Use of Federal Funds for Bringing 5-Year-Old Mississippi Children to Washington, D.C., for Dental Treatment

Published by the Government Accountability Office on 1971-08-02.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

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                           COMPTROLLER      GENERAL        OF   THE   UNITED   STATES
                                         WASHINGT0N.D.C.          20548

         Dear Mr. Downing:
                Your letter  of September 17, 1970, requested that we
         comment on questions raised by one of your constituents                con-
         cerning the use of Federal funds2.otiringingJ~~ar-pld                   Mis-
         sissippi   children  to Was,h_ing~on,,....-?.~~~=
                        _ o.mx--F.r.-~..
                                      _---w             -fqr dlntal     treatmx
                                                               -a-.-... --.-_F______a
         Spec?TETly,Vhe      asked:

               --Whether the parents              of the children had requested                  den-
                 tal care from local,              State, or Federal agencies.
               --Who had determined             that       the dental            care was necessary?

               --Whether proper treatment could have been provided                               in
                 Mississippi  or some nearby State.
               --Whether it was the most economical and cost-effective
                 action to bring the children    to Washington for treat-
                 ment at a cost of $250 a child.
                Your constituent   also suggested that we conduct studies
          of the propriety    and efficiency    of expenditures by the De-
        / partment of Health, Education,      and Welfare (HEW) and by otherZZ
          agencies involved in socially      oriented programs.

                We have reviewed available     documentation     at HEWhead-
         quarters,   Washington; the HEWregional       office    in Atlanta,
         Georgia; Howard University,       Washington, where the children
         were treated;    and the Delta-Hills    Educational     Association,
         Inc., Sardis, Mississippi --the organization         responsible     for
         operating   the Head Start project under which funds were made
         available   for the dental care.      We discussed the conduct of
         the project with officials      at each of these locations        and the
         Mississippi    State laws for the licensing      of out-of-state      doc-
         tors and dentists    with officials    of the Mississippi      State
         Boards of Medical and Dental Examiners.
               In brief,   our review has shown that the Association     is
         having difficulty    providing the preschool children  partici-
         pating in the Head Staxt project with the n

                                  50 TH ANNIVERSARY                   1921- 1971


        and dental care.     The Association    cited a number of reasons
        for this situation,    including   a lack of funds, a shortage of
        doctors and dentists     in the area, and difficulties          in ensur-
                                                      . ..___.~.
                                                              ..-.                      th
                                                      he Civil      Rights      Act  of
                                                                      1.1.^- _I . ~_,...."
               For these reasons the Association     entered into agree-
        ments with Howard University-     -which is developing    a compre-
        hensive health project    in Quitman County, Mississippi--to
        provide the medical and dental services.         Howard University
        dental personnel,    however, were unable to readily      obtain li-
        censes to practice    in Mississippi,   which prevented their pro-
        viding the services in Mississippi.        The licensing   problem
        was the primary reason for transporting       the Mississippi    chil-
        dren to Washington for dental treatment.
              Following is a brief history  of the Mississippi                Head
        Start project   and comments on the specific questions                raised
        by your constituent.


              The project under which the Mississippi children  were   rlsl
    L   provided dental care was funded by an OEO grant under the Head
        Start program authorized  by the Economic Opportunity  Act of
        1964, as amended.
              The OEO grant, effective     July I, 1969, was awarded in the
       amount of $1,049,953 to the Mississippi        Industrial    College,
       Holly Springs, Mississippi,       to establish  and operate--through
    g its delegate agency, the Delta Hills Educational           Association - - qqqb
    ,'a Head Start project     for 1,060 preschool children       in the five
       counties of Grenada, Panola, Quitman, Tallahatchie,           and Tunica,
       Mississippi.    The project    grant provided for the development
       of a comprehensive health services program for the program


       This program is designed to assist economically        disadvan-
taged preschool children      to achieve their full potential      and
provides for grants to public and private nonprofit          agencies
to establish    and operate comprehensive projects      for child de-
velopment, encompassing programs for health, nutritional,             ed-
ucational,   psychological,     and social services.    The program
was administered    by the Office of Economic Opportunity        until
July 1, 1969, when administrative        responsibility   for the pro-
gram was transferred      to HEW.
       HEW's manual of policy instructions        for the Head Start
program requires     that each Head Start project        provide,   or ar-
range for, comprehensive health services--including              medical
and dental examinations,      treatment,    and preventive     measures--
for all participating     children.      The manual also provides
that, in developing a health services program, a grantee uti-
lize other health programs, services,          and resources already
available   in the community and limit the use of project             funds
to supplement, if necessary,        the existing    local health re-


       Because HEWrequires       that a Head Start project    provide,
or arrange for, dental examinations          and treatment for chil-
dren participating     in the project,      such services are provided
routinely.     The transportation       of 290 children  to Washington
for dental treatment was specifically          approved by the parents
of the children.      The determination      of need or extent of
treatment was a medical decision based on the examinations
given by Howard University         personnel in Mississippi.

