f iiiiiiiiiiiii iiii * E 111111 211 6 * 4ir NOTE.-DO NOT USE THIS ROUTE: SLIP TO AL CLEA.F?AHCES C@@ APFROVA@ AGVNCY BLDG. ROOM TO-. Riso' APPROVAL El REVIEW n PER CONVERSATION D SIG?IATURE IICTE A.14D SEE ;4E D AS REQUESTED ACTION COMME!IT El I.,@OTE AHl) PF,TURN (D NECESSARY D FOP YOUR INFOr,'-' ATI-I)II REPLY FOP, gEMARKS: u will find sectioll on RMP (p.5-8) YO of interest. (Fold here for return) ---------------------------- To From PHONC 326@ - Foltm HEW-30 REV.1115$ ROUTE SLIP 19?2 0 - 4@2-401 - - OASR C+ oA S14-SA T-,rD 'YEi.@'Al L V D "f'@ Os /ES etary 4LOr @Ll a'.. '-'T T (-i' ITDU" P has Del 3 acia,: O'@,7 Z7, orca .-L L, y is a n,@ Co p on o-.i tie C-E-,P the to a a -I.: e,:- crship @.7 th H to -lie 0 c-- c ,-- c @, r r c, s a'@- s c,@ -a r , P vou -Drc--v@.oiis docis4-o@@i -"ha-,: o-rov.4.c-:er o@ to!-a]. cou-,icil -a- rsn@p. recall:': a! ed to s F, -,2 e 'r@ c: r e i s h o -.,? t o L tI e I't S. B u r t o rL C o Li r.@ c: O,-,e 1.7ay -J..,; to iii1plclrl"@-,it@@,-VL,,:,, c- -'--e one ii a -@ i d P i -Li the ie i-7i -ctncies. Five !la-,,,e Lo 7ierg@, th@,-L -@h C;:,- si).c,i P,.nrc,-arc:, not prohibiteci 'Llom -3 ii-L he-,c I-" e. or 4 La, i. I. --:F lat-4, v-c-@,T of the s@ by eit LI %"I. .1@- C,.L n v a no,: ,ct been (:evolopcd and ocause an-d anpcars t:o be a,-i ol)taiiabl.t@ P thal- yo-., to Y,')U'@- -@,-@vi@.0-Lis Clec-,Ls.-'Lo-. to r i,.erge counci,.s -I.-,,zther t',, .7,a 'the y o.Tc P rc-Com:@.-:Yls that o-L.,!,,@ T) 'D C Cl f-@ I i I L I -I 'cire in ,i c'.-I c to -.11@, be unw@,s -raen them with -1 c; -,at it I.-70 bu for -L@ull revie-%.@. O@L VA anLA @@ec-.t3. i@- should 0 2. be L-Iat miiiy %nd i),)!) OC'L: iv 41-ics I)rOviclc 'services to aroas oi--Iie-r cnco.@i),asscd..])y the local CIIP @r, Cy. z., -Ic@ c;-c local. Cfij? A,,citcic@:-; p Ci vol of $60 i-iillion. C)Vcr-'J@l to z,,@; S"-Ltco 'I)Y "-'i. ai-,,Ilysis office CZ-,iiio to a Ti-ic question,-, ttic-rc-fore, -ic'@,, Icvc..-,L quickly ;,,, w,-nt to do is 1,1,@ I:.O 17 C, c i c'@fo-1-1: '[)Y @Lu*j',l ii-@plo-me-,-,ration of Ci-!'2 cnil '@)c achieved x.7j.tl,iiii three yc-@,.rs. 1. Litlioi:j.ziL:L,) n --Ilc)ujd, Llic-rc@forc-,, I;o ",',L'.Cll SU,-.is as i-,.i,-y I)c,. rcou:Lrcd, or (abc)-,lt 80% ol- tlc tc)zt-lai LstiTI.,,atc-,.cl need). T-,,;o factors )five !)ecn cited is the iT-pl@,@Lcntat-Lori of CPP: z,-,d (2) aem,2.n.i.si:r t-ve difficulties i7 L a L L in or-a-,aizirg CH-2 aranc@-es. P wi-th 11 'that 3,000 planners 0 - C> will be -..icecied. O,-i 1-Y a s I I . nu@,.Der of 41-raiiied "Plarners" are r n 'A - I Lor cac'@i a,,,c@icy; most o@@ ti@e staf'L of CIIP a-encies arc., presently ir.%114-viduals -,@'.-Io %.,c5:c ii i Variety of related such as ecor@o.-,ii-cs, statistics, business administration, and various 'ir-alth fields. Eveii i@@ "partners" were des-Lred exclusively, a rc!--ciz,' server, by the -ourna' o' Assoc@atioi 4,50u' ls .-ow receiving health ers pl--nni-n cc-@czit-'on in U.S. In addition, i:,.c-,nl" cl,,: are cc,.-.-i--:unii:y Planning eeucall-ioti. A second factor in the rate of -is of time a-eiic-Lcs. At -orc,.sert there 9, arc CHP (1)) ar,enc-@es -is have been @o . - Fir-..i pl"- i: ar. additional 90 acreages in F-Y 1973. Some States are or-sraniz-Lr,-, these ac-,C,,'Icir-ls w@Lt'io-L,t Federal fur,6s at present in a-r,'--ic,.Pation of future Federal sLppor'L-. Thus, at the end o@L- FY 197'@ only cbout 40 additional a-eiicies C> will 'De required for full national co-vera-e. C> 4 B - Y@-Lindirtg of State CII,P A!zencies P concurs @7iz:li the ii recoi-@,.ciided authorization level of $20 miTlion. zor State a-encies. Altho-ti no was conducted in arriving at this figure, a rou_vli asti,-,@te inii C.