Mr. SPRINGER. Let me give you a lead, then. I just had a letter from a doctor this morning in my district, to whom I had submitted Mrs. Bolton's questionnaire, which she sent around the other day.

His answer to that was there should be a nurse for every doctor. Dr. CLARK. The need is much more than that.

Mr. SPRINGER. The need is more than that?

Dr. CLARK. Much more.

Mr. SPRINGER. How many more?

Dr. CLARK. The need is changing, and the need is increasing, because nurses are doing so much more than they formerly did.

Mr. SPRINGER. That is what I want to know; how much more?

Dr. CLARK. Well, I think we have something like 3 nurses to 1 doctor, now. Maybe it is three something. There are approximately 175,000 doctors in active practice and about 400,000 graduate nurses. And, we do not have enough active nurses at that ratio.

Now, what the ratio should be is pretty difficult for me to answer. Mr. SPRINGER. Did the President's Commission make a survey on that?

Dr. CLARK. Yes; it did. The statement of our Commission was that we might be short 50,000 nurses by 1960. They say there are 365,000 active graduate nurses in practice at the present time which is quite an increase since 1900 when there were 12,000.

Mr. SPRINGER. 1900?

Dr. CLARK. Yes, sir.

Mr. SPRINGER. How many are there in the armed services?
Dr. CLARK. I do not know.

Mr. SPRINGER. Roughly?

Dr. CLARK. I can't even give it to you roughly. I am sorry.

Mr. SPRINGER. May I ask this? Has the cream sort of been skimmed off of the top by the armed services on that?

Dr. CLARK. There is not any doubt but that the Armed Forces, the Veterans' Administration, and the Public Health Service have been pretty stiff competitors for nurses, because the salaries are better than elsewhere.

Mr. PRIEST. Will the gentleman yield for one question?

Mr. SPRINGER. Yes, I will yield for a question.

Mr. PRIEST. My question is whether or not the figure that Dr. Clark has given applies to graduate nurses? It does not include practical nurses?

Dr. CLARK. Not the one I gave, Mr. Priest, the 365,000 are the active graduate nurses. And, there are about 400,000 more auxiliary nursing workers, and the statement is that there is need for 450,000 auxiliaries.

Mr. PRIEST. Thank you.

Dr. CLARK. By 1960.

Mr. SCHENCK. Will the gentleman yield?

Mr. SPRINGER. Yes, I will yield to the gentleman from Ohio.

The CHAIRMAN. Mr. Schenck.

Mr. SCHENCK. Doctor, the cost of training nurses, nurses' training in hospitals, as I understand it, is rather high for at least the freshman year.

Dr. CLARK. Yes, sir.

Mr. SCHENCK. Would it be feasible or possible, or good, to have the women's organizations in the military services, such as the

WAVES and the WAC and the SPAR take nurse's training in the military hospitals? Would that be of any help?

Dr. CLARK. There used to be an Army Nursing School. It has been closed. And I think most people are dubious about the training in military hospitals, not because they cannot do all right from the standpoint of the technical training, but because the population of a military hospital is a rather unusual one, if you compare it with the civilian population. There are very few elderly people-relatively few women and children, and yet when the nurse goes out into practice, if she goes into another hospital, she is going to take care of those people mostly. So, it is not a very good population group to train girls on, you see, and, therefore, I would not think that was the ideal solution.

The problem of nurse education is, as I see it, is partly that, as you said, it is expensive for the nurse, although hospital nursing schools by and large do not charge a very high tuition. I think our tuition at Massachusetts General is $350 for the 3 years, but, of course, the girl gets her room and board and uniforms and then, during the last 8 months of training, we pay her $25 a month, so she gets back $200 in cash, in our particular hospital. The more important problem is that of the girl's time, that is, it takes so many years out of her life, and the fact that if her family needs her to work to support them then she is not able to do that. A major problem beyond that is the cost of running a nursing school. The important things that are needed, I would say, are some scholarship aid for candidates for nursing schools, and aid to the schools themselves because of the expenses of operation. I think that both of those things in Mrs. Bolton's bill.

Mr. SCHENCK. Will the gentleman yield for just one other thing? Mr. SPRINGER. Yes, I will yield to the gentleman.

