,233. . ' 745 + 4,142 + 32,112 + 36,254 , + 140 + 2,158 ;- 18,742. ' -116,584 \ -1,426 '4- 15,776' 72,177 .- 56,401 - 260 + 347 + 6,060 + 6,407 + 1,287 + 4,610 2- 4,966 '' 346 1. + '14 + 547 7 410 - 957 + 1,900 '+ 7.343, - 15.899 7- 8,556 - 812 .. - 91 - 20,529 - 20.620 . + 179 + 6,588 + 1,364 + 7.932 ' ( 14 + 4,423 + 6,085 +10,80E1 - N57 3.039 27,991 31,030 - 256 1,971 -, 17,078 .- 19,049 + 605 + 2,027 iT 0.379 - 4,082 - 1,449 - 7.401 + 14 '95 +. 7,394 4 + 130 :1.082 4.752 - 4,834 P 1181111i may na WO to the iota because of rounding Source (2)330 . . 26..)1 .9\ I Table 6: Federal Grants-hi-Aid (6) per poor person, FY 1970 r V latal Rai Melo WM*" Medicaid TIM XIX (Medicald) Total hese. Mcluding Medicaid U.S. Nab. Malin Ariz Mc . Calf 8:82 7.17 10.20 4.43 4.47 5.39 36.12 3023 63.00 54.73 '10.01 32C 93.20 32.04 0 0 5.89 240.94 129.32 k.27 63.00 54.73 25.90 . 273.58 Colo : Pon" Del D.C. A 15.47 9.47. 7.76 37.41 7.31 ..- 66 67.71 37.76 1 5 26.53 /1114 85,82. 193.88. 40.57 103.45 16.01 152.42 261.54 78.33 213 .20 42.54 o Ga Harrah a Web° III Ind 5.74 16.67 7.97 8.15 4.97 28.80 112.45 39.18 33.47 56.93 109.62 63.10 9044 23.73 85.73 222102.2887 123.91 61.88 Iowa Kane Ky Maine .... 4:83 5.50 4.04 2.91 5.24 443821 ... 728165 28.27 21.82 35.30 44.68 89.35 55.46 39.77 55.78 85.88 132.11 83.73 61.59 91.08 . Md Mass, Mich , Mad Miss 15.58 13.86 10.28 7.92 3.31 50.59 65.32. 56.37 38.61 17:89 101.95 1 280.82 160.79 7.54 152:54 346.14 199.40 25.43 Mont Nebr Nev N.H. 8.33 7.73 11.16 11.91 7.95 41.15 46,16 43.10 9 436..0134 , 48.82 64.13 51.42 87.91 ° 110.29 19827..0582 106.51 N.J. N.M. N.Y. N.C. N.D. 4.06 ' 5.55 8.71 5.71 4.86 36.28 43.70 40.67 35.45 40.59 475.4893 41.61 273.69 19.89 87.84 82.21 8V." 31436 .. 55.34, 128.43 Ohio Okla . Dreg Penn R.I. 9.32 2.63 7,51 6.20 6.54 43.78 26.20 41.56 4891.8835 51.17 133.64 41.89 1997018038 94.95 159.84 8145 150.24 212.15 S.C. S.D. Tenn .Texas Utah 4,49 3.81 5.09 4.23 6.65 24.39 28.94. 30.46 22:52 61.92 38.98 .42,44 15.60 43.54 88.88 63.37 70.98 .4808 66.08 150.80 Vt Va Wash W. Va. Wisc 7.27 5.88 8.61 4.27 5.30 75.60 28.23 34.87 .26.23 39.43 163.19 26.14 11.5.71. . 32.91 194.71 238.79 54.37 150.58 59.14 234.14 Wyo 9.32 . 57.42 24.32 81.74 Source: 13) 333 27 ( 247 L Tabley:-Width and welfare fu and department , estondltures as perm Wine state's &nerd fund, Connecticut and Vermont' bolo oblooditeot on &bib bactions Expoadlutos by habit depaansiver Slott 0ft:androns on votaart functions irrwea dint A. don/name . 1935 6.3% 0.4% 42% 6.3% . 1940 5.7 0.6 10.0 4.1 1060 157. 4.7 18.8 187 inn 13.3 3.3 , 15.8 15.8 1970 9A 2.0 19.6 19.6 B. Vonnont . , C 1935 1940 /11 1.4% 1.0% 15.2% 6.4% 1950 s 7.8 1.7 . .13.2 112 1960 L9 1.3 13.0 7.0 1970 4.9 1.5 13.2 13.0 gams ow Data not ovadatn. 28 lb Current NOM publications National 'Center for Heal toh Sekvices Research publications of interest to the healthcommunity are available on request to NCHSR, Offite of - Scientific and Technical Information, 3700 East-West Highway, Room 7-44, Hyattsville, MD. 20782 ttelephone: 301/436-8970). Mail requests will be facilitated by encloSuie of a selfradhesive mailing label. These publications also are available for sale through the National Technical ..Information.Service (NTIS), Springfield, VA /12161 (telephone: 703/ 557-4650). PB and HRP numbers in parentheses are NTIS order num- . bers. 'Publications which are. out of stock in NCHSR are indicated as . available only from NTIS. Prices may be obtained Hoff' the NTIS order desk on request. 6 Research 'Teats The Research Digest Series providesoverviews of significant research supported by NCHSR. The series describes either ongoing Or completed projects directed toward high priority. health services problems. Issues are prepariod- by the, principal investigators performing the research, in collaboration with NCHSR staff. Digests are intended for an interdisciplinary audience of health services planners, administrators, legislators, and others who make decisions on research appVations. (HRA) 78-314) ,gvaluatigi of a Medical Information Systedi in a C5mmunity Hospi- tal (PB 264 353) (HRA) 78-3145 -Computer-Stored Am- bidatory Record (COSTAR) (PB 268 342) (HRA) 7743180 Program Analysis of Physician Extender Algorithm Projects (PB 284 610, available NTIS only) (HRA) 77-3181 Changes in the Costs of Treatment of Selected Illnesses. 1951- 1964 -1971 (HRP 0014698) . (HRA) 77-3163 Impact of State Certificate-of-Need Laws on Health. Calif Costs and Utilization (PB- 264352) d (HRA) 77-3164 An Evaluation of Physi- cian Assistants in Diagnostic Radiglogy (PB 266 507. available IITIS only) (HRA) 77-3168 Faceign Medical Graduates: A Comparative Study of State Licensure Policies (PB 285 233) (HRA) 77-3171 Analysis of Physician Price and Output Decisions (PE 273 312) (HRA) 77-3173 Nurse Practitioner and Physician Assistant Training and Deploy- ment (PB 271 001, Eriraileible NTIS only) (HRA) 77-3177 AutOmation of the Problem-oriented Medical Record (PB 288 881) L.) 29 249- ) /*earth titlionartes The Research Suinsiory Strict- provides -rapid access to significant results of NCHSR.-supported research projects. The series presents executive summaries prepired by the investigator* ailthe completion of the project. Specific findings are highlighted in a more concise form thin in the final report.. The Research Series is intended for health' services adminkstratorsi planners, and er research users who require (recent findings relevant tcOmmediate .problems in health service*: . (HRA) 77-3162 Recent Studies in Health (PHS) 78 -3183 Recent Studies in Health Servicei Research, Vol. I (July 1974 Services Research, Vol. II (CY 1976) through December 1976) (PB 266 480) (HRA) 7773178 Meaty of Medical Care Assessment Using Outcome Measures (PHS) 78-3193 Optimal Eiectrocardi- (PB 272 455) ography .t. Policy Research The Policy Research Series describes findings from the research program that have major significance for policy. issues of the moment. These . papers are :prepared by members. of the .staff of NCHSR or by independent investigators. The'series is intended specifically to inform those in the public and private sectors who must consider, design, and implement policies affecting the delivery of health services. ° (HRA) 77-3182 Controlling the Cost of Health Care (PB 286 885) Research Reports 1 The Research Report Series proVides significant research reporti in their entirety upon the completion ?f the pro3elo Research Reports are developed by the .principal investigators who conducted the research, and are directed to selected users of health services, research as part of a continuing NCHSR effort to expedite the dissemination of new knowledge resulting from its project support: (HRA) 76-3143 Computer-Based Patient (HRA) 77-3184 1960 and 1970 Hispanic Monitoring Systems (PB 268 508) - Population of the Southwest by County (HRA) 7J-3152 How Lawyers (HRA) 77-3188 Demonstration and . Medical Malpractice Cases (HRP 0014316) Evaluation of a Total Hospital liformation (HRA) 77-3159 An AnItlysie fi3j the System (PB 271 079) Southern California Arbitration Project, (HRA) 77-3189 Drug Coverage under January 1986 through June 1675 (HRP National Health Insurance: The Policy Op; 0012466) tions (PB 272 074) (HRA) 77-3185 Statutory Provisions for (PHS) 78-3204 Experiments in. Inter- binding Arbitration of Medical Malpractice. viewing Techniques: Field Experiments in Cases (PB 264 409 available NTIS Health Reporting (PB 276 080) Research Managemeq's The Research Managenlint Serid describes programmatic rather, than technical 'aspects of the NCHSR research effort. Information is pre- sented on the NCHSR goals,lesearch objectives, and priorities; in ad- ' dition, this series contains lists of grants and contracts, and adrninistra- 30 254 Live information on funding. Publications in this series are intended to bring basic information on NCHSR and its programs to research plan- . ners, administrators, and others who are in.volved with the allocation of research resources. (HRA) 76-3138 Tfie Program in Health (HRA) 77-3179 Research on the Priority Services Research (ReVised 9r76) t Issues of the National Center for Health . Services Research. Grants and Contracts . (HRA) 77-3158 Summary of Grants and Active on June 30, 1976 Contracts, Active June 30; 1976 (HRA) .77-3194 Emergency Medical (HRA) 77-3167 Emergi6cy .Medical Services Systems ResearchProjects. 1977 Services Systems Research Projects (Ac- (HRA) 78-3202 NCHSR Research Bib- bye as of June 30, 1976) (PB 264 407, liography (July 1. 1976 to June 30, 1977). available NTIS only) (PB 273 997) Research. Proceedings . _ The Research Proceedings Series extends the availability of new research announced at key con ferences,1symposia and seminars sponsored or supported by NtEISR. In addition to papers presented, 'publications in this series include discussions and responses whenever possible. The series is intended to help meet the information needs of health .services providers and -bthers who require direct access to. concepts and ideas evolving from the exchange of research results. (HRA) 77-3138 1Vomen and Their, Health: (HRA) 77-3181 NCHS14 Research Con- Research Implications for a-New Era (PB ference-Report on Consumer Self-care in 264 359, available NTIS only) Health (PB 273 911) (HR*76-3150 Intermountain Medical (HRA) 77-3186( International. Conference Malpractice (PB 268 344. available NTIS on Drug and Pharmaceutical Services only) Reimbursement (PB 271 386) (HRA) 77-3154 Advances in Health Sur- (11RA) 77-3195 Emergency Medical vey Research Methods (PB 262 230) Services: Research Methodology ti ny (' 3:1; 251 '10/ILIIMUMW/C NIA I. Ihmpos: he 1C1S1"1193 11E7 l .. X lectpues Morse.. So- 4. Tele old UMW* ORCIRTAINTIES00 NORM MILD SULTS POLICIES: imrAcT,im SArpon b..4 April 1978 TOO 111:1228; mak lasemrch Digest Series k t / 4141111 Volts 11. Pool Isms. ORponeases Nor dolbeas N. Porte...ag Orgastuade R.M. U... Ie. ,,/-1../Perb Uri So- --- end We ilaiwermity School of Medicine Deportment at lnideetolegy end\Public Health 60 Colleen Street lee Semen. CT 06310 ilel.i 203/432-45661 11. Carassn/Gesa N.. . HS 00900 . Ompaisone Mar Aakeno Research IX Typo el 114.H Pena* c".."Digest Series 6/1/72 - 5/31/76 12. learavro. sad . OHM. PIS, SASS. latiessal Center for RealthServicas 3700 lent-Seet Ilighamy, loom 7-44 (STIR) 1y La ND 207112 - (Tel.: 301/6364,270) i misaemaserammo. ISBN Pub. DO. (PBS) 7L,3190. 