- @Ltes that such a sum would "i)urcliase"-,a:3ouL 16 staff T,.c@r,")--rs for each of the 56 State and $22,000 in total (a) a-ciic-'Le s (.i f: r o costs 1)c.,r staff greater financial of States as opposcd to Ic)cai- areas, the States can ind @'noL,ld suD-Dler,- era!, funds sufficiently to add needed staff ent Fed abovl- this lev--I. T"I,o O@ccrc',:z-,,CY C. P C s o iii-II.--,-)urton be S 1) C-'@ c ].,y I)IICC@F to Cl,'3:i.L@Y L,-Ic relationships fui-,et:3, bidets can be @,,djii@-i:cd by the proper ;:ii,.iourL 't: 40 and 41 an(] Sci- ar,r@c:s with the recojiur,.c,-tei,-tl-ion by 11 that the roatclii.iig level be L, se@- at 80/20', that (b) a,,,eiLcic,.,,, be @Lllo@.iecl to usc,. "clean" r iv,-t t e p ft,,ii@is (but not provider Luiids), and that States be cticotiraf,,cd to c;c)c)v(liiiatc CIIP with other planning agr-@i-Lcics. Ilowcvcr, we foresee a serious probl.ci!i for soi-.@z! (b') iri obtaiii-Lii.1, the 20'/'., share. i):c private, non-I)ro:L:Lt ar,,encies i,ili;-c'n receive little public @,.orcy. I.'cx,7 States have -enactcd enabling legislation for CITP. in -,--(!.si)o,.ise to @l-',ie c-ncouracei.-.,-@nt of 0-@IB Circular A-95, and i,-i an attempt to coordinate bein6 established by seve-@-nl Federal programs (transportation, urban development, economic 'Stealth, ctc ) , a'L:,no.@t all States have establislic@d sub- and development districts. A-95 requires Federa-1 to observe those -ec,,,,zztT)ilical areas. @.o,-.ie States have also established regional cc)urc-Lls in those districts xh, icli serve ds umbrella agencies Lor all the planning ,-cr,cies. State tax fu- 0 a ids are tren provided t the planning agencies tlirou.-h the re-ional pla-,in-;-n-, councils. P believes that coordination of p lcLn-,.iir).g aid sharing Of staff and facilities can best be accomplished 'cL@rou,,,,ri such u,-d;)rc-L a @i-encies. Therefore, P recor@-nie-@ids that model legislation be developed for States authorizing suc7n -e,,,,ional councils and also providing State a,-Id local .C s throu-h their. .Lundin- for C-.qP a-encie As an alternative approach for funding health plannin-, P suggests that the possib4-l i 4#--y of a Federal tax on health insurance be e--,:n.Lored. The costs which a community pays for health insurance is in proportion to the services it uses and the benefits it rec eivcs. One o4.the benefits of comrchensivc, health plannin-, should eventually be to reduce or retard the growth of health A for relatiii- benefits to costs is to require a portion or all of the expenses oL Cil,'-O to be paid by third party reli-.!D-Lirsc@-rs, includi-.ic, 'L\icdicarc, @,nC, '4;cclicaid. Such a tax, if use, only for the 20"1. @on-nu4-iity sli-n-re %qould amount to about 1/10 of one percent of premium Cliir-4i2s. If all Cr!P costs were borne this way, the rate @ould be betwee-,i 1/4 and li2 of one percent. civisorv Counci' 5 thit the a-cncy than a policy board. 1-@'e feel rLli-T@o,-,c hc--cc! is ',:o iiivolve citizens botli ii-i a,, in - ztrd Projects. -,O t @-7C@l I. @Li, 'chc past because the ,V,4 .Cry CC I - - , have u-,,tallv all and the council series s Jim as "wi.i-L6o--.1.1 dressings" CIIP @;-@,d cotilicils arc !)otli policyi7 oards and both have. bc-@(-,n ver,,, successful i-Li effc,-ct-Ln.- citize-i the co-Li,.acil:@ @-ct-,ial-1-y T,.iaile the decisions. Therefore, that the a,@ency have a policy board. Fur-',-her, P reco,-.-.fiiencis that tiia Ci;P statute be tii--.t the councils be policy boards. 5B c 0 1-i -q P wi'@'n ,-he II that the council of the -1 o@fi@-r -co-,jircd, to ',Iiavc@ a majority of co-,IsLL-.iers and ti-rc, q.-ercy be, i. both of these groups should be represents d. ,lie p,,irDose of ir",Pierienti-i2 aoc.-.icy co-a,@.cils is to provide technical assistance in develop2.-a rojects. Thus, it ray be appropriate -or a i-iaioril--y of the v;en.