I 525 IU-% 1975 )3703 M 05140324 8 NATIONAL LIBRARY OF MEDICINE The Regionalization of Personal Health S ervices EDITED BY ERNEST W. SAWARD Published for the Milbank Memorial Fund by PRODIST New York 1975 Regionalization of Health Services: Current Legislative Directions in the United States KARL D. YORDY The concept of regionalization of personal health serviceshas been advocated for many years to provide a framework for organizing the complex functions inherent in modem medical care. The Daw- son lieport (1920) in England and the writings of American propo- neiits such as Grant (Seipp, 1963) and Mountin (Mountin et al., 1945) propose the same basic concept as a guide to the planning of health services. The factors that led to a concern with regionalization- greater specialization based on expanding knowledge and accom- paiiied by problems of increased costs and access to services of acceptable quality-liave intensified in recent years; yet regionaliza- tion remains a concept rather than a reality in American health care. With the imminence of National Health Insurance strengthening the already existing trend toward greater regulation of the health services industry, it is timely to take the i-neasure of regionalization as an active principle guiding national policy. The focus of this paper is on federal legislativ e intent and the specific legal mecha- nisnis that might be used to implement regionalization, including those previous legislative actions which are the direct antecedents of current legislation. The realities of specific legislative provisions, legislative history expressing Congressional intent, and experience with the halting efforts of legislative iTitecedents during the past three decades all 202 The Regionalization of Personal Ilealtli Services Legislative Directions 203 provide CILIES to the type of environment provided by the American political system for implementing planning strategies such as region- The Federal Legislative and ali;,atioii 'I'lie analysis Nvill show that there is ample reason to be Program Antecedents of Current Legislation skeptical about any strong commitment to regionalization in current legislation. But Such conclusions are speculative. The primary The National Health Planning and Resources Development Act current legislative event, the National Health Planning and lie- of 1974 is based on and replaces the legislation authorizing three sources Development Act of 1974 (]'.L. 93-641), was signed by the federal health programs-the Hill-Burton program providing assis- taiice in the construction of health facilities, the Regional Medical 1'resicleiit on Jan. 4, 1975. Its future implementation will take place Programs, and the Comprehensive Health Planning programs. In in a climate greatly influenced by the probable passage of some addition, the Act removes authority for the experimental health form of tiatioi)al health insurance and a growing array of other services delivery systems that were created by administrative action regulators, mechanisms ,it the stite and federal levels. using broad research and development authorities. A brief review of these preexisting prograi-ns traces the thread of regionalization Definition of Begionalizatioii through previous federal legislative policy. The Hospital Survey and Construction Act (P.L. 79-725), corn- inonly known as the Hill-Burton Act, was passed by the Congress in A definition of regioiializttioii that follows closely the classic 1946. The basic purpose of this legislation was to support state Concept of 1),tNvsoii, Grant, and N@lotiiitiii is used in tl)is paper to surveys of the need for hospital facilities and to provide matching I)roN,i(le (telliiii(litig ei-itei-it foi- the legislative analysis. Ilegioil',Iliz,'I- graiits to assist in the construction of hospitals and public health tioii is an explicit plan covering a defined geographic area. The ' plan centers. While the primary justification of this legislation was in sets fortli specific resl)oiisil)ilitiesfor providing access by the POPU- terms of the need for new hospital construction, especially in rural latioii to the full irri@, of functions involved in the delivery of areas, following the hiatus of construction through the depression modern medical care. 'I'liose functions are divided among several and World War 11, a review of the legislative history reveals some levels of care according to the complexity of the services and the reference to the concept of regionalization as a basis for hospital frequency of their use among the defined population. Each practi- planning. During the Senate hearings, Surgeon General Thomas tioiier iiid institution is assigi)ed responsibility for particular sets of Parran described a regionalized plan (U.S. Senate Committee on those fui)ctioijs, usually %vitli a major focus on one level of care. 