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In the Senate bill there is provision that the Surgeon General is to be aided by a Federal hospital council in which the public would have only a minority representation. We believe that the provision of H. R. 5628 is much sounder in that public representation is equal to that drawn from professional and technical groups. Of even greater importance is the fact that in the Senate bill the council consisting of part time people is not merely advisory but actually has power to control and even to overrule the Surgeon General. This is an unsound proposal since its adoption would place the control of public funds outside of public officers. The American Federation of Labor vigorously advocates the use of representative advisory bodies but it has never asked and does not believe in any proposal to place final public control of public funds anywhere except in the hands of responsible public officials. The American Federation of Labor believes firmly in the wisdom of the constitutional provisions that the executive powers should be lodged in the President and his subordinates. This makes for responsible government in our democracy. Anything contrary to it would weaken or destroy the democratic processes we have labored and fought so hard to preserve.

The limitation on the number of public health centers and the general method of distribution of such centers throughout each State provided in H. R. 5628 likewise represents an advance over the similar provisions in the Senate bill. Whereas the Senate bill limited the number of such facilities to one for each 30,000 population, this bill limits it to 1 for each 20,000 population. Inasmuch as consideration of the needs of rural areas were prominent in the reasons for the enactment of any legislation of this kind, it is important that the limitation of this section not be too stringent. In our opinion it would be better still to raise the ratio to one facility for each 10,000 population. There are many rural sections where the population is so scattered that the facilities would not be easily accessible to those dependent upon their services if this limitation is too restrictive.

The bill as passed by the Senate provided that the Surgeon General should have among others, the responsibility and authority for prescribing general standards of construction and equipment for hospitals of different classes and in different types of locations. In our opinion this provision is greatly improved in H. R. 5628 by providing that the Surgeon General shall also have responsibility for prescribing standards for maintenance and for operation as well as for the construction and equipment of these facilities. This appears to us to be a sound provision as it provides that basic policy shall remain in the hands of the responsible Government official, in this case the Surgeon General, but does not limit the adaptation of policies to local needs and local situations. This provision will give the Surgeon General the authority to disapprove projects where on the basis of his knowledge and after consultation with his advisory council he is convinced that the expenditure of Federal funds for the construction of health facilities would be unwise in view of a likelihood that a particular project would not meet accepted standards with respect to maintenance and operation. This we submit is essential to the development of a sound and workable program.

There is one other respect in which we think H. R. 5628 represents an important improvement over the bill as passed by the Senate. I refer to the provision in the Senate bill that any State or locality or




private nonprofit organization applying for funds under the terms of the bill and which is not satisfied with the determination of the Surgeon General denying a construction project may appeal to the United States Circuit Court of Appeals. We feel that this would establish a bad precedent in that it would for the first time under a Federal program of grants-in-aid provide for the overruling of an administrative decision on the part of a responsible administrator by the courts. We fear that the practical effect of this provision of the Senate measure would be endless delay and litigation. There are sufficient safeguards in existing law to prevent the misuse or misapplication of funds, and therefore this provision does not appear to us to be necessary.

While as I have stated the American Federation of Labor believes that the enactment of H. R. 5628 would represent an important step forward in a program to meet the health needs of the country, there is one major point at which we feel this bill is seriously deficient. That deficiency relates to the lack of any provision of funds for operation and maintenance. Every competent study of the health needs of this country has demonstrated the close correlation between poverty and ill health. This correlation exists with respect to areas as well as with respect to individuals. It is not only possible but entirely likely that the areas showing the greatest needs for health facilities will also be the areas where it will be most difficult to provide funds necessary for the operation of such facilities. We feel therefore that this program will be incomplete until there is some provision for funds for maintenance and operation.