-@be.-s to be providers. The CIIP agencies will have a i.,iajor@-ty of considers and will have approval authority over all projects oi the !-rL-plcmenting a-ency, so will have effective control over Droviders in th,-t way. (See further c6i,-nients on 5D.) 5C - PuD'Lic Feariii,, o-.i Plan of A,,-,ency P disagrees with the H reco,-ic,-,crdatioi-i.tnat the iiiplei-iienti-Lig agency be rc(iu4-red to hold r,,,iblic he@,rii7,@s o-Li its plan. P reto-mands that the a,-,encv hold no public hearings on either its'plans or its specific projects, altlou,-,Ii its business certainly should be conducted in public. A public hearin- on projects co-,iducted by the ii,-pler,@entinc, a-eiicy would e4LL-cLectively preclude the CHP a-ency iro,-i disapproving any project. Instead, P recommends that the t=, ageiicv specific projects s e -ded of reviox-7 P'7c>Cc'-S. 5D Y@IP as '_-Ile T-2p p the follc)win,, e4 SCU, I qSiC, C) f a for the Secret ry's consideration. ".lost o@ the :i,,ajor criticisms of li-@,@-ve not been with the edmi,-Liscering itscl'L nor even -@.,-@Lth ti-ic- "revenue fundin- approach - j--,-isti2.ad they ',,.ave been criticisms of the mission, of the activities supported by There are three basic questions corce!rriii- the mission of P@T. lq-h--t: missio.-. does the Dctpartirc,-it C-osire for M,,-L? 2 T%Tha@@ mission is R.@,'P capable of aid willing to accept? To i..,--'iat extent do these co@-,acidc!? 3. '1110 prese!lt mission of l@N,,P is b,-sicr@I.I.y tliat@-'df iiii)rovinc,,, the quality of the'provider/pati.ert encounter. A rumb er of subordinate questions arise coiicerni-z-ir, the corill-intiatio,-..@oL' that present mission or t@ 0 !)Ossibility 'of ail alternative one. 1. Is the present mission of i'@@i - that of suppoz--,4.,.g education and trainin& proarar,,s ior providers @q,io are already employed - an C> appropriate use of Federal tax funds? Should providers be 0 v c:,zi-,ected to provide high quality care with ut such i,.icenti es. 2. II' Federal intervention is reqLi@L-,--ed 'to ass-Lire hicli quality. care, is this form of intervention the most desirable? The P,"-,'P system relies entirely on vol.i-,-..'itary participation. It offers no extrinsic re-,,7,irds; it ro,-scsses no sanctions. S'nould the Federal government irstcad require performance ? in order to assuze @ju-@ may be aU.,;Cful-ins',--@-u-rent td- uzdc':i_-take the role of utilization aid performance review, since it is provider controlled but is T.-ore inclusive t,iali medical societies. In their national Meeting in St. Louis last January, lioi-7evc-r, R.%iP's strongly rejected this lipolicer.iaii" rol:e. The Sc6retary 6. 3. iiyliat results is the present R:-,P system reallv '@Iiieving in iril)roving quality of care? Are iclcquate data available to provide significant measures of results, or are only anecdotal data avai'Lable? Are those providers being reached who most need aid? 4. I-,Iiat priority does the present r,@ip mission merit compared with that of assuring access to any quality of health care for those Ni,%6 do not now receive it? 5. H has pointed out that ILNT and CIIP should be viewed together and that R@T might begin implemeiitin- the plans of CHP. Since CIIP is mainlv concerned with improving access - the distribution of 'Health manpo-,ier, facilities, and services - should the mission of IU@IP be changed accordingly? To what extent would the PllPts be willing to accept this new mission? 6. 'As a result of various legislative and administrative decisions, several activities for ir.