Mr. MURPHY. That seems to be a problem on a national basis. Have you expanded the State medical schools to train more doctors and more medical personnel?

Governor SMITH. West Virginia only has had a State medical school in the State since 1952. It graduated its first doctors in 1960. It hasn't been expanded because it was really just getting up to its ability to graduate the 66 or 76 that it is set up for as medical doctors, and to be producing 75 dentists and 200 nurses that are scheduled for that program.

It has not been expanded since its original start. It has just grown to where it was supposed to be.

Mr. MURPHY. The State has had to rely on outside medical schools? Governor SMITH. Up until 1952 students were getting 2 years of medical instruction at West Virginia University and then completed their courses at the Medical College of Virginia under a contract arrangement with the medical college.

Mr. MURPHY. Many Governors have stated that they have a gravitation from the rural areas of their doctors into the urban areas and thereby creating a vacuum of qualified medical people in the rural

areas.

Is that true in West Virginia?

Governor SMITH. I think that is true in West Virginia. We have several counties in which we do not have a qualified medical doctor, and that is one of the problems that has been involved in this regional approach in southern West Virginia. Instead of getting the doctor to the patient, we are going to try to bring the patient to the doctor.

Mr. MURPHY. We have tried in some Federal programs to gear them to having doctors stay in rural areas under some Federal training programs.

Would you advocate an increase or a greater assertion on this type of program?

Governor SMITH. The thing that I always imagine and visualize and what we are going to have to do in the rural areas, is to establish, well, if you are going to use the Navy's vernacular, a corpsman, out in the area with a small staff of a nurse or a small unit where they could probably diagnose the case and then have the ability to get the patient to the area where the facilities are for the doctor to give the proper health care.

You can't build a hospital every place. Costs of hospitals and medical services, the skills, the training, and the equipment that are needed are such that you have to go to a regionalized approach, so I would advocate that the Congress, if it wishes to get into this, create these satellite training or satellite examining units in the rural areas, and then beef up the strength of the medical center so that the person who is brought there can get the finest of care.

Mr. MURPHY. But it is your opinion that it is essential for the Federal Government to participate in these medical health programs right with the States and try to resolve some of the health problems particularly in rural areas.

Governor SMITH. The rural States are usually States that have financial problems and unless you have this assistance the muscle and financial strength of the Federal Government-it would be impossible to do the task.

Mr. MURPHY. Governor, in New York we have a very controversial action called Medicaid under title XVIII or the Medicare Act that was passed.

Has your State legislature enacted any legislation similar to the New York notion?

Governor SMITH. No, sir. The only thing that we have done to implement title XVIII is to extend the program that we had originally. We were in the original Kerr-Mills act. We were one of the States that were in that, so we have kept that going. We have just added to it some of the provisions to pick up the dependent children up to age 21. We have not gone any further into that, into the Medicaid end of it. Mr. MURPHY. You haven't established an income level for people to be eligible for that particular title?

Governor SMITH. No, sir.

Mr. MURPHY. Thank you very much.

The CHAIRMAN. Dr. Carter. I might say this is a medical doctor we have on the committee.

Governor SMITH. I understand he is from our neighbor State of Kentucky, too.

Mr. CARTER. Governor, I certainly want to compliment you on your excellent presentation and on your keen insight into medical problems in rural areas particularly.

Certainly I should hope that you would be able to get more organizations into those rural areas, but in case that is impossible under a plan such as yours, and it is to be hoped, as I see it, I think your idea of getting patients to the doctor is extremely good because it will certainly increase the amount of work more doctors can do and also provide aid for those in distant areas. Thank you, sir.

The CHAIRMAN. Thank you, Dr. Carter. Mr. Ottinger.

Mr. OTTINGER. I am glad to have you with us, Governor. This program in one of its major components calls for long-term planning for hospital facilities. We have in many States, however, critical shortages of hospital facilities at the present time.

Can you give us any idea of what the situation is with respect to your own State?

