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the lack of adequate facilities for hospital and medical care in rural areas, and have aggressively promoted programs to improve these facilities.

Last year a special national committee on medical care was established by the American Farm Bureau Federation to help bring about improved hospital, medical care, and health facilities in rural areas.

I might add that during the past 10 years, we have had several similar committees which have been at work studying this problem.

Numerous conferences have been held by this committee with representatives of the American Medical Association, the American Hospital Association, the United States Public Health Service, and other interested groups.

State farm bureaus are being encouraged to set up State committees to develop programs in their respective States. The national committee is continuing its work in collaboration with the American Medical Association, the American Hospital Association, and other interested groups. It is giving particular attention to developing recommendations to assist our State and county organizations in working out effective plans to provide and maintain adequate hospital and medical services in rural areas.

At the present time, there is a woeful lack of facilities in most rural areas for adequate medical care, hospital care, and public health services. This is not due to any lack of appreciation of the importance of these services on the part of rural people. It is due mainly to the economic disparity of rural areas with industrial areas, and the lack of sufficient local resources to provide for

such facilities. As a member of the Report Committee of the White House Conference on Children in a Democracy in 1940, I was impressed with the fact that most of our hospitals, clinics, and public health centers are located in urban areas, and that the shortage of such facilities exists mainly in rural areas. I quote the following statement from a report prepared for the White House Conference:

Hospital care is difficult to obtain or entirely lacking in some areas. Whether it is had when needed depends on the accessibility of the hospital and means of transportation, on the ability of the family to pay for care, or, if the family cannot pay, on the provision by government, usually local government, of facilities in a public hospital or of payment for care in a voluntary hospital. More than 1,300 counties do not contain a registered general hospital. In the aggregate these counties contain 17,000,000 people. They are characterized by sparse population, a very small percentage of urban population, remoteness from metropolitan centers, and low taxable incomes. In 520 counties one or more small proprietary hospitals are the only general hospitals; in 423 counties there are local taxsupported hospitals. Metropolitan areas are in the main well supplied with hospital beds for general medical care. In many cities voluntary hospitals predominate, indicating that economic oportunity rather than social need has been a determining factor in the present distribution of hospitals.

While that was made prior to the war, as you gentlemen know, because because of the war conditions, there has been very little change in the amount of facilities except as there may have been some veteran facilities established or war hospital facilities.

Before the war there was an acute shortage of doctors generally in rural areas. This situation has become more critical. It is vitally important that steps be taken to correct these conditions in the postwar period. One of the most important steps in correcting the doctor shortage in rural areas is the establishment of adequate hospital and diagnostic facilities in rural areas. In order to attract capable men trained in modern medicine and surgery, to practice their professions in rural areas, it will be necessary not only to offer them some reasonable degree of assurance of a fair income, but also proper facilities for applying modern scientific methods for diagnosis and hospital treatment—all of which is beyond the ability of the individual doctor to provide. Obviously, this is a community responsibility.

The provision of modern hospital facilities, clinics, health centers, and related facilities is essential to the improvement of rural health.

Much can be done through voluntary, cooperative prepayment plans for hospital care and medical care to enable rural people to obtain adequate medical care and hospital service, but such plans, and I want to emphasize that, cannot be put into operation if hospital facilities are not available. In cooperation with the American Hospital Association, our State and county farm bureau organizations are already cooperating in prepayment plans for hospital care, and in many instances, also medical care. These plans have been very successful.

I believe there are at least 21 State farm burears that are cooperating in promoting throughout their respective States these prepayment plans.

For example, in Minnesota, where such a prepayment plan was inaugurated 5 years ago with 1,954 members in 13 counties, there were in 1944 approximately 32,000 members of hospital associations in 64 counties, based on 1944, and I am sure is larger now, and the number of affiliated hospitals increased from 75 to 113 during this period. Such plans enable farm people to obtain adequate hospital care at a comparatively low cost. The amazing growth and rapidly increasing membership of these prepayment hospital plans in a large number of States shows the acute need for this service.

During the Senate hearings I was asked to put in a digest of these plans that are operating in about 21 of our States, and you will find a résumé of that appearing at page 323 of the hearings and continuing for a number of pages.

