caid program, again, by Federal regulation, Congressman Dellums, we have a medical care advisory committee, which is required under title XIX of the medicaid program.

There are a number of providers: optometrists, druggists, physicians, representatives from hospital providers, as well as a large number of consumers on our health advisory council.

We do involve, largely through the structure of our committees, planning committees the developmental disabilities that the council recently appointed has key providers on it, as well as consumers.

The federally required advisory council with regard to drug addicts and to alcoholics also have providers.

Through the mechanism, Mr. Chairman, primarily of our established, many of them federally required, committees, advisory committees, we do involve providers to a large extent in our planning process.

Ms. Johnson, did you want to say something?

Ms. JOHNSON. I just wanted to add that we also involve the health profession medical providers in establishing standards for new services under the medicaid program.

Mr. DELLUMS. Thank you very much.

Does counsel for the minority have any questions?

NURSING HOME REGULATIONS

Mr. PATCH. Yes, thank you, Mr. Chairman. One reason cited during staff investigations over the summer for the absence of enough longterm care capacity in the District was strict nursing home regulations which private operators have to follow.

A suggestion was made that if the regulations were not so strict it would provide some incentive for attracting more long-term care facilities.

Are these regulations another example of federally mandated regulations which you must follow? Or do you have any flexibility to use your regulatory power to provide incentives for long-term care?

Mr. Russo. The local regulations-States have an option in their licensing and certification processes. They can follow their local regulations or they can follow the Federal regulations.

If there are local regulations, those local regulations must be followed. There is no disputing the fact, as you've indicated, that the existing local regulations with regard to licensing and standards of health facilities, long-term care facilities, particularly, are rather stringent, when compared with the Federal requirements relating to long-term care facilities under title XIX.

This extraordinary and unfortunate fact has been addressed by the District of Columbia Council. The District of Columbia Council has amended the local statute. The mayor has approved the amendment. The District of Columbia Council has amended regulation 7415, enacted in 1974 by the then-appointed District of Columbia Council, which is the local statute, establishing standards for licensing purposes of skilled nursing homes and intermediate-care facilities.

The Council has amended 7415, and in this process has brought these provisions on standards and requirements much more closely in line with the title XIX HEW regulation. In that process, the District of Columbia Council has also included standards on licensing requirements of community residential facilities, which includes the licensing and establishing of standards of adult foster homes and adult group homes.

On November 7, the congressional layover period will end on this amended legislation, and these new, more realistic provisions will then be implemented. This is going to help us considerably, not only in enabling the private long-term care providers, but also our own longterm care facilities, such as District of Columbia Village, as an example, to better meet the new and more realistic standards and licensing requirements.

LONG-TERM CARE FACILITIES

Mr. PATCH. Just as a follow-on to that, do you have any plans to, once the legislation is enacted after the layover, attempt to get that word out to those who might be interested in opening long-term care facilities?

Mr. Russo. We certainly do, Mr. Counsel. I do want to state that during the city council process in amending regulation 7415, many, many of the private long-term providers testified at Ms. Shackleton's hearing on the proposed amendments, and were deeply involved, for example, in developing the standards on the licensing of community residential facilities, adult foster homes.

As soon as the amendments to 7415 become law, and, as I said, this is supposed to be on November 7, we will mount a massive public information campaign to assure that all providers are thoroughly aware of the new standards, and this will be done primarily through the frequent contact that Ms. Johnson's staff, in her Division of Licensing and Certification, has with these private long-term providers. Mr. DELLUMS. The Chair yields to Counsel for questioning.

WAIVERS

Ms. MOSBAEK. Yes. I'd like to return to the waiver to 93.641. You mentioned that the District of Columbia did not want to lose its identity as a jurisdiction and "control over its own destiny."

Mr. Russo. Yes.

Ms. MOSBAEK. Is this not a parochial attitude that works against area planning?

Mr. Russo. I do not think it is, not if we can demonstrate that we can still bring about effective, cooperative, coordinated regional health planning, even though we retain our prerogatives and our integrity as a separate jurisdiction, which we certainly are.

MS. MOSBAEK. But C.O.G. testified that there were no means to enforce this agreement.

Ms. JOHNSON. That's not true.

Ms. MOSBAEK. Could you then explain what means there are?

Mr. Russo. Are you talking about the Metropolitan Area Cooperative Agreement?

Ms. MOSBAEK. The planning agreement, yes.

Ms. JOHNSON. As a matter of fact, we've had two meetings this summer, specifically to work out project review criteria for the District of Columbia medical facilities project under review to be decided on this December.

The last meeting was only 2 weeks ago.

Mr. BRAUER. Following that up, what our interests, are, I think, is that we have construction going on in the suburbs, and with the increased movement of hospital beds seeming to go out there, doctors may well follow. Do we have a mechanism in that you can say to Montgomery County: "It's not appropriate-it's not good for the overall area needs to build an addition to a suburban hospital" or to another facility.

That, looking at the overall needs, and, particularly, the needs of the District of Columbia, that that's not appropriate.

Do we have that checkoff, given the system that we have now? Ms. JOHNSON. We are beginning to as a matter of course, though we have not reached formal working agreement, circulate to the other signatories to the HSA agreement all projects under review and give them an opportunity to comment.

We have commented on projects in other jurisdictions, and they have commented on ours.

Mr. BRAUER. Just to make it clear. The limitation that you have is the right to comment? There is no checkoff, there is no necessary assent from the District to a new facility?

Ms. JOHNSON. If you mean, do we have right of approval, no. But I think we all take each other's comments into consideration in making our own decision.

Mr. BRAUER. All right. I would just like to follow quickly on to two other areas.

