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struction programs. The administration of the program in each State will be carried out by authorized State governmental agencies. The program has two purposes: First, to inventory existing hospitals and survey the need for additional hospitals and develop programs for the construction of such public and other nonprofit hospitals as will, in conjunction with existing facilities, afford the necessary physical facilities for furnishing adequate hospital, clinic and similar services to all of the people, and second, to construct public and other nonprofit hospitals in accordance with such programs. In other words, the design of this legislation is to develop an integrated system of hospitals and health centers that will make these facilities more readily available to an increased number of people, especially to serve rural or needy areas. The program is thus directly related to the health and welfare of the Nation.

The American Hospital Association does not lightly recommend Federal grants-in-aid for hospital construction or any other purpose. We understand the need for economy in the use of Federal funds. In addition, we sincerely believe that the high quality of hospital and medical service which has been developed in America is directly related to the incentives found in a free and independent professional group inspired by a desire to be of service. There is real apprehension that the use of Federal funds to expand the distribution of health facilities may deteriorate into a medium of control. Hospital care of sick people requires all the efficiency of modern industry imposed upon the highest type of professional skill and training, and all of this against a background of personal service inspired by the finest humanitarian instincts. It would be dangerous to destroy by excessive bureaucratic dictation the incentives that have led to development of the finest hospital and medical care in the world.

The American Hospital Association believes that the Hospital Survey and Construction Act as passed by the Senate has been developed with a recognition of these dangers. We further believe that the ready availability of hospital service is so vital to the health and welfare of the Nation that the use of Federal funds is amply justified. The distribution of wealth among the States is so uneven as to prevent adequate distribution of hospitals except through Federal grants-inaid which will tend to equalize this maldistribution of hospitals which now closely follows the per capita income of the people. The American Hospital Association believes that this act sets forth a program which can use Federal funds with maximum effect toward making hospital services available to everyone.

Thus it will be seen that the American Hospital Association favors the Hospital Survey and Construction Act not through self interest, but rather, in spite of some apprehension of Federal participation, as a forward step toward accomplishment of the aims of the association, namely, better hospital care for all the people of the Nation.

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A THREE-POINT PROGRAM OF HOSPITAL CARE

We view this legislation as the first step in Federal aid toward providing adequate hospital and health care for all of the people. A careful inventory of present resources, a survey of additional needs, a plan for an adequate hospital and health center system, and Federal grants-in-aid to assist in the construction of necessary additions to

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present facilities—all of this is a necessary preliminary step in the better distribution of hospital and medical care.

But the American Hospital Association believes that as a second step, further Federal congressional action is desirable to provide such care for the medically indigent—those who cannot pay for such care. This act has been criticized because it does not provide for maintenance as well as construction of hospitals in areas of greatest need. Complete hospital care for the whole Nation is too great a task to be accomplished in any single program. It must be remembered that accurate determination of total need awaits completion of detailed state surveys.

It is expected that these surveys will show many areas, of extremely low income where neither construction nor adequate support of a hospital can be expected without assistance. Hospital and health care for indigents is a subject in itself which will require the most thorough study by the Federal Congress, and it is a subject on which, so far, Congress has not acted. The absence of provision for Federal grants-in-aid to match State funds in any realistic amount for hospital and medical care of the aged is a further indication that the Federal Government has not yet recognized or attempted to provide for this group of medically indigent in spite of its interest in these charges who obviously have frequent need of hospital and medical care. We regard Federal assistance to the States for medical and hospital care for indigents as the second vital step in making adequate hospital and health services available to the entire population.

