Mr. THOMAS. Your crippled-children program seems to be an exception to the other two programs in that it runs into State residence requirements.

Miss ROCKWOOD. Yes; in some States.

Mr. THOMAS. Were those residence requirements in force in the States before this particular program was enacted?

Miss ROCKWOOD. Usually, yes.

AVAILABILITY OF FEDERAL FUNDS FOR CARE OF NONRESIDENT CRIPPLED

CHILDREN

Mr. THOMAS. You state that Federal funds are available for meeting the cost of medical care to nonresident crippled children in connection with this interchange of residents from one State to another. Now, in allotting your funds to a State, do you give special consideration to that type of expenditure, or is that type taken out of the general allotment?

Miss ROCKWOOD. It comes out of the general allotment to the State because when the allotments are made they are not made on the basis of an allotment per child; they are made on the basis of allotments for the whole program of services to be rendered, and then they are administered by the State. As the needs of particular children come to the fore, provision is made for the individual child.

Mr. THOMAS. Do you feel that this reciprocal agreement procedure is more expedient than if the Federal law itself required that there be no residence requirements of any sort?

Miss ROCKWOOD. It has worked so far because the State agencies are always ready to provide care for nonresident crippled children. They do work, either on an individual basis-that is, the occasional child who may come to the State under an arrangement for its care with the State where the child's residence still exists-or with nearby States they may have a formal reciprocal agreement, so that they know whenever a case arises the other State will be ready to assume responsibility for the cost of care until the child's legal residence is established in the State to which he has been moved.

STATE RECIPROCAL AGREEMENT PROCEDURE

Mr. THOMAS. We notice, in your exhibit (pp. 16-17) in connection with a "chargeback" of a child who had migrated from one State to another, a suggestion that such process or procedure of billing the States from whence they came was rather cumbersome, and the suggestion was made that the law should be amended or some procedure established to facilitate the handling of such a matter. Do you think that if the crippled children's program were in line with the other two programs, that is, that no residence requirements whatever be set up, it would eliminate this reciprocal agreement procedure?

Miss ROCKWOOD. Of course it would, if there were a definite requirement in the Federal law. It would eliminate the necessity for it. Mr. THOMAS. I might ask you the same question I asked Mr. Kratz; there is the possibility that you would have a tremendous number of reciprocal agreements among States?

Miss ROCKWOOD. Yes. There are a group of reciprocal agreements but it hasn't been necessary to develop an extensive system.

Mr. THOMAS. Do you feel that in actual practice nonresidents are accorded the same treatment as residents in each State-as the State insists it will accord in its plan? Do you find any discrimination between residents and nonresidents?

RESTRICTIONS ON USE OF STATE FUNDS

Miss ROCKWOOD. We haven't had any evidence of the intent of the State or local officials to discriminate. Of course, it is true that newcomers to a community may fail to get service as promptly as those who have been there longer and who know how to get service, so that there might be a situation where the nonresidents and those who are moving from one community to another would fail to be served as readily as the more stationary family groups.

Mr. THOMAS. Mrs. Warren, would you like to add anything to this discussion?

Mrs. WARREN. I think not, Mr. Thomas.

Mr. THOMAS. The crippled children's program is an exception, then, because of provisions within the State laws.

Miss ROCKWOOD. Yes.

Mr. THOMAS. And you feel that because a resident provision is in the State law you couldn't reject a plan which had a residence requirement?

Miss ROCKWOOD. As I say, the issue has never arisen.

Mr. THOMAS. Because of the reciprocal agreements?

Miss ROCKWOOD. Yes. This is true, also, that up until 1939 all Federal funds were matched with State funds. Since 1939 a portion of the Federal grant does not have to be matched with State funds, so that it would be possible to encourage the use of Federal funds in case there were any serious legal restrictions on the State service.

Mr. THOMAS. Miss Rockwood, Mr. Kratz would like to ask you a question.

Mr. KRATZ. That brings up a point which troubles us sometimes. While Federal funds are spent concurrently with State funds in our program, there is an increasing tendency for the budget officers of the State to put as many restrictions on matching Federal funds as there are on State funds. I wondered if that bothered you. It bothers us in some States, which consequently could not spend Federal funds.

Miss ROCKWOOD. So far as I know we haven't encountered any difficulty which couldn't be surmounted.