NEIGHBORHOOD CLINICS AND D.C. GENERAL

I am interested in the relationship between the neighborhood clinics and District of Columbia General. Is there a formal relationship between the administrative officers and professional staff at the clinics and at District of Columbia General, so that you have followup here from the immediate clinical and backup acute care?

Mr. Russo. Right. I certainly do hope that the fact that District of Columbia General Hospital soon will be out of DHR and under the control of an 11-member independent commission will have no bearing on this.

But within the past several months-and I'm sure that Dr. Washington is anxious to talk to this point-efforts were underway, planning was being developed to link the medical staff at the community health and hospitals community-based clinics to District of Columbia General Hospital inpatient and outpatient services.

Perhaps, Dr. Washington, you might want to elaborate on that. in greater detail.

Dr. WASHINGTON. Thank you, Mr. Russo, Mr. Chairman, Mr. Brauer. Yes; there's a very close relationship between the public health clinics and District of Columbia General Hospital.

Besides the fact of their being in the same Department initially, there were written agreements to refer patients to the clinics and also to the hospital. That is, perhaps, most strongly demonstrated between the maternal and child health program clinics and the hospital, where records are actually transferred from the clinics into the hospital when patients come to the point of delivery and need certain kinds of obstetrical and gynecological services.

Those records go to the hospital, the patients are treated; and the records are transferred back into the clinic so they can be followed. One of the reasons for having the clinics set up as they were was to have a sort of bilevel system, so that patients could be treated in their neighborhood, go to the hospital, and return to the neighborhood so they wouldn't have to remain in the hospital for a prolonged period of time.

Irrespective of the fact that District of Columbia General Hospital is not in the Department of Human Resources, it is still a District of Columbia facility, and the legislation does maintain a continuing close relationship.

Mr. BRAUER. Is there a budget fund item to ensure the transfer of medical records?

Dr. WASHINGTON. No; there is not a budget fund item, but there is a written agreement, signed by both sides.

NEIGHBORHOOD HEALTH CENTERS

Mr. BRAUER. Just one last thing, and maybe into two parts. Have the neighborhood health centers suffered because of employee ceilings and hiring freezes?

Mr. Russo. I think, in order to be completely candid, the answer has to be yes. The establishment of employment ceilings has further retarded the process of filling positions.

Mr. BRAUER. That is a problem, as we discussed, at Forest Haven? Mr. Russo. Yes.

Mr. BRAUER. It is a problem, I suspect, at District of Columbia General.

Mr. Russo. Yes.

Mr. BRAUER. Is it purely a question of money, a question of priorities within the District of Columbia budget?

Mr. Russo. Let me just give an example. In preparing our fiscal year 1979 budget, we had to take a 1 percent across-the-board cut. These were mandates issued to all department directors, Mr. Chairman, by the Mayor. And all directors had to swallow these cuts-a 1 percent across-the-board cut.

In addition to that, no dollars would be made available for such mandatories as in-grade increases, which is, you know, a pretty substantial amount of money.

We developed our 1979 budget, as we have done in the past 2 years in DHR, strictly based on a ZBB process. We're well into this thing. And as we ranked all of our programs, administration by administration and office by office, with respect to the neighborhood health centers, both Dr. Washington and Dr. Standard made it clear to me that, ideally, in order to meet the level of funding authorized in fiscal

year 1979 or to meet the "mark," so-called, that was given to DHRthey made it clear to me that we really should close at least two or three clinics in order to meet that mark.

We tried to close a clinic, Parkside Clinic, about 3 years ago. This was indicated in a budget that this clinic was going to close. The money was cut.

Because of an uproar of community resentment, and because this clinic served such a vital community need, Parkside Clinic was not closed 3 years ago, and is still very much in operation today.

Because of this money problem, we have made the decision that we will not, in fiscal year 1979, close any of our community-based health clinics, but, for some of them, we will reduce their hours from 8-houra-day coverage, perhaps, down to 4-hours-a-day coverage. But we will not close any of the clinics.

I cite that example, Mr. Brauer, to certainly concur that money is the basic problem in terms of fully staffing the community health clinics.

The same thing applies to the three community mental health

centers.

Mr. BRAUER. Mr. Chairman, I just want to say, on behalf of staff, that we certainly appreciate the amount of cooperation that Mr. Russo and his staff at DHR have given to us, not only in this hearing, but in all the dealings we have had in this other legislation. And I certainly appreciate the time you have taken to assist us.

Mr. Russo. Thank you.

Mr. DELLUMS. Thank you. The point is well taken. And I would like to first ask Mr. Russo, if we have any additional questions, may we feel free to submit them to you and your staff in writing? Mr. Russo. Please do, Mr. Chairman.

STATEMENT OF REPRESENTATIVE DELLUMS

Mr. DELLUMS. Thank you. Mr. Russo, before we recess until tomorrow morning, I would first like to place these hearings in some broad context so that, again, you understand the nature of these hearings.

I guess it was back in 1974 or 1975, it was documented that we spent, roughly, in the aggregate, $140 billion in this country on health, which is an extraordinary amount of money. Certainly, at this point, it is much higher, probably the largest single industry in this country at this moment.

But even given that substantial amount of resources, there are still extraordinary needs and tremendous problems all over the country in terms of our delivery system of health.

And given the rising concern on the part of consumers and others, I anticipate that within the next 1 to 3 years, the issue of health will become a major and important item on the national agenda for debate and consensus and, hopeful, the development and design of some vehicle to eradicate the problems.

President Carter has indicated that whatever the mechanism developed by his administration will embody several principles, two of which are that whatever approach he embraces will be universal, and it will be comprehensive.