necessary to call it some sort of administrative board if we are going to give it administrative authority. It no longer is an advisory council then.

Dr. SENSENICH. The name in the bill as it was modified is that of Federal Hospital Council. Whether that is the proper one or not, I do not know. I just want to make one point clear, Mr. Priest I do not think that council should interfere in the ordinary administration of the act. I do not think that they should in any way prove a complexity in the matter of the administration under the Surgeon General, but that in those States which determine policies and the essential operation of the bill, then I think the Federal Council should very definitely have a voice with some authority.

Mr. PRIEST. Even to the extent of vetoing a decision of the Sur geon General?

Dr. SENSENICH. When it comes to policies; yes.

Mr. WINTER. Has not a lot of this been brought about by the American Medical Association's opposition to socialized medicine?

Dr. SENSENICH. Frankly, I think with regard to medicine as well as with regard to industry and with regard to any other activity of the group in the country, it is a very serious matter to place too much authority in any one individual.

I do not think that is democracy.

Mr. WINTER. I agree with that 100 percent.
Dr. SENSENICH. Now, if I may conclude.

The Surgeon General should have no authority as to the operation of the facility to which Government aid has been extended, except that the particular facilities should continue to function within the field originaly agreed upon and that the nonprofit classification be maintained. The hospital, general or special, constructed on Government funds does not in itself give service. Let us not lose sight of that fact. It is only a facility in which the local community can organize its efforts to care for the sick. This local community can do a better job of adapting its service to its local problems and social attitudes than can a Washington agency not primarily engaged in the care of the sick.

Let us stimulate the communities to do what they should do and to provide the money to carry on in the facilities provided and in the future, develop such additional facilities as are needed.

Just one other thing in connection with the meetings.

There is a provision, a reference in here, to meetings of State agencies. It does not mention the hospital council. No doubt they will be included in those meetings. I think that is highly desirable so that they would get the reflection and the experience in the local States.

A general pattern of policies and requirements should be worked out by the Surgeon General in that 6-month period and that has something to do with the appeal situation.

And the pattern, as we will call it, to be defined by the Surgeon General and the Federal Hospital Council should be sufficiently broad, but at the same time clear enough so that it is evidence that there cannot be gross inequalities by reason of inadequate surveys, and they do have the right of withholding certification in the event they are not meeting those needs.

Mr. WINTER. What do you think about limiting the provisions of any legislation passed on this matter at this time to that of going out and having the Federal Health Department, under Dr. Parran, in conjunction with the States, first make a survey and find out what this situation actually is?

Dr. SENSENICH. Well, I do not think so. That is, again, not reflecting on the Public Health Service, I do not think that Dr. Parran, at the moment, has the personnel with the experience in the local communities to be able to conduct that survey.

Mr. WINTER. What I mean is, the first section of this bill provides for the several States to inventory their existing hospitals, and their additional hospitals required for carrying out the purposes of this bill. If this survey was made first before any legislation for constructing hospitals was considered then we might be able to determine the requirements for hospital construction.

Dr. SENSENICH. That, obviously, is the first step. There is no question about that. I would be in agreement.

Mr. WINTER. First to find out what we are doing and what the needs are going to be.

Dr. SENSENICH. If you feel that that is necessary in order to approach the rest of the problem more intelligently, I have no objection. Mr. WINTER. It certainly is necessary before you can build a hospital under this bill or to find out where they are needed.

Dr. SENSENICH. That is true. It is a question that I think, like all other proposals, there must be some idea as to what the ultimate step will be. If there were some way of the Government committing itself, of course, it cannot commit a future Congress, that might be wise.

Mr. WINTER. What I am still driving at in my mind, I do not want to see the Federal Government allocating hospitals on something of the same basis that we do post offices.

Dr. SENSENICH. I agree with that. That is what we are trying to avoid in setting up this survey.

If I may conclude I just want to say that we appreciate the opportunity of being heard and you can count upon us; we will be very glad to offer the facilities of the American Medical Association in any way we can be helpful in the consideration of the bill.

And, furthermore, we would be glad to cooperate fully in trying to make it operate if it becomes law.