'I'be hierarchical system set fortli in the I)Itii has provisions for ilitegra- Education and Labor, 1945: 59-60). Parran's plan, which seems to be tioll of tile colill)ollei)t parts, including referi-,il patterns ul)wlrd based on the concepts of Joseph Mountin, sets out a four-tiered care system consisting of health centers for primary and emergency care, through the levels of cire tiicl established patterns of coristiltition rural hospitals, district hospitals, and medical centers, or base (,ii)cl related e(iticatioi)). hospitals. His plan was laid out in some detail. The following A full implemented policv of regionalization would require y exchange during the hearings (p. 60) provides an early indication of Constraints oil the types of services that could be offered by an the reluctance to iii,,tke a real commitment to a conceptual plan individual or institution. Such a policy would also imply specific NN,itliiii the American political system: responsibilities to provide the defined population with each type of care. The policies to carry out such an organized regional systeii-i Senator I'cl)l)er: 'I'liat is essentially the pattern which is conteni- might be referred to in other fields @is franchising rather than I)Iated in this bill, is it not, I-)r. 13arraii? regionalizatioii. Dr. Parran: It is. Legislative Directions 205 204 The Regiotialization of Personal lIealtli Services The next major legislative event that bears on regionalization Senator I'aft: Do you mean to sa@, it is going to be forced on the states, whether or not they want it? was the passage of the Heart Disease, Cancer and Stroke Amend- ments of 1965 (P.L. 89-239). This legislation authorized grants for I)r, Parran: By no means, Senator 'raft. the establishment of Ilegioiial Medical Programs (RMPS) to consist 'Flie only reference one can find in the original flill-13tirtoii Act of "regional cooperative arrangements" among health care institu- implying that regionalization would be a guiding principle is tions, medical schools, and research institutions to facilitate the amended language (Section 622A) introduced by Senator 'Faft wider availability of the benefits of advances in the diagnosis and calling for the state plans to include treatment of heart disease, cancer, and stroke. The law grew out of the number of general hospital beds required to provide the report of the President's Commission on Heart Disease, Cancer -III(] Sti-ol@e, cliiii-e(l 1)), Dr. N/ficliael ])cl3,,tkcy. 'ri),it report recoin- ade(Itiate hospital services to the people residing in tile state and illeiided the establishment of a national network of regional centers, the general method or methods I)v which such beds sliall be local diagnostic and treatment stations, and medical complexes. distributed iiiioiig base ii-ets, intermediate ti-e,.ts, ,tii(i rural '['])is concept of t regionalized system for each category of disease areas. was fundamentally modified in the final legislation to reflect the On this thin reed of legislative purpose and history was based the objections of private 'medical practitioners, hospitals, and medical centers to the detailed categorical arrangements proposed by the hope that the Ilill-BtirtOD state plans might become an instrument DeBakey Commission. for regionalization of health services. While the state plans did not ize contain a designation of base, district and rural hospitals, most The administrative guidelines for RMPs attempted to emphas' observers would agree that the flill-Btlrton Program did little to regionalization as a theme for the program (U.S. Department Of influence the kind of functional integration required for a regional- Health, Education, and Welfare, 1968), yet the basic mechanism of the program was voluntary and responded to plans developed by ized system. each RMP. Press res for implementation of an explicit plan for liecognizing tile lijriitatioi)s of a state plan and coiistri.ictioii u I regionalizatioii were not applied, partly because of the strong grants as mechanism for implementing health facilities planning, reaction to the original DeBakey Commission concept. The categor- anieiidii-iejits to the flill-Btirton Act in 1964 provided grants for ical focus of the program, confusion over shifts in national policy, areawide health facility 1)1,iiiiiiiigigeitcies. These planning agencies, preoccupation of much of the health care system with the imple- established outside the framework of state or local government, were based on the -%voluntary Health facilitv planning igeiicies Mentation of Medicare and Medicaid, growing concern over the rising costs of medical care and access to primary care, and already carrying out ficilit@, 1)1.ttitiii)g