       The grantee, in its application  for a grant for the
Head Start program, proposed to obtain the medical and dental
services through arrangements with local physicians       and den-
tists.    In December 1969, however, the Association--the     grant-
ee's delegate agency- -entered into an agreement with Howard

University    to provide the required health services at a cost
of $47,543 during the first      year of operation     of the project.
The agreement provided for the health services to be provided
in Mississippi    by the university's    medical and dental person-
nel using mobile health equipment.         As previously   pointed out,
Howard University      is in the process of developing a comprehen-
sive health services project       in Quitman County.

       The Association,    in its request to Howard University         for
assistance,    stated that the needed medical and dental ser-
vices could not be provided satisfactorily          by local physi-
cians and dentists,      because there was no assurance that the
services would be provided in compliance with the nondiscrim-
inatory provisions      of the Civil Rights Act of 1964. Also the
agreement with Howard University        stated that the shortage of
physicians    and dentists    in the project   area contributed     heav-
ily to the problem of obtaining       health services for the chil-
dren.    In its request the Association       also stated that it
considered its limited       budget to be insufficient      to finance
the cost of the needed services through use of local practi-
tioners and requested Howard University          to furnish   the ser-
vices within the budgeted funds ($47,543) available.

       We found, however, that only limited         efforts      had been
made by the Association       to obtain the services locally.           The
director   of the Association       informed us that the Association
had sent letters     to local doctors and dentists          listed   in the
telephone directory,      inquiring     whether they would furnish        ser-
vices in compliance with the Civil Rights Act, but had re-
ceived few replies.       The director,     however, did not produce
any evidence indicating       how many local doctors and dentists
had been contacted or that they had been requested to submit
data on charges and on the number of children             that they would
       In our opinion,   such information  was necessary to deter-
mine definitely    whether medical and dental services could be
obtained locally    at a reasonable cost.    The director  informed
us that comprehensive efforts      had not been made to obtain the

services from other than Howard University    because he felt
that the arrangement with the university    would be extremely
advantageous to the Association   since the university   was in
the process of establishing   a comprehensive health services
project  in Quitman County.


      According to the terms of the Association's        agreement
with Howard University,    the health services to be provided
by the university   in Mississippi     included comprehensive med-
ical and dental examinations,      screening and testing,      and nec-
essary follow-u'p treatment consistent       with the limitations
imposed by the mobile facilities       available  and by the sever-
ity of the medical services needed.

      Late in 1969 Howard University    personnel went to Missis-
sippi and performed examinations     and screening services for
approximately  1,000 program participants.        Because Mississippi
State law did not permit out-of-state      dentists   to practice    in
the State for extended periods without becoming licensed,          how-
ever, Howard University   officials   decided to bring the chil-
dren to the university   in Washington for the required dental

        Since the licensing     problem was the major factor in
Howard University's      decision to bring the children         to Washing-
ton, we talked to university         officials   about the measures
taken to obtain licenses to practice           in the State.      They in-
formed us that the problems with State laws had not been an-
ticipated    before entering into the agreement with the Associa-
tion, because they had been told by a representative               of the
University    of Mississippi     that he could arrange for them to
perform the needed medical and dental services,              They added,
however, that this arrangement had not materialized               because
this individual     had left the University       of Mississippi.      Ap-
parently,    no one else was able to make such arrangements.
     A total of 290 children were brought to Washington dur-
ing August 1970. Howard University   officials told us that the

children  had been selected on the basis of medical and dental
needs.   An official  of the Association      said that none had been
brought to Washington without parental approval.          An official
of the Association   said that Howard University       had offered to
treat all the children   participating     in the Head Start project
as needed.   Parental approval,      however, could be obtained for
only 290 children.

