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We must strive, I feel, to develop a truly comprehensive, effective, and continuous interrelated system of health care for those who need such health care wherever they live and whatever their social and economic status.

Hopefully therefore these hearings and the discussions to follow will lead us to work in a spirit of partnership and cooperation which will assure that high quality services, particularly rehabilitative services, will be made available and accessible even to our least advantaged and most vulnerable fellow citizens.

Thank you very much.

Mr. SYMINGTON. I thank you very much for your statement for both its content and its brevity.

With the permission of the witnesses, I would like to establish my own schedule of witnesses here which may not be precisely in accordance with the schedule some of you have at this time and I would like to call on Commissioner Alan Miller, Commissioner of Mental Hygiene for the State of New York.

We are very glad to have you with us today.



Dr. MILLER. Many thanks for holding the hearing and for inviting

I echo Irving Blumberg's remarks about the leadership the Congress has exercised and our gratitude for your being here. I personally feel proud as a New Yorker that among you is Congressman Hastings. I have a written statement which, with your permission, I will not read, but which I would like to have made a part of the record. Mr. SYMINGTON. It is so ordered. [See p. 120].

Dr. MILLER. In my statement, I do describe briefly something of the impact that the community mental health centers program has had in New York, what impacts it ought to have in the future and, in short, my reasons for thinking that it should grow.

I would like to depart from my written testimony to talk briefly and even personally and perhaps autobiographically-in part to establish my credentials, which sounds too formal-and about my relationship to this program, which I think has given me a chance to see it to, observe it, and to be an actual part of it, which is a fairly unusual experience.

I was on the staff of NIMH in the early 1960's. Those were exciting days when the Congress and the Executive were trying to put to work an enormous new surge of energy and concern for the mentally disabled and to find new instruments, new governmental and voluntary instruments, for bringing an unprecedented level of concern for and response to the problems of the mentally disabled.

In that exciting era-I was in charge of field operations at the time—a number of programs were born. Some of them were intended to be short lived. These included (1) a comprehensive mental health and retardation planning effort, which produced in every State a new involvement of thousands and thousands of citizens in thinking through the problems of their own States; (2) the hospital improvement programs which were, I think, unfortunately short lived; and

(3) the comprehensive community mental health services program and the retardation facilities program.

They all represented a kind of federalism, a federalism which I regard as the most healthy kind. They were not Federal programs that made State and local programs something less. They were strong Federal programs based on the assumption that strong Federal programs of a certain character would in fact stimulate and make possible local growth initiative and competency in every community in the country.

That was their thrust and that has been their consequence.

In 1964, I came to New York. I was in charge of a community program and had a chance at that time in that capacity to see how this new legislation could really make a difference.

Even in a State which had already made strong commitments and developed deep involvements in community mental health programs, this act became-to use the overworked term, but most appropriately here became a catalyst. It was not a reward for good intentions. This was an opportunity for the development at the State level, as well as at every county level and for every population group, of a response to the needs and desires of citizens naturally grouped, and of the stimulus it provided throughout the State.

It has brought about a qualitatively new kind of development of health services.

There are certain characteristics of the community mental health and retardation services programs which to my knowledge make them unique among Federal health legislation.

Their focus throughout has been on working with whole populations, with natural geographically defined populations. These programs were not designed to select special clientele according to a number of restrictive criteria, but were rather designed to respond to the full range of needs of an entire population and to work with it and to find ways to do so.

That unique approach, that focus on whole populations, I think, has been the essence and the strength of the community mental health program as we have seen it grow in many States and localities.

For the last 4 years I have been a member of the National Advisory Mental Health Control and in that capacity I have examined, analyzed and finally approved every application for a mental health center that came before the HEW.

I have thus had a chance to see the same kind of experience in every part of the country. Every center is not a static phenomenon. It is the result of a process and it is itself the beginning of a process. Every center has created a living entity in each site where it is located.

This dynamic movement has given each community that has applied it an opportunity to hammer out natural workways for itself. That is why I think it would be important to enable this kind of effort to begin and to grow in all the many areas of the country, this State included, which have not yet had the same kind of support from a Federal program which not only has provided necessary and critical funds but has also carried with it the high level of leadership that only the Federal Government can provide for an idea whose time is long past.

