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And it is a great tribute to the Congress that it has responded to the need to put our better knowledge to work providing services to the mentally ill as quickly as scientific developments have made it possible.
The better way,” that we now think is feasible, is treatment of the individual in the community. This is what was recommended by the Joint Commission on Mental Illness and Health in 1961, and this is what this committee and the Congress wrote into law in the 1963 enactment, which we now ask you to extend.
Responsibility for the care and treatment of the mentally ill has traditionally rested with the States and their communities. I hasten to say that this is wholly proper, and that we have no desire to supplant them in this responsibility. We do seek to help the States relieve themselves of what could otherwise be a crushing financial burden. State and local agencies in the United States now spend an estimated $3 billion each year as the direct cost of meeting their responsibilities in mental health.
I might add that various statements have been made of what would be needed if they were to do this on an adequate basis
in the neighborhood of $6 billion a year, or even $7 billion a year. This gives you an idea of the liability that States and local governments have at the present time. The total cost of mental illness in this country is far greater—including, I might say, $20 billion which is lost in tax funds by individuals who are not able to work, but who might otherwise be able to work if they were not mentally ill. In any case, all of these are huge, intolerable costs; direct costs to State and local governments of at least $30 billion over the next decade and a total cost to our society of perhaps $200 billion in that period, if we continue to have the load of mental illness that we have at the present time.
The objective of the Federal program is to stimulate and assist the development of community facilities which we know can both reduce the necessity for institutional care and also reduce the length of time such care is required when it is necessary. The establishment of community facilities for the prevention and treatment of the mentally ill will allow the States and the localities to carry out their responsibilities in a more sensible and humane, and a far more economical, manner—and that is the goal of this important Federal legislation.
We have only begun a very large job. In the last 11 years, the population of State mental hospitals has been reduced by 19 percent. In the period between December 1963 and December 1966, alone, the population of these hospitals declined, from 504,000 to 426,000. I think that is a point worth stressing, when we have so many social problems that, in this area, there has been a decrease in the burden that the States and localities, and Nation as a whole, have had to bear. But many more could avoid long-term institutional treatment if community facilities were more widely available.
We estimate that one in every 10 Americans will become mentally ill at some time during his life. These people will require treatment; in many cases, serious illness, and the need for hospitalization, can be prevented if services are readily available to them in their own communities.
Increasingly, private insurers and Government programs have recognized the necessity to cover the costs of mental illness. And this alone will be significant, because it will provide insurance funds to pay for the kinds of services that are being provided. The medicare program now provides hospital insurance coverage with certain deductibles and coinsurance for a total of 190 days of inpatient care in a psychiatric hospital during an individual's lifetime; and coverage under the voluntary, supplementary portion of more than $250 for outpatient psychiatric services. Title XIX of the Social Security Act, or popularly known as medicaid, also enacted in 1966, allows the States to receive Federal matching funds for services provided to the medically indigent elderly in mental institutions, particularly stressing trying to get them out of the mental institutions into community-based facilities. These legislative developments all constitute part of the same broad changes which have taken place, and which are still underway.
The Community Mental Health Centers Act of 1963 was enacted on the basis of dramatic evidence developed by the Joint Commission on Mental Health and Mental Illiness that those suffering from mental illness can be more appropriately, more intensively, and more successfully treated through local programs of mental health services using facilities in the patient's own neighborhood rather than through largescale custodial programs such as those which existed in State hospitals in the past.
As you know, the Community Mental Health Centers Act, which you enacted in 1963, authorizes grants to assist in the construction of community mental health centers. It is, in general, patterned after the Hill-Burton program. Appropirations were authorized for fiscal years 1965, 1966, and 1967, which are to be allotted among the States on the basis of population, financial need, and the need for community mental health centers, with grants being made from these allotments to cover between one-third and two-thirds of the cost of construction of projects, depending upon the per capita income of the individual States. Priority in making the grants is accorded to centers which will provide comprehensive mental health services.
