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MONDAY JUNE 19, 1967


Washington, D.C. The subcommittee met, pursuant to recess, at 10:05 a.m., in room 1302, Longworth House Office Building, Hon. Joseph Y. Resnick (chairman of the subcommittee) presiding.

Present: Representatives Resnick, Nichols, Montgomery, Goodling, and Mathias.

Also present: Christine S. Gallagher, clerk; and Martha Hannah, subcommittee clerk.

Mr. RESNICK. The subcommittee will now come to order.

Our first witness will be the Honorable Lisle C. Carter, Jr., Assistant Secretary for Individual and Family Services, accompanied by the Honorable Donald A. Slater, Deputy Assistant Secretary for Community Development, Department of Health, Education, and Welfare.

You may proceed, Mr. Carter.


Mr. CARTER. Good morning, Mr. Chairman and members of the subcommittee.

It is a great pleasure for me to appear before you this morning, to take part in the work of your subcommittee in this very pertinent problem of rural development.

In many ways, the problems of rural poverty are even more perplexing, even harder to deal with realistically, than those of our largest cities. Just as in urban circumstances, poverty is a complex of problems, and people trapped by it suffer from a range of inadequacies

. Whatever the difference in emphasis or impact in the city and in the countryside, the elements of poverty are similar: poor health, poor schools, inadequate social services, unemployed and underemployed people. Poverty has the same destructive effect upon people, whether it destroys in a crowded tenement or an isolated country shack.

In the Appalachia region, for example, infant mortality is twice the national average. Deaths in that region resulting from infectious diseases are some 33 percent higher than the national average. The same area has serious deficiencies, in long-term care facilities and general hospital beds.

Another depressed rural population, migratory farmworkers, displays similar health characteristics. Infant mortality among migrants is 30.6 per 1,000 live births as compared to a national average of 24.8. There are 4.4 maternal deaths per 10,000 live births for migrants compared to a national rate of 3.5. Both infant and maternal mortality rates for migrants exceeded the national average by approximately 25 percent.

Comparing isolated rural areas against the Nation in numbers of physicians and dentists available, reveals substantial shortages. IsoIated rural areas have only 59.1 physicians per 100,000 population, compared to a national rate of 100.8. There are only 27.4 dentists per 100,000 of isolated rural population as contrasted to a national rate of 54.1.

The result of these shortages is demonstrated by the amount of med. ical services the population receives. According to the National Center for Health Statistics persons on farms outside of an SMSA averaged only 3.3 physician visits per year compared to 4.8 for those living within the SMSA. For dental visits the deficiencies were sharper. People living on farms averaged 0.9 visit per day or one-half those made by the population within SMSA. Families living in poverty or belonging to minority groups averaged fewer visits than the rest of the populaton so it can be assumed that the rural poor and rural nonwhite population received less medical treatment than the low averages for the total farm population.

And when one turns to the schools, there is a similar disparity there. In years of school completed sharp differences emerge between rural and urban populations for those most likely to be caught in the grip of poverty, the nonwhites. Nonwhite farm males over 14 years of age attain a median of only 6.1 years of school completed as opposed to 8.9 years for urban nonwhite males and an 11.2 median years completed for urban white males. In 1965 one of every five farm children, age 14 to 17, had not completed elementary school as compared with one of seven nonfarm children of the same age.

Our goals for high quality in health care and education and job skills and welfare services are matters of national concern. We are just as determined to seek solutions to the problems of poverty in rural area as in the cities.

Yet, while the problems are similar, while the goals are the same for the poor in the city and outside, the means of coping with the problems and reaching the goals must necessarily differ.

Many programs have been fashioned to address this complexity of elements that make up poverty. In recent years, our ability to be more effective against poverty has been considerably augmented by the addition of a series of positive programs enacted by the Congress. They have produced important contributions in improved health and welfare servces, education programs, and employment prospects for many poor people.

A number of these activities bear directly on the needs of rural areas and people. An appendix of HEW programs which address rural problems is attached to my statement for the record.

But, in spite of the programs enumerated in the appendix, and in spite of our increased efforts on several fronts, we are still faced with

serious problems in the area of rural poverty. And while it might be assuring to say that we have all the answers, that the tools we have are adequate, or that a few more dollars here or there would solve the problem, such observations would not be accurate.

Efforts to deal with poverty anywhere presume local will and initiative. But will alone is not enough. In order to employ HEW resources effectively, local initiative must be supported by at least three fundamental ingredients.