Thank you.

Mr. BROWN. Before you leave the stand, Doctor, I want to take 30 seconds in connection with some of my questions of a moment ago, which were evidently misunderstood by some of my colleagues and which I hope have not been misunderstood by you or others interested in this program relative to the discussion of the general problem of Government subsidies, and so on. I think it is very apropos to this bill for the reason that just the day before yesterday, the House of Representatives voted down, by an overwhelming majority, 2 or 3 to 1, a subsidy program of $600,000,000 for housing, which the exponents of the bill insisted was for veterans. It did not say so in the legislation, but they "said" it was for veterans.

The tone of Congress may not be the same as it has been in the past, and one of the problems that you are going to have to confront is whether or not you can sell the Congress of the United States on going

into any kind of a hospital-building program through Federal Treasury subsidies, because it is subsidy, pure and simple. That is the reason I brought up the subject.

I think it is very apropos and very germane.

Dr. SENSENICH. I understood that, Mr. Brown, and I would second you that I do not like to see the Congress sold.

Mr. BROWN. You have to sell Congress before this legislation is enacted.

Dr. SENSENICH. I understand.

Mr. PRIEST. May the Chair state that insofar as his observation with reference to his colleague from Ohio's statement is concerned, I believe I thoroughly understood my colleague and the position he has taken. I simply wanted it clear for the record that insofar as this bill is concerned, in my opinion, it ties it down very definitely to a fixed period with a fixed appropriation and I think I did understand my colleague, and I am not taking great issue with him there. He is stating fundamental issues, but I did want it clear that this bill is a fixed We have certainly appreciated your being here as a witness.

program.

Thank you so much.

We will now hear from Dr. Johnson. Will you identify yourself? Dr. JOHNSON. My name is Dr. Victor Johnson, secretary of the Council on Medical Education and Hospitals, American Medical Association.

STATEMENT BY VICTOR JOHNSON, PH. D., M. D., SECRETARY, COUNCIL ON MEDICAL EDUCATION AND HOSPITALS, AMERICAN MEDICAL ASSOCIATION, AND PROFESSORIAL LECTURER IN PHYSIOLOGY, UNIVERSITY OF CHICAGO, CHICAGO, ILL.

Dr. JOHNSON. Gentlemen: On behalf of the American Medical Association I wish to express my appreciation for the opportunity to state to this committee that the legislative proposals under consideration as worded in the amended Senate Bill 191 passed by the United States Senate December 11, 1945, have the support of the American Medical Association, its board of trustees, its house of delegates and its officers, representing a membership of 125,700 physicians in the United States. I also wish to offer to this committee and, should this bill become law, to the Surgeon General of the Public Health Service, to the Federal Hospital Council and to the State agencies, whatever information and assistance the American Medical Association can provide.

The council on medical education and hospitals of the American Medical Association, of which I am the executive officer, has been concerned for over 40 years with the maintenance of medical care of a superior quality, primarily by fostering and stimulating high standards in the education of physicians and specialists both in medical schools and in hospitals.

This department of the American Medical Association provides free consultation services to medical schools and to hospitals engaged in educational programs at the levels of the internship and of residencies in special fields of medicine. Surveys and inspections of medical schools and hospitals are conducted, when requested by such institutions. This council also promotes improved care in hospitals not

engaged in the teaching of medical students, interns and residents. A hospital register, which now includes 6,611 hospitals is maintained; this is done as a service to hospitals and the public, since the register includes only those hospitals which have been determined by inspection, upon request by the hospital to measure up to certain minimum standards of hospital and medical service. A detailed annual report is prepared by the council on these hospitals, with complete statistics regarding beds totalling 1,729,945 in 1944, admissions totalling 16,036,848 in 1944, births totalling 1,919,976 in 1944 and other useful information which is at the disposal of the public, the profession and also of this committee.