14 I Tederal.Realth Policies in the . See PS 262 939 for Ilia report entitled: 'Impact of Stet., Of Comnetticit and Vermont (Final liport)." 14 Aboress . policy under Titles V and III and Vermont for the years between policy Intent and. of. Congressional intent. NEW services-vith special ref - study offers 0 basis for a mat - or the country es aybols. T - mall laws; states faced with ertain to comply even with the federal states faced no loss of provide sufficleit funding to as- with continuous reporting to be served and services to be Thie'repart the impact of federal health asseemes child of the Social Security Ait upon the states of Connecticut 1935 to 1975..sed analyseethe VISD011a for the, discrepancy state mancutice. .Research methods comprised a review ,rageletioas, state legislation, administrative performance. ersece to arks/rural variations. and WSW. Ws elegy roar policy evaluation studies is other tat,sa law federal agemcidm diversely interpreted federal policy. short funds, end ezteml preesures failed MIST esedate., Since RIM fal to monitor Its programs, feeds or penalties.. Racemeandations: that Congress anie state cooperationitoretat pert-Orme:0e maimiztheaml to oowlatioos to avoid Interbureautratic con- more involved in legislation and . . . , _. . represent approval or . Services Research or the ..4 Federal child health policies. Title. ZIT (Medicaid) Title V ift ..: 16. Abstracts'fcontlaed) ;: provided; that administrative agencies be consolidated fusion: and that child health advoclin.groupa become In monitoringprograms. .15. Suonledbetary Sates (continued) ' ICIER publication of research finding. does not..iecessarlly official endorsement by the National Center for Health' Saporta:mm.0f Health, Education. and Welfare. 171.14emdwm/Opes.ErW4Teme . Health services research Impact of federal health polities on states Child health eervices. Connecticut and VermOnt Maternal and child bealth/state adninietration ID,. COSATI F te la Gm.. 15L1=1.5"alii. public. Available [ram National lanai Technical Information Service, Springfield. VA (Tel.: 703/557-4650) 22161 ". 117'17 Cl.., '"" pl. ".. a Pw. 4 eat. 35 ,..,,,,u2,,Yegiree. PTIK LASSIF 1ED 1:0113110 PT AND IN V 0 THIS FORM MAY' BE . r STATE OR . . Diener StENT OF HIALTH SERVICES, Sacramento, Calif., august 28,1978. Mica/. Signis, Staff Dingell*, Senate Commas), on Finance, Senate Office -Build . Washington, D.C. Dein Mi. &man : California has receige a copy of the amendments to S. 1,392 dealing with the Child Health Assessment Program (CHAP),-which were inkr- duced by Senator Cranston. We feel that these are good amendments and Cali- fornia is in full agreement withthem. There are some areas of clarification we will need on the technical aspects of some of these amendments. We are ' working directly with Senator Cranston's office in seeking this clarification. We are requesting- that .the Committee include these-comments as'an addendum to our .August 21, -1978-letter. to th4 Committee, which contained California's written testimony on 8. 1392 and 11.11. 13611. We ask, that this addendum be included In, the Record along with our August 21, 19/6 letter. , The three areas we address below have been discussed with SenatorCranston in the past, and we Would like to bring these to the Committee's attention at this time: , . . 1. Development Aumentent.California concurs-with Senator Cranston that the developmental assessment issue should be fully 'examined. It has been Cali- fornia's experience that requiring developmental assessments as a separate, sPe- cifie component should be deleted frOm any-child health program, as there is no clear, acceptable definition of what a "developmental assessment" should encom- pass. In California's view, there is no existing de opmental assessment instru- 1 ment'which is acceptable as a screening tool. Th national and local publicity that has been focused on the deficiencies of developmental assessment and'the ,. damaging consequences of the inaccurate labeling of persons that frequently occurs has already had a negative impact on California's EPSDT program. Numerous studies indicate that development assessments do not take into- con- .sideration different cultural and child-rearing practices and backgrounds. Upon the recommendation of a broadly representative developmental screening task force, California eliminated the use pf a specific developmental screening tool from its EPSDT health assessment In 1976.. Therefore, California recommends that dayelopmental assessments be done in the general context of the health history. 2. Count of Screens.California's experience under EPSDT leads us to believe . that it would be advisable for the CHAP legislation to -speak to -the manner in which health assessments will be reported to HEW. Currently the federal .' Department of Health, Education and Welfare (HEW) allows only completed screens to be reported according to guidelines in HMV's "Program Instruction IS-NCSS-PI-74-13". When compiled according to these HEW guidelines, Cali- fornia's reportqd statistics always appear deceptively low. For this reason it would seem appropriate to specify reporting requirements in the statute, rather than to leave this process to interpretation through HEW regulations. According to the HEW guidelines, California has many "partial screens", pri- manly due to four factors: (U)IPnsician providers many times do not periorni vision and hearing 'testing because these tests are routinely done by the sehooli . under a state legislative mandate; (1) I Many health assessments are rendered incrementally over a period of time. sometimes by more than one provide;. California's current 'manual cl'aims processing system does not, have the capa- bility to link these component parts into "completed screens" :1( c) Many physician providers bill preventive child health services, including EPSDT screening, directly. to the Medi-Cal billing system. Because the billing codes used in the Medi-Cal billing. syntein 'are not always, as precise as those used in the Child Health and Disability Prevention (CHDP) Program system (CHDP administers the EPSDT progrankin California), HEW does not allow such creens to becall "completed screens". (d)' Some providers do not, in fact, prove all the ma 7 dated EPSDT service. Further work with these providers is necessary. - . .....,:, The resujt is that these "incomplete screens" (health assessments) -are-liever- included it California's quarterly tally. and the flkures do qof reflect the tree,-,' . . .. , . .picture. It is California's position that there is a good deal more prevegftve - health care rendered than the figures would indicate. We would Suggest that = the new health "screening program being created under CHAP: (a)Mititelillow- ° antes for vision and hearing testing which is done in schools; (b) Alloiv stsitear time to develop automated capabilities that could link screening components I .' . k 253' 41 . .. .. . .. done over time or by different providers into .complete screens, and allow the counting of partialereens when at least the health_ history and physical exam'- nationaareehne; (c)-Count DT screens billed to the Medi-Cal billing system as "complete screens"; (d) Allow.. states time for orientation, educatioe and monitoring of providers as to what constitutes a "complete screen:'. In the meantime, accept "partial screens" as "complete screens" if the health history, -.4: ''- *Mica examinaticui.and selected additional components are completed. . . 3. Penalties.California again recommends that penalties be eliminated, that any penalties assessed tebe repealed, and that there be no penalties assessed in the future. ea that the assessment of penalties' has deliteri- -ons effects on ddid programs. We strongly suppOrt the recognition of .. positive,efforts use of financial. incentives. (This issue Is also addressed on plige 8, of ottr'August 21, 1978 letter to the committee.) . delivery of these / California brings tothe committee's attention that the provision of child health. services, and the creation of a. program .(cliag) to assure services has been the subject of correspondence between California and Senator 4 -1 Abraham Ribieoff (on S. 1892) and Congressman Paul Rogers (on H.R. 6706) in SeptemSer, 1977: t. ; The current set of amendments to this very ImpOrtant legislation, introduced recently. by Senator Cranston, .have received the, full support of the California DePartmellt of Health . services. which administers the child health programs in this state. . .) ..1 : . . We appreciate the opportunity of providing these comments to the Committee as it considers 8..1392, and its potential impact on child health in California. If you wish further information on these issues, plea telephone., either, Ramona ThoMpson, (916) 3=-8041, of the Child Health and Disability Preven- tion Branch, or. Joan Spieler of California's Medical Assistance Program at (916) 445-1995. ' . Sincerely, c. \ . ._ . . BivEsite A. Mxsas, Direct*. c j . ''HE AMERICAN OCCUPATIONAL THERAPY ASSOCIATION, INC., t . . August 30, 1978. Hon. HERMAN E. TALMADOE, c . 