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Against this backdrop, let us examine the Community Mental Health Centers program. In 1963, the concept of community-based care for the mentally ill was an idea whose time had come. There was mounting evidence that the mentally ill recovered more quickly and with a far lower emotional burden on their families and loved ones when they were treated in their home communities. For 10 years, the Federal Government provided support, first for construction and later for initial staffing costs of community mental health centers to demonstrate the viability of the concept. By the end of this fiscal year, the Department will have provided financial support for the development of over 500 community mental health centers across the Nation.


The value and effectiveness of innovative community mental health centers have now been amply demonstrated. These centers can and will continue to play a very important part in the management of emotional illness. However, it is time to shift the responsibility for developing and operating such facilities to State and local agencies which must ultimately bear the major responsibility for the direct provision of public health services of all kinds.

Our decision to phase out support for community mental health centers is consistent with the philosophy which underlies our health strategy, that it is appropriate to underwrite promising new methods of health service delivery, but only until their feasibility has been proved or disproved. As the Secretary said before this subcommittee on March 29, 1973, in announcing that the Department is not proposing extension of the Community Mental Health Centers Act but will continue to honor its commitments to existing centers, "The need for federally funded demonstration has been met."


We believe that the States are firmly sold on the community care principle and are willing to assume the primary responsibility for carrying the program forward. A significant number of centers are already in place. Every State has at least one community mental health center-which has received Federal support-and, in others, such as Kentucky, Maine, and Montana, for example, more than threequarters of the population live within the service areas of funded centers. Further, many States have adopted a community mental health orientation to service delivery. We note, for example, that in 35 or more States community mental health services acts which provide a State commitment for continuing support have been enacted or are pending.

In a few States, for example, Mississippi and Alabama, a significant portion of current State revenue-sharing funds have been dedicated to mental health improvements. In Baton Rouge, La., city-parish revenue sharing funds will be used to purchase a building to provide a full range of outpatient services as part of the Baton Rouge Community Mental Health Center. In addition, as the Secretary also said on March 29, "The success of the individual centers which do prove viable

should be an adequate incentive for other localities to undertake these services to its people." We believe that the current momentum behind the community mental health concept will be adequate not only to maintain existing but also to stimulate the establishment of new


An additional aspect in insuring the fiscal stability of any center is its ability to maximize its utilization of medicare, medicaid, and other third-party health insurance programs. Federal initiatives and technical assistance are now aimed at helping community mental health centers makes maximum use of such resources in their planning for services. Regional offices and NIMH central office staff have been advising center directors on ways to arrange for basic benefit packages in public and private insurance programs so as to eliminate gaps in coverage for mental health services. In addition, center staff are being trained in cost accounting techniques and sound fiscal management, in contract negotiation, financial planning, and fiscal resource development. There has been extensive and focused assistance in the development of a data base.

But it is not enough to assure an adequate flow of funds to a project. The Department has been equally concerned with the way these funds are spent. The results of evaluation studies are being made available to center leaders to improve the delivery of services required by the residents of the catchment area. They have also been encouraged to conduct regular utilization reviews of each mental health service to insure high quality of care within reasonable cost boundaries.


In short, the Community Mental Health Centers program is not being terminated. What is being terminated are Federal grants for new community mental health centers. Sufficient funds have been requested to complete existing commitments. The administration is, however, continuing to support, with technical assistance, consultation, resource development, and the dissemination and diffusion of mental health knowledge, the future success of the program and will retain a strong leadership role in the stimulation, development, and strengthening of community-based mental health programs.

We will be pleased to try to answer any particular questions you may have.

Mr. ROGERS. Thank you, Dr. Zapp. Mr. Hastings.

Mr. HASTINGS. Thank you, Mr. Chairman. I will be brief, because it seems as though we have been over this ground before and probably will be again. Doesn't it seem that the real question at issue is whether or not the congressional intent was that these be demonstration projects only, as opposed to what the subcommittee feels that is, it was not a demonstration program?

Dr. ZAPP. Mr. Hastings, I think that is the heart of the question before the committee and between the executive and congressional branch of the Government.

I would tend to focus some more on another issue. We have had disagreements on the legislative history before the committee. I agree with you any continued discussion is probably no more apt to bring agreement than when the Secretary was before the committee.

Mr. ROGERS. Did you say there was some disagreement on the legislative history?

Dr. ZAPP. I said: On the disagreements of the legislative history between the Department and the committee when the Secretary was here before.

Mr. ROGERS. It is in writing, and it is very clear. I am not sure I understand that statement. In fact, if you need it read to you, I can read it on page 9 of our own committee statement, where we say: "The long term goal of the community mental health program is the establishment of a network of comprehensive mental health services that will serve the total population of the United States"-total population, not 500 communities. "The overall response to the program, as reported to this committee, testifies as to the readiness of the Nation to institute a community system of mental health care.

This potential can be realized, however, only with an adequate base of resources for planning, initiating, and developing the quality of programs essential to assure the equitable provision of services to all communities.

I don't think there is any question about it. The Department may be stating how they want to proceed, but the legislative history is quite clear; and, as one of the authors of the act, I can confirm what is in writing; it is correct.

Dr. ZAPP. I will acknowledge what you read as part of the legislative history but would further state

Mr. ROGERS. It can be confirmed in any other part of the legislative history.

Dr. ZAPP. I think the Secretary was drawing a further analogy to the fact that this committee, as well as other committees, continue to review certain programs and the fact there was an expiration date originally on the authority as well as continued expiration dates placed on the authority.

Mr. ROGERS. We review all legislation originating in this committee. That does not mean the program is not adopted-because we are reviewing it. We are reviewing it now because you don't seem to understand the intent of Congress. That is why we are reviewing it.