These are some of the reasons why I think, Congressmen, that we are dealing with a matter of crucial importance. We are dealing with more than a matter of trying to decide how funds should be provided. We are dealing with a much more fundamental matter: Namely, how do we meet our responsibility to mentally disabled people.

The mental health program was not intended to be wholly dependent upon Federal funds. Federal funds made it possible to begin something, often in impoverished areas with special groups of vulnerable people who would not have been able to start such programs when they did.

If you look at the experience in New York and every other State, you will find that the funds provided by the State and by local, public and voluntary resources have far exceeded the Federal funds. But what cannot be measured, even proportionately, is the opportunity which this program has provided for something to grow in each new place in a way which was appropriate to it for us in New York, and I can only speak now for New York as its commissioner of mental hygiene.

We think we have made a good start in this process.

We have just adopted some interesting and important legislation, called unified services, which makes it possible for us to join the State and local capacities in every county and city in New York.

The community mental health program would greatly help us continue this essential work.

I thank you for your patience and for coming to New York and we wish you well.

[Dr. Miller's prepared statement follows:]



I am Alan D. Miller, Commissioner of Mental Hygiene of the State of New York. I am most concerned to see the maintenance of the Federal Government's effort in the provision of Community Mental Health Services.

In New York we have reduced the average daily inpatient population of state hospitals from a peak level of 93,000 to a little over 41,000. Although this reduction is the result of a number of factors, a significant one is the provision of adequate treatment in local community facilities. It has been amply demonstrated that a well functioning community health service can make a significant impact on admission rates and more importantly resident patient rates in state hospitals. Since the care of the long term state hospitalized patient represents a tremendous expenditure of public money, continuation and expansion of the mental health center program is fiscally sound.

The saving in human distress and the elimination of the personally damaging effects of long term hospitalization in remote impersonal institutions are, of course, too well known to require further description by me.

It seems strange that on the one hand the Department of Health, Education, and Welfare, through the Developmental Disabilities Services Act, is making specific grants to states to help plan for deinstitutionalization of the mentally retarded but on the other is threatening to extinguish the Community Mental Health Center program, which has the potential to be a great force for deinstitutionalization of the mentally ill.

Since the Community Mental Health Center program started, New York State has built, or has in process of development, 26 mental health centers at a total cost of $98,855,000. Of this amount, $15,622,000, or 15.7 percent represents the Federal share of costs. Thus, a relatively small investment of federal dollars generates considerable resources from the state communities. Furthermore, the success of the concept has allowed us to develop three community mental health centers without any construction costs, using existing buildings in a variety of imaginative ways.

There are currently expressions of intent from six communities wishing to engage in construction of community mental health centers. While it is as yet uncertain how many of these will be developed in the absence of federal support, I know that this source of funding often makes the difference between a go or a no go situation. This is particularly true in poverty areas where the potential for voluntary agency or local governmental participation is small.

Of course, construction, though important, is not the only part of the community mental health center program which concerns me. It has been our experience in New York that gross annual operational costs for a center run at about one-third the capital cost.

For the year ending March 1973, the Federal Government gave to centers in this state $10,823,245 in staffing grants; state and local funds from various sources accounted for just over an additional $20 million. There have, however, been several community mental health centers in this state built with federal aid which have not received staffing grants. For example, Buffalo General Hospital and Arden Hill Hospital in Orange County both have newly built community mental health centers. Their staffing grant applications have been approved, but not funded. Brookdale Hospital with a mental health center in operation sought additional funds for an expansion of its catchment area. Again, the application was approved, but not funded.

Now, it is true that all these centers, by imaginative use of staff and by staff sharing with other facilities, have begun to develop programs. In Buffalo where the mental health center director is also the director of Buffalo State Hospital— many of the staff move freely between state hospital and community mental health center programs, unhampered by questions of whose payroll they may be on. This makes for sound program development and particularly for continuity of care, a point stressed very strongly by the federal regulations.

However, with no federal assistance the program operators are bound to move their services in directions where third party payments can be made.