'Chairman, pint:See Subcommillee.on-Health,, Senate, Russell Senate Office BuilditiP, Washington, D.C. , . DEAR Ms. CEstsitsw. : The American- Oecupational. Therapy. Association is pleased. to submit this statement on S. 1392, the "Child Health. Assessment Aot", which strengthens and itaproves tbe early and periodic screening diagnosis and treatment Program (EPSDT). ,. For over sixty years this Association has represented independent health Cpraesaionals who specialize in alleviating the suffering and increasing the inde- pendence . and productivity. of the aged. the physically or mentally disfibled, and the economically or culterally. disadvantaged. OCcupational therapy prac- titioners are trained in curricula involving developmental psychology, anatomy, neurophysiology, and the social sciences. This training is followed by field work ,. experience in areas such as psychiatry, rehabilitation, developmental disabilities; and gerontology. . . .,_ Occupational therapists are among the few non-physician mental health pro- fessionals who are trained in the medical. and biological sciences. They provide services in general and.psychiatric hospitals, nursing homes:community mental .health and mental retardation centers, rehabilitation agencies and home health settings. and public arid- 6rivate school systems. rs Of the occupational therapists engaged in direct service to clients, 25 .pe4nt work exclusively with persons under the age of twenty. Many of these therapists perform developniental screenings, sutp as'the Denver Developmental Screening Test, iik children up to age six to ittliseover any dexel2pmentardeficits which could hinder their performance in school or at work. The Associatimeand;the 25,000 members which it represents. therefore, have a direct interest id legislation which improves the provisions of screenjng, diagnosis, and treatment services to Medicaid eligible children. The Association. is pleased that N. 1392 expands the eligibility of children for Medicaid Services and provides incentives to the states to encourage the provi- . :don of quality -health rare services to eligible children within, those states. 34-464 0 - 79 17 25 'However, we believe that there remain several problem areas in the Child Health Alinement Program (CHAP) which need to be addressed before this legislation is enacted. The Aimehttlon is concerned that S. 1392 gives states the option of including lie =eluding care and services, for individuate under age 21, for the "'treatment of mental illness, mental retardation, or developmental disabilities ./." We be- Helm that if tbncoverage for these services remains optional and not mandatory. Many states will not provide treatment servicei for these individuals. The Association strongly believes that the growth and-development of Medicaid- eligible children will stiffer if emblems discovered by .the .screening of the develop- mentally disabled, mentally retarded, and emotionally disturbed are not treated or at legit referred for treatment. Therefore, We recommend the deletion of the following discriminatory language in-S. 1392, Section 3(()) : 'tut not necessarily including (!)'.those for the treatment of mental illness, mental retardation, or developmentalpsabilities." The above language was eliminated in the House Subcommittee on Health and the Environment, and we strongly urge your committee to follow this lead. The Asslociation appreciates this opportunity to submit our comments on the Child Health Assessment Program and stands ready to .offer our assistance in the implementation of. this much needed legiklatiOn. Sincerely, JAMES J. GARIBALDI. - Executive Director. AMERICAN ACADEMY OF PEDIATRICS. Evanston, III, August 22. 1978. Hon. Heaucts E. TALMADGE., CAOrTIOSOS. Subcommittee on Health. , Committee on Finance, U.S. Senate, Washington. D.C. Dena Smrxros TALstetoac: In the near future the Committee on Finance will be asked to consider the Houk-passed version of S. 1392, the "Child Health' Assess- ment Act." As per yourletter of March 20. 1978. to Dr. Martin Smith. member of the Academy's Executive Bout. we are pleased to note that you plan to. include in the scope of those hearings a review of the etdministration of Maternal and Child Health programs (S. 3188 and S. 3401). While the Academy elected to sub- mit written testimony in response to the August 14 hearings. we will requelt to testify at these expanded hearings. In the interim, the Academy wishes 0) draw the attention of you, and your colleagues on the Committee to the implemention of current and ani amended ireislatitin on EPSDT aspects of the Medicaid Law. AB you appreciate and understand. the passage in 1967 of the EPSDT compo- nent of the -Medicaid Act heralded a very deliberate change in the concept from the remainder of theAct It represented an expressed intention to seek poor children: it, -periodically assess their health and health needs and to secure the distinct services required to meet their needs on an ongoing basis throughout the child and youth age periods. This purpose was a most distinct difference from financing personal medical care. The judgment of the Academy is that the Admin- istration is-just beginning to appreciate this difference. and. thus, the purpose has newer been fully realized. Cur judgment is ba,sed essentially on the reluctance of the Addlinistration to deielop an appropriate staff, in federal central or regional offices which-is knowledgeable and technically competent to administer a health., care program for child , as opposed tp a staff to administer a financing mecha- nism per se. The changes proposed by the Admini ration in S. 1392 and those modifications present In this bill reported by the nous ,Committee do alldress useful improve-. meats in such issues as eligibility and fins gig. However, it is our judgment that unless very definitive changes pre made in the administration of the EPSDT component, the legisla ve improvements alone ate insufficient. You ant your col- leagues rightfully and persistently ask why there. is so much difficulty having private medical pract o rs participate in Medicaid. including EPSDT. The Academy expresses i ft belief that without a significant voice isithe formula- tion of policy. regulatio s, guidelines and ongoing advice to the respective stet* offices from those knowledgeable about child health and the delivery of ambula- tory child health cache Administration of EPSDT and the whole of Medicaid itself has a strictig71111ancial orientation. As important at financial fraud and 2:y 255 , . abuse issues are,- they -haie never been issues in priveative care for children in - thils country. Our task is to :seek poor -children and have them beCome part of a . sensible, Iligh-qnslity, on-going health care program. The fraud and abuse-in this respect is the failure of the Administration to understand the purpose of the 1967 amendments and to staff the agency appropriately: .. We respectfully stiggest you examine the, number and roles of physicians, nurses and allied hrerschnel employed in the central add tegional Offices of the'llPSDT and whealo -Medicaid Program& Without such talent in significant numbers and appropriate Positions to diiect the Program,' it is impoesible' to expect that the Program offers to the states the-direction and advice hitended by Congress. r - . - P t -- We suggest jeu consider the following structural changes in order to 'realize the intentof Congress : - 1.. Centralise and elevate within DHEW the authority, and responsibility for,' -health programs serving mothers and children. At-present there are two principal, ollices carrying this responsibility,, ape under the Public Health Service adlilin- istering title V SSA.and one in th -Health Care Financing Administration ad- '. ministering title XIX SSA. - . ' . 2. Authorize the organization a. fr natttonal advisory body on in 1 eimp and child health within DHEW, This grouP would review all health p ms serving mrTho :hers ancichildien and advise Congress and the Administratio on the content and implementation of such programs. :1 - -3. Authorize each State to develop a similar advisory-body to assist in abistate level administration "and implementation of maternal and-child health prognimi 4. Direct the Secretary of DHEW to develop a staff in the central and regional (dices competent in the content and delivery of child health services. - The Academy appreciates and supports the wisdom in the separation of legis- lative and executive powers in our government. The steps we epggest do not in- ' ' fringe on that prInciple. We believe these changes will greatly assist the realiza- tion of the. intent of the 1967 amendments, and those currently before Congress. In closing, I would add that, despite the aboye-cited criticism of she EPSDT Program, the Academy continued to consult and cooperate with the Administra- tion in the general area of provider participation in Medicaid programs. We are interested in seeing practical, waking relationships developed at all levels and in all aspects of that program. Nvertheless, the shortcomings in EPSDT and the effect of -those shortcomings on gur nation's children force us to speak out in favor of reform. . . .-; Sincerely yours, .i -.... DONALD A: CORNELY, M.D., Chairman, Tait-Norce on EPSPT. and Titlf V. . "... i '' . STATICMENT OF THE AMERICAN MEDICAL ASSOCIATION /. ' . ThAlberIcan Medical Association takes this opportunity to submit its views' on ,S., 1392, legislation that would modify Abe. qurrent Early. and Periodic Screening. Diagnosis, and. Treatment (Epspr) program under the Social" Security Act. - , BACKGROUND ON PROPOSED LEGISLATION . . This proposed legislatfon would. amend title XIX (Medicaid)" of the Social Security Act to provide foto a Child Heplth Assessment Program. The stated purposes of enacting this new Child Health Assessment Program are to modify - the current EPSAT progratri .end to extend Medicaid EPSDTeligibility to those Children whose families are O lOW ilICOme but who do not otherwise qualify for Medleaid because of family structure. . . S.1392 would reqVire states to offer through their Medicaid programs the provison of child health assessments and priinary care to all children under SIX years Of age Whose family ,meets the state's income test fOr Aid to Families with Dependent Children (AFDC), but whose family structure makes them in- eligible fop AFDC. In addition, the state would be required to Prr ovide child health assessments and primary care to children under the age otwenty-one whose families ere receiving aid or assistance- under certain statervelfans , progradia. . ' - .- -.- , .- .; I r . An individual under the age of twenty -one who has received a health assess- . ment' under the Child Health Assessment Pr Ogram would continue to he eligible, for medical cake for six months after eligibility for .medical. assistance woul* otherwise terminate because, his family .exceeded the eligibility limits to continuer" in the Medicaid progrem.. 