in some communities. (;ivell resistance of health care providers to compliance with more formal 110 regulatory power, these tg(@ilcies itteiiil)tcd to iiiflii- plans were all rea eiice tile course of facilit), planning through persuasion, the I)tll)lica- soiis,tliat eroded the potential of RMP to evolve into a broader force for regionalization. Such political commitment tioii of planning studies indicating needs, and the stimulation of as there was to RMP was in terms of specific activities undertaken better institutional plai)ning. In spite of these attempts to emphasize planning, it seems clear by each RMP, rather than a commitment to a broader concept of organization of health services. that the political strength of the Ilill-13tirtoii program was based oil 'I'lie next legislative antecedent, the Comprehensive Health construction or modernization of I)e,,tltli facilities, not oil tile creation I)Iaiiiiing program, was authorized by P.L. 89-749 in October 1966. of all integrated regional s),steiii of cir(,, tile former being I purpose Comprehensive Health Planning (CHP) was deliberately steered more to the liking of oiji- I)oliticil tradition. 206 The RegionalizatiOll of Personal Health Services Legislative Diiectio?ts 207 awa), from the Hill-Burton program's concern with construction of administrative difficulties indicate that this short-lived program health facilities and the RMP categorical and action-oriented em- cannot be considered as any further evidence of political commit 1)hasis. 'I'be planning mechanisms created at the state iiid area\vi(le 11-leDt to the implementation of regionalization. levels were to encompass all factors that relate to health. These planning agencies replaced the areawide health facilities planning agencies created under the flill-Burton Act. 'I'lie legislation itself A,as The Political and Legislative very general. Review of the legislative history provides few CILies to Context for the New Legislation a ii-tore specific intent other than an ernpliisis on the need for coordination of splintered categorical federal programs. "Iliiie the An unusual legislative climate was the breeding ground for the planning agencies were encouraged to formulate local plans and new legislation replacing all the programs just described. Strong priorities for action, they were given no power to implement their conflict between the executive and legislative branches of the plans or to enforce constraints on tiiidesii@,il)l(@ diij)licttioil of' SCII'- fe(leril government led to legislative bittles ovei-,ttitlioriziiig legisla- vices. tion and ipl)ropriitioiis. 'I'he President desired in early 1973 to Stibse(Itient legislation and policies give these I)Itniiiiig agencies eliminate many federal programs, including liegional Medical responsibility to review and comment on other federally supported Programs and Hill-BurtOD, and to reduce funds for others. The health programs and provided a reeinphasis on the planning of resulting confrontation led to a determination by the Congress to health facilities by tyiiig Medicare and Medicaid reimbursement seize the initiative in rewriting federal health legislation, rather than policies to planning agency recommendations concerning the need reacting to executive branch proposals-the primary pattern of for facilities. Nowliere in the legislation itself or the legislative initiative in recent years. The Congressional committees history of the program can one find specific indication tl),It Colt)l)l'(@- were sensitive to rising pressures for resolution of problems of lieiisive health planning A,as to be used as an instrument of regioiiili- health care costs and the distribution of services. The committees z,ttioit as it is defined in this paper. seemed determined to make the iienv legislation focus specifically on Another federal program intended to improve the organization defined problems of the health care system. In formulating sharper of the health delivery systery) on an areawide basis was the Exl)eri- objectives, they wished to resolve the confusion surrounding the merital Health Services Delivery Systems program, initiated in 1971 roles of the existing programs. The imminence of national health by administrative action and funded through the National Center insurance added to the pressures to create a stronger planning and for Health Services Research and Development. This program had development rneclianisrii through federal legislation. as its intent the establisliiiiedt of coiiiriiiiiiity management structures 'I'liotigli the iiexn, legislation was conceived in tii initial atillo- intended to improve the organization of the health delivery system, sphere of legislitive-ex(@ctiti@,e conflict, t surprisingly broad area of in order to improve access