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We have no State program, as such, as you plan in this bill. The next legislature which meets in January, has that job to do.

Mr. Brown. According to Dr. Parran, there has been an intensive survey in progress in Tennessee.

Mr. CHANDLER. Under the jurisdiction of a counselor agency; yes, we have. I think we are making good progress in Tennessee.

Dr. Parran has been of great help to us. I want to pay tribute to him.

Mr. WINTER. According to the chart, on the basis of income, placed in the Senate Report, the State of Tennessee ranks among the high ones.

You have an average of four beds.
Dr. Parran placed that chart in the hearings.

Mr. CHANDLER. I do not see how that could be when 53 do not have them.

Mr. WINTER. You do not have it on population.
Mr. CHANDLER. In the cities we have two very fine medical hospitals.

Mr. PRIEST. Without objection, the letter from Dr. Hutcheson may go in the record. (The letter referred to is as follows:)

STATE OF TENNESSEE,
DEPARTMENT OF PUBLIC HEALTH,

Nashville, Unit 3, February 25, 1946. Hon. WALTER CHANDLER,

Mayor of Memphis, Memphis, Tennessee. DEAR MAYOR CHANDLER: I have your letter of February 20 requesting that I give you a review of S. 191 (the Hill-Burton Hospital bill) including arguments in favor of and against this bill. For whatever my opinion may be worth I am setting out below my opinion in regard to this bill; first, argument in favor of the bill, and second, some criticism of certain sections of the bill. Unfortunately, most of this is based on opinion. We are at present in the process of making an accurate survey of our hospital needs in accordance with certain sections of the bill. The data have not been tabulated, and will not be completed until about April. I should point out that such opinions as I have formed are based on reasonably accurate estimates and not guesses.

For your convenience I am enclosing a summary of the most recent revision available to me of the Hill-Burton Hospital bill.

As I understand the Hill-Burton Hospital bill the intent of this proposed legislation is, to some extent, to force the States to develop an organized plan of hospitals. - I would like to call your attention to the fact that, while we in the United States have more hospitals than any other country in the world, there is practically no coordination of hospital services in the United States. Certainly no coordination of hospital services exists in Tennessee. All of our hospitals are operated independently and have no connection with one another. They vary from institutions that are deserving of the title, teaching hospitals, to institutions that should more properly be termed low-grade sick boarding houses. For example, except in the large metropolitan areas of our State, or the United States, it is practically impossible for a physician to find a hospital that is adequately prepared to assist him in the treatment of malignancies.

This is because of the lack of services in pathology, X-ray, and radium-therapy. Many cases treated locally in institutions lacking these services must be treated, largely, by guesswork. Many of the local hospitals, particularly in the rural areas, maintain only elementary bacteriological and serological services. Rarely does one find'a laboratory in a rural hospital equipped to do blood chemistry work.

Those of us who have given serious thought to the question of providing medical care to the people in the rural areas realize that the chief difficulty in providing this service divides itself into two parts: (1) shortage of medical practitioners, and (2) shortage of hospital facilities. Obviously, this bill is designed to correct, to some extent, the latter, but in correcting the shortage of hospitals in the rural areas we will do much to correct the shortage of medical practitioners. At present young physicians are not going to the rural areas, largely because of the

fact that they are well trained. We take these boys who are, before they enter medical school, fairly well educated. We give them an intensive 4-year course in medicine, then we ask them to take at least 18 months internship in a hospital approved by the American College of Surgeons. During this time these boys have been trained to use the most modern diagnostic aids and the most modern equipment in the treatment of their patients. Then they are released from the hospital to practice medicine, and it is not reasonable to expect that any large number of them will be satisfied to begin their work in an area where there exists no modern facilities to aid the physician in the practice of medicine. Most of them must practice with no more aid than the few professional gadgets that can be crowded into an old Boston bag. The result is that the men simply do not go to the rural areas.

Modern hospitals constructed in our rural areas will act as a stimulus in encouraging the younger physicians to practice in these areas, and these modern hospitals will further improve medical services because they will make it possible for the rural physician, in a comparable period of time, to perform at least three times the volume of work that he can do without a hospital and, at the same time, render a better service to his patients.

I think this latter argument is the strongest argument that can be made for S. 191.

You will note in section 621 the last sentence states that the sums appropriated pursuant to this section shall be used for making payments to States which have made and had approved by the Surgeon General, State plans. The word "plan" is used frequently throughout this act without any specific definition of the word, and it is my belief that the Surgeon General, in conference with the "Federal Hospital Council,” will draft rather rigid regulations setting out just what this “plan” must include. I anticipate that at least, the plan will require a coordination of the various hospitals to the extent that the smaller hospitals unable to maintain resident special services such as pathology, bacteriology, radiology, etc., will be required to arrange for these services on a contract or fee-for-service basis from the larger hospitals or institutions. This is not an unreasonable requirement. As a matter of fact, it is a policy that has been followed successfully for as long as I can remember by the United States Public Health Service, Division of Marine Hospitals, and, to some extent, it is a policy that has been followed by the Army hospitals.

