be financed in this effort by the rest of the country and I want to find. out first whether that is, in fact, true.

In other words, will New York City be receiving more than it pays, if you know and can answer that question, in such a program as this comprehensive health planning program first, and then the next question is:

Can you give me the rationale for why this should be done with Federal funds and not local funds?

Dr. BROWN. What is your district in Ohio?

Mr. BROWN. The seventh district.

Dr. BROWN. Which area is that?

Mr. BROWN. Well, it is a seven-county area in west central Ohio. Dr. BROWN. What city?

Mr. BROWN. Springfield is the largest city.

Dr. BROWN. I am from Ohio and I was trying to think of the area. I haven't looked at it recently.

Certainly, our health problems in the low-income areas of New York City are every bit as great or worse than those in that area.

Mr. BROWN. Sure they are in the low-income areas of your city. My question is: The city taken all in all, with the ratios of doctors to citizens of 1 to 450 is a vast improvement over my area.

Dr. BROWN. Now, perhaps Mr. Elliott can respond to the question on whether we pay more taxes than we receive in New York City. I think the importance of the planning legislation is that it focuses on the official designation of an agency for planning which to date we did not have and in that sense, strengthening the idea of planning. Funds are always important to finance or expand an existing activity. The official designation of such an agency is the most important one in my judgment.

Mr. BROWN. Let me tell you what is bothering me and then I will let you worry with the problem from there.

I don't think any one of us on this committee, or you either, object to the problem of medical costs and planning to try to see if those medical costs are reduced and that the average American citizen has the highest possible medical services. And I don't think any one of us feels that you can do this without a certain cost.

The question that I am asking is that, and this is a problem we face in every aspect of the Federal Government now, we are facing in this country a $29 billion deficit. This program as it develops is going to cost not millions of dollars but billions of dollars as I understand it. This is a wonderful program and a very needed work in our country. It is a very beneficial program for the average American citizen and one I think, therefore, that could be extremely popular.

It is like motherhood, the flag, the Marine Corps and good health and everything else rolled into one. The guts of the problem is financing.

Now, how much can the Federal Government put into this is the question we are ultimately going to have to answer. Nobody objects, I am sure, to the program as it is laid out.

Mr. OTTINGER. Would the gentleman yield for just a comment on the relative position of New York in Federal financing?

I think I can be helpful on that. I believe in every distribution program in which the Federal Government is involved, New York pays more than it receives.

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Within New York State, New York City has, in every program within the State, contributed more than it has received.

Therefore, in New York City the Federal program as a whole is way behind the eight ball. Indeed, because of its relative affluence within the Nation and within the State, New York City's position as compared to the other States is that it has always contributed a great deal more than it has received in any program.

Mr. BROWN. It is also true of the State of Ohio and probably also true of my district which is, I think, the thing that prompted my question.

Mr. ELLIOTT. Let me just deal with a couple of those problems. In the first place, what Congressman Ottinger said is completely accurate. No matter how you measure this the city of New York pays way out of proportion with the money it has received.

I may also say that the city of New York has not in the past and certainly is not now carrying out its own responsibility. We are what can only be described as a high tax island.

I suggested to you that we have a 5 percent State tax, a State, city, and Federal income tax and that we support a school system in excess of $1,000 per pupil per year.

As Dr. Brown suggested to you, over the next 5 years we will spend half a billion dollars in our own moneys for hospital construction.

The city of New York faces national problems. This is true for the major cities across the country. They are not simply assaulting the problems of the local areas. As you know, there is a very subtantial migration into the major cities from rural areas, particularly in the South, and has historically been for a period from Puerto Rico, so that the cities are in effect national centers for taking impoverished peoples and training them, bringing them into the economic mainstream of the country, and this often takes a generation to do, at which point they spread across the rest of the country.

I think that the kind of question you are really asking is one of the priorities of national resources and I think that I am perfectly convinced that the kind of standards which we are trying to achieve in health as we are in education and in housing and some of the other areas are minimal standards for a nation of the kind of ability and affluence of this one.