to care and moderate the increase of igreenient rapidly emerged. The Administration and the Congress costs while maintaining or improving the quality of care. '].'lie could agree that the existing programs had not been sufficient programs were also intended to achieve greater integration and instruments for improving the effectiveness and efficiency of the coordination of the federal health funds being provided to the health care system. There was agreement to replace the multiple selected communities. This program was plagued from its begin- planning structures of the previous programs with a single planning ning by lack of clear policy objectives, by administrative reorgiiii- program involving both state and areaNN,ide components. There ,N,as zatioiis at the federal level, and by a temporary funding commit- agreement on the need to sharpen the objectives of the new meiit. The lack of specific legislative authority as well as the program and establish clearer criteria for accomplishment. In spite 208 I'lie Regioyializatiott of Personal Healilt Services Legislative Directions 209 of the areas of agreement that emerged between the Congressional eluded in the Congressional intent, a Congressional view that the committee staffs and the staff of the Department of Health, Edlica- lack of clearly specified objectives and procedures impeded the tioii, tiid \@'elfare, it is still fair to conclude that the basic initiative effectiveness of RMP and CHP, the provision of more detailed for this new legislation came from the Congress. procedures because of the regulatory impact of the new legislation, As the intent to di-aft legislation that looked afresh at tile and finally the sheer diversity of issues dealt with in this legislation. structures for 1,)Iaiiiiiiig, regulation, and development, of tile health The amount of detail makes a brief summary of the law difficult, but care system proceeded, a number of major policy issues needed to the following are the key features of the legislation that have be resolved-issues that had ii(@vei- been cleirly settled in previous i potential significance for its use in implementing regionalization. legislation. 'I'liese issues included The legislation would establish a tbree-tiered planning structure. -tile iiifltieiic(,- of public t(ititorit@, over the predominantly At the f@e(lei-al level the Secrettry is i-e(Itiired to specify national private health cir(@ sector; guidelines for liciltli I)Iitiiiiiiig, including standards respecting the -tile division of' 1-(@SI)ollsil)ilities ',tlllollg tll(- ipl)roi)riite supply, distribution, and organization of health re- local levels of gon,eriiiiteiit; sources, and a statement of national health planning goals, stated to -the degree to A,hich the major sources of health care financing, the extent practicable in quantitative terms. To guide the Secretary's both public and I)rivite, are subject to the influence of actions, the Congress his provided a specific list of national health niiig agencies; priorities. In developing the national guidelines, the Secretary will -the extent of regulation over capital use, rates, and the (listri- be advised by a new National Council on Health Planning and btitioii of iiiaiil)o-,N,er; Development. -the relationship of medical centers, including niedi'cal schools, 'I'he basic operating level of this planning system will be a to a structure for the planning of health services; and network of health systems agencies with responsibility for health -the relationship of the planning structure to other federal planning and development in geographic areas designated by the health services programs. governors of the states. These geographic areas are to have a The success of any attempt to develop and implement plans for substantial population base and encompass the full range of health regionalizatioii of health services in this country would seem to be services needed to meet the needs of that population. The "health heavily dependent on how these issues are received. However, the service area" \N,ould. seem, therefore, to be an appropriate geo- pressures of compromise prevented a clear resolution of any of gr@tl)liic base for regioiialization. These health systems agencies are them, except perhaps tile strengthening of controls over the tvtil- to prepare long-range beiltb systerlis plans and short-range annual -II)ilitN@ of capital for the construction of iiexv facilities. iiiil)leitieiit@itioii plans that A,ill achieve the goals of increasing accessibility, tccel)tal)ility, continuity, and quality of Ilealti) services ,tiid restraining increases in the costs of these services. 