Unfortunately, in a great many rural communities there are no hospital facilities available, or existing facilities are very inadequate. I have been informed by the president of one of our large State organizations that its members were very anxious to inaugurate such a plan in that State for prepayment hospital care; but after investigating the matter they found that there were not enough hospitals in the State which could qualify to make it possible to establish this service.

They are now preparing legislation to introduce into their State legislatures for a State appropriation, hoping that this bill will pass the Congress, and they will be in a position to go to work right away.

Accordingly, it is impossible to inaugurate this badly needed service for rural people in that State until more hospital facilities are made available and existing facilities are improved.

In order to meet this acute and widespread need, we therefore strongly favor Federal grants-in-aid to the States to assist in providing needed hospitals, laboratories, clinics, diagnostic centers, public health centers, etc. We believe such assistance should be limited to a grantin-aid basis, to be matched by State and local funds, on a basis that will safeguard against Federal ownership and control of such facilities. These hospitals and related facilities should be locally owned, locally operated, and locally controlled. Adequate provision should be made

for the maintenance of such facilities before grants are approved for construction purposes. Care should be exercised that Federal approval of standards is not utilized for the purpose of maintaining Federal control over such facilities. The allocation of funds to the States should be based upon the needs for such facilities and the financial inability of the States to provide needed facilities.

When S. 191 was under consideration by the Senate, we presented a number of suggestions for clarification and improvement of this measure. Most of these suggestions were adopted in principle, at least. We would like to suggest, however, some further changes to clarify and improve this measure. We strongly favor the provision in section 622 (d), which requires that special consideration be given to hospitals serving rural communities and areas with relatively small financial resources in determining priority of projects.

The Senate hearings on S. 191 contained overwhelming evidence of the importance of giving priority for projects in rural areas, because the greatest deficiencies of hospital services and public health centers exist in rural areas. It is unquestionably the purpose of this bill to assure such priority. However, in order to more fully clarify the intent of Congress on this point, and assure that this policy will be fully carried out, it is suggested that a similar provision be inserged in the declaration of purpose in section 601 (a), and also in the authorization of appropriations in section 621.

I think that is the intent of the act, but this suggestion is merely to make certain that this is applied throughout in carrying out the act.

Another principle which we believe is of fundamental importance in such legislation is to foster and preserve the maximum of local initiative and responsibility, and to avoid centralized control. One of the weaknesses in the bill as originally introduced was that it vested too much discretion and control of the program in the Surgeon General. In order to correct this weakness, numerous amendments were agreed to by the Senate. While the bill has been much improved by these amendments, the measure still places too many determinations and too much control in the hands of the Surgeon General, and too little responsibility in the cooperating State agency. I wish to respectfully recommend that the bill be amended to provide that the State agencies which are to be established under this bill should determine such things as the standards for hospital construction and equipment, location of hospitals, child health centers and other facilities, the priority of projects within their States, and the methods of administration of State plans within their respective States. We believe such matters can better be determined by State agencies, which make the surveys and develop the program, than by the Surgeon General in Washington. It would be necessary, of course, for the Surgeon General to review these projects, plans, and determinations, and give final approval, inasmuch as they involve the expenditure of Federal funds.

I think I might add that it is the intent of the bill, the spirit of it at least, but it is my feeling, in studying the bill, that the State agency ought to have the immediate responsibility of making those determinations and plans because of the fact that they are right on the ground, they know the conditions in their States, and the conditions will vary in different States, and because of the complexity and the varying differences in the different States, it is my feeling that they would be better able, at least, to map out the plans and determinations particularly as to

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the locations of these hospitals and these standards, but, of course, necessarily, they should all be subject to final approval by the Surgeon General inasmuch as the Federal Government is putting up the money.

Mr. PRIEST. S. 191, as it passed the Senate, it seems to me, places the entire responsibility, insofar as a State plan, insofar as location, at least, is concerned, within the State agency.

I wonder if there is a particular provision of the bill which you think should be amended in accordance with your view that would further clarify that. It seems rather clear to me that responsibility is within the State agency.