STATEMENT AND TESTIMONY OF DR. J. W. MOUNTIN, ASSISTANT SURGEON GENERAL, STATES RELATIONS DIVISION; AND DR. R. A. VONDERLEHR, ASSISTANT SURGEON GENERAL, DIVISION OF VENEREAL DISEASES, UNITED STATES PUBLIC HEALTH SERVICE, FEDERAL SECURITY AGENCY, WASHINGTON, D. C.

Mr. THOMAS. Our next witnesses will be Dr. Mountin and Dr. Vonderlehr.

STATEMENT IN REPLY TO COMMITTEE QUESTIONNAIRE

1. Under title VI of the Social Security Act and the Venereal Disease Control Act how are the funds appropriated allocated to the various States? (If on population basis, are census figures used?)

Funds are allotted to the States on the bases of (a) population, (b) extent of special health problems, and (c) financial needs of the respective States. For the fiscal years 1939-40-41 the Census Bureau of 1937 midyear estimates were used for the population basis. For the fiscal year 1942 the 1940 census population data were used.

The above paragraph refers to the manner of allocation of funds by the Public Health Service for title VI of the Social Security Act, and the manner of allocation for the Venereal Disease Control Act is essentially the same except that item (b) should read "extent of the venereal-disease problem."

2. Are any of the funds available under the above acts, subject to allocation on basis of State need, regardless of any other condition?

Approximately one-fourth of the funds were allocated on the basis of financial need, as determined by the ability of the States to raise revenue, expressed in terms of per-capita income differences obtained from data supplied by the Bureau of Foreign and Domestic Commerce for the 5-year period 1935–39.

3. Does your program under the above acts require approval of a State plan? State plans are submitted by the State health officers of the respective States for approval by the Surgeon General, in accordance with the terms of both acts.

4. Do any of the State plans, which are approved by the Surgeon General, contain any provisions in relation to residence?

The funds provided under title VI of the Social Security Act are expended mainly for preventive health service rather than curative medical care, and the plans, therefore, do not include residence restrictions, since public health measures cover the entire population group within a particular jurisdiction regardless of residence requirements.

The regulations covering allotments and payments to the States for venereal disease control activities require that diagnostic and treatment services shall be as freely available to infected residents of other States and counties as to people who reside in the governmental unit providing the services.

5. Does your office feel that it has any discretion in the matter of approving a plan containing residence requirements, or it is possible that you could reject a plan which did contain residence requirements?

In the absence of any specific provision in the Surgeon General's regulations governing payment under title VI of the Social Security Act, it is felt that rejection could not be made to a State plan which contained residence requirements.

Under the provisions of the Venereal Disease Control Act, however, the Surgeon General does have the power to reject a plan which contains residence requirements.

6. Does your office know whether or not nonresident persons in any State are precluded in any way from the benefits of your program?

In several instances where actual treatment is given for cancer and tuberculosis nonresident persons are undoubtedly precluded from the treatment benefits under title VI of the Social Security Act. However, in public health control measures, especially if police measures must be resorted to, no individuals are precluded (this comes under the jurisdiction of State and local health departments).

Through a questionnaire all States advised this office that clinics receiving benefits under the Venereal Disease Control Act furnish nonresidents diagnostic and treatment services.

7. If nonresidents are precluded from the benefits of your program in any way, is such preclusion brought about by either (a) any provision in the Federal law, (b) any provision in a State law, or (c) any administrative practice, either Federal or local?

If nonresidents are precluded from the treatment benefits under title VI of the Social Security Act, the preclusion is because of provision of State or local law.

There is no provision in the Venereal Disease Control Act which precludes benefit of the program to nonresidents. In fact, the contrary is the fact as stated above.

A study of the medical problems associated with transients, released in Public Health Service Bulletin No. 258, summarizes available information on the various provisions in State and local laws which pertain to relief for nonresidents.

8. If, in fact, nonresidents are in any way excluded from your program, have you any means of preventing such practice?

Existing regulations governing the allotment of venereal disease funds provide a means for preventing the exclusion of nonresidents from the benefits of the program. However, the amount of Federal funds which is used for treatment under the provisions of title VI is so small that the number of persons reached would be negligible.

9. Is the presence of a considerable number of transients in any State recognized as a special health problem in the allotment of Federal funds?

Increase in population incident to military concentrations and increase in industrial workers in defense industries were used as a basis for the special health problem allotment for the fiscal year 1942. Any transient increase in the population of a State, other than the increase of population mentioned above, is considered as a local problem to be handled through the State plans submitted to the Surgeon General for approval.