Mr. SCHENCK. The point that I was trying to make was that in the Navy there are opportunities for young men to become corpsmen. Dr. CLARK. Yes, sir.

Mr. SCHENCK. Many of whom are very expert.

Dr. CLARK. Absolutely fine.

Mr. SCHENCK. And do a great job.

Dr. CLARK. That is right.

Mr. SCHENCK. Therefore, I am wondering if a similar opportunity could be given girls in the Air Force, and the Army and Navy, and

so on.

Dr. CLARK. The corpsmen are very expert. In fact, at one point last summer they practically saved Massachusetts General from closing, because we were so short of nurses. We appealed to the Chelsea Naval Hospital, and they let corpsmen come over evenings and help out. We really would have had to close several floors if we had not had that assistance. They were very good and they are well trained; but they are trained, I would say, more on the level of a practical nurse, than the graduate nurse we know today. For example, they are not skilled in certain technical procedures, in giving medicines, intravenous solutions, and things of that sort, which are a very important part of a nurse's duty, if she is in private practice or in a hospital.

Mr. SPRINGER. Doctor, directing your attention to the top of page 4 of your statement, first paragraph, you mention here as a part of the

tooling-up program "the continuation of Federal grants for medical research."

Dr. CLARK. Yes, sir.

Mr. SPRINGER. Did the President's Commission make any survey of how much medical research we ought to make in the next 10 or 15 years? Dr. CLARK. How much additional?

Mr. SPRINGER. Yes.

Dr. CLARK. We just recommended that the grants be increased, if I am not mistaken. There were several recommendations about research. One was that there be some change in the method of financing research through Federal grants in aid. Now, as you know, most of the grants for research from Federal agencies are in the form of project grants. This means that if an applicant is interested in doing a certain type of experiment he applies for support and may get it for 1, 2, or 3 years, seldom longer. The statutes under which the research grants are made are, moreover, somewhat categorized-heart, cancer, mental illnesses, neurology and blindness, and so on. If you happen to be interested in something that is not in one of those fields, it is pretty hard to get a Federal grant.

Our recommendation was that Federal research grants be of a more general character and of a longer term.

I will give an illustration of why we made this recommendation. We had in our hospital two young men interested in a certain technique for the localization of brain tumors, and it was a brand new idea. They were unknown men. We knew them, but the Federal agencies did not know them.

Now, we could endorse, and did endorse, the applications for Federal project grants, but it was a pretty sketchy notion they had and they did not get the grants. I think the Federal Government was right, incidentally, at least under present policy.

We happened to have a little fluid money that had been donated by the pharmaceutical industry and other friends of the hospital and we were able to put those young men on that support for a trial run, so to speak. After they tried out their idea for a year or so, they were able to get a project grant.

The recommendation of our commission was that there be some more general sort of institutional grants available, so that an institution would have more fluidity in the way in which it could use the money, so that, in our particular case, we could have taken some of that fluid fund and supported these young men with it while they were trying out their idea.

That was one of our recommendations.

Another was that the grants should not be so categorized, and that there be grants in larger amounts.

But I am frank to say that we did not make any dollar statements of the exact amount of increase that would be required. All I can say to you is that the promises in what is going on in research is such that one certainly would hate to see it curtailed.

Mr. SPRINGER. Doctor, turning to page 5 of your statement, first paragraph.

Generally from that, I understand that you are in favor of or would recommend that there be for Federal employees or people receiving Federal assistance, that the Federal Government enter into or consider the possibility of aiding them in getting medical attention?

Dr. CLARK. Yes, sir.

Mr. SPRINGER. Now, what form would that take? I mean, how is this going to be financed?

Dr. CLARK. I would say that there would be different ways for the two groups you mentioned. In the case of the Federal employees one would hope that the Federal Government might see fit to act as many private employers have, and as the city government in New York City has, namely, to permit deduction from payroll for purposes of paying health-insurance premiums, and to assist by an employer contribution. That is exactly what is done in New York City. Mr. SPRINGER. This is on a voluntary program or a compulsory program?

Dr. CLARK. I was implying, I think, a voluntary program, sir. In New York City, the city government, under a special statute that was passed in the early years of Governor Dewey's administration, permits payroll deductions on a voluntary basis by the employees and it matches the contribution of the employee to cover the premium for the employee and his family.