As the third step, the American Hospital Association believes that the average self-supporting individual must be assisted in meeting the cost of catastrophic illness. The association has developed a program aimed at meeting this need among employed persons in its sponsorship of the Blue Cross Plans for prepayment of hospital care. These plans, developed by hospitals as an organized group, now protect over 20,000,000 persons in all but five States; this is one-seventh of the population, and the proportion is rapidly increasing. In the short span of its existence, the Blue Cross movement has become a potent factor in the improvement of the distribution of hospital services. It is almost unbelievable that the Federal Government with its wide interest in health and welfare, has, as the Nation's largest employer, failed to take the simple action necessary to permit its Federal employees to avail themselves of Blue Cross protection. Instead of criticising and deprecating the Blue Cross prepayment principle, the Federal Government might well study ways to support it, in view of its wide acceptance and continuing growth. Prompt action by the Federal Government to permit pay-roll deductions by Federal employees, which is the key to the growth of prepayment hospital and medical care plans, would encourage other employers to do likewise, and further encourage the extension of this proven method of facilitating the distribution of care.

With adequate physical facilities, with provisions for financing hospital care for the indigent, and with the employed population largely covered by prepayment hospital and medical insurance, this country could have as much pride in the distribution of hospital and medical care as there now is in its quality. We have the finest care in the world, and it could and should be available to every citizen.

VOLUNTARY SURVEYS ALREADY IN PROGRESS

The survey features of this act can be valuable educational devices. This is evidenced by the fact that State-wide surveys are now in progress in 44 States and the District of Columbia. Behind this Nationwide movement, which is already well under way, lies a very significant story.

The American Hospital Association some years ago foresaw the present demand for broader distribution of hospitals

. It appointed a special committee to look into the problem of planning to meet the hospital needs of the Nation. This planning committee recognized that adequate planning could be done only upon the basis of a thorough study of existing resources and needs. Grants totaling $105,000 were secured from three large foundations to finance such a study, and, in order to have a completely unbiased and independent report, a commission on hospital care, consisting of twenty nationally noteworthy people in all walks of life, was selected to direct the study and establish its policies. Under the chairmanship of Thomas S. Gates, of the University of Pennsylvania, and under the direction of Dr. Arthur C. Bachmeyer, Director of the University of Chicago Clinics, the commission on hospital care has been encouraging the States themselves to survey their own problems, assisting them in the establishment of methods and technical procedures.

As of February 15, 1946, the commission on hospital care reports the present status of these surveys as follows:

I. Surveys in progress : Arizona, Arkansas, Colorado, Connecticut, District of Columbia, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Rhode Island, South Dakota, Tennessee, Texas, Vermont, Washington, Wisconsin, Wyoming, and District of Columbia, total, 33.

II. Preliminary surveys completed : Alabama and Utah, total, 2.

III. Surveys officially authorized—not started : Delaware, Florida, Maryland, Ohio, Virginia, and West Virginia, total, 6.

IV. Surveys being planned : California, Louisiana, Mississippi, Nebraska, North Dakota, Pennsylvania, and South Carolina, total, 7.

These individual State efforts are somewhat lacking in coordination of method, and in many States the program is handicapped by lack of funds, but there is a surprising and gratifying evidence of desire for Nation-wide cooperation. The Hospital Survey and Construction Act will go far to provide a means of equalization and assistance in the development of a Nation-wide, integrated system of hospitals and health centers, and we believe the survey feature of this legislation may be of greater long-term significance than even the provision for construction of additional facilities.

STATE RESPONSIBILITY FOR STATE PROGRAMS

As with all Federal legislation, the division of authority between the Federal and State governments must be considered. We favor the pattern set forth in the act as passed by the Senate, because it recognizes two essential needs: On one hand, there must be adequate standardization and proper coordination of State programs to assure

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that Federal funds will be expended for the purposes of the Nationwide program; in addition it must be remembered that there is no generally accepted pattern now recommended for all areas. But on the other hand there must be opportunity for local participation and understanding of the aims of the program. Hospital care is more than mere buildings and equipment; it is a personal service. Any program to expand that personal service must have the full support and understanding of the people who render that service. Only in this way can a program be developed that may meet the particular problems and needs of specific areas and communities.

The State seems to be the logical political division to accept the responsibility of local participation. It is sufficiently large to permit a program that will use professional and physical resources of urban areas to support adequate hospital care for rural areas. And, of course, it is expected that State funds will be used to supplement Federal assistance in the program.