Mr. Ogg. It is true that they develop a State plan, but other provisions of the bill, as I read it, require the Surgeon General to make quite a large number of determinations. I have a list of them here. I will read a few of them.

For example, the Surgeon General determines the number of beds required to provide adequate hospital service for various types of facilities.

He determines not only the number of these facilities but their distribution throughout each State.

He determines the method of determining priority of projects within each State.

He determines the general methods of administration of State plans in each State, the issuance of requirements.

Mr. WINTER. What page are you reading from? Mr. Ogg. I do not have the references here. Mr. WINTER. I mean in your statement that you are reading from. Mr. Ogg. I merely had a memorandum on which I had jotted down a list of the determinations which the bill specifically requires the Surgeon General to make.

The only point I am making there, Mr. Chairman and gentlemen, is that it would seem to me that these determinations should be made by the State agency subject to approval of the Surgeon General, rather than requiring the Surgeon General to make the initial determination. That is the point I am making. I think you could easily take care of that by adding, on page 6, section 622 of S. 191 as it now reads, "within six months after the enactment of this title, the Surgeon General, with the approval of the Federal Hospital Council and Administrator, shall, by general regulation, prescribe," and then there is quite a list of things he is to prescribe, if that were changed to read somewhat along this line: "within six months after the enactment of this title, the State agency, with the approval of the Surgeon General, after consultation with the Federal Hospital Council and Administrator, shall by general regulation prescribe," it would put the initial responsibility upon the State agency to determine these matters, but would give the Surgeon General the right to veto or to require modifications if, in his judgment, they were not sound or were not in accordance with the purposes of the act.

I just suggest that for your consideration.

Mr. PRIEST. It is worthy of consideration. It would seem to me that the other side of the question, as you suggested earlier in your statement, conditions might vary so among the 48 States that it would be most difficult to get 48 different State agencies to come to any agreement whatsoever on some of these regulations, and that in the interest of expediting the program, that it would probably be better to have uniform regulations prescribed as early as possible.

Mr. Ogg. I think that would apply to some general regulation. I think that would be true there. I think with respect to where these hospitals are to be located within the States and such matters as that, I believe the local agency, probably, would be better able to determine that than the Surgeon General.

However, I think it is wise, since it is Federal fund, even in that case, that he should review it to make certain that the locations are based upon sound principles and that political considerations or other things might not have entered into them too much.

I just suggest that for your consideration.

I want again to reiterate that we heartily favor the principles and objectives of this bill, and that our suggestion here is intended to strengthen rather than in any way weaken the administration of the bill, but we are certainly very enthusiastically for the bill and hope that it will be speedily enacted.

We are strongly opposed to the inclusion of the requirement in section 625, that all projects must give assurances in their applications that prevailing rates of wages will be paid in the construction of such projects, to be determined in accordance with Public Law No. 403, approved August 30, 1935. This provision has no place in such a bill as this. It will hamper and retard this program, add unduly to the cost of construction in rural areas, and should be eliminated. We also strongly favor the inclusion of mandatory provisions for representation of agriculture on the national and State advisory councils.

In closing, I wish to reiterate our appeal for early action on this legislation, as it is of urgent importance to rural people throughout the Nation.

We do not see any necessity for such a requirement in a bill of this character.

Mr. PRIEST. Is your theory largely that in some rural communities a great many of the citizens pitch in and do the work in the oldfashioned way? Mr. Ocg. Absolutely, and they will get the maximum.

. Mr. Priest. It is the old corn-husking, barn-raising theory?

Mr. Ogg. There will be so many interested that will pitch in and get the most with the least amount of money, and where they are willing to do that, they should have the opportunity. I want to make clear that we are not in favor of

any oppressive wage rates or anything of that sort, but, on the other hand, let us be practical. When you get out in the country it costs not as high; that is, the costs are not as high as they are in metropolitan centers, and I think we have to be careful not to do anything that might be used to jack up the costs unduly.

Mr. Brown. In that connection, is there any likelihood that the Federal administration would put any requirement on as to the type of employees? For instance, that only union members could work on this project, inasmuch as Federal funds are being expended thereon? That is what was done on practically all of the war construction work. you know.

Mr. Ogg. We would be very strongly opposed to anything of that nature being required.

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