In the case of public assistance, of course, the recipients are receiving assistance through Federal grants to the States.

Mr. SPRINGER. Aid from the States?

Dr. CLARK. Yes. And for persons dependent upon old-age assistance, aid to dependent children, aid to the blind, and to people who are totally disabled.

It is permissible under the present law to pay for medical care out of those assistance grants, but there is a ceiling on the amount of a grant which can be matched with Federal funds. This means that it is often impossible to use Federal funds to pay for medical care. In Massachusetts, for instance, the average grant for old-age assistance is well above the Federal ceiling. It is, therefore, impossible in that State to obtain any additional Federal funds to pay for the medical care of old-age assistance recipients. What I would advocate is a separate grant to the States for the medical care of these assistance recipients, separate from the grants for general needs like food, clothing, and shelter. In this way the State welfare department, or the local and State welfare departments, would have a pool of funds, with Federal aid, to provide medical care for people who are receiving federally aided public assistance.

Mr. SPRINGER. I believe you have a solution for that, do you not, under your present old-age assistance?

Dr. CLARK. You have, provided the fund does not exceed the Federal ceiling for the grant. I have forgotten what the ceiling for an old-age grant assistance is today. Is it $60 or $50 a month? I am

not sure.

Mr. SPRINGER. Which is matched by the State government?

Dr. CLARK. No, I think that is the ceiling in which the Federal Government will participate, by paying half.

Mr. SPRINGER. It is far more than that, because the recipients are receiving considerably more than that.

Dr. CLARK. If they are receiving more, it is being paid from State and local money because it is above the ceiling in which Federal Government will participate.

Mr. SPRINGER. The Federal Government will pay 50 percent.
Dr. CLARK. Fifty percent of $50 a month.

Mr. SPRINGER. Well, I will pass that by, for the time being. Dr. CLARK. But the important point is that payments for medical care must come under that ceiling if there is to be Federal participation. The result of that is in the State of Massachusetts, where the average old-age assistance grant is something like $70 per person, payments for medical care simply cannot be shared at all by Federal funds.

Mr. SPRINGER. That must be incorrect, because in the State of Illinois, where I had something to do with that, I know that medical care came up and there was always something extra to take care of. We will go on from there, Doctor. I would like to ask you this general question:

As we get further into this health problem on a bigger scale, and the Federal Government gets further into it, do you think that the quality of medicine is likely to decline?

Dr. CLARK. No. On the contrary, I think it is likely to improve. When you say "further into it," I do not want to put that in without any qualification. How far do you mean?

Mr. SPRINGER. Let us take Great Britain. Do you think if we went that far into the plan, that medical services would be improved? Dr. CLARK. That would be very difficult to discuss, sir.

Let me go back and approach it in another way. I think by adopting such measures as the President's Commission suggested, there would be a net improvement in the medical services in quality, as well as quantity. Otherwise I would not be in favor of them at all.

Now, so far as Britain is concerned, British circumstances were so different from ours at the time the National Health Service was adopted, that it is not easy to compare with circumstances in the United States. The British had a different kind of history, having had a health-insurance system since 1912. They had a different set of problems to face. They had been terribly damaged by the war. Their voluntary hospitals were on the rocks, financially. There was a situation we have nothing to compare with.

Now, for Britain, I dare say the thing is going along. I have talked recently with the Director of the Scottish Branch of the National Health Service. I spent 3 days with him at a conference, and he on the whole gave an optimistic report. There are troubles, but he thinks they are diminishing. That is for Britain. I do not say that it applies here at all. In fact obviously it could not.

Mr. SPRINGER. We were over there in November, and I got this impression in talking with many people, including the ministry-and, we went out also and talked with the regional groups, and this is the impression that I got. There is no doubt that the medical service had greatly expanded and they were caring for lots of people who formerly did not receive much medical care. In other words, there were more people participating; more people receiving medical care. However, I do not think that there is any doubt in the minds of the doctors we talked to that the quality of the medical service had declined.

Now, may I say this, in some modification of that. It was not nearly as great today as it was 3 or 4 years ago.

Dr. CLARK. That is what I was told.

Mr. SPRINGER. Some of the kinks were being worked out. But, there simply was not the contractual relationship-I think that is the