HOUSE OF REPRESENTATIVES, Washington, D.C., April 16, 1969.

Hon. ROBERT H. FINCH,

Secretary, Department of Health, Education, and Welfare,
Washington, D.C.

DEAR SECRETARY FINCH: This is in reference to the recently announced plans of the Department of Health, Education, and Welfare to convert the Public Health Service Hospital, 14700 Riverside Drive, Detroit, Mich., to an exclusively outpatient clinic, effective June 30, 1969.

As you know, the proposed closing of the U.S. Marine Hospital in Detroit would mean that the entire Great Lakes area would be without a Public Health Service hospital. In view of the provisions of the Public Health Service Act with regard to medical services to be provided seamen on U.S. vessels, I fail to see how closure of the Detroit facility can possibly be contemplated.

I am sure that you are aware that section 322 of the Public Health Service Act provided that U.S. merchant seamen shall be entitled to medical, surgical, and dental care at Public Health Service hospitals. Additionally, the act provides that several categories of Federal employees shall be entitled to similar medical

care.

The Department's release of April 2, 1969, stated, "Patients who require hospitalization will be cared for in a number of ways. They may be referred to other PHS hospital installations, or to other hospitals, Federal and non-Federal. This will provide care at installations closer to places of beneficiary residence." The Department's statement is patently inaccurate in at least three particulars. First, in referring to other Federal hospitals in the Detroit area, I presume reference is made to Veterans' Administration facilities. I am sure that the VA will advise you that its facilities in the Detroit area are fully occupied and that for this reason it often has to deny hospital care to veterans with non-serviceconnected illnesses and disabilities.

I am pleased to call to your attention the published hearings held by the Intergovernmental Relations Subcommittee of the House Committee on Government Operations on April 29 and 30 and May 3, 1965, as well as the Government Operations Committee's report, House Report No. 544 of the 89th Congress, on the topic of the proposed closing of Public Health Service hospitals. Specifically, I would call your attention to the letter of Frank H. Weitzel, Assistant Comptroller General of the United States, to Chairman Fountain of the subcommittee, which appears on pages 49, 50, and 51 of the report and to the second to the last paragraph of this letter which reads "We perceive no legal basis for admitting merchant seamen to VA hospitals ahead of veterans eligible for treatment of non-service-connected disabilities."

Thus, it is obvious that it is not reasonable to anticipate that VA hospital facilities will be available on a regular or consistent basis to merchant seamen and others entitled to hospital care under the terms of the Public Health Service Act.

Second, while it is true that it is possible for arrangements to be made for non-Federal hospitals in the Detroit area to provide care for persons entitled to hospitalization under the terms of the Public Health Service Act, am convinced that an objective survey of the present load of these non-Federal hospitals shows that providing such care would unduly tax the already overloaded facilities of the non-Federal hospitals. It is proper to expect the non-Federal hospitals in the Detroit area to provide medical services to any person who requires same, but it is quite another matter for the Federal Government to impose an additional and unwarranted burden on such hospitals because of your Department's unwillingness to support facilities which are now operational and which could be kept in operation with relatively modest outlays.

Third, the double contention that patients requiring hospitalization "may be referred to other PHS hospital installations" which will mean that care shall be provided "at installations closer to places of beneficiary residence," is totally inaccurate insofar as a substantial number, perhaps a majority, of seamer on ships in the Great Lakes trade are concerned. It is certainly obvious that a person who resides in the Great Lakes area and who requires hospitalization, in a PHS facility is not going to be closer to his place of residence if he is sent to a hospital in New York State rather than in Detroit, Mich. If this contention is inaccurate, I would be most pleased to be advised as to the PHS hospital facility which would enable a patient who is a resident of Michigan or Illinois, for instance, to be cared for "at installations closer to places of beneficiary resi

dence." I am sure that you will agree that the Department's statement of April 2 in this regard is mere sophistry.

A reading of the hearings and report of the Subcommittee on Intergovernmental Operations to which I referred earlier, makes it clear that the Department's contention that "the declining caseload and the limited size of the hospital make it no longer feasible or economical to continue operating as an inpatient facility" is open to considerable doubt. I woud greatly appreciate being provided at your earliest convenience with cost figures to substantiate this contention. These figures should be in the same format as those provided in the subcommittee's hearings and report.

I would also like to draw your attention to the provisions of section 328 of the Public Health Service Act and to a provision of Public Law 90-174, the Partnership for Health Amendments of 1967.

Section 328 of the Public Health Service Act authorizes cooperative use on a reciprocal or reimbursement basis of PHS hospital facilities.

Public Law 90-174 provides authorities whereby PHS hospitals and clinics may orient their activities toward community health needs and enable them to enter into arrangements with local health organizations, institutions and individuals which will be of mutual benefit to themselves and community health programs.

