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Mr. Harris. Of course, the schools are on nothing like an equal basis now. If you did not get the hospitalization program on any better basis than the schools, you would not have accomplished the purpose.

Mr. Brown. Some of the wealthier States will begin to wonder whether they can maintain their hospitals and the schools and the other public institutions out of their own income, or whether they will have to reduce the level of service they render their people in order to bear the burden of taking care of the people of other States.

In other words, will this lift all of the people up to a higher level, or will it take some of the better States down to a lower level ?

Dr. SMELZER. No, I do not think so.
Mr. Brown. I hope not. I am just wondering.

Dr. SMELZER. There are not very many States that are actually providing hospitalization for medical and surgical care. They are mostly mental and tubercular and chronic diseases.

Mr. Brown. I am talking about all sorts of hospital service, city hospitals, county hospitals, church hospitals, and charity hospitals of different kinds, on the basis of the ability of the people in each State to pay taxes or to contribute to charities, or what else, to support them. That makes a better community.

I am wondering if you do not have a complete service there. It is probably because they have not felt and believed that they could support a complete service. Dr. SMELZER. I think that is right.

Mr. Brown. And, of course, I am just wondering, Doctor, to follow that a little further, where this money comes from that we pass out from Washington.

Have you any idea about that?
Dr. SXELZER. I do not know. I pay part of it.

Mr. Brown. Is there any secret source? I thought probably the people of the various States were paying it. So, in the end, we are taxing the same people, except we are redistributing their money on a different line when we go through the Federal government than when they distribute their own money through the State and local governments; is that not correct?

Dr. SMELZER. That is right. That is why we are interested in seeing that it is properly spent and administered.

Mr. Brown. You come from Philadelphia, I believe?
Dr. SMELZER. Yes, sir.
Mr. Brown. In Pennsylvania ?
Dr. SMELZER. Yes, sir.

Mr. Brown. Do you see any possibility that if this type of a program is carried out to its full fruition Pennsylvania might not get quite as much, and some other State might get quite a little more?

Dr. SMELZER. That is right.
Mr. Brown. You favor that program?

Dr. SMELZER. I think so. I do. We happen to be considered one of the wealthier States. Right now we do not have to do anything in Pennsylvania on that. We are one of the seven States I mentioned that have not waked up yet. Right now we have not decided to do anything in Pennsylvania on that.

Mr. Brown. Mr. Marcantonio says that is because you have a Republican governor. I thought it might be because of the exponent of the bill living in that State. Usually that is the procedure. At least I know that is true many times. Perhaps your missionary work should begin at home, Doctor.

Dr. SMELZER. Well, we have tried very hard, sir. I think we will get there. Perhaps when they see the money coming to do the survey we may get it.

Mr. BROWN. All right.

Dr. SMELZER (continuing statement). In summary it might be said that the American Hospital Association lends its active support to this legislation in the form in which it passed the Senate because its membership is in position to realize the urgent necessity for providing additional hospitals and related facilities and making them more widely available. Our support is given because the urgency outweighs the dangers of a Federal program which might lead to excessive Federal control of hospital and health activities. The delicate system of checks and balances provided in this act tends to lessen this apprehension, provided Federal control is carefully limited, a measure of uniformity and standardization is provided, and there seems to be a reasonable safeguarding of the expenditure of Federal funds, but the essential responsibility of the program is and should be placed in the hands of the State governments so that the State programs may be individually administered according to special State needs. The act recognizes that hospital services are essentially personal in nature, and that the program requires a high degree of cooperation and selfdevelopment; thus, the people who will have to render these personal services are given a measure of responsibility in a partnership with Government-at the State level in State advisory councils, and at the Federal level in a Federal hospital council-in which persons with outstanding experience may have a part in giving this program a practical and effective application.

The American Hospital Association and its members have given much consideration to the need of better distribution of hospital services which are universally recognized as the finest in the world. We feel that this program for the careful expansion of facilities for rendering that care merits your careful and earnest consideration. As a first step in the improvement of the distribution of hospital and medical care, we urge the prompt and favorable action by this committee on the Hospital Survey and Construction Act as passed by the Senate.