Local participation will also be enlisted on the advisory councils in each State that are required to be established to consult and advise with the agencies which will administer the programs within each State. In these State councils will be representatives of public and nonprofit hospitals and of State agencies concerned with the operation of hospitals; it will also include representatives of the consumers of hospital services, and this appears proper, since at the State level, the problems will be quite broad in nature, and will especially concern the application of the program to local circumstances with which these people will be intimately familiary.

FEDERAL STANDARDIZATION AND COORDINATION

But it is equally essential that these individual State programs should have a degree of uniformity, and that they should be brought within limits of a sensible and practical nature. Such coordination has been provided in this act in the authority given to the Surgeon General of the United States Public Health Service, and the Federal hospital council. This agency can be effective as a clearing house of information developed in all the States, and it is the logical governmental agency to advise on professional matters in a program to integrate and expand the hospital system of the Nation. By its over-all standards and regulations, the individual State programs can be kept within reasonable limits of uniformity which will assure the safeguarding of Federal funds.

The danger of excessive Federal dictation is avoided by careful definition of the areas within which the Surgeon General and the Federal hospital council may prescribe standards. These areas have been so established as to assure that the survey and construction programs will be reasonably uniform throughout all of the States that participate in the program, and yet they likewise assure that Federal control shall not extend to the operation or direction of those hospitals once they have been constructed. There is a requirement that the participating States shall legislate as to such standards of maintenance and operation, but the act wisely recognizes that this is a State responsibility with which the Federal Government should not interfere.

The psychological factors of hospital care are frequently of equal importance with the physical services rendered, and we are quite anxious that there should be a maximum amount of eagerness and enthusiasm on the part of those who will handle this program at State and local levels. It is recognized that proper control through standards and regulations is indispensable, and we are pleased that the act in its present form recognizes the necessity of having the program properly understood and sympathetically administered by those who will actively participate in it. Any attempt to impose a new or strange pattern by theoretical and impractical dictation from outsiders who are not familiar with the everyday working problems of hospital care, could lead only to confusion and resentment, and ultimate waste of Federal funds.

FEDERAL HOSPITAL COUNCIL ASSURES PRACTICAL PROGRAM

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The need for a practical approach to the problem of expanding and integrating the hospital services of the Nation appears to have been met in the provision of a Federal hospital council which will advise and consult with the Surgeon General and participate in the formulation of over-all standards. At the Federal level, the policy decisions will be of such nature as to affect the whole Nation-wide program and the responsibilities are therefore so great that the nature and functions of this Federal hospital council should be carefully examined.

Within 6 months after the act becomes law, the Surgeon General and the Federal hospital council must promulgate standards and regulations with which the participating States must comply in developing their State programs and plans. In this function the Federal hospital council will advise with the Surgeon General on such highly technical questions as the size of operating rooms, safety standards of hospital construction with relation to the specialized uses of different parts of the hospital, location of X-ray equipment, proper size of hospitals with respect to the size of the community, and also with respect to efficient operation, the minimum diagnostic facilities to be required in hospitals of various sizes, and a multitude of similar complicated professional and architectural problems upon which the future of America's hospital system may depend. It is obvious that this council will require the greatest possible amount of professional and technical experience and wisdom that can be brought to it from the field which has developed hospital care to its present high standards. Therefore it was our original recommendation that the Federal hospital council should be composed entirely of persons outstanding in fields pertaining to hospital and health activities, and that a majority should be authorities in hospital operation. It is well established that the best advice on any subject will come from people who have specially trained themselves for a lifelong career in the particular field. We can assure you that there is today no field more highly specialized than the hospital field with its many scientific developments and complex facilities for the care and treatment of an endless range of human ailments. Consequently, we have noted with some concern, the efforts to weaken the Federal hospital council by substituting "consumer members” on a council whose decisions, at the Federal level, will be largely professional and technical. Undoubtedly that council will wrestle with problems upon which even the experts may disagree, so it is obvious that consumer members who have not had the advantage of working

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