There was a debate in the Senate before the Senate committee and I think there will be testimony before this committee, Mr. Chairman, as to whether or not the State health agency should be specifically designated as is done in certain other health legislation or whether that discretion should be left with the States. The bill before you leaves the discretion to the State to have a separate hospital council, or authority, under whatever name, or to utilize an existing department of the State government.

I have just a few more suggestions, Mr. Chairman.

Thirdly, I would urge the committee to give most careful consideration to the desirability of amending section 621 to enable the program contemplated to more nearly fulfill its purposes. I mentioned earlier the great disparity between the estimated costs of facilities needed and the appropriations authorized in the bill. With such a disparity I fear that the bill will inevitably lead to false hopes, as to the extent to which its limited provisions will meet the problem it is designed to solve.

I hope the committee will consider not only the need for increasing the limits of authorized annual appropriations but also the desirability of extending the program optionally beyond a 5-year period. This option obviously would be exercised by the Congress through its appropriations authority.

Mr. WINTER. You say you favor increase in the amount. How much would you suggest?

Dr. PARRAN. The bill as originally drafted, Mr. Winter, authorized an appropriation of $100,000,000 a year for the first year and thereafter such amounts as the Congress may determine.

In the table which I submitted, non-Federal health facility needs, you will notice under prewar construction costs, the size of the job, namely, of constructing the needed new physical plant and of replacing obsolete plant, amounts to close to $4,000,000,000. This bill authorizes $75,000,000 for 5 years, and requires State matching, which brings the total amount of funds available up to $640,000,000.

Mr. WINTER. Is the amount set out in the statement handed to the committee; is that the total cost or is that the Federal Government portion?

Dr. PARRAN. The former.

Mr. WINTER. You are suggesting that this be in excess of $6,000,000,000, in excess of that?

Dr. PARRAN. The over-all prewar estimated construction, costs from all sources, approximately $4,000,000,000.

Mr. WINTER. I understood you to say that, but I thought you said you did not think this was sufficient.

Dr. PARRAN. The amounts authorized under this bill are 5 times $75,000,000.

Mr. BROWN. As a Federal grant?

Dr. PARRAN. Federal money. Then the requirement of State matching brings that total to almost double, to around $640,000,000.

Mr. BROWN. That would then leave up to the States, the local communities, the various charitable organizations, churches, and so on, to furnish the hospital or to furnish the equipment, and the rest of the money?

Dr. PARRAN. That is correct.

Mr. BROWN. In the State of Ohio, we have a program already for something like $75,000,000 worth of hospital construction for the state alone. I know of at least a million and a half, perhaps $2,000,000 worth of hospital construction contemplated in my own district, for most of which bonds have been issued.

I presume the same situation exists all over the country. We are building hospitals here, and we are building them everywhere else. How far do you think we should go in Federal aid to hospitals?

Dr. PARRAN. Mr. Brown, after all, that is a question for future Congresses to determine, in the light of other needs of the country for other kinds of projects, in the light of anticipated income of the country and in the light of the need for employment.

I mention the need for employment because the construction of hospitals is, as a secondary consideration, a most useful form of public work. It provides work for the people on the job, work in fabricating the materials, work in fabricating the equipment and additional service personnel to operate those facilities in the interest of health.

Mr. BROWN. I agree with you. I am very sorry that we did not do more hospital construction and less leaf raking in the past 15 years. That is past, however, and we are now looking to the future.

You have been very helpful in giving your opinions to the committee as to this legislation, and I am wondering if you could not give us some information as to your idea, your thought, for certainly you have in the back of your mind some thought as to the total amount of Federal contribution, what it should be, how far we should go?

Dr. PARRAN. We had contemplated, we had considered this to be a 10-year job, costing a total of about $4,000,000,000.

Mr. BROWN. From the Federal government?

Dr. PARRAN. Over-all.

Mr. BROWN. How much does the Federal Government

Dr. PARRAN. Between two and two and one-half under the current formulas.

Mr. BROWN. Then you would increase this from $75,000,000 a year for 5 years up to somewhere from 200 to 250,000,000 a year for 10 years; is that it?