'I'lie agencies Description of the New Legislation call ilso develop specific action plans for particular programs and projects to be carried out \@N,itliiii the I)Iiii. These agencies call be The National flealtli I)Ianiiitig and Resources Development Act citliei- iioiit)rofit corl.)or@itioiis established for this purpose or public of 1974 tl)at emerged from this legislative context is a very detailed I)ktiiiiitig agencies that meet the very specific requirements provided piece of legislation. Among the reisoiis for this degree of detail -,N,ere in the It seems cleir from the legislative history that tile the perception by the Congress that the executive branch had (,oiigi-ess expects most of these tgeiicies to be nonprofit corpora- iiiistise(I broadly ,N@ritteii ttitliorities to icliieve purposes not ill- tiolls. 210 The Regiotializatioii of 1et-sonal Healtit Services L(,,giviative Directiotis 211 In between the federal and area levels, the legislation establishes The law contains extraordinary detail concerning the structure of state health planning and development agencies, advised by a the health systems agencies and the state agencies, criteria for their statewide health coordinating cotiiicil. This state agency is expected functions, and requirements for coordination with related activities. to prepare a state plan based oil the area plans, be responsible for t The law also gives the Secretary very strong'responsibilities for state medical facilities serve is tile planning Igeilcy for reviewing tile effectivel)ess of the agencies tnd taking action to al)l)roN,al of cil)ital facility expansion under Section 1122 of the correct deficiencies. Social Secui-it), Act, tii(I idiiiiiiister t state certificate-of-iieed I)ro- The provisions of the law and the legislative history were graryi. examined for evidence of intent to carry out the concept of regional- The distribution of responsibilities iiiioiig tl)ese tl)ree levels izatioii. Nowliere in the Act does the term "regioiialization" appear. would seem to emphasize gotl setting and evaluation of the effec- But the "national health priorities" set forth in the Act do Dot contain tiveiiess of planning tg(@ticies it tii(, federal tile development provisions that are supportive of the concept of regionalizatioii. of specific loiig-r,.tiig(, tii(i iiiil)l('Ill(@lit(itioll plans It tli(@ Among the I)t-iol'ities in Section 1502 ire the follonviiig: level, Ill(i the conduct of, i-eglil@itol-N, ,Ictivities It tile stite level, -VN,itli (2) 'I'lic development of Illtllti-ilistittitional systems foi- coor- substantial reliance in the conduct of those activities oil the plans (iiiiatioii or consolidation, of developed by the health systems igeiicies. In idditioti, the health institutional health services (iiieltid- systems agencies are given the power to review and approve or il)g obstetric, I)CCliiti-ic, emergency medical, intensive iii(I coro- disapprove many federal gr@iiits and contracts providing for the liil'y cli'e, Iil(l radiation therapy services).... development, expansion, or support of lieiltl) resources. The Health (5) the development of illulti-iiistitutional arrangements for s),steiiis agency and the stite liciltli I)Iiiiiiiiig ai)d development the sharing of support services necessary to all health service agency are also authorized to review at least every five years the institutions.... appropriateness of all institutional health services. Ilowever, the (7) The development by health services institutions of the agencies are given no specific regulatory power to discontinue ally capacity to provide various levels of care (including intensive of these services. care, acute general care, and extended care) on a geographically Tile Act authorizes the Secretary to give additional authority to integrated basis. not more than six state planning agencies to carry out a program of 'I'he long-range plans to be developed by the health systems rate regulation. This limited number of programs will be used for agencies would seem to be the most specific mechanism for la),ing the purpose of demonstrating tile effectiveness of sucli rate- out a plan of regioiialization within the structure of this Act. These regulation activities. plans are to describe "health systems in the area which, when Other provisions of the Act provide for assistance in the con- developed, will assui,e that quality health services will be available strtiction or modernization of medical facilities in accordance with and accessible in a manner which assures continuity of care at the state health facilities plan and the provision of a small amount of reasonable cost for all residents of the area . . ." and the plan shall funds to each health systems agency from which it may iiitke graiits .1 take into account and [be] consistent with the National Guidelines all(] contracts to assist in the implementation of its foi- I-lealtli