Governor SMITH. I couldn't make a guess, but it seems to me the task force on health reported that we would have a shortage of some 5,000 hospital beds by 1980. That is the figure that runs through my mind. I refer to the type that would be suitable for medical care at that particular stage in our history.

We have been running a shortage in the field of there are three different classes of care. I am just trying to think of the one it applies to. It is not the intensive care that would come in the hospital, the critical case, but the "convalescent" care. Maybe that is the term I am thinking about.

The Hill-Burton funds that we are using now are primarily diverted to the building of those units that meet that particular need. I would be glad to give the committee a complete breakdown on the report of the Task Force on Health and a complete breakdown on this situation on what exists and what we anticipate it will be in 1970, 1980, 1985, through the years.

Mr. OTTINGER. Are there hospitals to your knowledge in West Virginia that are really in a critical condition where they get emergency cases and they actually have to put them in the corridors, where people

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have to wait for substantial periods of time before they can gain admittance?

Governor SMITH. It would be only a rare instance that they couldn't handle an emergency case, but there is presently in most of the hospitals in West Virginia a delay in making hospital bed space available to the doctor who wishes to have a patient admitted.

It is probably true all over the State of West Virginia at the present time.

Mr. OTTINGER. Has this been aggravated by Medicare to a considerable extent?

Governor SMITH. I saw a report the other day that there was only one hospital in the State in the Medicare program which attributed part of its overload to Medicare. That was the Appalachian Regional Hospital in Beckley, where 38 percent of their case load was Medicare patients and they are running about five percent over their rated capacity, to they attributed that 5 percent to it, 38 percent to Medicare— but it could have been just the other way around.

I don't know whether that would be an accurate statement or not. Mr. OTTINGER. What has been your experience with Hill-Burton? Is it adequate?

Governor SMITH. Hill-Burton funds have never been fully adequate. We have never had enough allocated to West Virginia to meet the demand each year that we have been able to provide of the matching funds from local communities for hospitals.

It has always been a matter of rationing the Hill-Burton funds to those areas that have the most pressing demand. This year, for instance, we could have used three times the amount of Hill-Burton matching money that was available.

Mr. OTTINGER. Thank you very much. It is always a pleasure to have you with us.

The CHAIRMAN. Thank you, Mr. Ottinger. And I might say that my friend in New York had a special reason for asking about the hospitals because he is trying to get a program into this bill, and I think this is good.

Mr. CARTER. Mr. Chairman.

The CHAIRMAN. Yes.

Mr. CARTER. Might I add a little to this?

The CHAIRMAN. Yes, surely.

Mr. CARTER. Certainly in Kentucky, and I feel sure in parts of West Virginia, but I know that Kentucky hospitals in rural and mountain areas are terribly overcrowded, and I know further in our State we do have insufficient Hill-Burton funds. I think in this field there should be an increase in the amount made available. I could point out there is one hospital I know quite well which was built in 1953.

An addition was made in 1964 and still there are patients in the halls in that hospital because I have been there and I have seen them. This condition exists largely throughout the mountainous area of my district.

Governor SMITH. We have the same situation in certain places, Weston, for instance. There is a great need for a hospital there and the Hill-Burton funds ran out and people don't have the money and right now we are trying to find ways and means to build that unit so desperately needed in the central part of West Virginia.

Mr. CARTER. Hill-Burton funds now are providing in some places only one-third of the amount needed.

Governor SMITH. Sometimes I think it is even less. It squeezed out less than that sometimes.

The CHAIRMAN. I might say that a little later today we will have a witness from the American Hospital Association representing them. I am sure that he will be able to answer on all the facets of this.

I think you have done very well, Governor. Mr. Watkins. Mr. WATKINS. Mr. Chairman, it is certainly a real pleasure to see the distinguished Governor of the State of West Virginia and to hear him make his plea before our distinguished and wonderful chairman. I am sure that you two don't have too much time to get together, but I do admire you as Governor of your State coming in here to talk to us about money, money, money-which is a great item on the Hill today in every category.