-,)rovi-@i- the quality of care formerly supported only by L@\,%IP are now being supported by other IIEW -ir tion's new cancer and heart organizations. The Id istra initiatives have placed quality improvement programs for those diseases into the respective institutes of-...NIH. Following cnActr,,.ent of the Administration's new health manpower legislation, the Department has placed responsibility for the developinent'of -6 - --i@ -nd upgradin,, rainin- programs into general c nt 1,-ig education a BIM'.-, Responsibility for developinr-,',AHEC's was also placed into Bl*fE. Should the Department have several agencies supporting the I . ties? Should support of these activities same acfi@i by RMP be @terminated? The P@I@IP Administering Mechanism 14 H has pointed out that much time, effort and money have been devoted in the past seven years in developin- the RIMP mechanism t'ne RAG's and the core staff. In 1972, approximately $44.4 M3. on (about 40% of pro,-,ram funds) was used for support of the P@IP riec.@anism; i.e., administrative costs and staff activities. Core staffs now average about 30 full-time equivalent positions, and staff salaries run as high as $45,000 per year. However, li has pointed out that the F.AG'c,, not the core staff form the linkages with tile community. By comparison, CHP State,,agencies have an average staff size of about six. 7 The Secretary I-low much money sho"].cl the Doi)art-,iient continue to provide to support the evil, r,,,,ochanis,@i? I-riia. size should core staffs be? §hould salary levels be broti,,,,It into line with those in the Federal gove@&-.ic-nt? 2. At present,, I;U.,IP's are accountable to themselves and to raN!PS in IIS@21A. And yet, R@IP is discussed as a form of revenue sharin,,. 14hat is the desirability of a revenue sharin- pro-rar,-, which is C, not accountable to locally elected officials? 14hat is the likelihood that the Administration or the Con,,,ress would propose to continue such a revenue sharing program. Funding @lechinisia Ttie fundin- mechanism used for P,.%!P activities is basically a modified revenue sharing approach, although contracts and specific project grants are also used for certain activities. Some of the most visible accomplishments of KiP to date have resulted from activities supported by contracts or earmarked a ants; e.-., the development of emergency medical systems projects and IU,'.0 project grants. True revenue shariti- might place no restrictions on &rant funds; however, the Administration's eciiali revenue sharing programs all have some earmarks. Should-RI@T basic grant funds be earmarked? 'Should the basic grant be used to implement CFP p lans with additional activities, such as "mon3'.torin quality," supportcd.by earmarked funds? RNIP as an Implementing Agency The basic'purpose of an implementing agency is to provide the te chnical assistance necessary to develop projects. Simply publishing a request for proposals is n6t sufficient to implement a grant program. Someone has to provide assistance to communities to develop projects in response to those requests. Some of the clearest successes of @'T have been in providing such "implemen ing" assistance. iEN@ s have helped to develop projects- foi-lieart, cancer, stroke, and kidney disease care all over the nation. Both the Admiiiistration's Eriergency 1,4edical Systems Program and' the K',IP ENIS program have been implemented throu-h And many other smaller health services delivery projects have been implemented through 1Z',!T, including ambulatory care projects amounting to $14.6 million in FY 1972. Thus, P,'-T has 'proved to be a ve@y effective "iT,-,plementing,agency" in the past, mentor ans. although it has not acted As an.imple., of CHP pl 8. The Secretary for P makes the 'Lollo-@.,inc, recommendations f or @P.I: The RI-a) mission .si uuld be changed to that of improving access to care, althounh additional acLivities'i@li'i'@vl-it be supported through the R@i-P inec-@,- Ls.