There are certain points of this bill that should be clarified. For example, in every instance the State is charged with the responsibility of making surveys, drafting plans etc., yet there appears to be wording that could be interpreted as permitting the Federal agency to make payments direct to political subdivisions and even to "other nonprofit agencies in, States." It would appear to me that if the State is responsible for the plan, all payments should be made through the State agency.

In section 632 (a) toward the latter part of the subsection there is a statement to the effect that the Surgeon General can withhold certification or payment from States where there is a failure on the part of the State or any local subdivision or voluntary agency to use the money in accordance with the plan and that funds may be withheld until the State makes repayment of Federal funds improperly expended.

Here again, if the State is to be responsible, all Federal allocations should be made direct through the State agency, and not to local or voluntary agencies. I believe the intent of the bill is to make payment through the States but the wording is not clear.

I believe section 623 (a) (9) goes a little bit too far. This section states “providing that the State agency will make such reports in such form and containing such information as the Surgeon General may from time to time reasonably require, and give the Surgeon General, upon demand, access to the records upon which such information is based.” I know that the State and Territorial health officers have the utmost confidence in the present Surgeon General, Dr. Parran, but we do not know who the succeeding Surgeons General will be, and what they think is reasonable might be a terrible burden on the State health officers. I know that I am not going to be particularly interested in collecting detailed information from hospitals in Memphis, either for the State department of public health or for the National Public Health Service, and even if I should be interested, I have an idea that I would have a terribly difficult time getting this information from the local hospital administratoi.

All the national agency needs is information sufficient to assure them that the hospital is being operated in an efficient manner and without profit to any individual stock holder.

Under general regulations, section 622 (e) the present bill states, “General standards for construction and equipment for hospitals of different classes and in different types of location.” There probably is no way around this statement; however, it should be remembered that general standards tend to become minimum requirements, and in order to improve facilities minimum requirements are elevated to the highest possible degree and become maximum as well as minimum requirements, to be met with difficulty in some locations.

Section 633 (b) provides for the appointment of a Federal Hospital Council. It is my opinion that this council will be of little service to the Surgeon General and that the bill could more effectively be administered by creating in the office of the Surgeon General another full-time division responsible to the Surgeon General for the administration of this title. Actually, there would be made, not a new division but rather a section in the Division of States Relations; however, this is a question that sould be answered by the Surgeon General and not by the Commissioner of Health in Tennessee.

If this bill passes it will become mandatory that the State Department of Public Health in Tennessee be given some authority in the field of hospital administration in Tennessee. This could be accomplished by the passage of a law by the Tennessee Legislature. For your information I am enclosing a copy of what I think should be included in the law. This is under section 2 of the enclosure. Section 1 sets out what I believe should be the composition of the State Hospital Planning Board which would come before the legislation.

If you tink a trip is indicated, I shall be glad to come to Memphis and discuss this with you prior to your Washington visit. Yours very truly,

R. H. HUTCHESON,

Commissioner. H/h. Mr. PRIEST. The committee will stand adjourned until 10 o'clock Monday morning

(Thereupon, at 12:15 p. m., Friday, March 8, 1945, the committee recessed to reconvene Monday, March 11, 1946, at 10 a. m.)

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HOSPITAL CONSTRUCTION ACT

MONDAY, MARCH 11, 1946

HOUSE OF REPRESENTATIVES,
COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE,

Washington, D.C. The subcommittee convened at 10 a. m., Hon. J. Percy Priest, chairman, presiding.

Mr. PRIEST. The committee will come to order.

We are met again this morning for further consideration of the bill S. 191.

Our first witness today is Mr. W. R. Ogg, who is director of the Washington office of the American Farm Bureau Federation.

Will you give us any further identification necessary and proceed with your statement?

STATEMENT OF W. R. OGG, DIRECTOR OF WASHINGTON OFFICE,

AMERICAN FARM BUREAU FEDERATION

Mr. Ogg. Thank you, Mr. Chairman. My name is W. R. Ogg, director of the Washington office, American Farm Bureau Federation. I have been in that capacity for the past 9 years and prior to that was secretary-treasurer for 4 years, and prior to that assistant Washington representative for 8 years.

I have been with our organization for over 20 years.

It is a pleasure, Mr. Chairman and members of the committee, to appear this morning in behalf of this legislation, S. 191, which has already been approved by the Senate, and I understand a number of similar House bills, including one by you, Mr. Chairman, are pending before the committee.

Mr. PRIEST. If you will pardon the interruption, may I state that the bill I introduced, except for one or two major provisions, follows more closely the general provisions of S. 191 than any of the others.

Mr. OgG. Thank you, Mr. Chairman.

On behalf of the American Farm Bureau Federation, representing nearly 1,000,000 farm families in 45 States, I wish to strongly urge early action on the Hill bill, S. 191, which has already been approved by the Senate. A number of bills similar to the original Hill bill have been introduced in the House and are now pending before the committee.

When S. 191 was pending before the Senate, we suggested several amendments. Most of these suggestions, in principle at least, were embodied in the bill as passed by the Senate.

The American Farm Bureau Federation and its affiliated organization, the Associated Women, have long been generally concerned over

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