Although I subscribe to the view that, whenever possible, mental health programs should be funded in the same manner as generic health services, there are some unique problems. In general, health services are paid for on a fee for service model through private or governmental insurance. Most fee for service programs are geared to traditional in-hospital care the most expensive way of providing treatment to psychiatric patients. Few third party payors cover partial hospitalization, and such payment processes never cover the vitally important area of prevention. Since the Federal Government rightly mandates, through the consultation and education element of center programs, a preventive approach, it makes little sense to be advised to seek third party payments. Unless and until we have a universal health insurance program which covers the area of prevention as well as treatment, direct governmental support of staff carrying out these functions is essential.

Another particular of the federal program which potentially is most useful is the provision for providing specialized services within mental health centers for children, for alcoholics, and for other special groups. The problems of providing third party payments for many of the services that these kinds of clients require are similar to those I've just outlined in regard to preventive services.

The single most important value of the mental health center program has been its focus on the need for population-based services. The concept of providing services on the basis of total population needs in an area has been a powerful tool in overcoming some of the problems inherent in the kinds of discriminatory selection of patients that all service providers are prone to, that is, to serve the interesting case or the non-troublesome case. It has also provided a basis for the systematic study of an area to insure that consideration is given to all of the services needed by the population in that area.

We have used these concepts in new legislation in New York State which Governor Nelson A. Rockefeller signed on Tuesday, June 12. It provides for a unified system of mental health, mental retardation and alcoholism services jointly planned and delivered by state and local government in partnership with voluntary and private agencies. There are requirements for strong integrated planning efforts requiring a participation of consumers as well as providers in these efforts, and a strong requirement for effective evaluation and measurement of program effectiveness. The continuation of the Federal Community Mental Health Center program will be of great assistance to us in implementing our plan for the development for a unified system of services within New York State.

I would like to take this opportunity to make known to you a major concern I have about what seems to be the proposed direction of the Federal Government in regard to the support of health manpower training. The recommendations contained in the Administration's proposed budget for 1974 will substantially reduce the level of funds available for the support of training grants, research fellowships and research scientist development activities of the National Institue of Mental Health, of the Health Resources Administration, and of the Social and Rehabilitation Services Agency. I believe this to be a very shortsighted approach to the future needs of this country for the development of the kinds of services which are needed by our citizens, particularly in urban poverty areas and underdeveloped rural areas.

The shortages of health manpower continue to be a major obstacle to the development of adequate health services. We find this to be particularly true in providing services for the mentally disabled. If we do not continue to invest money in training, we will find ourselves with a generation gap in the development of health professionals and paraprofessionals, and we will have in the future an even greater problem than we have had in the past in regard to the number of trained people available to render preventive, treatment and rehabilitation services. I would urge you to scrutinize the budget for training purposes carefully and hope that you will be able to assure yourselves that it will provide sufficient funds to insure that we will continue to have an ample supply of health manpower for services and, at least as important, for research.

Mr. SYMINGTON. Thank you very much.

You mentioned a new State law. Are there improvements in Federal legislation that you would recommend at this time or just further emphasis on what we are already doing?

Dr. MILLER. I have always thought that the heart of the mental health centers legislation has not been-although the concept is important and had to be emphasized early-the so-called five essential services: inpatient care, partial hospitalization, emergency care, outpatient care, and consultation and education.

There was, as I said, a great deal of emphasis on these essential services. They were important because their inclusion reflected the recognition that every population requires a full range of essential mental health services.

I think the heart of the center program, however, was not the five essentials as such but the idea, the concept, of a single focus of responsibility. There had to be a "living" organism that had to have the ability to assess its needs and have a program to provide all the needed services.

As to improvements, there are certain needed flexibilities and I propose them cautiously because, as you can see, for personal as well as professional reasons, I regard the program as a precious piece of legislation.

I think, for example, that it might be possible in some areas to support a center whose major thrust was not residential care-as long as there were adequate provisions for residential services-but other forms of services some of which we may not be able to conceive of today.

Various day services and partial hospitalization services are part of the total mental health program, but in some areas they will be all that is really needed to fill out the program.

These are services which today are virtually never covered by thirdparty payments. It is difficut to get adequate financing for such


I think that these forms of services might be modified. I think there are various ways of considering their formula, their duration, and their structure; but I won't go into them now.

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