NEED FOR HOSPITALS

The availability of hospitals and diagnostic services is one important factor in the proper distribution of medical care to the people. The modern practice of medicine, which has become increasingly complicated, demands these facilities. The availability of hospital beds has increased far more rapidly than has the population in the United States. Hospital beds have tripled in number from 1909 to 1940 while the population did not double. During these years hospital beds have been provided more than one and one-half times as rapidly as the population has grown. In all general hospitals including institutions maintained by Governmental units, there were 925,818 hospital beds or nearly 7 beds per thousand of the population in 1944. About half of these beds-489,758-were in such Federal general hospitals as those of the Army, Navy and Veterans' Administration.

The ratio of general hospital beds to population set as a limit under the proposed measure is between 4.5 and 5.5 to 1,000. The existing over-all supply of such beds now exceeds this limit, if Federal hospitals are included. However, it is generally recognized that the distribution of the existing general hospital beds is faulty, with a concentration in large urban centers and in the wealthier States or counties and a deficiency in smaller communities and economically less favored States and counties.

It has been found that physicians may choose to locate in a community providing these facilities even though their income may be less than in areas lacking them. It has been found that, in areas of equal per capita income, there may be three times as many doctors if hospitals are available as there are if such necessities of modern medical practice are lacking. Studies by the American Medical Association and the committee on postwar medical service indicated that twice as many medical officers returning to civilian practice planned to go to areas with deficient medical service if hospital and diagnostic facilities were provided, as compared with those willing to locate in medically deficient areas without such facilities. Therefore, the passage of the Hospital Survey and Construction Act should contribute materially to a better distribution not only of hospitals, but of physicians and of medical care generally.

STATE SURVEYS OF HOSPITAL FACILITIES

One of the most commendable features of the proposed legislation is that it provides for a determination of where hospital deficiencies

lie, by State surveys of hospital facilities and needs. This attack upon the problems is the scientific approach which appeals to physicians and other scientists, who recognize that research must precede effective action in medicine. The determination of local needs by surveys conducted in every participating State should provide invaluable information upon which to base the continuation of this program. If the law should provide for nothing but these surveys, it would be worth while. Already many States have authorized or even started such surveys, stimulated in part by the sound scientific approach set forth in this program.

THE FEDERAL HOSPITAL COUNCIL

At the hearing on S. 191 before it was amended in the Senate Committee on Education and Labor, I and others urged that the authority of Federal Hospital Council be increased with "powers both of veto and of initiation of action," in the relationships of the Council to the Surgeon General of the Public Health Service S. 191 has now been strengthened in this regard, by the inclusion of the following provision regarding State plans for hospital construction.

If any such plan or modification thereof shall have been disapproved by the Surgeon General for failure to comply with subsection (a) the Federal Hospital Council shall, upon request of the State agency, afford it an opportunity for hearing. If such Council determines that the plan or modification complies with the provisions of such subsection, the Surgeon General shall thereupon approve such plan or modification.

Furthermore, the general regulations for implementing the act, to be formulated by the Surgeon General, apparently require (p. 6):

the approval of the Federal Hospital Council

There is also the wise provision that (p. 24):

*

Upon request by three or more members, it shall be the duty of the Surgeon General to call a meeting of the Federal Hospital Council.

An additional desirable safeguard against possible arbitrary administrative action is the provision (p. 25) that:

Upon the application of five or more of such State agencies, it shall be the duty of the Surgeon General to call a conference of representatives of all States agencies joining in the request. A conference of the representatives of all such State agencies shall be called annually by the Surgeon General.

The administrative problem of the respective roles and responsibilities of such a council and of the Administrator in this case, the Surgeon General of the Public Health Service has been thoroughly debated by a Senate committee and testifying scientists in recent weeks, in hearings on bills to provide a National Science Foundation. In a recent version of such legislation apparently receiving wide attention S. 1720, the National Science Board, appointed by the President, is given considerable authority. The board is empowered to evaluate the program of the foundation periodically, make recommendations to the President or to Congress, publish its own conclusions in annual reports by the administrator, elect its own chairman, appoint and prescribe the duties of an executive secretary of its own selection and meet at the call of its own elected chairman. Similar provisions in the administrative organization under a Hospital Survey and Construction Act would probably further increase the likelihood of achieving the desired ends.