Planning Policy issued by the Secretary under Section 'I'lie )aNv also authorizes the Seei-etii,y to provide technical 1501 respecting supply, distribution and organization of health assistance to planning agencies @iii(I to support centers for ]rental resources and services . . ." (Section 1513 a 2). planning, will engage in studies to improve planning tech- A readingy of the legislative history, particularly the reports of the ni(Ities and provide technical and consulting assistance to tile health House and Senate committees (U.S. House of Representatives systems agencies and the state agencies. Committee on Interstate and Foreign Commerce, 1974; U.S. Senate 212 The Regionalizatioti of Persotial Healtli Services Legislative Directio?is 213 Committee on Labor and Public Welfare, 1974), fails to provide any make "eil an), expression of intent. Adiiii'listi-,Itik,e action bN, tl)e is unlikely to be suffl- further specifics concerning the content of the plans. Along with the Secretary through regulations and guidelines detailed analysis of experience with the antecedent programs and cicilt. descriptions of the proposed legislation, the House report (pl). Even if that intent and commitment were clear, unresolved 32-35) does contain a list of seven principles that the House policy issues can quickly begin the erosion of the administrative will Committee followed in writing the new legislation. Most of these and energy necessary to bring about major changes. As has been principles concern the processes of I)Itiiiiing, tlid Done provide any pointed out, a number of these major policy issues were raised in t he additional legislative intent concerning regioiializatioil. 'I'lle itistifi- course Of CODsideriDg this legislation. Compromises emerged on cation of the Deed for better health planning' as revealed by the each controversy. It is clcai- that the influence of public authority reports and other legislative Iiistor@,, eriil)liasizes the rising costs of over the predominantly private health cire sector remains liniite care, the (ILil)lication of services, lick of tccess, and uncoordinated iiore Spec d, and tli(-, responsiveness of the private sector to ' ific federal programs. 'I'lic legislation is described is t ilec(,sstl,y Ste]) to iii-iii(iites of responsibility iiiidei- a health services plan is therefore liell) (1)(@ ll(',iltll system respond to tll(@ I(I(Iitioli'Ll (I(,[Iltli(ls Ili(i- (,Iucstioiiible. ciliated from iiatioii@il iieiltli iiistii-,.tiice. In the reports, ']'lie division of responsibilities among the federal, state, and attention is given to the inversion of financial incentives within the local levels of government remains ambiguous, as it has always been health system that creates a i)eed for I)Itiiiiiiig and regulation to with health legislation. In this new le . latioii, the Secretiry retains gis co contain the tendenc@, towird excessive use of services iiicl toward tisiderable responsibility for establishing objectives and ii oiiitor- superspecialization. But there is generally a lack of attention to li ing the planning and development structure, establislii ng a clear specific principles or organizations that \Board re(Iiiire to federal role. Yet the health systems agencies seem likely to bypass a local government in most iiistadces, and the relationship between One must conclude that any further specificity concerning ntains the see the state agencies and the health systems agencies co ds regionalization as an intent of this program must be provided in the of considerable CODflict. The relationship of medical schools, medi- Secretary's guidelines or be developed by a health systems agency at cal centers, and other health manpower training activities to the its ONNID iiiitiativei planning framework seems absent, yet any meaningful concept of regionalization must include concern with manpower distribution. Beginning efforts are iiiide to relate the planning structure to the The Prognosis for sources of health care financing, partictilarl y with regard to capital Regionalization under This Legislation financing and a modest step toward rate regulation, Yet the impact of the financing iziecbaiiis,,is, especially with the Imminence of The previous section points out that the potential to use this national health insurance ' on iiiaiiy-other aspects of health services legislation as an instrument toward regioiializatioii is consistent witf) organization are profound, and the ultimate linkage between plan- both the structure ii)cl tl)e priorities established in the legislltio". ning and fiiiaii'eing is not yet established. 'I'lie legislation does take a However, it has also been pointed out that evidence of intent to use major stel) ill resolving confusion among federal programs and in the legislation foi- this purpose is ]lot explicit. 