The amendments you enacted in 1965 authorized grants to meet part of the initial cost of professional and technical personnel of community mental health centers. The grants may cover the costs of these personnel for a period of slightly over 4 years, with the Federal share of these costs declining from 75 percent for the first 15 months to 30 percent for the last year of the period. Only centers providing essential elements of comprehensive mental health services are eligible for these grants.
This new approach enlists community resources to meet the total mental health needs of its people through an inclusive program of inpatient care, outpatient care, partial hospitalization, emergency service, and community consultation and education services. Each community mental health center develops its own plan to provide these services to the young and the old, the rich and the poor, the acutely ill, and those who may be saved from severe illness by early treatment.
The community mental health center is a local program of mental health services offering a broad spectrum of types of care to all of the population of a geographically designated area. It is not necessarily a single building or a type of building; the program may use any combination of a variety of facilities--clinics, general hospitals, mental hospitals, remodeled space, or halfway houses.
The program of a community mental health center is designed primarily to provide an adequate range of services to meet the mental health needs of the community as a totality, irrespective of the type of building or facilities that are provided.
To provide all the services in a center which has none of them available, the center would need about 100 professional and technical personnel. The average center, however, already has some of the services, and needs about 50 professionals made up of psychiatrists, psychologists, social workers, nurses, rehabilitation and occupational therapists, and such technical personnel as technicians, dieticians, laboratory technicians, orderlies, et cetera.
At the conclusion of my testimony, Mr. Chairman, this report which Dr. Yolles, the Director of the National Institute of Mental Health, has made, will be appended. It gives you a full report on the program to date, including the number of centers that have been provided with grants, a full listing of all of those by States, and something about the goals and the ways that we went about developing this program. Dr. Yolles will later point out that so far to date we have funded 173 projects, 100 of them for construction, 47 for staffing, and 26 for both construction and staffing, and we hope by the end of this fiscal year to have funded 286. He will develop this further in his presentation.
The neighborhood community mental health centers being built and staffed with Federal assistance under the Community Mental Health Centers Act are providing care which will reduce both the severity and duration of disabilities resulting from mental illness. This goal is being achieved in communities across the Nation through an alliance of Federal, State, and local governments, professional groups, hospitals, and welfare agencies, both public and private. They are working more closely together than ever before on the basis of two principles: continuity of care for the patient, and partnership in responsibility on the part of all those who can help.
A center plan is inherently local; it must be designed by the community, which alone can assess its needs and resources. A center serving a large section of Harlem, for example, will have space and staff for treating narcotics addicts and special techniques for reaching disadvantaged people in emotional trouble. A center in western Kansas will face a number of different problems. There the problem is geographic accessibility of services, and establishing services on a scale which can be supported by a small and very scattered population. In a suburban California center, people may be able, in general, to pay for the services they need; but in a deprived Appalachian area, they may not. The centers may be located, as is one in Philadelphia, where a medical school has long prepared the way; or it may be located, as is one in Florida, where the local general hospital has never before had a psychiatric unit.
The point is this: there is not, and we do not intend that there shall be, a single, inflexible model for a community mental health center. Every one of these communities needs a center of its own design and making. This diversity makes the early success of the centers program, in my opinion, all the more impressive.
Indeed, diversity has been reflected in the type of applicants receiving grants for both construction and staffing support. For example, over half of the sponsoring agencies have been private, nonprofit groups. Also, well over one-third of the center grants have been made to rural areas, that is, cities or towns serving 50,000 persons or less.
As of March 27, 1967, more than $54.5 million in Federal funds had been obligated to assist the construction of 126 centers. State, local, and private matching funds of $109 million brought the total to $163.5 million—$17.8 million has been obligated for 73 staffing grants under the 1965 legislation; an additional $16.5 million is available for fiscal 1967 and we anticipate the approval of another 58 staffing grants by July 1 of this year. In all, more than 173 communities in 43 States have provided the initial enthusiasm and the community support to establish community mental health centers under the existing legislation.