First, poverty programs require skilled manpower for their execution. Yet, we simply cannot expect to increase the availability of health services in rural areas if there are no medical personnel available. We cannot expect children exposed to inferior education by ill-prepared teachers to acquire the tools necessary to cope with the complex circumstances of the modern world. Health and education are only two areas of acute manpower shortages in rural areas.

Secondly, antipoverty programs require service delivery mechanisms and adequate institutional arrangements in order to see that vitally needed services and programs actually operate to the benefit of the people for whom they are intended. Here we also find the rural areas less well equipped than their urban counterparts. Governmental structures in rural areas are often rudimentary; county welfare units are frequently seriously understaffed; public health agencies and other important service units in many areas virtually nonexistent.

Finally, although this does not complete the list of basic necessities, antipoverty programs require adequate resources to bring together and generate necessary manpower and institutional and service mechanisms, over and above the manpower and institutional mechanisms themselves. On this score, we also find the rural areas deficient. It is more difficult and more costly to mount comprehensive and high quality programs in thinly populated areas. The unit costs for providing services are higher; the local tax base is weak; the property tax acts as a barrier to local program development; and matching money for State and Federal programs is more difficult to find.

The Department is engaged in activities that will contribute to meeting these requirements and the appendix I have submitted describes those. I would like to, however, cite briefly some relatively new areas of interest.

To confront serious manpower shortages in health, education, and social services, in addition to ongoing programs for trainin professionals, the Department is supporting the development and training of new kinds of auxiliary personnel : health aides, community mental health workers, teacher and social work aides, personnel for "new careers” in child care, and the like, to perform those functions that do not require the long years of training necessary for supplying people with needed services. Many of these activities are getting support under existing authority for adult education, vocational rehabilitation, and other programs. Two OEO programs in which we participate significantly, foster grandparents and home health aides, have already proved the value of such programs.

The Teacher Corps is bringing to some rural areas some of our most skilled and imaginative educators to assist communities in raising the level of their school programs.

Under the leadership of the Department of Agriculture, HEW is cooperating in three concerted services projects in rural areas that emphasize involving more rural people in ongoing education and training activities. Studies of the effectiveness of the three concerted services projects now in existence show that from two to five times as many rural people are participating in the involved programs in those counties as in other rural counties where such extra effort has not been made. In addition, Agriculture is in the process of organizing the same kind of effort in health services, in which HEW will be playing a major role. The States have already been designated and the process of selecting the target counties in these States is underway.

There are new resources in the offing as well which will help us reach our goals for rural areas. The President's messages to Congress on children and youth, and on older Americans recommend a number of measures which will benefit the rural poor.

The President has proposed a number of significant improvements in the social security program. The combined changes in social security suggested by the President would reduce by more than 2 million the number in poverty. These changes are designed to raise benefits from their present inadequate levels, but there are other objectives as well: to permit greater work force participation of beneficiaries who are able to work, to provide health insurance benefits to disabled beneficiaries, to seek better coverage for 500,000 farm workers who are presently severely disadvantaged because of the transitory nature of their employment, to provide benefits for disabled widows and to guarantee at least a $100 per month benefit for anyone who has worked substantially in covered employment for 25 years.

The proposed increase in benefits of at least 15 percent with a minimum of $70 a month will be especially helpful to persons in rural poverty. So also will be the increase in the payment for uninsured persons age 72 and over from $35 a month to $50 for an individual and from $52.50 to $75 for a couple.

Many families and individuals, dependent on public assistance, live below the poverty level. In computing public assistance payments, each State defines minimum need and, unfortunately, 33 States do not even meet their own minimum standards.

Child welfare services have been limited outside of population centers. There are currently 1,000 counties, predominantly rural, with no child welfare services available; other counties have too few workers. The 1965 Public Welfare Amendments required that child welfare services be made available statewide by 1975. This year, the President has facilitated the efforts of States to achieve that goal through his proposal to raise Federal matching and to pay the State 75 percent of the cost of employing and training additional child welfare personnel, the same percentage now paid for public assistance services in public welfare agencies.

The President has also proposed legislation to promote early casefinding and treatment for crippled children. We are also requesting increased funds for the medicaid program title XIX of the Social Security Act, as it affects needy children. After July 1, 1969, if proposed legislation is enacted, medicaid will require States to provide early casefinding and treatment for poor children. Extension of these services will benefit needy children in rural areas.

The President has proposed pilot programs in both maternal and children's services and in dental care. Location of these pilot projects will be determined by the need of an area; priority will be given to

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