In view of the established shortage of both Federal and non-Federal hospital facilities in the Detroit area, I find it impossible to believe that these two provisions of law could not be used by PHS to secure substantially full utilization of the available beds at the U.S. Marine Hospital in Detroit. I would appreciate your providing me with full information on what actions, if any, were taken by the Department to implement the directions of Congress contained in section 328 of the Public Health Service Act and Public Law 90-174.

The Department's statement of April 2 and subsequent conversations with its staff fail to convince me of the wisdom or the propriety of the scheduled phasing out of inpatient services at the U.S. Marine Hospital in Detroit. On the contrary, I am fully convinced that inpatient services must continue to be provided, and improved upon, if the PHS is to fulfill its statutory obligations.

I am taking the liberty of sending copies of this letter to Charman Garmatz of the Committee on Merchant Marine and Fisheries and to Chairman Staggers of the Committee on Interstate and Foreign Commerce with a request that these committees fully explore the Department's proposed action with regard to the U.S. Marine Hospital in Detroit. As you know, I am a member of both of the committees in question.

So that the committees may be able to exercise their legislative oversight responsibilities with regard to this matter, I respectfully request that you rescind the directive that inpatient services at the U.S. Marine Hospital in Detroit be ended as of June 30, 1969.

With every good wish,

Sincerely yours,

JOHN D. DINGELL,
Member of Congress.

Mr. FLOOD. Have you tried since that time to contact him by telephone?

Mr. DINGELL. Yes. I have talked twice to the Secretary-rather, to the Under Secretary, Mr. Veneman, who, incidentally, is a very fine gentleman, most pleasant. I have had a personal meeting with Mr. Veneman and a number of assistant secretaries of Health, Education, and Welfare on this point in which I stressed precisely the same facts that I am stressing to you today. I must confess I have had relatively minor success.

Mr. FLOOD. I have heard it said down through the years that there is a conspiracy of some sort going on to abolish all of these hospitals, not just the one in Detroit, but ultimately to phase them all out. Mr. DINGELL. There was a big closing atempt during the previous administration, which I am sure you recall, where actually it was attempted to close down some 14 or 15 of these hospitals. We had quite extensive hearings by the Merchant Marine and Fisheries Committee,

where we have responsibility for the welfare of seamen, and by the Government Operations Committee. The staff of the Committee on Interstate and Foreign Commerce, of which I am also a member, went into these in considerable detail. There are problems in connection with these hospitals of which I think you and the members of this committee should be aware. One is the fact that we have an extremely difficult time in terms of attracting staff, and currently there is a tremendous staff shortage. Some of these hospitals are small. The Savannah Hospital is the smallest; Detroit is the second smallest, I believe. Mr. FLOOD. What do you mean by "small"? How many beds are there in the hospitals?

Mr. DINGELL. Detroit has a practical functioning level of around 147, and I think Savannah is around 80. Other hospitals are bigger but not appreciably so. Some are very large, going up to 800 beds, which is quite a large hospital.

In addition to the serious staff shortage, the smaller hospitals also have problems in procuring certain specialized equipment. However, this problem can be very easily met since most of these hospitals are in urban areas and tend to have large numbers of major hospitals close by to provide on a contract basis such needed specialized services. So this really is a relatively minor problem. The major problem is that of procuring staff. For the last few years they have had no problem in terms of procuring medical staff, that is, doctors, and so forth. The reason is that doctors, by preference, choose to go into the Public Health Service rather than a branch of our Armed Services to fulfill their military obligation under the doctors' draft.

However, when this law expires, Mr. Chairman, you can anticipate very major staffing problems in the Public Health Service hospitals. I think this committee could and should inquire very carefully of the Public Health Service as to what plans they are making with regard to that eventuality. Now, the problem of supporting staff, such as technicians and people of that kind, is not solved so easily. The Veterans' Administration hospitals are generally able to procure doctors in sufficient numbers and the reason is a very simple one: they have a large enough flow of patients so that the doctors can develop their specialties during the periods they choose to work as Government physicians and then move on out into the practice of medicine.

If some provision were made in these public health service hospitals to utilize the flow and interchange of physicians between those hospitals, Veterans' Administration hospitals and other Federal hospitals, I think you would find, first of all, that there would be a number of benefit increases. First of all, these are hospitals that are in being, their capital costs are low, and adequate use of this kind of facility can result in significant savings in money. They could be utilized, for example, for military dependents who are entitled to certain benefits at Government expense, and service-connected Veterans' Administration patients, as well as certain other categories of Government entitlements for health benefits and health care. Now, if these facilities were more fully utilized it should be possible to attract sufficient doctors and to expect over the long term to have an adequate flow of doctors into and out of these hospitals.

Now, this kind of problem in Detroit is not unique. It is met in all the hospitals. I would cite one last thing that you ought to keep in

mind in consideration of this closing, and that is that the chief official of the Public Health Service in charge of the hospital is strongly opposed to the closing.