'Child health assessment could be provided on6 by a health care provider Who entered into an egreenient with the state agency responsible for adininistering the state Medicaid program .to provide to eligible children services including: pert- odic health assessments, a'minimum 'range. of diagnostic and treatment services, and when indicated, referral to approPriate providers for needed treatment. To be eligible to participate in: the program a health care provider would have to assume responsibility-for the -management,of the. medical care of each indlildual assessed to assure that all medical/ services which are offered under the state plan and ,which are found to be necessary pursuant to an assessment are Aniade available in, a timely manner and that .reassessments are performed as reqtliredi,Uregulations to. be promtilgated by the Secretary.' .As an incentive to states to enroll eligible children with health 'care providers participating in the program,. the,federal matching cpntribution would be in-. '.creased. Forany state, this incentive rate would be half of the sum' Ot the state's, .current Medicaid matching rate and 90.percent (but not less than 75 percent), for7sunili expended during each quarter which are attributable to child health "assessments; cUagnosii; treatment:', follow-up and medical care Managenient Of itidividusle who. have ,been assessed under an approved child health assessment prOgrain. : . . Feteral reimbursement under' the 'Medicaid program would be contingent upon a state meeting snail standards as the Seerepap may determine for the purpose of (a t informing' families of children .eligibletvatiet the program of the availability of ehild health assessment -settrices; (b) assuring: the provision of child.health. assessments in a timely "manner; (e) assuring the. provision, of any. . medical care or service. the need for tvidch isiischNed by assessments and' (b) assuring compliance with terms of 'agreementslt has with providers. of services under a state's child health assessment program. ksailure to comply with the stated requirements% would subject the state to cr.30 percebt reduction' in the. federal matching rate under. the Medicaid, program. where the Secretary ileterminesi that a state has nit the criteriii 'pursuant - t to reguletionS) .fir good performance' under the Child' Health Assess- meht, Program, ,a. V,5 percent federal' niutching rate "bonus" 'for administration of tiitrograut wouldbe made to the state. . .- " ." . COMMENTS' The AthericairMedic.al Association express-es its strong support for the. goal of . expanding the availability of quality health care to Children, particularly the children from medically ,indigent families who should .benefit most from health Care Services such as those cur4ntly provided under the EPSDT program, Physi- chills, perhaps more than anyone else. appreciate the. importance of adaqUate health assessment and care for ttur young people. It is in the formative years of growth and development of the imaidual, both physically and intellectually.. that such services are the most crucial. The importance of adequite health .assessment and rated cannot.be emphasized too strongly. and the al profes- -0 sion is most pleased to support the, formulation of legislation to expand access to America's health care delivery syseeni to meet more adequately;the needs of our nation's children and young people.. . The early'and periodicscreening, diagnosis, and treatment (EPSDT) program has come under increasing scrutiny recently. There is little question, that imProve- ment in the EPSDT program is needed. President Carter. in hiA.health Initiatives message to the Congress last year, observed that the'EPSDT prgoram reaches only 30 percent of the 12 million children currently eligible fol. Medicaid; that approxi- mately 22 percent of the claildren screened under EPSDT and found`to need treat ment do not receive the services required"; and that the present prograth 'does not react an estimated 700,000 children under six years of age who are in families whose income meets state 'financial requirethents for Medicaid hift whose family structure makes them ineligible for Medicaid. '- While we recognize the weaknesses of the present prograiratWe believe that the EPSDP'program under the MediCaid law is fulfilling a needed service and de- r e- . ', 257. .; ,, .. . . 4, -.. . 410 seoestaLV fitinued support but o ytwith appropriate Modifies on. However, we. froth assuring-full access to quail y tare.. are concerned 'that the =Alike ions proposed by this legislation would detract , . . First, the Federal GOvernment. is .already deeplakinvolv.ed in a large numUkr. . of healthcare programs, each addressed to variornrsegments ok the population. .AccordIntly, the approach to. meeting the health care needs of our citizens has often'be& fragmentary. For example, in attempting to assure maternal and child. . health, two sial programa exist, the Maternal and Child Health Care provisions under title V of the Social Security Act and the current EP.SIY1! program 'Under title XIX of the Soeial SecuritY Act. While these two programs are in many id- stances complementary, theY,are also duplicative in other instances. We believe .that each of these programs has a. function thll should be retained:11nd in ,many respects. expanded, to assure quality health care to eligible children and their mothers. Yet; we would drge that. these programs must. be viewkd: together. .. Neither program was intended nor' canreach all .deserVingssibtential beneficiaries. 4 other reason why we -believe, that the legislation as it'is proposed is not an 7 Mite -approach to assuring full access to the health needs of :our 'nation's Idren,is that the. Child Health AssessMent PrograM would contipue Ito be . administered. under the present:Medicaid program. Under present law, a state , having a Medicaid program is required to provide EPSDT services to all ,children . eligible forlledleald, yet, the program has failed to do so. We recognize that the proposed legishitiondoei provide Increased incentives.to .a state to provide child health assessment services. Nevertheless, we fail to. understand how increased incentives alone I provide assurance that the health services will, nicjact, be previdetrder e respective. state Medicaid programs. The. Medicaid' program haS left ups in e provison of "mandated" services by the respective states, and the bill would not eliminate this p6tentiatfor leaving gaps.. Furthermore, the Child Health Assessment Program., does not id/dress the health needs of pregnant women and mothers of young children who arethem- ., selves noteligible for Medicaid. Certainit the health of the unbornand.trianewr. born cannot be separated from the health of the mother. It is .for this reason that we.emphasize the continuing need for a program to provide not only for the health of young children, but as well for pregnant women and 'mothere,of very/y4riung children. , . . . . , As, to-speCific provisions of the Child Healt Assessment.Pic ram, we have several strong concerns. First, we note the requ remeht underthe WI that qhild health assessments under the program may be ded only by a health care provider who enters into an agreement with the state. agency responsibk.for. r:04 administering or supervising the adrainistration%ef the state Medicaid plan. is provision is undesirable, and maid result in the receipts of levels of ;health care. 'fee those individuals recettleg care under, the CHAP program different from . those individuals receiving care thrOqgh other health car& providers.To. require a health care provider to enter into a health care agreement is not only onerous for the provider, but . could tend. to concentrate CHAP beneficiaries around a . --. limited range of providers, such as in special CHAP clinics. This provision in itself could lead to curtailment of the individual family's right to select a physi- cianOr other health care provider and may in fact effectively deny a benefIciarY 'desired -medical attention by restricting 'the medical resources. available to such (11A.P beneficiary. . i By requiring only health care provide that have contracted with thestate . Medicaid agency to be germitted to provIlle CHAP services could result loathe, evolvement of Special-`clinics" for the provision of CHAP services and thuslit preclude any participation by health care providers or phyfdclans who Atni ht othetise desire tdcproiride such services: This could result not only in seve ly . restricting. the availability of medical services but ..in failing. to take aqvanta e of the broad range of medical services now readily. available through the priv e health care sector. The establiShment of a "mini-health delivery system" -ap la- gous to a government .health service under an erpanded.EPSDT program will limit access to many. of the available medical resources in our present system and may well thhift the sco and quality of services. to CHAP beneficiaries. In addition, under the bill a health careprovider participating, in the Child Health Assessaredt Program would be required to take responsibility for the man; , ageMent of .the medicaLcare of each individual vssessed.to assure that all Inedi- mil services which are offered under the states. Nledyekid pre tram are made avail- able in a timely 'manner and the reatsessments .1zerfOrMed as required in , ), .1. regulations to be issued by the Secretary. t.4 . -it . .. . . . , e The prOvider would be required to refer individnals to other appropriate pro- ; .viders, for ally corrective treatment which is not 'available. directly from the paticiPating provider. The health. care provider would be required to follow-up . this referral to assure the prevision of such treatment. . - . . . . While it is. desirable forait.pittient to haVe a prImary physician On., whOm that .patient may rely for the ordination of his meffical care, we mast take strong .' exception to any-specifleation in the law thatipequikes the health care provider to' assume reaponsibflitt'.for:assuring. that a patieilLreceived specific follow-up . treatment We need only. point out that.,the .physiMi-patient relationship is a . :. voluntary one and as such a physician maintains do control over whether a patient will return