Columbia in Relf v. Weinberger and National Welfare Rights Organization v. Weinberger require that projects using Federal funds for nontherapeutic sterilizations instruct legally competent candidates for the procedure in the full nature of the operation, its irreversibility and side effects, and specifically inform them in writing that a decision not to be sterilized will not result in the denial or withdrawal of any other benefits to which they are entitled. The regulations require a 72-hour waiting period between the signing of the consent form and the performance of a non-therapeutic sterilization.

In September 1977, the U.S. Court of Appeals for the District of Columbia Circuit entered a decision in Relf v. Weinberger which allowed the Secretary to promulgate proposed new sterilization regulations limiting Federal funding to sterilizations which the patient has voluntarily requested with full understanding of the irreversible consequences. Major revised features of the proposed rules include a longer (30 day) waiting period, increased physician responsibility for assuring informed consent, special safeguards which would make sterilization available only under certain conditions protecting the interests of mentally incompetent individuals who can understand the nature and consequences of the procedure and those who are institutionalized, and a prohibition on the Federal funding of hysterectomy for the sole purpose of family planning.

In 1975, Congress enacted section 205 of Public Law 94-63, which makes it a felony to coerce anyone to undergo an abortion or sterilization through the threat of withhholding any Federal program benefits.

Umbrella Grants

Another cause of concern in some sectors is the consolidation of small grants under one "umbrella" grantee. Many clinics were consolidated into existing HEW grants after the transfer of small OEO clinics to HEW. This was done to streamline management of the clinics and to reduce costs. In 1975, with the completion of the OEO transfers, the systematic consolidation of grantees also ended. Due to concerns raised during this period, the congress provided in an amendment to the then section 1001 of title X, that "local and regional entities shall be assured the right to apply for direct grants and contracts under this section, and the Secretary shall, by regulation, fully provide for and protect such right."

The committee believes that the diversity and broad geographical dispersion of the 5,000 organized family planning clinics offer access to family planning services in the most effective manner to individuals wanting those services. On the other hand, the committee does support HEW's desire to stress greater integration of comprehensive family planning services into other health care settings such as neighborhood health and migrant health centers. This move was initiated-in keeping with the intent of the legislation to make family planning services widely available-because it was felt that other ambulatory health service programs funded by HEW did not provide a sufficient range of family planning medical and social services to their clients. This policy also highlights the preventive health nature of family planning services and the value of such services as an integral part of ambulatory health care.

The committee notes with satisfaction that the Departmental witnesses provided assurances that neighborhood health and migrant health centers receiving title X (now part A) funds must meet all the guidelines and regulations which apply to other title X (part A) grantees,...

THE COMMITTEE BILL

Changes in Statutory organization of title X and XI of the Public Health Service Act

S. 2522 as reported would repeal part B (Sudden Infant Death Syndrome) of title XI of the Public Health Service Act, add it to a revised title X, Family Planning and Human Development Programs, which would then include a part A, Voluntary Family Planning and Population Research Programs, and a part B, Sudden Infant Death Syndrome Programs, The reasons for this combination are as follows:

Conbining these programs in one title pulls together two related programs. Research has shown that SIDS has no apparent genetic base so as to jusitfy its inclusion in title XI. Research has also shown that many SIDS infants were born to very young mothers, were of low birth weight, or were born prematurely-all conditions which can be reduced through proper prenatal care.

During hearings held by the Senate Appropriations Committee in April 1977, on SIDS, Dr. Eileen Hasselmeyer, Chief of the Pregnancy and Infancy Branch of the National Institute of Child Health and Human Development testified thet 50 percent or mote of the crib deaths could be prevented or reduced if premature births of prenatal problems were prevented.

Research in sudden infant death syndrome, high-risk pregnancy, and high-risk infancy as well as in population research is carried out at the same NIH Institute-The National Institute of Child Health and Human Development. In addition, the research in the two programs is related in many ways.

