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Mr. HAMILTON. Mr. Chairman, I am pleased to testify in support of H.R. 6431 before this distinguished Subcommittee on Public Health and Welfare which in recent years has led the Congress in historic legislative breakthroughs to assist in the treatment of mental disorders.

This committee is well aware of the enormous tragedy, personal and social, brought about by mental disorders.

Mental illness afflicts about one out of every 10 persons in this country. It is often a significant factor in criminal behavior, delinquency, suicides, alcoholism, narcotics addiction, divorce, and accidents. The overall cost of mental health has been estimated to exceed $5 billion. The personal tragedy that attends each instance of mental illness is the highest cost of all.

Americans spend more for chewing gum than for psychiatric research to get Americans out of mental hospitals. One out of every two hospital beds in the United States is occupied by mental patients. State mental hospitals are often overcrowded. There are more people in hospitals for mental illness than for polio, cancer, heart disease, tuberculosis, and all other diseases combined. Not a single community in this country provides an acceptable standard of service for mentally ill or retarded children.

The Mental Health Centers Act, authored by this committee, has begun to meet the challenge of mental health in a most heartening way by providing for mental health centers. As a result of the Mental Health Centers Act, a trend has been initiated in the treatment of mental illness to move away from the State hospitals and toward an emphasis on the community-directed mental health center. In 1965 almost two in every three patients were not hospitalized. They received either private office psychiatric care or were treated in one of the 2,000 mental health clinics in the United States.

The need for comprehensive community mental health centers is abundantly clear. The mental health center is a multiservice facility. It can provide easily accessible services for the early diagnosis and treatment of mental disorders, both on an inpatient and outpatient basis, and a resource for continued treatment for individuals returning to their home communities following periods of extended hospitalization. Services and training are made available to help restore a patient to his fullest mental, physical, social, and vocational abilities. Such mental health centers serve as a central focus for mental health services to the total community population.

The Indiana State Department of Mental Health strongly supports H.R. 6431, as does the Indiana State Mental Health Association.

I am persuaded that the enactment of H.R. 6431 can mean the difference between providing comprehensive care and service at the earliest practicable date to those afflicted with mental illness, and an indefinite delay in meeting these needs.

The State of Indiana, prompted by the Federal legislation, has now begun to move aggressively into a comprehensive community mental health program. By June 30, 1967, Indiana should have five approved mental health centers, and at least three more applications are planned to be submitted during fiscal year, 1968. The presently approved center projects will need help in procuring staffing funds in the future. It is

projected that Indiana will need to build and staff approximately 20 comprehensive mental health centers in the future to begin to meet the needs of its population.

Daily, I receive letters from Indiana's Ninth Congressional District which ask for advice on how to acquire mental health services for family members. The tragic fact is that at the present time I can only refer these people to the State hospitals where the waiting lists for admittance are discouragingly long. Public interest to provide facilities to combat mental illness and retardation in the Ninth District is high. Clark County Memoral Hospital has been approved for a construction grant of $530,000, and comprehensive community mental health centers are in the planning stages in Bedford and Columbus, Ind.

Important measures passed by the 95th Indiana General Assembly show Indiana's willingness to participate as a solid partner with the Federal Government in developing community programs to meet the needs of the mentally ill and retarded. One act provides a permanently dedicated source of funds to assist communities in matching Federal grants for the construction and operation of mental health centers. A portion of cigarette tax revenues will provide approximately $10 million in matching funds over the next 4 years. These funds will be available in the event that some committee find it impossible to provide adequate matching funds through local tax sources.

Another measure enacted by the Indiana General Assembly broadens the definition of community health centers for the mentally ill and retarded, gives counties permission to issue bonds as well as levy a 10-cent property tax to finance facilities, and provides that counties may support a center in a neighboring State that serves Indiana residents.

Indiana is beginning to meet the challenge of mental health. However, continued progress in Indiana's efforts to control mental illness and retardation is predicated on the continuation of Federal support. The passage of H.R. 6431 is essential to the success of Indiana's program.

Mr. JARMAN. Thank you for your presentation Mr. Hamilton.

Our next witness today will be the Under Secretary of the Department of Health, Education, and Welfare, Mr. Wilbur Cohen.

Mr. Cohen, we are pleased to welcome you and your associates here today, and you may proceed with your statement in your own fashion.


DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY DR. WILLIAM H. STEWART, SURGEON GENERAL, PUBLIC HEALTH SERVICE; DR. STANLEY F. YOLLES, DIRECTOR, NATIONAL INSTITUTE OF MENTAL HEALTH; AND JAMES F. KELLY, ASSISTANT SECRETARY, COMPTROLLER Mr. COHEN. Thank you, Mr. Chairman. Accompanying me today is the Surgeon General of the Public Health Service, Mr. William Stewart; the Director of the National Institute of Mental Health, Dr. Stanley F. Yolles, on my right; and the Assistant Secretary, Comptroller of the Department, Mr. James Kelly.

My plan this morning, Mr. Chairman, would be to read my testimony, my prepared statement, and insert some materials in the record, and then at the conclusion of that, Dr. Yolles will make a brief chart presentation of the charts that are here which will attempt to illuminate some of the more important points. And at the conclusion of that, of course, all of us will be available for questioning.

Mr. JARMAN. That's fine. You may proceed.

Mr. Cohen. I am pleased to come before this subcommittee today to support H.R. 6131, the Mental Health Amendments of 1967 introduced by the distinguished chairman of the full committee, Mr. Staggers.

I should like to add, Mr. Chairman, that I wholeheartedly concur in the observation you made about the very significant contributions that this committee has made in the development of mental health legislation and mental health program over the last 20 years. We wouldn't be where we are today if a great deal of other legislation had not preceded this which came out of this committee.

H.R. 6431, recommended by President Johnson in his February 28 message on health and education in America, will carry forward landmark legislation recommended by this committee and enacted in 1963 and 1965.

Under this legislation the kind and quality of mental health services available to the people of the Nation is rapidly being transformed. The heart of the program is the concept of providing care to the mentally ill in the communities where they live—where they will have the support of family and friends.

That concept may seem perfectly logical and ordinary to the members of the committee. This, in itself, is a mark of the tremendous progress we have made in the mental health field.

The last half century in particular has seen a revolution in our attitudes toward the treatment of the mentally ill, and in our ability to deal meaningfully with mental illness.

Consider how great a distance we have traveled in a remarkably short time:

It is 113 years since Dorothea Dix succeeded in her fight to have Congress pass a bill appropriating 10 million acres of public land for the benefit of indigent insane, only to have President Pierce veto the bill.

It is 59 years since Clifford Beers, graduate of Yale and a former mental patient, really broke open the whole development in the field by writing book entitled “The Mind Which Found Itself,” which really gave spirit and substance to what has become the mental health movement in America today.

Then, of course, the tranquilizing drugs, which greatly expanded the number of cases which could be managed outside of hospitals, have been available only since the early 1950's.

Today, by no means do we have guaranteed cures for mental illness. Indeed, the history of the treatment of mental illness has been all too full of overenthusiastic devotees of one "cure” or another. But we do have far better means of dealing with mental illness than ever before.

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

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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 thé 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

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