One of the obvious reasons for this urban concentration is the availability of health and hospital facilities and their corresponding absence from small towns and rural areas. The establishment of hospitals and health centers properly equipped to afford a nucleus for medical care in needy small towns and rural areas is one element of the general formula for correcting the current maldistribution of medical personnel.

A hospital construction program, therefore, will have missed its purpose if it does not promote the building of hospitals and related facilities in at least rough proportion to the need. That is to say, rural areas and small towns must have first consideration because their deficiencies are greatest, whereas the needs of urban areas for new construction and replacement of outmoded hospitals ought to be secondary.

I stress this priority because the rural areas will probably be relatively slow to organize and present their needs effectively, whereas the relatively lesser needs of urban areas are likely to be brought forward more promptly and pressed more vigorously.

The financial aid proposed by this bill is one of its most significant features of hope in this situation because without such aid there is little likelihood of making the conditions of rural medical practice sufficiently attractive to interest and hold the physician who would otherwise go to the large cities. It seems to us that any significant development of general hospital and health centers in rural areas is dependent upon some such stimulation. Moreover, this is a strategic time because of the number of physician veterans who were not established in practice prior to their military experience and who might well give favorable consideration to a needy area if there were some assurance of the early establishment of a suitable hospital nearby.

With your permission, I should like to turn now to some of the specific deficiencies of this measure and to draw to the attention of the committee, as others have probably also done, the fact that this bill will meet only a fragment of the needs of the national health. This bill provides only one piece of a larger pattern, and the Congress will be asked to give consideration to the other pieces from time to time. Moreover, the sums authorized under the present bill are adequate for only 20 percent of a conservative estimate of the total need. The 5-year limitation is such a short time that numerous projects will have to be planned and undertaken simultaneously (in order to come within the time limit) perhaps so soon after the passage of the bill that there is danger that they may be inadequately planned and integrated.

The bill contains no provisions to insure the maintenance and operation of institutions which were constructed with the funds provided. Moreover, the failure of the bill to include any authority for the Surgeon General to make regulations regarding the maintenance and operation of added hospitals opens the way to possible exploitation and exclusion practices, especially by nonprofit institutions. While it is desirable as a general principle to retain the maximum degree of local control, as is done in this bill, we are of the opinion that the whole intent and purpose of this legislation will have been defeated if it should result that hospitals are built with these funds and then are not operated in such a way as to bring good medical care to the people or to produce discriminatory results as among patients or physicians.

While these deficiencies of the bill are important in themselves and in terms of the future, we would be inclined to endorse the entire

measure as it now stands, were it not for our general disapproval for the position it is proposed to give the hospital council. The creation of an advisory committee which represents both producers and consumers of the services which will be rendered in these facilities is a most commendable idea, the disposition of the representation of these respective interests is satisfactory, and the tenure of these appointees is wholly acceptable. However, we advise strongly against the investiture of administering and quasi-judicial functions in a body of parttime and occasional officeholders. Forgetting for the moment that this bill relates to hospitals and health centers, and focusing our attention on the basic relationships involved, the fundamental nature of advisory and consultative groups is that they are drawn together from different interests in the community and because of these different interests, and their technical familiarity with different aspects of the subject, they meet together and give the practical administrator a cross section of both technical and community-wide views on the effect or likely effect of proposed actions. All these values are lost when an advisory group ceases to be advisory only but, instead, advises with one hand while actually participating in the administration of the program and sitting in judgment upon their own decisions on other occasions.

Our views on the authority of this Council coincide with those expressed by Senator Murray in his addendum statement attached to the report of the Committee on Education and Labor to the SenateReport No. 674, Seventy-ninth Congress, first session.

I may say together with the statement made by the American Federation of Labor, the one indispensable principle of administration which is violated here is that authority and responsibility must be commensurate we speak from the standpoint of public administrators generally. The bill places the responsibility upon the Surgeon General but a substantial part of the authority is given to the council. The council is wholly and completely independent; this is unwise and unprecedented in a part-time group upon which it is proposed to bestow final authority for so important a part of our national health program. The council owes allegiance only at the moment of its appointment; immediately after appointment, they are entirely independent of the Surgeon General, of the Administrator, and even of the Congress.

Mr. PRIEST. I think my own position with reference to the council has been made a matter of record.

I would like to ask you one further question: I understood that generally you would support the bill with that one exception. How do you feel about the question of court review or court procedure with reference to a State plan that might not be approved by the Surgeon General?

Dr. ATWATER. We welcome the opportunity of saying that we are disinclined to provide for court review. We, therefore, would share the opinion of the American Federation of Labor in that regard, that such review of administrative decisions is not a wise precedent.

Mr. PRIEST. That is my own position in the matter.

As a matter of fact, I think it is a rather dangerous procedure if we embark on it now or at any other time. As I see the situation, if we place responsibility on a Federal administrator in connection with this or any other program and then when it comes to a question of his

approval or disapproval, a district court may say, "You will have to approve this or otherwise," I think we begin to tear down our whole system of the relationship that have been built up over a long period of years.

I appreciate your statement in that connection.

We appreciate your appearance before the committee.

I regret that other members of the committee had pressing engagements, otherwise.

We have two other witnesses scheduled for this morning, one who lives nearby, Mr. Anderson, who has kindly agreed to appear tomorrow, but I understand that Dr. Boas cannot appear tomorrow, and I have consulted with the members of the committee who have to leave, and it is their wish that you make your statement today, Dr. Boas. We are glad to have you here.