The position of the American Federation of Labor is that the soundest method of providing funds for the operation of health facilities is through a national system of health insurance as proposed in President Truman's health message to Congress. However there are other ways to provide funds for this purpose. If this bill is enacted in its present form without making provision of funds for maintenance and operation, it will indicate all the more clearly that it does not represent a complete health program. Perhaps it is the intent of Congress to provide such a program by a series of separate enactments. If this is the intent of Congress and if it is so understood, we gladly approve the enactment of H. R. 5628 in its present form. In the event of its enactment we should be glad to assist in working out a fully rounded adequate health program. We trust that the enactment of this bill without provision of funds for maintenance and operation will not delude either Members of Congress or the general public into believing that its provisions will solve the health needs of the Nation. Mr. PRIEST. Are there any questions? Mr. Cruikshank, we appreciate your statement.

I am particularly interested in the position you take with reference to what I consider the two major points of difference in the bill I introduced as 5628 and S. 191. Those points are the court review procedure and the administrative authority of the council.

I feel rather strongly that both provisions as contained in S. 191 constitute a rather dangerous departure from our usual procedure in the administration of Federal funds. Personally, I was glad to see the position you took with reference to

I those two provisions.

Mr. WINTER. I have just one question.

Mr. Cruikshank, would you want to see any of these bills passed if it was the intention of the Congress to stop right there and not provide funds for maintenance and support of these hospitals?

Mr CRUIKSHANK. I think the bill takes a sufficiently important step forward to warrant its passage, even if the funds for maintenance and operation are not included. I would hazard the forecast that if it is possible there are some other measures or some other means of providing funds for maintenance and operation, the Congress will find that they have only taken a half measure.

Mr. WINTER. Do you not think the provision that provides for the States to show that they can support the hospital before they get the Federal funds is sufficient?

Mr. CRUIKSHANK. Well, at that point I would go a little farther than I went in the prepared statement, I believe, Mr. Congressman, because I believe that we can foresee that as the States begin to work out their programs, first, they develop a survey, and these surveys we have no reason to believe will be different in their findings from the studies that have been made by others who have studied the health needs of the country, so that we can forecast pretty accurately, I believe, we can anticipate that they will find that the needs for health facilities will be in the impoverished areas.

Then they will be confronted by the fact that existing facilities have followed not the pattern of need, but the pattern of ability to support them, and they will then be confronted with the problem of developing a plan that will place facilities in the areas of greatest need, and then they will be immediately confronted: How are we going to support and operate them when we get them built? So I think the States will come right up against that same difficult problem. Mr. WINTER. Do you not

think that the States themselves and the people in those States have some obligation in addition to the Federal Government for providing funds?

Mr. CRUIKSHANK. Yes, I believe the bill presupposes that obligation, that it provides only a grant-in-aid program. It helps them get over the hurdle of the first capital outlay for health facilities. I think that there will be places where they will be able to anticipate some method of operation and maintenance, once they can get over the hurdle of initial heavy capital outlay that is involved in the construction of projects of this kind, but I believe, also, they will find that there will be areas of acute need where the whole problem will not be met at all by simply building or the construction phase of the program,

Mr. WINTER. Those areas would be greatly in the minority, would they not, taking the Nation as a whole?

Mr. CruIKSHANK. Quantitatively they would be in the minority, probably, but I believe we can anticipate the qualitative problem that they will be in many instances the areas of the greatest and most acute need.

Mr. WINTER. How many of your organization, if you know, are taking advantage of the Blue Cross system!

Mr. CRUIKSHANK. I do not know what percentage, but I should imagine that our organization representing pretty much of a cross section of the country, aside from the top-income groups, would be about the same as that of the rest of the country, and only 15 percent of the population is now served by any voluntary health plan, and only 3 percent of them are serviced by any plan that offers complete medical service. And I should judge we would be in about the same situation as the rest of the population.

Mr. WINTER. You think that only about not to exceed 15 percent of your organization is participating in any program of that nature?

Mr. CRUIKSHANK. On the assumption our membership is a fair sample of the population of the United States.

Mr. PRIEST. Are there any further questions?
We certainly thank you, Mr. Cruikshank.
Is Dr. Atwater here?