Dr. PARRAN. I would prefer to leave the matter within the discretion of Congress after the first year, and say an initial appropriation of $75,000,000 a year, also to have the bill operate over a 10-year period. If, on the other hand, the Congress wishes to impose a ceiling which—I hope that the ceiling would be lifted after the first year from $75,000,000 to $150,000,000, and that the bill would operate over a 10-year period.

Mr. BROWN. That would not give the $2,000,000,000, or $2,500,000,000 that you say is necessary.

Dr. PARRAN. That would not, and especially as I think you pointed out, Mr. Brown, in connection with the mental health bill, nobody knows how much a dollar will buy 5 years from now.

Mr. BROWN. That is right.

Dr. PARRAN. And that is the reason my first recommendation would be to leave it to the Congress from year to year to determine the amounts to be appropriated under the bill after a specific authorization for the first year.

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Mr. BROWN. We have had a housing bill over on the floor for the last 7 or 8 days or years, it seems like, and under that, I am not so sure we would have much to say as to whether we could build any hospitals or not, for you or any one else, because everything would be up to the housing expediter to determine, as to whether any construction or any materials could be used for any hospital or for any other construction. So perhaps we are just wasting a lot of time here even considering this legislation until we know whether we are going to have all power vested in a building expediter, and what is desired, and what his judgment may be.

We may know more next week than we know now about the picture. Dr. PARRAN. I am sure the committee is not wasting its time in connection with this matter. I consider this to be one of the most important issues before the Congress.

I should like to draw your attention to the fact, that I know you are familiar with on reflection, and that is, that it is going to take some time to get this program under way. We cannot start building tomorrow. It is necessary to get these State surveys made, and plans drawn, and unless we do, we are likely to waste money in building hospitals in places where they are not needed. There is one monument I would not want erected to myself, and that is empty hospitals.

Mr. HARRIS. In relation to the amount authorized as proposed in this legislation we have been discussing, how would that affect the allocation under the formula of this bill to the various States?

Dr. PARRAN. If the ceiling were taken off, do you mean?

Mr. HARRIS. I mean if it is left at $75,000,000 a year for the first 5 years or a total of approximately $750,000,000, would-with the State matching it, that being provided, would not that give a very small proportion for the needs in each State?

Dr. PARRAN. It would, Mr. Chairman, and even if construction costs were down to the prewar level, it would do less than 23 percent of the needed construction.

Mr. WINTER. On an annual basis?

Dr. PARRAN. Over-all. Over the 5-year period.

Mr. HARRIS. The question is, then, how would you determine just where the allotment should go?

Dr. PARRAN. The allotment formula is set forth in very great detail in the bill, Mr. Chairman. It is based upon population and per capita income. With the current amount of $75,000,000, the way it works out is that $75,000,000 a year of Federal money, matched against this $64,178,000 of non-Federal money, an average per inhabitant of about $1.04. Now, the total amount of money, both Federal and State, which would be available to each State on a per capita basis, would vary from 68 cents in the more wealthy States up to slightly over $1.40 in the poorer States. That is for the total Federal and non-Federal funds.

For the Federal per capita amount under the fairly complicated but precise formula set forth in the bill, the Federal funds would vary from 25 cents per capita to approximately $1.

Mr. HARRIS. Who would determine in the various States as to where the hospitals would go?

Dr. PARRAN. A single State Hospital Authority is required to be created which must first make a survey and submit an over-all plan

with indications of priority of need for the several projects within the State.

Mr. HARRIS. The point I am trying to make is, as I understand your testimony, if only $75,000,000 a year for 5 years were provided, at the end of that time, you would have only 23 percent of the needs of those various states met.

Dr. PARRAN. That is correct, sir.

Mr. BROWN. Dr. Parran, now some one else may be doing something about meeting those needs besides us.

Dr. PARRAN. Thas is also correct, Mr. Brown.

Mr. BROWN. So that is not quite a true reflection that the people will only have 23 percent of their hospital needs met in the next 5 years. Dr. PARRAN. We will agree that only that amount, namely, of 23 percent will have been met with Federal aid.

Mr. BROWN. With Federal aid.

Dr. PARRAN. So we all agree on that.