Dr. ZAPP. The point I was about to make to Mr. Hastings in more central than our agreement or disagreement on the legislative historythat is, the Federal involvement in the mental health centers at this time. The health strategy is as expressed in my statement. That is the appropriate Federal role.

We are saying: With changes made by Congress itself, as well as proposed by the executive branch, during that period of time, we have indicated a much stronger emphasis on individual assistance. In fact, most of the HEW budget goes out for payment of services as opposed to developing systems for delivery of services.

We feel at this time the Federal role should be one of adequately demonstrating new concepts and proving they are worthwhile and turning them over to State and local resources to operate. We have a responsibility and now are giving a commitment to improve mental health and to provide financial access to health services. We see this as the role of assistance to individuals.

Mr. ROGERS. Yes; I understand.

Dr. ZAPP. That was a different role than I think Congress assumed in 1963, prior to the passage of medicaid and medicare.

Mr. ROGERS. One can have all the money in the world, but, if there is no facility in the community, no doctors, no psychiatrists, it doesn't do any good, does it?

Dr. ZAPP. I understand, Mr. Chairman.

Mr. ROGERS. Excuse me; it is your time again, Mr. Hastings.

Mr. HEINZ. Mr. Chairman, should I indicate that nearly all of his 5 minutes has expired?

Mr. ROGERS. We have not yet invoked the 5-minute rule, Mr. Heinz, but I will remember that as you begin your questioning.

Mr. HEINZ. I just hope Mr. Hastings will be brief.

Mr. ROGERS. All right.

Mr. HEINZ. Let the record show this was accompanied by a wink. Mr. ROGERS. All right.

Mr. HASTINGS. Is there any difficulty with the concept by the Depart


Dr. ZAPP. None at all.

Mr. HASTINGS. There is no need to get into facts or figures as to what it has accomplished in the communities?

Dr. ZAPP. No; we would find ourselves one of the strongest supporters.

Mr. HASTINGS. You make reference to national health insurance as shortly to be introduced which will contain some mode of delivery of service to mental health, and yet the pragmatics that we deal with indicate there will not be any passage this year by the Congress of any national health insurance.

I think you are probably aware that this committee won't have jurisdiction over the matter; the Ways and Means Committee does. Any argument saying national health insurance could supply some of the need to community health centers-that probably won't mean anything this year. I know the committee cannot say it is going anywhere, because Congress is not going to act. I have to remove that from my mind as an argument on this year's funding for health in community mental health centers since I am convinced we will have no national health insurance.

At the same time, I am aware the administration will not submit this year a special revenue-sharing health proposal which will provide funds for the continuation of this type of community mental health center. I am correct on that, I believe, from the testimony of the Secretary when he came before the subcommittee.

Dr. ZAPP. I think it highly unlikely we would get into health revenue sharing. The Secretary indicated we have it under review. We share with the community a certain sense of that under 314(d) funding that goes to the States. How far we will go with that is not yet decided by the Department.

Mr. İHASTINGS. Certainly in the foreseeable future, this coming fiscal year, we cannot expect the States will receive any financial help from revenue sharing or benefits from the national health insurance?

Dr. ZAPP. That is correct. My comment on national health insurance is part of a long-range financial base. There has been an increase through third-party reimbursements, from the Federal sector, the States, and, in many cases, from insurance companies.

We are saying that it is our proposal and that this be further enhanced. When Congress passes national health insurance we will have a component. We are not proposing to withdraw any support or assistance made to the community health centers.

Mr. HASTINGS. Those in place?

Dr. ZAPP. That is right. We feel we should not get involved in any new starts, any 8-year commitments.

Mr. HASTINGS. If we believe in the concept of getting new starts, we don't cover anywhere near all of the country. I am referring back to the funding necessary to get them started. I have to rule out national health insurance, rule out special revenue sharing for health.

You mentioned 314(d). I understand the administration is asking for special earmarking on 314(d). Am I correct?

Dr. ZAPP. That is correct. There is no way--I think we have indicated that-of retrenching from community health. The State should have more flexibility and choice to set their priorities. We think, with some 35 States having or having pending before their State assemblies community health assistance acts indicates strong commitments from the States. We don't think it is something they will shy away from because the earmark is not there.

Mr. HASTINGS. I think that is true. My own State, the State of New York, already has a strong ongoing program. I know those legislatures don't move that quickly. My concern is that, without funding available for new starts, without the knowledge that all these States are, in fact, going to be able to establish programs-this is my interest in continuing this program as well as others for 1 year to give us and those States and communities the opportunity to find where they are going to find the money to make new starts.

I am not saying there should not be some consideration of the administration's position, but I know of no alternatives now; that is my problem. As of June 30, there is no more program. I don't know of the alternatives that will allow new starts to be made around the country.

I won't belabor the point; you know my position. We have discussed it many times. I think it is consistent with what I feel is the obligation of this committee and the Government that we provide those alternatives. I don't see them now, and that is my major interest and concern in extending for 1 year as those become more visible to us.

Thank you, Mr. Chairman. I yield back the balance of my time.

Mr. ROGERS. We will give you more time if you need it, Mr. Heinz. Mr. HEINZ. Thank you, Mr. Chairman. Dr. Zapp, there has been a reported population decline in our State mental hospitals-a decrease in population of our State mental hospitals. Do you agree with this? Dr. ZAPP. Yes; I have no disagreement with that at all. Mr. HEINZ. Is there data to support this?

Dr. ZAPP. Yes.

[The following information was received for the record:]


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The above table indicates a total reduction of 150,314 resident inpatients over the period 1957-1972. This is a 35 percent reduction overall.

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