Dr. ATWATER. The American Public Health Association is an association of between nine and ten thousand professional workers in the field of public health and includes members from medicine, dentistry, nursing, engineering, and other allied professions. Although a substantial number of the members are engaged in private practice, the great majority find employment in organized health agencies, most of which are under public auspices. The broad objectives of the APHA point toward a single goal, that of raising the level of human health. For the purpose of implementing that objective, the association recently adopted (October 4, 1944) a statement of principles with reference to medical care, and I am authorized to state that in the opinion of the executive board, this bill (S. 191), is in reasonable compliance with those principles which relate to the need for physical facilities.

We think the bill in its present form will go a long way toward meeting the needs of the Nation with reference to hospitals and health centers and, after first emphasizing the need for such facilities, I should like to draw the attention of the committee to some limitations which the bill has in its present form. On February 27, 1945, I appeared before the Senate Committee on Education and Labor in support of the original bill, S. 191, and placed our association on record in support of the general need of such facilities as contemplated by that bill. With this thought in mind and in the knowledge that the association's formal indorsement is available to the committee, I shall be more brief than might otherwise be the case.

Under modern circumstances, a health department is expected to carry out a variety of measures which require the services of a highly technical staff. Suitable accommodation and equipment for such a staff cannot properly be satisfied by the improvisation of old buildings. It may be stated conservatively that less than 10 percent of the local health departments of the country are now provided with physical facilities which even approach reasonable standards. Some of the health departments occupy crowded quarters in basements or attics of county courthouses or city halls while others are more generously provided for in abandoned school buildings or converted dwellings. I cannot emphasize too strongly the serious inadequacies of present housing facilities for local health departments nor overstate the urgent need for the construction of a substantial number of health centers as contemplated by this bill.

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We believe that a good grade of health service requires that special type of facility which has come to be known as a health center, and we are entirely in sympathy with the contemplated graduation of the size and cost of such centers according to the population and area to be served, as previously outlined by Dr. Parran. While, for the purpose of clarity and simplification, the needs for health centers have been expressed as distinct entities, actually in a specific community, the health center could and ought to be incorporated into a hospital if an entirely new building is contemplated. If a hospital already exists, the health center might take the form of an addition to the existing plant so that certain pieces of special equipment could be shared to mutual advantage. Under conditions prevailing in remote rural areas or in outlying districts of large cities distant from central hospitals, the functions of health centers might best be discharged in separate buildings which have been constructed and equipped from the point of view of the special health needs of such localities.

The American Public Health Association has another interest in the bill under consideration, and that grows out of its concern for the extension and improvement of medical care. The more outstanding public health accomplishments to date have come about very largely from improvement in sanitation and the application of measures for the control of communicable diseases. From this point on we think that further advances are likely to depend to a large extent on lessening the ravages of diseases that arise from other causes, for example, diabetes, cancer, and diseases of the kidneys, heart, and arteries. To these should be added the common run of physical disorders, such as those disclosed by the examinations under selective service.

No doubt further scientific discoveries will place many such conditions in the category of disorders that are preventable; but for the time being, at least, major reliance must be placed on early detection of these departures from normal-followed by prompt and effective treatment. As measures of diagnosis and treatment improve, the possibilities of raising the common level of health through medical service should correspondingly increase.

It is obvious that medical discoveries are only of value in proportion to their direct application to individual patients. Complete medical service available to every person regardless of geographic location or economic circumstance should be an objective of our whole system. While we are not considering today the requirements for the whole of such an objective, certainly one of those requirements is adequate facilities. On the other hand, fine physical facilities without the attendant qualified personnel will not bring medical service to our people. Indeed, one of the situations which has excited the widest discussion is the maldistribution of medical personnel in the years immediately preceding the war. There is every indication that this maldistribution will be intensified rather than improved when the medical personnel still remaining in the armed services are released and resume their civilian practices. Specifically, this maldistribution means that physicians, dentists, and nurses are concentrated in the larger cities out of all proportion to the population, while there exists a corresponding shortage of such personnel at the present time in rural areas. The factors which attracted these people to locate in large cities or to remove to them during the last decade, are still present and there is at this time no evidence of a diminution of their influence.

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