Mr. BROWN. We have been meeting, to a limited extend at least, our needs without Federal aid. It is true that we have not been able to meet the increased needs in recent years for many reasons: war, inability to get material, and labor, high prices, a lot of other things.

You spoke a moment ago as to the need for getting busy on this immediately, that every minute counts, or something of that sort, said we must get these surveys under way.

According to this record, or report, that you furnished the committee, just a few minutes ago, as of February 1, 1946, 31 states or 30 states plus the District of Columbia already have the intensive survey that you mentioned under way. Seven other states have officially authorized that survey, but have not yet started on it. Two states have no intensive survey plan, but have completed a preliminary survey and 12 states and territories including Hawaii and Alaska and Puerto Rico have not taken any action.

Dr. PARRAN. That, substantially, is correct, Mr. Brown.

Mr. BROWN. So, until we can actually begin construction, the haste on this bill is not apparent as it might be.

Dr. PARRAN. I am afraid I have not made myself clear and certainly I do not want to appear to be inconsistent in my two statements, but you have pointed out what seems to be an inconsistency. The facts are that in most of the states where they have made a start, it has been with a skeleton staff. They are beginning to learn how to make surveys, to agree upon certain general principles, to make certain pilot studies in one community, let us say, to test out how far they can get heretofore competing hospitals to agree on a joint plan to meet the need of that community.

The money is available to most of these state planning agencies, that is, the amount is minimal. Other witnesses can testify more in detail on that. This bill provides $5,000,000 to be made available to the states to help them to build up their technical staffs and really make a blueprint. This is merely just a rough study.

Mr. BROWN. I think that is very important.

I agree with you on the importance of that and perhaps the immediate adoption of it. I am not so sure but that I agree with the necessity of immediately adopting this bill in some what the form that it passed the Senate.

However, I am rather sure that I do not agree that the amendments which were suggested by Senator Murray and rejected by the Senate should be rewritten into this bill, and while I have the greatest respect in the world for the President of the United States, I also have a full recognition that, under the Constitution and our form of government, the legislative branch of the Government has a responsibility of its own to fix policies, and not the President; the President carries out the policies and executes the laws that are laid down by the Congress of the United States, and I am just wondering, if we follow that same theory through, if it is your opinion that we should, without question, accept all of the suggestions that the President has made relative to his so-called health program which some designate as a "socialized medicine" program.

Does your logic carry you that far?

Dr. PARRAN. Of course, I think every one agrees that as to the constitutional prerogatives of the Congress and respective prerogatives of the Congress and the President. You have referred to a socialized medicine program. Of course, the Dingle bill is not under consideration at this time.

Mr. BROWN. I understand the Public Health Administration has endorsed that measure.

Dr. PARRAN. I am not sure as to the endorsement of a specific measure. The Public Health Association is on record as supporting certain principles concerning a national program of medical care in general, are in harmony with such a measure, Mr. Brown.

Mr. HARRIS. At least that is not before the committee at this time.

Dr. PARRAN. It is not before the committee, but I think it is important to point out that, assuming any one of several situations in the future, the needs for this measure are still, in any event, very urgent and acute. First: If we continue our present system of private practice in the country, obviously, we need these facilities, especially in the rural areas and to modernize the hospital plans.

Second, if the recommendations of the AMA for expansion of blue cross plans, for expansion of voluntary medical insurance, should be the pattern, these hospitals will be needed. Or, third, if compulsory health insurance is adopted, such facilities will be needed in even greater measure.

Mr. BROWN. If I may, I would like to point out to the Surgeon General and to the chairman of the committee, the reason why I brought into this discussion the President's general health program, is the fact that his letter, which mentioned that program, was brought here and put into evidence by the witness, and that in that letter the President stated he wanted these amendments, for the purpose of implementing the hospital section of that program.

Therefore, I think my question is very apropos, and I am wondering whether we are today considering a measure that is to stand on its own feet as a Federal aid hospital bill or whether we are actually being asked by the President's letter, and by the testimony of the witness, to consider one section or one portion of a general program which has been submitted by the President? Therefore, I think my question was not only germane and parliamentary, but entirely applicable.