-.@ with the use of contracts or. earmarked c@rants, One additional. activity sli6uld be utilization/ performance review ot providers. 2.- V@,P should be -rade the implementing age-,icy for .i-IP plans. Ilence, R@LP projects should be in accordance with and pursuant to ti-ic plans ol-L CliP. in a-ree-iiiont with the Secretary's decision, CH'@D should review and approve projects of @N,!P. Activities of Mrt's should be carefully monitored to assure that they do not undercut the planning efforts of CHP. 3. @i'P should also be' used to aid in implementing other service development pro-raTps of I'LEvi. In addition to E.@iS and RiM? loan pro-r could ILelD to implement the Hill-liu.rton @lational Ilealtri Service Cori)s, C@TtIC's, 'iNeighborho@,,,14@@@t -Ccnters, Faml_i@"'lic-al@h Centers, etc. 4. Departmental support for education and ttainina programs should be :Wrided through BIL.,M and should be limited to the development of programs; tuition charges should pay educational costs in.full. tal support for cancer and heart activities should be funded only by NIH. IU@IP support of terminated. 5.1 An analysis of desirable staffing levels and consequent funding levels of the IC,@IP mechanisms themselves is needed. Staff and salary levels appear too high at present. 6. Since CHP will review and approve @IP projects, PIIP's should be brouaht into conformance with State boundaries. 7. 'Until the new mission of @%rP is clearly established, the PIMP, funding mechanism should not be revenue sharina. Instead 4t@ its activities should be carefully monitored with earmarks applied where necessary.. 9 'Elie Secretary lie,il.tli@ Revenue U'I"I)OSC of Ecalth Grant Consolidation 7A The issue paper discusses four purposes of present grant programs (p;AC'C 51). These same four purposes might be restated in the C, following way: 1. Financin,, of health services, a. Protection, prevention, aiia disease control services b. Provision of health services for @rtain target groups. 2. Support of State and local health departments, 3. Development of new health planning and implementing agencies, 4. Development of new community health resources. Each of the four categories of grants is discussed below, and the recommendations of P for a consolidated grant p.-ogran, are surimarized. 1. Financing of liez!lth Services As indicated in the issue paper, there are basically two kinds of grant, pro-tams which pay for healtboservices. d. Protection, Prevention, and Diseasd Control: Formula and project grants in this category support what can be termed traditional public health activities. Included are the basid formula grants under section 314(d) and ftse activities.fuiide under section 317 and 314(e) ior communicable disease control, venereal disease, TB, rubella, rodent control, and lead based paint poisoning prevention. 'Elicso grants are awarded to State and local health departments which usually provide the' services -directly. P recommends that these grants be included in grant consolidation. b. Services for Particular Pro'ect Groups: P recoruneiids that project and forr,,,ula grants in this catec-,ory which are presently made to State and local health departftiients for the direct provision of serv:Lr-es in pu l@i-c health clinics be included in grant consolidation. Included arc'i%!,CH formula grants and project grants for dental health for children. The Seerctiry. 