      Information developed by Howard University  indicated
that, while the 290 children were in Washington, about 1,100
carious teeth had been corrected,  13 hernia operations     had
been performed, and 68 other cases received ambulatory care.


      Howard University,      under its contract with the Associa-
tion, agreed to provide the medical and dental services in
Mississippi   at a cost of $47,543, consisting        of $41,043 (com-
puted at $38.72 a child)       for the examination and screening,
treatment and medication,       and laboratory   diagnosis    for the
1,060 children   participating     in the Head Start project;
$4,000 for the use of equipment and laboratory           supplies;   and
$2,500 for consulting      fees and miscellaneous     materials.

       The university       has billed  the Association    $43,176 (about
$41 a child)     for the services provided to the children          in Mis-
sissippi     and to the 290 children      brought to Washington.       The
university's     billing     was supported by a certification     that
the professional        services contracted    for in the amount of
$41,043 had been provided and that equipment and supplies had
cost $2,133.
      At the time of our review, Howard University     financial
records showed that costs recorded for this project       totaled
$38,337, exclusive  of professional   salaries.    We were told by
a Howard University  official   that such salaries  were not ac-
cumulated and charged to the project because the personnel
came from various departments within the university.         As many
B-164031 (2)

as 60 university              staff    members worked        on the     project     at one

          Information          was not available         at the Association          regard-
ing either         the      availability        of local    practitioners       or other
facilities         for      providing      the needed services           or the cost of
such services.                In the absence of such information,                 we did
not attempt          to     evaluate     the reasonableness           of the Associa-
tion’s       decision         to enter     into the agreement          for the services
to be provided              by Howard University.            The university        subse-
quently        found      it necessary        to bring     some of the children          to
Washington         for      treatment      because of the licensing            problems      it
had encountered               in Mississippi.

        It appears that the Association              entered     into the agree-
ment with Howard University            because (1) it believed            that
there was no assurance         that the health          services     could be pro-
vided locally      in compliance       with the nondiscriminatory              pro-
visions    of the Civil     Rights Act of 1964 and that its limited
budget was insufficient          to finance       the cost of the services
through    the use of local        practitioners,        and (2) Howard Uni-
versity    was willing    to furnish         the services      needed within        the
budgeted     funds available.

         Because of the licensing         problems,     however,    the univer-
sity was unable to provide            all the needed health         services    in
Mississippi.         Furthermore    the university       presently     is having
difficulty      in providing     similar     dental    services    under its con-
tract      with the Association       covering      the second year of the
Head Start      project.

        Howard University      officials       told us that providing        the
medical    services    under the agreement          for the second year pre-
sented no problem because two of its doctors                   had obtained
temporary     licenses    to practice       until   a permanent    license
could be obtained       under reciprocity          agreements.     Because such
agreements      are not available        for dentists,      the university’s
dentists    must take and pass an examination              before    being li-
censed to practice        in the State.

.    . .

              B-164031 (2)

                     To date, four dentists     have taken the examination and
              one has passed.     University    officials     informed us that this
              dentist was providing     services to the children.         They also
              said that the university       had contracted      with one local dentist
              to provide services and that attempts were being made to con-
              tract with two other local dentists.            Thus some dental ser-
              vices are available     in Mississippi      other than those being pro-
              vided by Howard University.              -
                      Because the Association    has not determined the extent to
              which dental services can be obtained locally         or the cost of
              such services and because of the university's         problem in pro-
              viding the dental care in Mississippi,       we plan to suggest to
              HEW that, when considering      a renewal of the grant for the
              Head Start project,    it determine whether the existing      arrange-
              ment with Howard University      is the most reasonable and prac-
              ticable    arrangement under the existing    circumstances.

                     Concerning your constituentls    suggestion that our Office
              investigate    the expenditures  of agencies where social activi-
              ties are involved,    we have full-time   audit staffs assigned to
              HEW, the Office of Economic Opportunity,       and other civil    de-
              partments and agencies to make continuing        reviews of their
              programs e Reports on these reviews are issued to the Congress
              and are summarized in the Comptroller      General's Annual Report
              to the Congress.

                   HEW, the Association,  and Howard University         have not been
              asked to comment on this .report.

                                                  Sincerely   yours,

                                                 Comptroller  General
                                                 of the United States
       Gi    t tQ-
               The Honorable Thomas N. Downing
            O.lHouse of Representatives