I just don't believe that we have begun to reach the point where our national resources are inadequate to the job and I think if you take any one of a realistic cost benefit and see what not over 2 or 3 years but over a generation or so you could accomplish in terms of making available manpower for the needs of the country that the kind of programs that we have been talking about today and that we are trying to do in the city of New York easily prove themselves

out.

It is true that the particular dollars sound like a lot or money but I can assure you that on behalf of the citizens of the city of New York they recognize and have shouldered, I think, far more than their share of the responsibility.

In fact, the cities-and New York is high on the list-have been carrying national problems on their own resources to an extent which is unrealistic.

Mr. BROWN. The question is not one of whether or not New York City has the ability to pay for these things, but rather, whether they will undertake to finance this problem.

Mr. ELLIOTT. No; the question is that the city of New York is bearing more than its share of the cost now. There comes a point beyond which a locality cannot and should not be asked to solve what I think are essentially national problems.

Mr. BROWN. These problems are going to be solved, are they not, at the community level? That is what I am perhaps confused about. Isn't this the objective of this plan?

Mr. ELLIOTT. They are going to be solved at the community level but they are problems that affect the entire Nation and are national problems.

Mr. BROWN. I have no question about that. I agree thoroughly on that. But, if the ambition is to solve them at the community level and if the ability of the community to resolve them financially is high, I am a little bit lost on why we are running it through the Federal process here related to the apparent ability of the Federal Government to fund these programs.

We are into a great many programs which we can't fund now because of the $29 billion deficit that we are talking about.

Mr. ELLIOTT. The way to solve the deficit is to raise additional

revenue.

Mr. BROWN. Which would add to that tax level in New York City, I gather.

Mr. ELLIOTT. That is correct, but if it became a question of Federal policy to return to the city of New York a greater share of its tax moneys these problems could be handled locally, but I think since that is not the present procedure then we are forced to seek Federal grants in order to achieve those results.

On the particular question of one doctor for 450 people, this is not a statistic which is applicable. We are not asking in these programs that Federal moneys be used to support those people who can afford to pay the private doctors. What we are talking about and what Dr. Brown has been putting all of his stress on today is the provision of medical services in those areas where the ratio of doctors is nothing like that and where the individuals are not able to afford it.

Mr. BROWN. Thank you.

Mr. Moss. The Chair would like to say there are other members who haven't had the opportunity for questions.

Mr. BROWN. If I may make just one comment, Mr. ChairmanMr. Moss. Very brief.

Mr. BROWN (Continuing). The ratio between rich and poor or the balance between rich and poor in my district is not as wide as it is in a city like New York.

On the other hand, my feeling is that the allocation of local resources is basically the problem of New York if you have one doctor to every 450 residents. I think we have a national problem more evident in my area since we don't have any way near that ratio of physicians to residents and we also have similar problems, although we apparently don't have the nurse shortage you do.

It just strikes me that there is a very interesting total problem here because of the question of whether or not the Federal Government

can, in fact, fund the programs such as this that we are undertaking. They are worthwhile in nature, but where is the money coming from. Mr. Moss. Mr. Kyros.

Mr. KYROS. Thank you, Mr. Chairman. I have no questions.

Mr. Moss. Mr. Stuckey.

Mr STUCKEY. No questions, Mr. Chairman.

Mr. Moss. Mr. Pickle.

Mr. PICKLE. I have no questions now, Mr. Chairman.

Mr. Moss. Mr. Adams.

Mr. ADAMS. I have no questions, Mr. Chairman.

Mr. Moss. Mr. Blanton.

Mr. BLANTON. No questions, Mr. Chairman.

Mr. Moss. Are there additional questions?

If not, I want to express the committee's appreciation to Dr. Brown and Mr. Elliott for their appearance here this morning. Your testihas been valuable to the committee.

mony

Mr. ELLIOTT. Thank you.

Dr. BROWN. Thank you very much.

Mr. Moss. The Chair would now like to recognize Dr. John B. Wilson, chairman of the Council on Legislation, the American Dental Association. Dr. Wilson, I note you are accompanied by an associate. Would you introduce him for the record and does he also have a

statement?