10. -or On the other hand, p reco-,i end,,; thi'- tl-,oFe grants which pay f services in iNrzite. health care organizations not be included in grant consolidation. Si,,-.cc these services irc sii,-iilar to those provided directly through public healul) cl.iiii.cs, some. States -,Ii,.ty decide to stop funding private projects and irstead use the funds for public health services. P feels that the Federal -overriiiient should avoid the expansion of the public provision of health services; instead, Federal funds should be used to subsidize the payment for services through the private sector. Our concern is not with who controls these pro-rams, but who provides services. Rither thii-L include these grants in grant consolidation, P rcco-.i:iiends that they be maintained at the national level temporarily and terminated as national health insurance assumes payment for the services. Social and outreach services not covered by health insurance can be reimbursed through other finencin- mechanisr,.s, such as Title IV-A. Included here are project c,rants which were originally intended as development projects but N-7hici@L are currently used primarily for financing services in centers already developed.; e.c,., i@l & I, C & v. a-,id 314.(e) centers. Future project @.rart programs should be restricted tothe provision of seed money for the development of services and should not be used as services financin- mechanisms.' 2. Sul>port of State and Local F-ealth DeparLi-,ients A portion of the Federal arants to State and local health departments for provision of services is also used to support the health departments themselves - staff salaries, administrative costs, etc. Thus, grants for the provision of services by health departments and support of healt'n departments can be considered together. 3. Development of Ni@CN-7 Administering L%Iechan4Lsms for Services Developr..ient In the same way that health departments administer grants supporting the Provision oil services, the purpose of planning and implementing agt-ncies is to administer services development activities. The development of planning agencies is underway, but many changes are required to improve their effectiveness. Your previous decision was not to include CliP giqants in grant.conso'lidation. As discussed above, P recommends that @-,T be made Sr.,plomenting agencies but that they not be included in grant consolidation. The Secretary 4. DclvelopTnent of i@c%-7 C,ot;-imtini t,\, III(, 0111rcc-0 For reasons specific to each program, P reco,,iiiends that services develop-acnt programs not 1-c, 'included in graiit coitsolidition.- in 5D ibove. -As The reasons for Dot includiri,- r@@iP are g:Lvcn discussed i-ii item SC beloi.@@, P -.ni 11 x,7ill be reco,.,r@lic-,ndi.ii,@, to you in a separate analysis that llill-Burtoi-i grants be eliminated. Inclusion of the ID--io ord Family Health Centers prot,r@,Li@- has not been disease(!; the I:'@'o Program is new, and Family Healtli Centers --re dc-,rorstration -,:zitits. Otlier programs, such as those for Neighborhood Health Cc-,-itcrs aid Community ,rental Health Centers i-iiii.ch x-7cre originally designed as se-.vice development programs but have gince become mechanisms for Federally subsidizing health care are discussed above. s On the basis of the above, P recommends that the following programs be'i,.icluded in grant consolidation: Formula Grants Project Grants 314(d) Dental 13&ealth for Chi:ldren @ICH Lead Paint Poisonin. Prevention Crippled Children Communicable Disease Alcoholism 314(e) Family Planning Rodent Control - Pubella Vaccination - Venereal Disease Tuberculosis Control Community Health Grants which P recommends not be included in-grant consolidation are the following: Formula Grants Project Grants Hill Burton Children and Youth liater nal and Infant Care Migrant Health 314(e) Centers Family Planning Clip 12. The $ecrctary of Effort p (,3i@a@,rccs N-7itn the recommendation of 11 tilat maintenance of effort be required. Such a requircitiont i.