Mr. Brown. I think, from the concluding sentence of your statement to the effect that you oppose any change in the Senate bill, you are opposed to these amendments that have been suggested here today by Dr. Parran, the Surgeon General; is that correct? Dr. SMELZER. Yes, sir.

Mr. Brown. You feel, in your studied opinion, that this board should have the authority to fix policy, et cetera?

Dr. SMELZER. I do.
Mr. Brown. Rather than having such authority placed in one man?
Dr. SMELZER. Yes, sir.

Mr. Brown. You are also of the fixed opinion there should be a
right of appeal to the courts in such cases?
Dr. SMELZER. As expressed in the testimony, yes, sir.
Mr. BROWN. Under those circumstances ?

• Dr. SMELZER. Yes, sir.

Mr. Brown. What do you think of the proposal that, perhaps it might be well to build offices for doctors?

Ďr. SMELZER. Of course, either I missed the boat this morning or else I was listening to somebody else at the time. I favor very closely the inclusion of doctors' offices in any new hospital construction for the use of the doctors.

Mr. Brown. At the hospital?

Dr. SMELZER. Who are on the staff of that hospital, for the convenience of the patients they are treating and the conservation of their time.

Mr. Brown. What do you say as to the construction of other offices for the use of doctors who cannot find places to locate ?

Dr. SMELZER. Whether they are connected with the hospital, and whether the offices might be at a distance from the hospital ?

Mr. Brown. For private practice.
Dr. SMELZER. I do not agree with that.

Mr. Brown. You are opposed to that? You would not want these funds used for that purpose?

Dr. SMELZER. I do not think it was intended to be used for that purpose. I think it would be quite in order to include either as a separate building on the premises of the hospital or within the hospital, offices for doctors who are serving either in the out-patient department or in the hospital.

Mr. Brown. That is, on the staff of the hospital, just like you have a nurses' home?

Dr. SMELZER. That is right.
Mr. Brown. Or anything like that?
Dr. SMELZER. That is right.
Mr. Brown. For the hospital?

Dr. SMELZER. Yes, sir. Whether the doctor would be charged would be according to the policy of the hospital and the ownership of the hospital, and so forth.

Mr. Brown. All modern hospitals do that, anyhow?

Dr. SMELZER. They are coming to it. They are not in a position, perhaps to do it right away, but Pennsylvania Hospal, for instance, in Philadelphia, has just purchased and converted a fairly large building across the street from the hospital in which they have doctors' offices that they rent to their staff for convenience sake.

Mr. Brown. For their private practice?

Dr. SMELZER. Private practice and for the convenience of the hospital.

Mr. Brown. Do you think of that as a Federal project?

Dr. SMELZER. If it occurred in the project that was catering to private and ward patients, I would, yes.

Mr. Brown. I do not mean for the benefit of the patients there, but for other people who perhaps call on that doctor but who would not require hospitalization.

Dr. SMELZER. Provided he was on the staff of that hospital.

Mr. Brown. In other words, if he is on the staff of the hospital and serves an hour or two hours a day, you would feel that it would be all right for the Federal Government to furnish him office space for his general private practice?

Dr. SMELZER. And rent it to him. I would not give it to him for nothing.

Mr. Brown. Then you think you would carry that further and say, “Now, if the man is still on the staff, he can still have that?"

Dr. SMELZER. I do not think you can do that.
Mr. Brown. He would have to move if he quit the hospital?
Dr. SMELZER. If he so did; yes, sir. I see no danger in that.

Mr. Brown. I am trying to draw the line where you would stop between rendering service and where you do not.

Mr. SMELZER. You mean in private and semiprivate and ward?

Mr. Brown. I have a distinct feeling that offices in a hospital for the staff doctors in connection with their hospital work is perhaps the province of a bill like this, if the Federal Government is going to give aid; but I think when you begin to construct office space for doctors, or dentists, or anybody else for private practice, then you are getting into difficulty, and the first thing you know we will be doing everything for everybody.