Vr follow -up treatment and /or consultation. The physician : cannot Cominand.the patient to return ter follow-up tre even.though . he. . realizes, that such follow -up is necessary to Ensure theFffectivenesti of earlier. treatment.To mandate bY'la:w., thatlrbealth care provider hi reapOnSible fora . : ....patient over whom.the provider has no control once that patient leaves the office .., or institution is at best a gratuitous requirement.incapable of fulfillment, Mit at its worst, is a clnditIon which may well deter participation by physicians In. the program becubse:of ostensible-legal implications. . -. . . We believethat the requirenient in the bill that the Ifbalthcare Provider follow up such referrals to assure the provision of the indicated treatment is iaapprOr priate for another reason. When a patient is 'referred to in specialist foltreat- meat, -the niitial specialist' is responsible for the patient's specialized care. ACCorciffiV0, the proyisions as stated-. in the bill should be inodifi to reflect the applicable law. ... . : i The itewOuld. require 'a. participatin ealth care provider in e- : Child '. Health Assessment Program to provide to i ividuals receiving benefits under the program "a minimum range" of diagnostic and treatment services. However, . no further definition is provided for what spefilfic services will be deemed "Mini- :. mum." Because the success of the Child. Ileallk 'Assessment Program will depend in large part. on -the scene of services made tivallable_to beneficiaries, we believe that it is crucial that any legislation not limit access to physicians. -', We believe that the use of the phrase "a minimum range" could be construed- in such a planner as to preclude yslcians and other hgaith care providers' who . may, nut '.haVe specific equipment nd facilitisoQn their offices from providing certain services (e.g., laboratory s vick, certain diagnostic equipment, or cer- tain reatment facilities)'..,k lack of such facilities doe's not, however, in any manner necessarily affect an individual's physician's ability to provide the.ailpre- priate assessment and care needed for beneficiaries under the Child, Health ., Assessment program. A strict deft on could 'thus remove ready. access to Mich' assessment': and care gimd Alionid he encouraged nor permitted under the bill:Our co.neeraOver the use ofthe phrase "a minimumradge" are even 'stronger When we consider other language of the bill in relation to "health care centers." The bill would require that-a State.plan for medical assistance. must provide.that .a State will encourage participation by 'physicians and health, care centers in the Child Health Assessnient Prograta. Success of the program will of hecessity require wide Particimtion.by physicians! As the prinCipal health care provider, the physician provides, and will Onntione to providei.the basic, structure around- which any ChB& Health -Assessment Program must befashalaed. f. require that a state encourage tpCarticipation by "health care centers" in thec ild Health Assessment Program raises. several questions .ith respect to assn ing full aceese.to quality lienitb care. The principal purpose f the CHAP i--program is to inereaiel'access to cafe, owever. requiring "health c re centers".. the health care available to most ch en at other than centers, No. definition is unduly emphasizes a particular locatio for receiving health .care and bverlooks provided of what will constitute a "health care. Cent-Sr:" The undesirable,:refer- ence to "health cite. centersShould be'removesj. ' .. l ..4' We see the desirability for Congress to express Its goncern over the seope of benefits:. If done through an expressio'n in (7ommitteestgiPoiks, greater flexibility would restrlt without freezini into statutory language the specific scope of hene- .,flts desired. At the same time, unless some speCification is proVided, a mere tegis la tive shell may be created without substance. . Another concern we 'have with the legislation is.that there is noprovision to assure fullest participation by physicians in the CHAP program. Presently he. ..._,EPSD1 pregream is under the Medicaid program and reiniimirsemenfls<let ''',1_ '' ..,, 259 -2 '::'. . . . , :. . mined' under that program. However, reimbursementis restricted.ln. many dates tkinsufficientievels. While under thastakete'no reimlitirsezient can exceed. what Medicare Wald pay (itself. set at ,an arbitrary level), Medicaid is 'generally lowep. 'Retention' of such levels will accentuate current '.problems facing the d program,gind with an artificially restricted payment mephanism.physi will be discouraged from participating in such programs, Any" such impedi- .' menu to phyliclan participation in the program Will'prevent full access by indi- viduals to intended benefits of the program. To encourage full participation and access, relmb Bement should be at usual and customary4evels. The bill * requires that a health care provider rendering services under the Child Health ssessment Program must make such rep,brts'as the state or the,- Seeretary of H W may require to assure complianCe with the4equireinents of the program; Ii.we,vet, no specific guidance is- piovided with respect.10 the content of these .rig nor the extent of days which alight be required% aueh .reports. Again, while' we do believe that the la', should,'not spell. out alrxietails _ as ate normally undertaken in reguliktions we do, believe that the.,;,!la* should . provide reasonable gnidanceAo the, agency responsible for' draiing. up specific 'guidelines or regulations for the administration of the prograrp. Therefore, we would urge that greater information be provided with respect to material that would be required to be included to be made. At the same time, the Subcommittee should 'weigh carefully the creation of burdensome paperwork and 'administra- tive impedimenta deterring program participation-. '- . . '`' As we'have expressed earlier, we fully support the provision of health. care . services as are envisioned ander the present 'early and periodic screening, dlagnolde, and treatment program. Our major concern is not that the program should not be improved,but rather than any changes be made so as not to dis- courage full opportunity of patients to have access to care and that any changes be made la 'conjunction with.an evaluation of other related programs: We are concerned, ea ht the Subcommittee, with health care costs, with efficiency in health care delivery; and 'with the quality .or health care services provided. Itls with these concerns in mina" that we raise these issues with respect to the expansion of the EPSD'r prograelts proposed in S. 1392. .. ..- We believe that in your consideration of modifications of the current EPSDT program; consideration should also be given to the availability of maternal and ''' . child health care under title V of the Social Security Act. Title V, in its support of local and regional program; has long been a prominent and effective source of health care for underserved children and yout . 'Established in. 1935, .rhis program -currently affords hlialth services to mot ers and children wTctror economic reasons, have difficulty in obtaining the s rviees they need. The - tile V program would he expanded under legislation recently adopted inf:a_joint effort of the American Medical Association. the American Academy ,of Pediatrics, ,and the American College of .Obstetricians and Gynecologists, so as to address thorkfully the spirit and intent of this program in meeting the national needs of maternal and child. care and giving added emphasis to special health service needs .of prospective mothers and the developing fetus. the heeds of the 'infant in its first year of life, and the need for treatment and counseling for conditions associated with pregnanc', venereal disease. drug addiction. and mental health. This .legislation has been introduced ns S. 3401. the vlias Amendments to the Maternal and Child Health and Crippled Services Act." We commend it to the attention-of thissubcommittee. . CONCLUSION In conclusion we would like to point out that in addition to needed changes in title V of the Social Security Act and to changes,in the-Child Health A.4sess- ment Act, some of the issues of :Kress, free choice, and quality, care would with greater efficiency and cost effectiveneks be handled through a .comprehensive health9 insurance proposal such as is set forth in S. 218=a health insurance program that the AMA supports. One ofethe advantages to be gained by such legislation is that the health care of all meinbers of families be,. all economic levels is taken into account, not just the health care of a particular memher.of a certain family. As you mielit well agree. oftentimes the health of one family member has a significant bearing on the health of Other fanilly members. . Accordingly, corisidei-ation must not be lost of a holistic.' approach as the most appropriate manner of assuring quality health care to all needy it We wish to reiterate our NtippOrt for the current EPSDT program. lieve that this program is fatifilling a vital need and-providiqg certain beaWirvices 2';:. 260 . . e to ch of low incoule families. Yet, while we support the present EPSDT Iprogra e believe that this program should not be viewed as addressing the total b care problems of our nation's children. As we pointed out earlier, ..