Family Planning clinics serve as the primary health source for many women and the clinics counsel women to seek appropriate prenatal care, referring patients to prenatal service, and encouragÎng them to seek the all important early prenatal care and guidance on good health and nutition habits during pregnancy which can help ensure the delivery of a healthy baby.

A major new initiative in the newly designated part A of title X is a special emphasis on preventing unwanted pregnancies among sexually active adolescents. These young mothers frequently bear low-birth-weight infants, have poor nutritional habits, and have minimum prenatal care, partially due to ineligibility for Medicaid reimbursement for such care and partially due to an unwillingness to admit they are pregnant in the early months. Preventive family planning services can help these women bear children when they want to and when they are prepared to take on the responsibilities of childbearing. Because of these factors, the committee placed in one title two authorities which address special needs of women and children. It is not the committee's intent, however, that these programs be administered as a single entity or program but, rather, that each continue to

be administered in a manner which most effectively addresses their separate, individual program needs, approaches, and philosophy.

Office of Population Affairs and Deputy Assistant Secretary for

Population Affairs

Many witnesses at the hearings urged that action be taken to reinstitute the position of Deputy Assistant Secretary for Population Affairs (DASPA) so that family planning and population research programs could be given the coordination and policy direction needed to make the most effective use of statutorily authorized program and Departmental resources.

Section 1001 of the committee bill includes provisions, with modifications of Public Law 91-572 establishing the Office of Population Affairs in the Department of Health, Education, and Welfare, and the position of Deputy Assistant Secretary for Population Affairs, describing the duties and functions of that position and Office. Although the organizational structure and line authority of responsibilities for carrying out family planning programs and population research activities were clearly set forth in Public Law 91-572, the Family Planning Services and Population Research Act of 1970, HEW's organizational and administrative arrangements have not always been consistent with the law or its underlying intent. Inclusion of these provisions in title X reasserts original congressional intent that there be a Deputy Assistant Secretary for Population Affairs who shall direct the activities of the Office of Population Affairs and administer the family planning programs and exercise general supervision over title X population research activities as well as coordinate and advise the Secretary on other Departmental programs relating to family planning and population research.

The committee bill directs that the DASPA shall be assigned no substantial functions or responsibilities not specified in part A or determined by the Assistant Secretary for Health to be necessary to carry out the purposes of part A. The committee was concerned by action taken in 1976 by the Secretary to appoint the Deputy Assistant Secretary for Population Affairs as the Administrator of the Health Services Administration. Adding such heavy responsibilities to those mandated by Public Law 91-572 to be carried out by the Deputy Assistant Secretary for Population Affairs, placed an extraordinary burden on one individual, diluted that individual's responsibilities to the family planning and population research programs, and diverted that official's primary focus from coordinating and supervising those

programs.

The committee was again concerned when it was proposed in 1977 to combine the duties of the Deputy Assistant Secretary for Population Affairs with those of the Deputy Assistant Secretary for HealthPrograms. The committee was pleased that the Assistant Secretary for Health, in his testimony, announced his intention to discard that proposal and reinstitute the DASPA position.

The committee believes that the responsibilities given the DASPA are of sufficient importance and size to warrant the full-time attention of the occupant of that position.

The interrelationships of programs authorized by part A of title X of the Public Health Service Act, by title V of the Social Security Act, and programs receiving assistance or reimbursement under the authorities of titles XIX and XX of the Social Security Act are many, and produce a particularly appropriate area for special focus by the Deputy Assistant Secretary for Population Affairs. The committee notes with approval the assurances given by HEW witnesses that efforts are being made to achieve such coordination and that, where individual title X part A projects encounter difficulties in qualifying under medicaid or title XX programs, HEW regional staffs work with projects and State agencies on a case-by-case basis to overcome such difficulties. The committee stresses that this is an important area for the DASPA's involvement. By working with the appropriate officials in HEW and having jurisdiction over the title XIX and title XX programs the DASPA can play a particularly valuable role in assuring that policies followed in those programs are conducive to the most efficient administration of each of the programs.