13otil the Ilistol.@, of tile i-elititig otlici- fe(leril lieiltli services programs to the licaltli s)?steilis antecedent legislation tiid general kiio-,N,Iedge of the Aiiiei-ic,@tii plans. political systeni's efforts to make substantial changes in major social If intent, coi-niiiitmeiit, and resolution of major policy issues are systems indicate that an explicit political commitment is liec@(le(I to all present, does sufficient authority exist within the legislation to 214 The Regiotializatiott of Personal Ilealth Services Legislative Directions 215 overcome the resistance of independent providers and the tendency This analysis is not intended to denigrate the significance of the of the political system to respond to particulars rather than general National Health Planning and Resources Development Act of 1974. schemes? The Dawson Report (1920: 7) refers to the need to relate In the author's view, that Act represents progress over preceding intermediate steps to the ultimate design: "To construct any part legislation. However, realism with regard to objectives and imple- well and to avoid mistakes in local effort, the whole design must be iiienting mechanisms is essential for effective actions. So must it be before the mind." for any progress towai-cl regioiialization through the current legisla- 'I'lie regulatory authority provided in the new le isl,,itioll is 9 tioll. focused on capital expansion and federal grant programs. Such authorities would seem to be useful in shaping the direction of new activities but not very effective in influencing the organization of References existing institutions and programs. ']'lie achievement of a regioilii- ized system through ititlioi-ity ovel. IIC\@, tctivities Would Dawson llel)ort (L@iiited Kiiig(loill Ministry of Health, Consultative Council take iiiaii@, yeirs. i-eiitiice in ,tcliievii)g regioll,,Ilizitioil on Meclicil and Allied Services) would still be based on assembling and disseminating data, I)tlbliciz- 1920 Interim lieport on the Future Provision of N/ledical and Allied Services. London: His Majosty's Stationery Office. iiig plans and recommendations, tii(i the persuasive capacities of the MOUIltiD, J.W., E.H. Pennell, and V.M. Hoge I)e,tltli systems agency. I)cttils of structure iii(I process sl)olilcl not 1945 Health Service Areas: llequirenients for General Hospitals and be mistakes for ret] ttitlioi-itNI, NN'liell I )oliticil commitment to I Health Centers. PIIS Bulletin No. 292. Washington: Government change exists. Printing Office. It is reasonable to conclude that this legislation has potential Seipp, C. (ed.) significance in achieving progress toward regionalization but that 1963 Health Care for the Community: Selected Papers of Dr. John B. the legislation itself is not sufficient for that purpose. What is needed Grant. Baltimore: The Johns I lopkins Press. first is a concept of regioiializatioii that contains modifications more U.S. Department of Health, Education, and Welfare appropriate for the probable directions of the Aiiiericiii lic@iltli care 1968 Guidelines. Regional Medical Programs (rev.). system. 'I'Iiis concept will have to provide for some real consumer U.S. House of liepreseiititives Committee on Interstate and Foreign Corn- choice among multiple delivery systems developed within an over- iiierce 1974 Beloit No. 93-1382. National lieilth I)olicy, I)Ianning, and Re- all regional plan. 'I'lie concept will also have to deal more explicitly with the legal and political realities of a private health care system sources Development Act of 1974 (II.R. 16204). Washington: Government Printing Office. and the federal structure of government in the United States. More U.S. Senate Committee on Education and Labor explicit political coinrnitii)ent for such a concept will have to be 1945 Hearings on S. 191, Hospital and Survey Construction Act. 79th sought from both the executive and the legislative branches. Finally, tl)e national health insurance program adopted will have to rein- Congress, ist session. Washington: Government Printing Office. U.S. Sonite Committee on Labor and Public Welfare force the coiiiriiitii)ciit. 1'erlial)s the intent to regionalize the treat- 1974 ]report No. 93-1285. Nttioiial Health Planning and Development iiieiit of end-stage chronic retail disease to be financed under the iiid I lealtli Facilities Assistance Act of 1974 (S. 2994). Washington: Nele(lici,ii-e Amendments of 1972 (]'. L. 92-603) will I)rovidet test case Government I)rintiiig Office. for that commitment. 'I'lie. Department of Itealtil, Education, and NN'eifare published guidelines for that regionalizatioii in April 1974, but specific regulations had not yet been issued at the time this paper was prepared.