-.4 EPS ices arealLUired to be provided under.existing state Medicaid plans. . Yet E servicave, not been provided to all eligitile Medicaid bene- .1icid-riei. e suspect. that many of the basic problems with the EPSDT program., may not in the scope of benefits but rather in the administration of the pro- .... grata. Therefore, we do not believe that the reforms suggested in this proposed ' legislation would effectively achieve the desired goals in providing increased .. -.;:,:seuallty health care services to children. . We )...e that the subcommittee consider our specific concerns with the pro- - posed lon to modify the purrent EPSDT p °grams. While we support the general colitept.embOdied in the/Child Health A &essment Program. legisla: tfOn,.Ove.:urge that -ai-Ont, oturnittee not additt, this ()posed legislation' without modifications 'reflecting our rns. . . ,:- STATEMENT OF THE DENTAL 111'01E:41AV 4EIVCIATICe; . israootierzos -7--, ,.. . .. , ... :. The American Dental Hygienists', Association lid pleased to submit a records,`,;. statement to the Subcommittee on Healttiof the Senate Finance Committee and to present its views and recommendations on S. 1392, the Child Health Assess- ment Plan and related bills. The Association testified last year on H.R. 6706, the-House counterpart bill introduced by the Administration, and supported amendments presented by Congressman Andrew Maguire and the American Dental Association, both of which advocated the inclusion of a dental care com- ponent for. Title XIX eligible children and matching funds to states at parity with levels .specified for .other ealth care servic6s. In the Senate, the Ariso- dation is pleased to support he amendments proposed by. senator Chiles, to". accomplish the same basic pun ose. In view of the extensive revie and consideratitm of the CHAP legislation by the House Commerce Health Subcommittee in 1977 and this year and the approval of H.R. 13611 (an amended H.R. 6706) by the House Commerce Commit- tee, the Association urges that the Subcommittee on Health amend S. 1392 in a similar vein. . GOALS OF TITLE 'V OF THE SOCIAL SECI:EITY ACT The Association recognizes that the Child Health Assessment Plan (S. 1392) introduced by she administration is intended to be u successor program for the title XIX, Medicaid, Early and Periodic. Screening, Diagnosis and Treatthent (EPSDT) program authorized by Congress in 1969, with implementation be- ginning in the eari70's. The' 196) Social Security Act amendments provided t clear evidence of thillatent of Congress that the states *ere required to include dental care for children in their EPSDT 'migrants in order to be eligible for federal matching funds. The acepteil definition intended by Congresa was that States. should provide dental .curc which is necessary for "relief of pain and infection and restoration of teeth and maintenance of dental health". In 1972, Congress gave further indication of its intent that Vision, hearing, and dental care be included in State Programs, fiy authorizing the 114artment of Health, Educa- tion and Welfare to impose peosities on states whch did not fully implement the EPSDT program,for the Medicaid - eligible children s 'smut:aloft. a Although the 1969 and 1972 Social SceuritY amendments established the intent' 0 . of Congress with retaheerto dental care for title XIX eligible children., the im- plementation of state dental.pritgrams nevertlielesS, has been spot-Idle and, in , general, disappointing. EverPthe-publication of HEW regulations for state'dential EPSDT programs in 1975 did not provide the impetus:needed to fulfill the major goal..of title V of the 'Social Security Act Which calls upon all states "to provide finality 'health services for prospective mothers, infants and childrerk4particuiar- ly in urban and/oelow income areas.. whare necess to quality care b4 otherwise limited". This. high e)fpectation and low fulfillment with regard to care pro- grams fOr needy children particularly dental careappears to be the foremost :reason which encouraged the Administration to introduce legislation lust year to -improve, refine and strengthen the faltering EPSDT programs. 2' 261 rs , . Since. the 'Admialstration intenda.-to replace the Maternal and Child Health DT pr rams with the new-tHAP legislation, the Association believes t an ideal opportunity Is now at hand for Congress to develop new legislation which wig allow it to carry out he original intent of the Title V, osocial Security -Act legislation. Longstanding Association policies support the passage of federal . programs which* provide comprehensite dental health care programs for all children. In addition, we support with the highest priority,- programs which . concentrate on providing health care tochildren of families eligible to receive Medicaid assistance through state and local government' he Association be- . Heves that dental care should be an integral part of the-:MI approach to the . prevention of disease and disability and Vat. the maintenance of good oral health of children and youth .14 an essential ingredient of their .total health and well -being. ADIIA. members also believe. that/it Js extremely, important that federal programs, such as; the CHAP, include adequate provisien and financial support for oral heillth care and services.. , . . . . I, f! .. . . . . WSW PROGRAM WEAKNESSES . - Over a 10-year period, 1967-1977 inclusive, Medicaid expenditures for delal services. increased- from $72 million to $400 million annually. -However, as a pereeht of all Medicaid expenditures for health care, the high point was 5.5 Percent in W68 and the low point 2.5 percent in 1977. In 1968 federal expenditu4s for all MeIlicaid health care services were $3,451,000,000,- while in 1977' they reached an ail-time high of $16,257,000,000. It Is obvious' that EPSDT dental health.programs ter disadvantaged and needy childrenan estimated 11,000,000- .15;000,000 eligible beneficiarieshave been comparatively ineffectual, despite . the efforts of 34 states to develop such programs. Even with Ita flaws, how- ever, the Medicaid program has made dealth care available to millions who, before 1965, were not able to obtain it. On the other hand, it Is an accepted fact that frbm 90 to95percent Of I children, from early. childhood tothe late'. teens, need dental care. Ahighly pla official of the Me.dicaid.Bureau of.DHEW, -. as recently as April 1978, told a .dents, audience that ".as far asthe Medicaid legitV . lative structure Is 'concerned, you have, if you rill, a second-class.Program only 34 states have choloen to provide (dental tare) and of those states, 12 of them to provide it only to the 'categorical needy' ; 1.e1,21slo e Who receive a cash welfare grant". Under the. circumstances described, the Association agrees that from a dental health care standpoint the Medicaid state EPSDT programs should be replaced \,, and that a CHAP program, amended to include dental' benefits for children up re age 21, should-be passed by Congress. In our view, H.R. 13611, developed by the House Commerce Health Subcommittee, voted up by the Interstate and Foreign Commerce Committee and sent to the floor of the House of Repre- sentatives, would remedy the many flaws of the current Medicaid program, especially those Which have discouraged state welfare departments and state dental otganizations from developing children's dental health programs.. ... . Although EPSIre Medicaid regulationscreqUired that .staters. provide "at least .,; such dental care as is necessary fci the 'relief of pain and Infection and 'for. T, the restoration Of teeth and maintenance of dental health"; states applied this. 'definition in a variety of ways: A majOrity of states provided-services only if a. health assessment had generated a dental referral. With fissessments'performed by physicians.and nurses, rather tit dental personnel (tem\ dentists or dental hygienists), only about 25 percent .1) tire screening resulted in dental refer;als. Only a few states paid for dental:service§ whether or not -an assessment had occurred. . .. , . . t ..- . Therels a consensus among pr ess Oriels in 'dentistry, medicine, and public' 'health that virtually all children and above -need dental care. The health screening requirement of the current ,PSOT program and the-Administration's CHAP (S. 1392), predicates eligibility for Medicaid dental benefits on a general' health assessment which is clearly inathetinate Or the dental needs of children. If the approach to dental care contained in H.R. 13611 were taken by the Senate, -04 children eligible. for a health assessment would automatically be referred to dental office, in which thorough and effectivi dental screenings, performed by licensed dentists or dental hygienists, could he accomplished. . The Association urges that the provisions of the House Commerce Commit- tee's bill mandating dental care for children eligible for CHAP program bene- . .... 262 flta be. approVed by the Senate: We also urge that Ali-children who. undergo. a CHAP clinic health assessment, simultaneously be referred to dentists or dental . hygienists who are .prOfesidonally qualified:to assess oral health care needs and provide preventive care that Is indigenous to general health care and well -being of children and youth. eraliatate match, averaging 55 rcent and ranging beteeen 50 to 78 percent. A second major flaw of EPS1 state dental programs has beeit the low fed- Thelldm_ni Istration's CHAP proposal increases the federal-&atch up to-a maxi- muitrOf 90 percent but it leaves dental services at the former low and inadequate level. As a mandated CHAP service in H.R. 13611, dental services would be at parity with all other health care services. The Association urges that this level of federal funding for children's dental health care be endorsed by the-Senate. Under the new matching level proposed for all health care services provided under state CHAP programs, there is no logical reason from the standpoint , of children'a,health and welfare to maintain dental care in its current second- class stattur." . . . .. Despite its awareness of flaws and ctiticisms.of state EPSDT programs, the AssociationAlleveatbat the efforts of some 34 to 40 state welfare, dental health 'departments and dental organizations to develop programs under . Title XIX Medicaid should not only be maintained but vastly improved. The higher federal matching formula included In H.R...13611 should provide the necessary stimulus required to attend to die -dental needs of childeki -of poor and disadvantaged families, We are eoncer ed that the, downgrading of dental care in the adminis-i tration's bill, omitting ntal carefronf the increas'of funding levels for medi- cal services, would adv r ly affect the state EPSDT programs now.operating:, An seven greater concern i that many existing children's dental care prograMs, forfthe lack of financial incentives td the states. may be permitted to deteriorate e be phased out entirely.. As inadequate nationally as Medicaid EPSDT dental pr ams hive been, it is.unthinice le that exaisting levels of oral health care services will not be maintained. ,- - . . ,. c _ . ''';'. .... . (4.18T EFFECTIVE 'CHAP DENTAL PLANS ti l' 'the Association is well'aware iifelhe conceWCof he Subcbniznittee on }ialth which relate tothe add-on costs oflfieliiding dental is in a new CHAS' bill: .We share the 'coqcernsor committee members of gress.: and .the general public that new progriliTs In the health and welfare areas should be considered sparing v, if at all..