Mr. FLOOD. What is his name?

Mr. DINGELL. I cannot give you his name right now. I will furnish that for the record.

(The information follows:)

The official referred to is Mr. Seward Proctor, administrator of Detroit PHS Hospital.

Mr. FLOOD. Mr. Michel.

Mr. MICHEL. Thank you, Mr. Chairman.

Our good friend from Michigan makes a very eloquent statement against the closing of the Public Health Service hospital in his own bailiwick. The only thing that distresses me about your statement, Mr. Dingell, is the fact that the inpatient capacity is 177 beds and operating capacity of 147 beds. According to your statement, during the July-September 1968 period an average daily inpatient load was experienced of 96, which suggests that at a time when we are hurting for adequate facilities to cope with all the patients around the country in other hospitals, where we hear of waiting lists and so forth, that maybe this is not the most efficient operation here, with only an average daily patient load of just a shade over half of its capacity, and that there is some justification for looking into the prospects of closing it.

I am not althogether familiar with what the average daily patient load might be in other Public Health Service hospitals as against their maximum capacity, but what would your comment be with respect to that observation?

Mr. DINGELL. I think you are pointing up the very thing I am complaining about here. That is, that we are not making adequate use of these Public Health Service hospitals. I think with fuller use we could probably achieve significant overall savings to the taxpayer since the capital costs are low, these hospitals were built in years past, and are still adequate structures. I believe there ought to be a real effort to utilize this hospital rather than to phase it out.

I mentioned that during the previous year they had something like 27,000 patient-days. They anticipated that during this fiscal year they would have 30,000 patient-days, which would be an increase to significantly over 100, probably on the order of 110 to 115 on a daily load basis if they were to utilize this hospital. I point out, too, that during the time you and I are discussing there were two buildings at the hospital entirely closed. They had been set up for an Urban Job Corps training program for medical technicians, and so forth. The buildings are beautifully furnished, they have fine carpets on the floors. But they were closed; in fact, those buildings have been lying idle and closed for a number of years.

We have this crying need for technicians, and are failing to utilize this hospital where health technicians could be well trained, probably at less cost than in other facilities. Now, what I am saying is that not only do you have a fiscally unwise judgment being made here but, in fact, you find a situation where the facilities are not even being used the way they should be.

Mr. MICHEL. You will have to agree there is much more to a hospital than simply a building.

Mr. DINGELL. I thoroughly agree.

Mr. MICHEL. Somewhere in your testimony there was mention made of the need for modernization.

Mr. DINGELL. There is not a really great need for physical modernization. In a hospital operation you have your choice between good and great, let's say, or adequate and superb. You can find hospitals, not so much in this country but in other countries, where the main physical plant is 100 years of age providing high quality medical care. The plant here dates from the middle 1930's which is not excessively old in terms of the age of hospitals in this country. It does not really require much modernization. Certainly, new equipment could be used, certain kinds of specialized health equipment would be desirable, but they are not absolutely essential to first class medicine, since within a matter of a few miles you have hospitals well equipped with this precise kind of thing and which, on the basis of some of the things we have done legislatively in my committee, could be and should be providing an interchange both of personnel, skills, equipment, et cetera, with other hospitals in the area. Right now in terms of the Hill-Burton extension, which my committee is presently voting on, we are considering the whole concept of regional health centers and regional care.

Mr. FLOOD. The Hill-Burton authority expires in June of this year, does it not?

Mr. DINGELL. I do not know whether it is June, but very shortly. There is no reason why every hospital in this area has to have, for example, a cobalt bomb, or must provide gynecology treatment, obstetrics, and so forth. You will find hospitals are making judgments that there are other hospitals in the immediate area which can provide these services better. Therefore, some hospitals will provide certain specialized care only on an emergency basis, and will emphasize other areas. Now, during the past year we tried to set up permission in the law not only for tax treatment but actual Federal grants for construction of certain kinds of auxiliary services; for example, joint diagnostic centers and computer banks, certain kinds of specialized equipment like cobalt bombs, specialized X-ray treatments, things of this kind, to be done centrally for a whole group of hospitals. In the Detroit area we have a major hospital complex just a few miles from the point where this Public Health Service hospital happens to be. So, this really is not a major problem. We have a hospital; it is in-being.

Mr. MICHEL. Are you saying this one could be used for extended care, utilized more for extended care?

Mr. DINGELL. It could be utilized more for extended care. You see, there is one other flaw in the position of the Departments; that is, they propose to keep open the outpatient services. I have not even calculated those services in my costs. By providing outpatient services only, you will find they are going to become very expensive without the previous daily patient to fully utilize certain services and prevent a great deal of idleness in these services.

Mr. MICHEL. I will be interested in reading your letter that you will submit for the record and see if we cannot get some kind of response to it, because I think you pose some very basic questions.