If the prevalence rate for venereal disease shows an increase in the venereal disease problem occasioned by the presence of a considerable number of transients in a State, the Federal funds allocated are directly affected through the factor "extent of the problem."

10. How does the Public Health Service prevent the spread of communicable disease between the States?

The Public Health Service prevents the spread of communicable diseases between the States through regulations applicable to common carriers under the provisions of the act approved February 15, 1893.

At the present time the Public Health Service is cooperating with a number of other agencies in an effort to prevent the interstate spread of venereal disease. To this end, data on blood tests among selectees found to be infected with either syphilis or gonorrhea are transmitted to the particular locality of their permanent residence for action by the local health authorities. The Army and Navy provide respective local health officers in whose jurisdiction the infection of the military personnel occurred, with identification data on the source of these infections. A Nation-wide venereal diseases assistance program, under the Work Projects Administration has been recently put into operation to help prevent the spread of the disease between States, especially in boom-town areas. As has been aptly stated, venereal disease must be fought on all "48 fronts." It is for this reason that it has seemed all-important that any regulations governing the allotment of funds for venereal disease control should have no restriction with regard to the treatment of the nonresident.

By cooperation with the several States and through allocation of title VI funds, the Public Health Service prevents the spread of communicable diseases between the States through immunization and environmental sanitation programs by States and their local subdivisions. Title VI funds are so utilized to strengthen State and local health departments in order to insure better communicable disease control measures with emphasis at local levels.

Public Health Service officers and special emergency funds are immediately available to assist State and local health departments to prevent the spread of communicable diseases whenever they reach epidemic proportions or whenever the danger of epidemic spread is anticipated, with special emphasis on the prevention of interstate spread of communicable diseases.

TESTIMONY OF DR. J. W. MOUNTIN AND DR. R. A. VONDERLEHR

Mr. THOMAS. Dr. Mountin, in your statement you say that in some instances an individual is aided through the funds provided in title VI of the Social Security Act. Could you tell us just how far such individual aid extends?

Dr. MOUNTIN. I think that is misleading. I think it creates the wrong impression, in that there is no direct aid to an individual. An individual might benefit by a program, but there is no grant to an individual.

Mr. THOMAS. In connection with cancer service or tuberculosis, an individual would benefit from some of the facilities your program

would provide?

Dr. MOUNTIN. Yes.

Mr. THOMAS. Just how would he benefit?

Dr. MOUNTIN. He might obtain diagnostic service in a clinic. That would be the nature of the benefit he would receive.

Mr. THOMAS. You say it is possible in such a situation that nonresidents might be precluded from benefits?

SCOPE OF MEDICAL CARE

Dr. MOUNTIN. There may be instances, although programs involving medical care to individuals are very limited under title VI of the Social Security Act. Title VI is for the support of general health organizations of the States and the localities, and for the support of sanitation, general preventive programs, and diagnostic services. There is very limited medical care and no institutional care. There may be rare exceptions to this statement but by and large such provision is very insignificant.

Mr. THOMAS. In other words, your program is what it says it isa public-health service, and it doesn't particularly affect an individual except insofar as one of these services might allow for diagnosis or other clinical attention.

Dr. MOUNTIN. I might say that for services involving care of the individual, such as immunization, diagnosis for tuberculosis, or diag nosis for cancer, so far as we have been able to determine, nonresidents are not barred from clinics. There may be instances where they are but such cases are few. When you get over into the next phase of care, that is, when you actually provide treatment or services or admit those individuals to institutions, then the residence barrier would operate.

Mr. THOMAS. That phase would be outside your program?

Dr. MOUNTIN. Yes. Of course these are general statements. There may be rare exceptions, but the instances in which our program fails to operate because of residence requirements I think are very few. As public-health programs expand to include more and more medical, and particularly institutional, services, the present State residence requirements would be a very serious handicap.

Mr. THOMAS. Dr. Vonderlehr, under your program there is no residence requirement, no such requirement in your national act-is there?

Dr. VONDERLEHR. That is correct.

Mr. THOMAS. And under your program you seem to be somewhat emphatic in your position that no rules and regulations, or rather no State regulations or laws which set up a residence requirement will be sanctioned.

TREATMENT OF NONRESIDENTS HAVING VENEREAL DISEASES

Dr. VONDERLEHR. That is correct; one of the main reasons for that, I might say, Mr. Thomas, is because of the character of the diseases. All of the diseases do not have the same character of communicability as syphilis and gonorrhea, and from that standpoint it is just as im

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