The difficulties faced by many individuals, and particularly adolescents, in surmounting bureaucratic hurdles created by differing eligi bility requirements in HEW programs were eloquently described by Dr. Loraine Henricks, of "The Door-A Center of Alternatives", a comprehensive health and social center for adolescents in New York City. Dr. Henricks stated:

Medicaid and welfare policies and practices are currently insurmountable barriers for many adolescents seeking health care. This is because of laws, regulations and practices which make it nearly impossible for a teenager to obtain medicaid or welfare, even when eligible and when pregnant. Health care programs are increasingly requiring proof of medicaid status prior to provision of services. We estimate that 80 percent of eligible teenagers under 18, and many under age 21, never attempt or never succeed in negotiating the medicaid application system. We strongly recommend easing access to medicaid for teenagers-including providing medicaid for teenagers independently of their family and their family medicaid card, easing regulations on documentation required for medicaid, establishing clearly that age is not a requirement, reducing the waiting period necessary to obtain medicaid, etc.

Efforts to remove such barriers should be undertaken by the DASPA as a priority matter in connection with the coordinative aspects of that Office.

The Committee bill also directs that the Office of Population Affairs be headed by a Director who shall be subject to the direct supervision of the Deputy Assistant Secretary for Population Affairs. The committee believes the duties of the Deputy Assistant Secretary are sufficiently demanding and complex to require a full-time director of the office to assist the DASPA in carrying out those responsibilities. The committee also believes that these duties and responsibilities are such that the DASPA should not be assigned any responsibilities not specified in part A or determined by the Assistant Secretary for Health to be necessary to carry out the purposes of part A.

The committee bill, recognizing the magnitude of the duties assigned the DASPA and the Office of Population Affairs, repeats the provision of Public Law 91-572 directing that the Office of Population Affairs be provided such full-time professional and clerical staff and the services of such consultants as may be necessary to carry out its duties and functions.

Voluntary Family Planning Services

Million of low-income individuals for whom cost or inaccessibility to services presented real obstacles to the use of family planning methods are now receiving these services on a regular basis from clinics or private physicians. About 5.9 million low-income women and teenagers are now reached through Title X and other Federal programs.

Despite these achievements, a great deal remains to be done. Over 3 million low-income women currently cannot obtain family planning services easily. These include an estimated 2 million sexually active teenagers who do not have ready access to preventive family planning services. An estimated 1.100,000 abortions were performed in 1976, one-third of them involving adolescents. Undoubtedly, many of these abortions could have been avoided with greater availability of effective family planning methods.

Although significant results have been achieved by HEW in making available to teenagers contraceptive information, education, counseling, and medical services, teenage pregnancy has become an issue of major concern. There are presently about 21 million young people in the United States between 15 and 19 years of age. Of these, more than half-some 11 million-are estimated to have had sexual intercourse almost 7 million young men and 4 milllon young women. In addition, one-fifth of the 8 million 13- and 14-year-old boys and girls are believed to have had sexual intercourse. Approximately 1 million of these teenagers become pregnant annually, and almost 600,000 give birth. Such pregnancies are often unwanted and frequently result in adverse health, social, and economic consequences for the individuals and families involved. Specifically, these consequences include a higher incidence of low birth-weight infants, a higher percentage of pregnancy and childbirth complications, and higher rates of school dropout, unemployment, welfare dependency, and outof-wedlock births. An adolescent marriage is also at high risk of divorce.

Joy Dryfoos, chair-elect, Population Section of American Public Health Association in testimony before the subcommittee reported on the high risk of unwanted pregnancy among sexually active adolescents. She stated:

What of the 1.6 million teenagers at risk of unintended pregnancy who did not receive contraceptive services from either organized programs or private physicians in 1975? The probability is quite high that they appeared in the vital statistics report for 1975. New analyses from the 1976 Johns Hopkins study of Adolescent Sexuality, Contraception and Pregnancy show clearly that among premaritally sexually active women aged 15 to 19, 58 percent of those who never used contraceptives had experienced a pregnancy,