STATEMENT OF ERNST P. BOAS, M. D., CHAIRMAN OF THE

PHYSICIANS FORUM

Dr. BoAs. Mr. Chairman and Members:

The Physicians Forum, a national organization of doctors all of whom are members of the American Medical Association or the National Medical Association, is heartily in accord with the general principles of the Hill-Burton bill for hospital construction. The great need for hospital construction throughout the country is well known and has been admirably demonstrated by the published studies of Senator Pepper's Subcommittee on Wartime Health and Education. As practicing physicians we know from our own experiences the grave deficiencies in hospital facilities. Repeated surveys have demonstrated the great lack of such facilities in many communities, particularly in poorer sections of the country which, unaided by Federal funds, are unable to create the needed institutions. Today it is impossible for doctors to give proper medical service unless they and their patients have free access to adequate hospital facilities. In addition hospitals are basic for teaching and for research in medicine, as well as in dissemination to the profession of advances in medical knowledge. It is a distressing fact that the United States lag behind a number of other countries both in the number of hospital beds available per thousand of population and in the distribution of hospitals and health centers. Government subsidy and construction has been the answer for the progress of these other countries.

The Hill-Burton bill goes far in its proposals toward remedying a bad situation in the hospital facilities of the Nation. There are, however, certain features of the bill, as amended, and passed by the Senate, which call for serious reconsideration. The bill as it stands contains a number of unfortunate provisions that tend to lessen its effectiveness.

Most important among these unfortunate provisions is the establishment of the Federal Hospital Council as an administrative body with power to override the actions of the responsible administrator, the Surgeon General. This part-time council, composed of members who continue with their usual occupations and whose primary allegiance is to associations and groups outside the Federal Government, are given final authority. As Senator Murray has stated, "The pro

* * *

* *

* * *

posed council is probably unprecedented. It could make for muddled, inefficient, and even bad administration Once appointed, they, the council members, are entirely independent both of the Surgeon General and the Administrator. There is no procedure for appeal from the action or inactions of this council *"" which is "accountable to nobody, responsible to nobody. Yet this new kind of independent agency has important administrative duties, quasi-judicial functions, and a veto power over the Surgeon General in carrying out a program that involves granting large sums of money from the Federal Treasury." Such a council thus becomes a semiautonomous administrative body, which is insulated from the general administration of the statute and inaccessible to control through public opinion. We strongly urge that the council be made only an Advisory council in the manner suggested by Senator Murray, whereby it would be assured that the council would be consulted, that it would make its views known if it thinks it has been ignored by the Surgeon General, and that the President and Congress could be informed of what is happening.

We also deem it essential that the public or consumer interest be protected by providing it equal representation on the Federal-State councils with the professional members. The amendments to the bill have strengthened such representation over the original bill, but such strength is still insufficient to serve the best interests of these who hope to enjoy the benefits.

The amendment that eliminates the establishment of many basic standards by the Surgeon General, with the approval of the council, is unfortunate. Under the present, amended bill, the Surgeon General promulgates only general regulations, largely in regard to the number of facilities to be built, while the maintenance, standards, and operation are determined by the States under individual State legislation. It would be more desirable to provide a better balance between Federal and State Governments, since expenditure of public funds is involved, by application of Federal standards to maintenance and operation. To require the establishment of minimum standards and then to leave the determination of their nature to the discretion of the individual States is running a grave risk of misuse of public funds by a single State. Although decentralization may be desirable, there would still be ample opportunity for individual variation and experimentation above the level of minimum standards set by Federal authority.

Another protection of the use of public funds is desirable in an assurance that regulation standards issued by the Surgeon General would require projects built with Federal moneys to make their facilities available to all qualified practitioners in the area. As Senator Murray has aptly pointed out:

The Government should not permit hospitals and other facilities which it constructs to be exploited by certain individuals to the exclusion of others for reason not related to the competence of these individuals and the most effective utlization of the facilities.

In the amended Senate bill, the appropriations for the hospital construction program have been cut to $75,000,000 per year for 5 years, an amount that would barely meet one-quarter of the known needs. The provisions of the original bill for $100,000,000 the first year, plus necessary amounts in succeeding years, would be preferable. This

is particularly true since the cost of necessary construction in subsequent years cannot possibly be accurately estimated at the present time, and the needs several years hence are quite unpredictable. Therefore, the less specific provision would be more desirable than the stipulation of a definite sum for future years. At the very least, the sum called for in the bill as it now stands should be doubled to make more of the needed hospital construction possible.

The provision exempting hospitals from providing services to persons unable to pay, if it is financially impracticable to accept them is unfortunate indeed, since it is these very patients who are most in need of such care throughout the country. It would be highly desirable to remove this condition if at all possible. But should such a condition appear to be financially inevitable, there should at least be an antidiscrimination clause attached to this proviso, for otherwise there is the distinct danger that the institutions supplying separate facilities for different population groups might bar the indigent of a minority group only.

To provide an over-all program, it will be highly necessary to consider how to maintain the hospital built under the Hill-Burton bill. No provision is made for their operation and upkeep, hence it is essential to consider that further legislation, preferably along the lines of the Wagner-Murray-Dingell bill and expanded social security, will be a basic requisite. This being the case, it is important that the Hill-Burton bill be so constructed as to be appropriate for a national health-insurance program. It would be unfortunate indeed if the new and much-needed hospitals and health centers to be constructed under the bill were to become nothing but bricks and mortar, or if those communities needing them most found that cost of upkeep prevented them from taking advantage of the hospital construction program. Yet this is exactly what will happen if there is no additional legislation to solve the problem of paying for hospital and medical costs, which is only possible on a democratic, wide-spread basis through national health insurance.

Mr. PRIEST. We certainly appreciate your statement and your appearance before the committee.

We will stand adjourned until 10 o'clock Tuesday morning.

(Whereupon, at 12 o'clock noon, Monday, March 11, 1946, the committee recessed until Tuesday, March 12, 1946, at 10 o'clock a. m.)