RLP:   9/30/74


                                      Area Designation Issues & Problems


                  Designation of  health  services  areas  will  be  an  important,  initial  step
                  in the implementation of the Health Resources Planning (HRP) program.
                  Several major issues  and  problems  have  been  identified  in  our  planning  and
                  preliminary  implementation  efforts  to  date  relative  to  area   designation
                  (AD). Those efforts  have  been  based  largely  upon  H.R.  16204  and  the  draft
                  House,Committee report.
                        1.  Only two objective AD requirements are legislatively mandated.
                            They relate to population  and  SMSAS,  and  compliance  can  be  readily
                            determined. To what  extent  do  we  want  to  effectively  limit  the
                            AD requirements to  these  and  allow  governs  wide  latitude  within
                            the dynamics at work within their own States, in waking designations?

                        2.  Waivers to both  the  minimum  population  and  SMSA  requirements,  are
                            permitted. It  is  assumed  that  relatively  few  waivers  should  be
                            granted. To what  extent,however,  do  we  want  to  try  to  "influence"
                            the designations to be made by Cloverna"@hro'ugli the criteria employed
                            in reviewing waiver requests, granting or denying them? (For example,
                            we probably want  to  discourse  governors  from  chipping  up  existing
                            areas that now  have  reasonably  effective  functioning  CHP  or  other
                            agencies and meet the mandated requirements.)
                        3.  Approval (or disapproval) of proposed designations, including
                            waiver requests, is reserved to the Secretary.  Who should exercise
                            or, his behalf the official  as  opposed  to  the  effective  approval
                            authority?  (It  is  assumed  that  regional  offices  will  work  the
                            principal responsibility for reviewing proposed designations,
                            and that  their  recommendations  will  be  tantamount  to  approval  in
                            the great majority of instances.)
                         4. A small ad hoc review  panel  cons!-sting  of  both  regional  (RO)  and
                            central office ,'CO) Staff, has bec-n suggested to handle exceptions.
                            What  should  constitute  an  exceptiov,?  For  example,  all  requested
                            waivers, or only those  where  RO  staff  and  CO  staff  disagree;  any
                            designation that  meets  the  population  and  SMSA  requirements  but
                            which, for whatever reasons a RO recommends disapproval?
                         5. Governors are recuired to submit their AD  pl-ans  wi-tl,-In  90  days
                            after the initial- notice in the  Federal  Re@ister  (F-R);  and  thc-
                            Secretary in turn i,,iust publish approved designations 4,-n  the  T@,
                            within 150 days of  that  notice.  Within  thoE;e  60  days  review  must
                            take place.    Little time will. remain after review to (1) neQoti-ate
                            substantive revisions required as a result of waiver requests
                            denied or other  non-approval  actions  or  (2)  for  the  Secretary  to


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                         designate acceptable areas in lieu thereof.  Should a minimum
                         grace period of 30 or 60 days be permitted?  With or without such
                         a grace period, who at the Federal level should be responsible
                         for designating areas when negotiations have-failed; and how should
                         this be done?