-In the present mood and temper of Cdngress and the general public, he add-on cost of s CHAP dental program will not be insignificant. Howev . the inclusion of dental °benefits udder the Medicaid program can) hard! considered as a new benefits package. Nor because a dental component is Inc) ed at federal matching levels adequate to encourage states to develop them, should their probable Cost-effectiveness. in the long run, to the nation's health be ignored. n our opinion. the public health 'policy view encompassed in the House Comme ee Committee's bill. which holds that dental care and pre- ventive oral health services are an integral part of the total health care of the ' nation's children and youth, is a sound poliev. It is also a policy whic we be- lieve will be endors by the Senate..IN e believe that the investme of public . .funds in a preve .e dental health program for disadvtrntaged and needy' chil- dren will be .a sound investinent iq the. future good health of the ext genera- tion otadillts:" - . I . . . . .- Although records and data from state dental health..31edicai programs are not available in;gretit abund nee. one. state. the strte of Califo la. has been successful in dereloping a sophisticated and- effectile 'Medicaid program. which might'well tut a model for other states to emulate. This plan 'deludes both the children.and adult Medicaid populations of the state. The California Denti- , Cal piogram, Its' it is called, is efficient. Ninety -four and one alf (94.5 percent) of the public funds expended.pay fdr dental care and spr ees: Only 5.5 pefcent re required for administrative services. Through regio :dental, offices, Denti- scheduled \ .. nearly 45,000 clinical screenings in 1976. In t e children's program, Denti-Cal enrolled 1.196:897 patients in the years 1974 -197. It provided a three- pear total of 750,000 preVentiv prophylaxis and topical fluoride treatments and -- completed 3.406.749 dental re' oration in the same three-year period. The num- ber of dentists partiCipating in Denti-Cal increasedlrom 8,000 in 19TA. to.more than 12,500 in 1976. . , , . --; f 1.f 263 0 The most impressive' accomplishments' of the -Denti-Cal program, however, are beat suromedup by the Executive Vibe-President of the California Dental' . Service, Dr.-Erie D. Olsen. In his remarks delivered at an April 1978 Confer cnce on Dentistry in the Medicaid Program, Dr. Olsenobserved that : The amount of dental care deliveries has almost doubled between 1973 and 977.. Total Program costs have. increased due to three fdctors. First, more citable reimbursement Is have resulted from annual fee increases which have approximated the crease in the.cost of living. Second, there has been the aforementioned incre in the utilization of beneficiaries. Third, the largest: :. increase in totaLprogram..costs has been due to the dramatic' increase in the . . N4 fer of people. eligible for Medicaid. Yet, the actual cost for each eligible isliot ganged very, much over the four years of the project even though pro-. gram utilization has gone up draniatically.. During 1974, Dentl-Cal's first year, CDS.paiff$&5.75 for each meent receiving care. Through effective adniinIstration, . dental review and accumtlglian of patient treatment histories,- the cost. per . . 'patient has since decreased to $74.90. These figures indicate, that more befte . ficiartes are receiving services while CDS' professionally oriented administratien . . Is reducing fhe coat of care. The California experience with state de Val Medicaid programsprobably. ,-, the largest dental program administered :by aby state governmentahould be reassuring to Congress, government officials and the public that t long benign neglect of dental conditions known to exist among the nation'a famlikklive near or at poverty levels, can be ended. TheexAmp e of California, r ldren whose' - 'and. $LRbral othsr states which have. been developing dental plans for state Medicaid progrfts, are -proof enoughthat public and private sector programa (fire.needed, widely utilized, and can be-cost-effective w40'n essential adminis- trative'controls are imposed. Because dental-Care is in#Insically a- preventive health service, the long-range cost benefits. for the ad* population of a futftre -4 . generation are probably incalculable. However, as anlEvestme t in health; long- range dental care programs for needy and poor chilcitin can no onger be shunted aside "because they are too expensive" for governinents to co ider. The Association urges the Subcommittee to judge the 'addition of mandated . dental aervicee in CHAP Medicaid programs on the merits of the services which can obviously be provided by the dental profession; on the need in relation to the imboryauce of dental care tot :elfildren:-n the foreseeable improvement of the general health and well-being of the next geveration of adults; and .finally, On the basis of .recognition by health professionals and consumers alike, that dental car is indeed a, basic medical service, rather than an optional service which is o expensive to add to current health care services provided under the Medics Progra Gil. year when:Senator Chiles introduced the "Children's Medicaid Amend- ments" for the-Administration's "Child-Health Assessment. Plan" (S. 1392), he "poirited,out that dental .cate was a "glaring omission" ip many state Medicaid Programs, despite the fact that dental-care "has the .highest ,rate of incidence . and the lowest rate of treatment for poor children". The Association concurs 1,. > routine dental care for eligible e children through the age of 17". ile we be- with this observation and the provision in his amendments "that states provide Weve that the upper age 11 t shipid he revised to 21, as 11.R. 1361 has done,, We share the Senator's vie s that dental-care for children is dear' a medical service and that untreated en-tat-problems can produce not only p in but also permanent physical impel ent. We believe,- as does Senator Chiles, that the exclusion of dental care fr m Medicaid, coverage at-levels recommended for other I health care services inclu ed IniS. 1392, is essentially !'an arbitrary attempt,to ssve'money that undermi es the central intent o_f Medicaid". We urge t at the Senator's colleagues on the subcommittee share these views by approvin "a bill which embodies the major features of House bill 1-fR. 13611. DENTAL MANPOWER RESOURCE8 j . . .. Thesassociation wishes to assure the subcommittee that the dental professiop . bas'ample manpower resources currently to fissiim,ediesponsibility to adminiater an expanded and jimProved CHAP Medicaid program: At the close of 1977 cal- endar year, there were 112,700 dentists engaged in private practice, 82,000 den hygienists, and 14.700 dental assistants. In 1976 and 1977, dental and dental urinary schools reported the cumber of graduates as follows: Z .Dental 5,177 (1977) :ir tal hygienists 4,616 (11n6) ; and Dental assisting ' 61208 (1976). , ,,- .6 --. , 0 i s 4 Thk current dental work force and the annual output of dental an tal . auxiliary graduates is more than adequate tip be responsive to an improVed nd expanded CHAP deatal.Medicsid program. In addition, between 1974 and 1977, the.profession has graduated more titan 8,000 Expanded Function Dental Auxil- iaries (.:DA) who under the direction of a dentist, an perform new and expanded functions in the dental care )delivery systetnEFDA graduatei . are e dental.bygietIsts ozi'dental assistants, who have either graduated froth accredited .dental auxiliary ,schools, or who have left practice temporarily to complete special, studies in Continuing education programs to become qualified to perforin . expanded functions as st e dental Imvs permit. .. The associatian wish s ittforni the subcommittee, that dental hygienists:- o are already licen e preventiveAre any' direct patient services, a s unique standby manpower resources of the dental professiow Dental . hygienists are ready and willing ,-to assist the profession in meeting further Increases in consume emends for.0ntal care. In order to obtain-a license to practice, dental hygienists must be graduates of acctedited dental hygiene . schools. The dental hJgtene educational. program includes instruction in..the biomedical, dental, and behavioral sciences and substantial amounts of pre- clinical and clinicaldentat hygiene instruction. In addition, in order to obtain a license as a Itegisteredq)ental Hygienist, most detail' boards examine gradu- ates for proficiencies In dental and periodontal charting, X-raheory and technique., and competency in rendering prophylactic' treatment and other therapeutie treatment procedures. In developing new or 4panded.,CHA1' pro- grams in all of 'the nation's 54) states, dental hygienists are qualified by educe- tio'D and license to assist detaists to provide the 'highest level of preventive dental care jo the currently undeserveq. Medicaid-eligible children's population. In. our.view. there should be no reason to set aside a Medicaid Children's den- tal program because of any claith, however spurious, that there is insufficient.pro- relational manpower. The facts speak otherwise and, in fact, reinforce the thew that given adequate financial incentives t velop quality. dental care . programs, state dental plans underCHAP can be ly improved and expanded in all states. SUM MAHN. The Association concludes this statement with the following summer( of its views and-recommendations: .7. The Association ,believes that dental services are medical services, as defined in the federal EPSDT Medicaid program for children, and that dental as ssmentdiagnoSis, and t.reatment