The authority for the construction grant program expires June 30 of this year. The legislation before the subcommittee would extend the construction grant program through fiscal year 1972, with an authorization of $50 million for fiscal 1968, and such sums as Congress may appropriate for succeeding years. The authority for staffing grants, which expires at the end of fiscal 1968, would also be extended by H.R. 6431. The bill would continue the staffing grant program in its present form for an additional 4 years, through fiscal 1972, with the authorization remaining at $30 million for fiscal 1968, and for such as Congress may appropriate for succeeding years.
The bill also makes two changes in the substantive provisions relating to mental health construction. First, it amends section 401 (e) of the act to allow the acquisition of buildings, as well as new construction. This amendment would give a further measure of flexibility to the program; in many cases, the program may be able to move forward more quickly and economically, and to provide services closer to the people who need them, if suitable existing facilities can be acquired, and adapted where necessary, for use as part of a community mental health center. New construction would not be required in every case; this amendment would widen the possibilities for local initiative in designing center programs, and would help assure that all available resources will be brought into play.
Second, H.R. 6431 amends section 204 of the Act to require State plans for construction of community mental health centers to include provisions for enforcement of minimum standards of operation of the centers. This means that the State must show that it has considered and adopted measures which will secure compliance with its own standards. This could involve regular inspection, licensure or financial restrictions. A choice of an effective approach would be up to the State itself.
Mr. Chairman, to achieve the goal of making essential community mental health services available to as many people in our country as possible as soon as possible, continued Federal concern and support is essential. Our goal is to provide these services in every part of our Nation; but our enthusiasm is tempered with realism. Speed and quantity alone, without the careful development and utilization of sound professional and administrative procedures are insufficient, and
ultimately self-defeating. Our request for continuation of these programs and our plans for further implementation are based upon such realizations. We mean to build a program in which numbers and novelty will not replace soundness of purpose and design. A community mental health center can only rise from firm foundations: from systematic priorities in the allocation of resources; from convincing evidence that service will in fact reach the people for whom they are intended; from a certainty that care will be comprehensivethat the continuum of human needs will be met by a continuum of responsive services.
Mr. Chairman, I am here today to ask the support of the committee in continuing this approach, and to urge early action on H.R. 6431. The first communities
ready to establish a center program on the basis of sound planning have sought and received Federal assistance. Neighboring communities have been carefully laying their own plans. The States have been helping them lay this groundwork for comprehensive mental health programs. Some will be ready to apply for Federal funds next year, and I believe many more in the years which follow. We ask that they be given the same opportunity which more than 173 communities have now had—to take local responsibility for mental health care.
Amendments dealing with mental health take up the first four sections of the bill, Mr. Chairman, and I would now like to go on to section 5 of the bill, dealing with project grants to Federal institutions. Federal hospitals are a valuable resource for training, research, and demonstration projects. They offer a diverse array of patients and treatment settings.
Section 5 of H.R. 6431 authorizes research, training, and demonstration grants to Public Health Service hospitals, Veterans Administration hospitals, and to St. Elizabeths Hospital.
Actually, this merely confirms in substantive terms in the statute a policy that has existed in a limited way through “point of order” language since 1960.
In that year, “point of order" language made St. Elizabeths Hospital eligible for research training, or demonstration grants.
In 1963, the hospitals of the Public Health Service were also made eligible, along with the medical facilities of the Bureau of Prisons in the Department of Justice. The 1966 language in the appropriation act is as follows:
[Public Law 89_787] SEC. 204. Appropriations to the Public Health Service available for research grants pursuant to the Public Health Service Act shall also be available, on the same terms and conditions as apply to non-Federal institutions, for research grants to hospitals of the Service, the Bureau of Prisons, Department of Justice and to Saint Elizabeths Hospital.
We are now asking that this policy—which has demonstrated its value—be made statutory and that hospitals of the Veterans' Administration be included among those Federal institutions eligible for the same kinds of grants. The language makes very clear that grants must be awarded under the same terms and conditions that apply to non-Federal institutions.