Certainly your cause is a worthy one and I think there are very few legislators and I think there would be none in my estimation, that don't have the fullest sympathy for every Governor from every State that is trying to make the progress that is needed in mental health and in the care of our people, but you are to be admired and I hope that we will see more Governors in here rather than sending in one of their heads of their departments to talk.

I respect you very much for giving us your valuable time. I would like to ask a question that Mr. Springer practically covered from the money angle, and I assure you that we are always interested in giving you as much as we can, but I think you are going to have to take a little cut the way things are going with the war and other things that are happening.

I would like to ask you about one matter, information more for myself. In your State you have a conflict of interest between the local municipalities where they have their health bureaus and now a new thing, that is perhaps not too new, but in the State of Pennsylvania there is a demand from the public that we have the health services handled by a coordinator, by a doctor and a staff that the counties have to set up to handle the affairs.

Is it necessary in your opinion? You just can't continue in every municipality to have health bureaus and then to have a county setup which I understand in my counties are going to cost something like $200,000. That is the county of Delaware and Chester County, Pa.

What is your thinking on that? Which is the most important? It seems to me a general feeling that it is hard to get to the bottom. Which is the best? You can't have both in my opinion, or can you?

Governor SMITH. We have kind of a coordinated effort because State funds are used in these county medical centers. We fund it on the basis of a coordinated effort. If it is a municipality of any size we make it a city-county unit, and if there is no large city or community we make it a county unit, so we fund it that way and I would say that is the only way it could be done.

It should be one unit.

Mr. WATKINS. Should be one unit.

Governor SMITH. Yes.

Mr. WATKINS. Which one do you approve?

Governor SMITH. Basically ours are county units, and of course, as I say, in this nine-region approach we are trying to get away from the county units. We are trying to get to regional units-nine of them. I found that the imaginary county lines that were so great and useful on various occasions in our history seem to be obsolete, out of date, today, and people move too fast and people don't live by county lines. They don't pay any attention to them practically, so we are trying to make our planning on the basis of where the people live and the county line in the middle still doesn't make any difference.

Mr. WATKINS. In other words, you prefer regional, or a county, or local?

Governor SMITH. Right. I prefer regional. It is money saving. It is economics. As you know here, you can't afford to give something to everybody; all you would like to.

Mr. WATKINS. That seems to be the trend today and every idea costs an awful lot of money.

Let me ask you one other question and then I will certainly not take up any further time.

Do you have any control in the State of West Virginia of your hospital charges?

Governor SMITH. No, sir.

Mr. WATKINS. Do you think in your opinion that perhaps States will have to get into that? I find that again in the State of Pennsylvania in the district in which I live that a hospital roughly runs anywhere from $42 to $65 a day.

In your opinion, do you think that there has to be some regulation by the State on the cost in hospitals?

Governor SMITH. Not unless it gets into the range that you consider a hospital like you would a public utility. I am basically just opposed to the idea of fixing prices on anything.

Mr. WATKINS. I can appreciate your opinion. I am not for fixing prices. I don't like the idea of fixing prices myself, but it gives me pause when the situation is running at leaps and bounds, and I remember just recently that the cost of a hospital room was $22 a day not too far back, and I was in Pennsylvania in the State senate, and where the State only contributed I think something like $10 a day.

Now they contribute $22 and the latest figure that I had on cost per patient, the room service, and all that went with it, and that is only, in other words, a registered nurse and perhaps a practical nurse with an attendant, indicated the cost went up without the registered nurse to $55 to $60 a day.

Somewhere along the line I just wondered in your experience as Governor whether you don't think you are going to have to look at this. I am not speaking for the State of West Virginia. I speak in general.

Governor SMITH. I think if it keeps bouncing as far as it has-and statistics indicate medical services to be the most rapidly rising item in the cost of living-that there is going to be a demand for someone to look into it, and if it is going to be looked into I would feel that the State should look into it, rather than the Federal Government.

Mr. WATKINS. I do too. I really truthfully feel there is something wrong with this system and I think that the cost is adding too much. One patient came to me who had a broken arm in an automobile acci