Dr. SMELZER. I do not think so, because if the doctor's time can be saved, can be conserved, is there not a possibility he can spend more time on his ward patients and give them better quality of care if he happens to be there rather than traveling back and forth?

Mr. Brown. If you would follow that through to the logical conclusion you would want to buy him a fast automobile to get there quicker.

Dr. SMELZER. He would not need an automobile at all. He would be right where his patients are, and that is the trend all over.

Privately endowed hospitals are not throwing any of their money away in providing doctors' offices, because they want to be nice to those doctors, but they are getting more in return than they did before.

In the first place, the rental can be applied against the hospital deficit or the hospital income for the work of ward patients. It is an income. You are getting more of his time and better service.

Mr. Brown. That is a private institution. I am talking about the Government going into the rental business, et cetera.

Dr. SMELZER. I do not see any difference myself. Many hospitals are State-aided and get a large amount of their income from the State, and yet the State has no objection to their building and providing offices and renting them to the staff.

Mr. Brown. Do you know of any States which build them?
Dr. SMELZER. That build them
Mr. BROWN. Yes.

Dr. SMELZER. Yes, I think in the State-owned hospitals of Pennsylvania there are doctors' offices but there are not many.

Mr. Brown. For private practice?

Dr. SMELZER. They are allowed consulting, the same thing, private practice. Pennsylvania is a little unique in that. They have Stateowned medical and surgical hospitals, have had for many years. There are about ten of them. There are 211 State-aided hospitals that get $8,000,000 from the State, which is a lot of money.

Mr. Brown. Of course, many hospitals get State and city aid.
Dr. SMELZER. A little more indirectly than in Pennsylvania.
Mr. Brown. All large cities have the same situation.

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Dr. SMELZER. Yes, sir.
Mr. HARRIS. Doctor, may I briefly ask a question or two?

As you understand the bill, it provides for a grant-in-aid to the States from the Federal Government for hospital construction?

Dr. SMELZER. Survey and construction.

Mr. HARRIS. To make the surveys. The money is allocated on a matching basis?

Dr. SMELZER. The State makes the surveys. The State agency is responsible for making the survey.

Mr. HARRIS. Yes, I understand that. The surveys and planning are made then through the State agency?

Dr. SMELZER. That is right.

Mr. HARRIS. But the Federal Government contributes $5,000,000 to it?

Dr. SMELZER. That is right.
Mr. HARRIS. Under this act?
Dr. SMELZER. That is right.
Mr. HARRIS. Now, then, the allocations are based on a formula that
is set up on per capita income, et cetera, is that right?

Dr. SMELZER. That is right.
Mr. HARRIS. Then standards are established by the council?
Dr. SMELZER. The Surgeon General and the council.
Mr. HARRIS. And the States must meet those standards?
Dr. SMELZER. Submit a plan that meets the standards.

Mr. HARRIS. Then they must show that they can maintain that hospital if it is constructed; is that right?

Dr. SMELZER. I think it says “reasonably show.”
Mr. HARRIS. I am asking you to clarify that.

They must give reasonable assurance that the hospital will be maintained by the local community or State agencies?

Dr. SMELZER. That is right.

Mr. HARRIS. We have to deal with these government agencies a lot here. Without any disparagement to any individual, we get a lot of inquiries from our districts, from people who want to get in on this program or that program, and we are asked about the practical procedure.

How about a little town in my State, in Arkansas, that wants a hospital, to participate in this program, just what would they do, if I got such an inquiry after this act has been made into law, just what would they do to actually obtain a hospital for that community and to participate in the program?

Dr. SMELZER. Putting myself in the position, we will say, of the individual who wanted the hospital in the little community in Arkansas

Mr. HARRIS. Or in Pennsylvania or Ohio, or any other State.

Dr. SMELZER. I would go to the State agency and say, "I feel we want a hospital in our community.” If the State survey had been made, then that agency ought to be in a position to say, “Well, we do not feel that your community needs a hospital.” And "there is a hospital 3 miles from you" or "five miles," or whatever the case may be, and it might end there. It would end there, I think.

If the State survey reasonably shows that there is a need for the hospital, they would be asked to submit plans for what they wanted to do, to meet the need.

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