should be mandated in CHAP lelSslation for edicaid-eligible chiMPth: . The Association strongly reconnuendt4 that federal matching funds for state Medicaid dental CHAP programs be troy-Heti at the same level as specified for all health care services; i.e., the federal matching shareishould he increased". over existing EPSDT funding levels by 25 percent and up to a maximum of 90 percent ; .k . . , 3. The Assoblation urges the fenate Finance Subcommittee to require that state dental CHAP programs provide oral health as44essruents,. diagnosis, 'treat- ment, referral, and dental care management for all eligible children and youth under age 21; in addition, the Subcommittee is urged, to require that oral health,' amseagnents, diagnosis, treatment, and referrals be automatic, or simultaneous, with other health assessments when individuals are registered in tht health assessment progr m; - Associat )n believes that preventive dental Care programs for Medicaid- eligft e clalldren w be cost-affective and produce long-range cost benefits which ' will in Ole public interest; and 5. Association is -confident that the dental pro ion, by utilizing its den 1 auxiliary work force at maximum, has sufficient liable dental man- po er currently ,to administer CHAP dental programs .ubstantIttily itn p ved levels of services; in particular th'e dental hygiene work force is uniquely p pared by education, license. and experience in dental offices, to assist the profession to maintain the highest quality of sere in the %livery of dental care to the nation's poor and needy children. .-APPENDIX CHIP ADMINISTRATIVE COMPLEXITIES ( MEW RESPONSE FROM PAGE 181 ) The The attached paper identifies 11 potential problems for States in administering CHAP. The solutions proposed are dependent upon the development of compre- ensive data preeessing systems. A separate paper on current systemleaPabilities of States' presents the projected time schedule for developing State systems to a trafficienf level to handle CHAP. The attached solutions represent ti3e kinds .of capabilities State systems would be expected tb. have when, they have reached the CHAP level of strfilcieney. These "solutions" are intended to serve as examples of the wa systems could handle the CHAP ad,ministrative complexities. but it is expected that States will r retain the flexibility'. to select alternalivesystems solu- tions to t ese probleras. . , Atte eht. CHAP ADMINISTRATIVE COliPLERITIES , . Problem Area : Varying Match Services for CHAP children receive (a) Whena child receives an as different match from those rendered to ment, the bill ...fnr the screen trig other medicaid eligibles. the.posting of 'an asgtssmOnt on- e eligibility file. (b) At end of quarter, the State . selects all'claims by recipient identifier and totals expenditures for AP children' separately: ,, ,- CHAP services vary in Federal match (a)*The\kc iputer files-wou a .0'1,, among famijy planning, inpatient serv- a cross-refer Tfce.file associating 0- of ices and ether services. service to nurtching rate. (b) Referring to the selection' de- . .scribed in 1(b.) above, claiths would be , classified by -service 'type within all 111, . claims for each recipient? Higher match ends when child is due (a) The eligibility file would contain for next assessment. . a field' denoting the date the next assess- . went is due for eaclchild. . ' (b) When the computer is totalling expenditures for CHAP children (item 1( b) ), it will ignore claims for any serv- ices rendered after thp next assessment due date if the next assessment has not 6- been conducted. I , Higher match for outreach. ( a I State could manually reebril the salaries. fringe benefits, overhead,. tied transportation costs %for; personnel en- .../ gaged in outrottch,This would be'simi- : tar to the methods States currently use to itftt, track of administrative &sits assoc(ated witicmedical personnel and their staffs. .. . (b) For personnel engaged in out- reach plus some other activity, the. State would have to document an allocation method' for distributing costs betw6en the two Activities. . ( 2(15) 2 -1 266 Problem Area : Eligibility ." PkOBLEU SOLUTION.; fr CHAP splits a famiLv'sseligibility or medical assistance three ways: - The family can be eligible for AFDC or on 4-fnonth continued AFDC cover- age, thereby receivir)g Medicaid; as is currently the case . A child can be indivjdually eligible for medicaid since, for example, a family income of $4,100 might leave the par- e..at(s) ineligible, while the child is eligible. ' The child also becomes eligible for ad- ditional services after having been as- QS sewed, so there, is a need to recognize a child as CHAP -eligible. 6 tal . . ..? Assessed children' with lapOes- in eli- gibility .wcpliti have to lie reidentitied for CHAP Ilenetits to continue without a requirement for another assessment upon becoming eligible again. Twenty-five States will have a new. eligibility determination process for children' in families under $4.200. It will take more staff and space to handle the workload. r (a) It hi '111tely,ttat States will have tb issue a siwtte medicaid card for childrebin the family. This should only be diMeilt for States which have not assigned separate medicaid identifying antihero to individual members of the family heretofore. A child's eligibility for medicaid would probably _be deter- mined...by the casewarker who is exam- 'Ling the family's eligibility for public assistance. . It is also likely that States will have to issue la separate CHAP card for a child who has been assessed. The CHAP' ,caseworker could issue g temporary. CHAP card upon learning that the as- sessmeut has been completed. When the, provider's I for the screen is sub- mined to ate, it could then nigger the issua ce a CHAP card ,,which would gm yell until the next assess- ment is due. (c). The plc assistance eligibility unit Will have to alert the medicaid unit responsible for updating the medic= aid _eligibility reference file when chap s in family income have made the fsmil ineligible, have placed the family on onth continued coverage, Or have ac e child on 6-month continued coverage. rates would-retain computerized eligibility records on each child for 12 months following ending date of Inedlc- aid coverage, Keeping inactive' files for" more than 12 months would become too . burdensome in relation to the lower likelihood of reentries after thtft time.,. (a I The greater the extent to which the eligibility criteria are similar to ones with which the eligibility workers are already familiar, the easier it will be to establish this. additional process. For example,' any disregards for CHAP eligibility should not introduice ne4V dis- regards not already present in AFDC. (b) The additional staff and space .problertis can oply be hatulled by ad- vanced Stale (or County) planning to have the necessary resources available. Problem Area : Provider Agreements 4, States 'Why haye to enroU new pro- eider types,. such as- Clilitrs. "practorNe,pd podiatrists; and ,ser-re- induraetnent schedules for them. 4 ( Use institute- fitr Medicaid Man- agement to provide examples of pro- vider agreentut4 and Feimbursement schedules States which already offer services from these proVider toes. :b .01111.= 267 P1110111E11 1641pUTI0N V States will 'have to yalve limits on (a) States amend provider manuals amounts, duration, and scope for CHAPto make providers aware of removal of children only. limitations for CHAP children. (b) ConiPuter processing routine will' match claim-against eligibility file, identify that recipient as, a CHAP child, and Awn rgnore service, limita- tions applicable to non-CHAP recipients. (d) States will, need to concentrate weir utilisation review activities upon*, services which nave had amount, dura . tion, and scope limitations removed. Ccipayments may be requlrea for , (a) Modification of the provider adults is a family, while they are pro- manuals should alert providers to' a - hibited forCHAP children. ,copayment policy which differs between children and adults. A CHAP card would help protect the ejjild from being asked for a copayment. The- computei 3. could adjust cost -sharing, and reLtn- . bursement between child and adult services. This conflict in copayment re- quiremeritS is already present under the current EPSDT pr m. 0,Prpblem Area : Tracking Children Into Treatm nt .. Many States hot have the cape- .c (a) EPSDT penal regulations will bait,' to track. Children, into treatment require tracking of each child with _or, Its S.-comfier/7, to aitioefitte a treat- problem conditions and ., will * help went bill with conditions found in motivate States to install improved scieenitig. - ,systems. ,(b)i A gen'eral systems design of a model. EPSDT Management-lnforma-- tion. System is being developed by j:IEW ts. and will he delivered to the States When the final penalty regulations -are -I promulga tett , . '.1. (c) The MediCaid 'Bureau will award contractsi in fiscal year 1978 for tech- nical assistance to. States in improving ikeir case managetherit systems. (d) The "Medicaid Bureau is hivesti- gating the possibility for advanced sys- .: tems funding (90/75 percent) for States del'elop computer systems which fulfill the principle functignal require- ments of EPSDT. o s ( HEW RESPONSE FROM PVE 184) The Department his developed a draft -request fur proposal (REP) which will toelicit proposals for-d6outOttitton 'sites. We expect to have the final EF-reo4 shortly. -Iglimtereacir*-::fff:th'e,,s1110P will depend on the availability of ndvisince titese demonstrations and eheir independent evaluations 'would cost excess of $4 million over a three-year. period. The funds are not avetiatrie to the projects cause of general limitations and higher-priority *oft. We would ope t.lh 19n sufficient funds could be found with which-to da these projedts. &Mien. HCFA. and the Robert Wood Johnson. Foundation have been cot rating en a series of demonstrations and evaluations to test new methods of delliering and reimbursing services byNexpanding the delivery of primary care and Preventiveservices in ambulatory clinic settings in mrderserved urban areas. t , 3'. 0 ' ' 4 , .A (4,