@ou).d penalize States which have put forth the grc,,@Lc.,;t effort in health. In addition, cli a rc!qlii.rertiont: would be very dif l'i.cult to administer. - The Su Federal roquircriciit on level of effort by the States can be considered io. f -'lie Finally, inflation would blur .to be ttic iiiitclil,i-ii, rat0 the iirpnct of ,-xic,.h a proviso over tinir@,. 8A - 31.14.(e) Cra,,.-LIs in (@,.aiit Coz)sol.iclz7iti.on P recommends that all the activities now supported by 314(e) funds except heal-tli centers be included in grant consolidation. Consisten@ with the reasons given in 7A above, P recommends that grants for Neic,,hbornood Health Centers and Family Health Centers not be included, SB - Include K@@'P in Grant Consolidation The recommendations of P for Ri-ir are -iven in item 5D above. 9 8C Include Hill.-Burton in Grant Con§olidation P a-rees with I, that Hill-Burton grants should not be included in grant consolidation, but for different reasons. As mentioned in the tib -I, ra -.qal6 stateroant by 11, an analysis of the Hill-Burton procr@.n is 0 underway. In an issue paper being prepared for yo-a. R and P will rec ornnend that the Hill-Burton ara-Lit pro-ram be eliminated. Therefore, P reco.@iLends that it not be included in grant consolidation unless Congrcss refuses to go along with the recuest to ter-.minate,the gr,,Lt portion of the program. You may prefer to withhold decision on this proQram until the issue paper 3.S forwarded to you. SD - Include ',k','iRrant Health Grants in Grant Consolidation. For the reasons given by 11, P agrees that migrant health grants should not be included in grant consolidation. 9A and 9B Earm,;-izrlk-,s@ for NICF, and Frontal Health P recommends that no earmarks be imposed unless a strong case, can be e that the S I divert most of the funds t rrad tates wl.'l o activities I I I The Secretary -not supported by the present pro,ra,-tis. I?resent health department expc@-@etitures o.-L7 State and 'Local funds appear to coincide with Federally funded activities. 9c - ),armarl,, for Iniio-,7ation In the first issue papLr, P opposed an earmark for innovation, and our position is unchanged. It viol--tcs the principle of locil dc,te-@7-@.,4-nation, is the ess,@ncc ot' revenues, sharing. It N-7ould rate administrative problems regirdiiic, %.that constitutes gene a innovation and could result in ill-plaiired change. Innovations and demonstrations of national concern should be administered out of Was'iiinaton through project grants. Laurence.E. Lynn, Jr. PREPAR-ED BY: CTAYLOr,/D@-.','cCLOUD:ASPE:8/14/72:x34204 C)J,- written ce Disagree lic,altli Fnd im-o'LcmentaL--ion 17baltiAi Co-oncils )r la. Stz3.@L-c- Health Council 1B. Arca%%7i'llie Iloaltil Council x IC'. Hill-B,,-,rton Council 1D. Training Agency Staffs 2A Salciry 2B. Merit Svstem Scope of Review 3A. 21-ppeal to S @L. at e 3B. Appeal to Secretary .3C. @lanpower 3D. OBO Projects 3E. VA Projects x 3P. DOD Projects Funding x -4A. Loca@ health planning 4B. Stite health planning 4C. @',IP x 4D. Hill-Burton x x 4E. Medicare 4P. ilatching level 4G. @i.atching funds 411. Certificate-of@Need 41. Human Services Planning p 1,7rittc-n rce Dis@gree Co,@t,,i@ents 57i,. Adv-Lsor@, Council 5.,-;. of council x 5C. l@,ozir,.nc! 5D. X@.!P x Revbnue s @arin Abstain 6A. Future action Geii(.ir-,i]. Pri.ncii@ies 72'@. Purposes x x 7B. Elected officials x -tj. 1 a x 7C. @'o r r,. 7D. State plans 7B@. Yk E. 'L--ching x 7P. Maintenance of EA@j@ort x x din OA. 314(e) x x x 8B. MIIP x 8C4 I.Till-Burton SD. l@ligra.-, t x x SE. @@ 0 @- n,,u 1 a x OF@. L'.Iatchii-ig Program Emn @ases x x c.'A. MCH 9B. Hea3.'-,h x x 9c. Innovation x x structure of Legisi'ation 10'@, Separate proposals x Please check if written cort,,-,ent s on the iL-eni are presented.