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
.
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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"
/
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;
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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
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.
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
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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.
.
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. 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
.
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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.
'
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.
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-
.
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.,
p t--
ALJAJ
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--.: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. /: '
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!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/' .'
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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
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,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
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::. .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.
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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. . -: -
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STAT.E.YIENT OF THE,ASSOCIA'il(IN OF STATE.ANI1 TE;1.:1.1Tote,L3.1.
417,,, AI, AND'1.1.11.LIf
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IIE41TF AND CRIPPLED. 0111-141:' ' 11',1_".ttu11..
.(Presented. By .Indson-Fbrce.. l'.I)Dilltil /.thr..c,-.-:
'i
i niel li., _ . servic..-. De-
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.. pertinent of HeuIth and 3deto.4,1 iiiiil)--tite)
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"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
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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.
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Mae foll6witag stafesoestatriamd recornmendstiOns 'are made-. then,-,in keeping *-
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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.
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...
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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.
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, ,.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.
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,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. .'
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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
.
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States,
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(;)
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.
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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
.
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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.
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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.
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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
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: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. -
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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
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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.
.
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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.
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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"
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' 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:.
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questionably require and to which they
uld otherwise be entitled by vistue.of
their financial status.:
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NEED FOB EARLY INTERirbiTION
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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
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them. We are..thus particularly dismayed at the exclusion from such services of
precisely that population which has a t4encinstrable need for them: mentally
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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.
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;:`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!
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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.
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1"Fresident Carter Gtve, Hope to Handicapped
Individuals," CongrPssional Record,
Vol. 123. No 99. June 9. 1977. pp ming/1-115691.
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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
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EXCLUSIONARY RATIONALE: FACT AND FALL,FY
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- 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.
.
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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
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'.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
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.
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
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A MEBICAN. Pusrac .HEALTH AssodiAncs,
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Washington,D.C., A agast.21; 1978.
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ROM RUSSELL B. Lorin,
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chairperson. Senate Finance
ommittre,,
Dirksen Banat
Offlae Bull ing,
Washington,
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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.
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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:
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2_._; An increase of up to a maximum, of lal.percent ill the Federal matching rate"
...: fOr -health assessments.
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',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
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'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.
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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..
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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
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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.
.
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,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
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14
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Tederal.Realth Policies in the
.
See PS 262 939 for Ilia report entitled: 'Impact of
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14 Aboress
.
policy under Titles V and III
and Vermont for the years
between policy Intent and.
of. Congressional intent. NEW
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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
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provide sufficleit funding to as-
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to be served and services to be
Thie'repart
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law federal agemcidm diversely interpreted federal
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anie state cooperationitoretat pert-Orme:0e
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represent approval or
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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.
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Child health eervices. Connecticut and VermOnt
Maternal and child bealth/state adninietration
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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.
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.....,:,
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,-,' . .
..
,
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.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
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.
..
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.
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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.
.
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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.
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Sincerely, c.
\
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BivEsite A. Mxsas, Direct*. c
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''HE AMERICAN OCCUPATIONAL THERAPY ASSOCIATION, INC.,
t
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August 30, 1978.
Hon. HERMAN E. TALMADOE,
c
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'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 -
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P
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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.
-
. '
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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
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-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.
.
.
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Sincerely yours,
.i
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DONALD A: CORNELY, M.D.,
Chairman, Tait-Norce on EPSPT. and Titlf V.
.
"... i
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STATICMENT OF THE AMERICAN MEDICAL ASSOCIATION
/.
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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.
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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.
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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.
:
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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
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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.
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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-
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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.
,
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, 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.
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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.
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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.
. -.
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. 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.
...
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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
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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
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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.
..
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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
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.
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.
.
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STATEMENT OF THE DENTAL 111'01E:41AV 4EIVCIATICe;
.
israootierzos
-7--,
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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..
,
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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.
.
..
,
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.
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.
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. (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:"
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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.
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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
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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).
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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
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,
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.
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Atte
eht.
CHAP ADMINISTRATIVE COliPLERITIES
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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
,
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(4,