STATEMENT OF DR. JOHN B. WILSON, CHAIRMAN OF COUNCIL ON LEGISLATION, AMERICAN DENTAL ASSOCIATION; ACCOMPANIED BY BERNARD J. CONWAY, CHIEF LEGAL OFFICER

Dr. WILSON. Thank you. Mr. Chairman and members of the committee I am John B. Wilson a dentist of San Marino, Calif. In addition to maintaining a private practice, I am chairman of the Council on Legislation of the American Dental Association. With me is Mr. Bernard J. Conway of Chicago, chief legal officer of the association.

The American Dental Association recognizes and endorses the major goals of H.R. 6418. As we understand it, these goals are to encourage States and communities to make comprehensive plans in order to meet efficiently the health problems in their own areas and to give them as much flexibility as possible in implementing these plans.

The concern we have with H.R. 6418 arises from the vagueness of the bill's language. It is difficult to speak with precision to a proposal that so largely lacks precision itself. The testimony of administration witnesses and the proposed regulations that have been offered do little, in our opinion, to offset this vagueness.

Our major concern is that the bill makes no attempt to define what is meant by "comprehensive health services." Without such a definition, there is no way to forecast how adequate this measure is. Will the programs, in fact, be as comprehensive as those under the superseded categorical grant-in-aid programs, which included a dental health component? Our fear is that unless some minimal guidelines are set, the programs may well be less comprehensive.

This is not a mere academic point of interest to the American Dental Association. A study of the long history of Federal, State, and local public health programs, prior to the 1965 initiation by Congress of a

dental health category, revealed a consistent and nearly universal neglect of dental public health.

Yet dental disease is one of the Nation's most serious, large-scale problems. It is certainly the most prevelant of all the chronic diseases that afflict mankind, being experienced almost literally by everyone. This is especially true with regard to the incidence of tooth decay and periodontal disease. While such other manifestations as cleft lip and palate or oral cancer are not so common, they cripple or kill thousands of people each year.

This evaluation of the serious nature of dental disease is not held by dentists alone. Others involved in and concerned with the Nation's health also endorse it. The Honorable Wilbur J. Cohen, now Under Secretary of the Department of Health, Education, and Welfare, for example, has underscored the problem in testimony before congressional committees.

And Mr. Cohen, like the association, has gone on to point out that dental public health has been grossly neglected on the Federal, State, and local levels. Among other things, he has said:

In 1961, for example, the Public Health Service made general health grants of $17 million to state public health departments. Yet these departments allocated to dental activities only $125,000-just 0.7 percent of the total-of the more than half a billion dollars spent in 1961 on all state health programs, only $6.6 million -about one percent-went to dental health.

This pattern of allocation of public funds is in sharp contrast with that of private funds, when $15 out of every $100 spent for health care goes for the purchase of dental services.

I might add that this picture basically is the same today as it was in 1961.

Continuing the quote:

So great a disparity cannot be ignored, for the current allocation allows less than four cents per person per year for all state and community activities in dental health. And four cents per person a year simply is not enough. It does not permit programs which even begin to meet the existing national need.

Given these facts, then, about dental disease, there can be no question but that it should be included in any reasonable definition of "comprehensive health services." This documented neglect on the Federal, State, and local levels, however, leads us to conclude that Congress should require such a definition.

The association was gratified last year when this committee, in its report on the Comprehensive Health Planning and Public Health Services Amendments of 1966 (H. Rept. No. 2271, 89th Cong., second sess.), indicated strongly that it too was anxious to clarify this point. On page 7 of the report, the following statement appears:

The Committee expects, however, that the regulations pertaining to planning will provide for the comprehensive concept that is intended to insure adequate recognition of dentistry and services for the mentally retarded and other institutionalized persons.

The association does not believe that the draft regulations we have seen fulfill this expectation of the committee.

While the lack of a definition of "comprehensive health services" is the chief reason for our concern, other illustrations can be cited.

There is, for example, the question of whether the program under consideration here is intended to confer authority to State health planning councils that would supersede or conflict with the provisions of