Dr. KIMMEY. Thank you, Mr. Chairman. I think that the statements made by the sponsors of this bill for the Congressional Record at the time of the introduction, as well as the other witnesses today, have highlighted necessarily the magnitude of the problem of the maldistribution of medical personnel in the United States.

The American Public Health Association, as an organization of 28,000 people, is interested in the problems of the health of the public of this country and supports the concept in S. 4106. We hope that this bill will be enacted.

I think that I would stress, however, as other witnesses have, that this is only the first step; it is a beginning of the solution to a very complex problem that we have in this country. Other witnesses this morning referred to the "health care crisis," and I think all of us refer to health care crises from time to time, yet maybe that is not the best possible term for what is wrong with health in the United States today.

In medicine, "crisis" implies that it is an appointive time which the patient will either get better or die, and this "health care crisis" seems to be going on for a much longer time than the definition would allow.

What we are really seeing around the country are these communities where people can't get medical care; they can't get a physician in what would be called a rural-urban community, and this is a health care tragedy of the first order. This is highly personal, and as we look at the physician-patient ratio and the charts and graphs and economic forecasts and so forth, we have a tendency to depersonalize the extent of the problem facing the country and the problem that this type of legislation, with its impact on the maldistribution of professional people, would be effective in solving or beginning to solve.

In relation to the indirect benefits of the bill, particularly strengthening of the carrier professional components of the Department of Health, Education, and Welfare and the attracting of more physicians into practice in the rural areas, we also see positive benefits that might accrue from the bill being enacted and this kind of program being established within the Public Health Service.

These comments in more detail, along with technical comments on the bill, are included in my formal statement.

I think that events of yesterday, Mr. Chairman, also enter into our considerations on this bill. My statement was prepared before S. 4296 was introduced by Mr. Cranston of California, the Health Professional Assistance Amendment of 1970, and I think that the proposal embodied in S. 4296 is also responsive to one of the problems highlighted in my prepared testimony, and that is the fact that of American physicians today, only 2 percent are black, and an even smaller percent represents other minority groups who are strongly represented among the poorer groups or the population. We need to look for ways to identify interested students in these fields to get these students together with the possible aid that is available to them, and do everything we can to increase the enrollment of students who might not otherwise be able to get into schools of medicine and schools of dentistry and other health professions and schools of public health.

Also, in view of yesterday's introduction of Senate bill 4297, concerning national health insurance, and other bills of the same type that have been previously introduced in both Houses, I think a bill of this type becomes of great significance.

The maldistribution problem, the fact there are 40 million poor Americans not getting access to medical care, will certainly become a greater problem if we don't have any national means for these Americans to come to the services. This is not to say we should delay for 1 minute the production of some type of supportive financial support for people that can't afford medical care, but rather that bills like this which begin to attack the maldistribution problem, and which begin to attack the shortage problem, which began to attack the shortage of allied health manpower as well as medical practitioners, are important bills that should be introduced and passed on an emergency basis to begin to tool up for the demands that will come on us with universal health insurance.

Mr. Chairman, those essentially are the remarks going to this and I would like to make a personal comment or two on this bill.

Starting in 1963 and going through 1968, I was a commissioned officer in the Public Health Service, the regular corps, and intended to make my career for the next 20 to 30 years in the U.S. public service. I was very personally involved in a way on the other side of the things that the previous witnesses have been making their observations about from the outside, and I was on the receiving end of some of these changes and was in the position of judging, in terms of my own career, what the changes that were going on in the administration of the Department of Health, Education, and Welfare meant in terms of career development in the future for someone who intended to remain as a commissioned officer for a full career and obviously made a decision in 1968, that the future for a commissioned corps officer, as far as an individual who wanted to make a career, was not as good as it was in 1963.

to

The CHAIRMAN. Just a moment, if I may interrupt.

Has anything happened in the past 2 years that would indicate that this was going to get better?

you

Dr. KIMMEY. No, sir; it has not. I think perhaps it got a little worse. The CHAIRMAN. The public health has gotten worse?

Dr. KIMMEY. Well, the comment was made about what I call the politization of the health segment of the Health, Education, and Welfare Department, and the fact that in the reorganization plan in 1966 it put the Assistant Secretary of Health into a position, a policy position, and essentially relegated the Surgeon General to a position of assistance, but with no operating responsibility directly.

If we had created a line authority, a Secretary of Health, or an Under Secretary of Health in HEW, and had retained a career professional in charge of the operations of the health part of the Department, I think this would have been a step forward.

One could argue that the Public Health Service, as a professional corps, in the past has not been as responsive to some of the social currents in the country as it might have been. It had a professional job to do, to quarantine, and many other things that have been mentioned, and it did this job very well.

I don't think you could fault it for this. On the other hand, in the social climate of the early 1960's, medical care for a nonbeneficiary was not a part of the function of the Public Health Service, and we might have been deficient in those days in this issue.

So I think, as we saw, as these became political issues, a move was made to put a politically responsive individual into the line of authority and incidentally, other countries have done this and this works quite well. But I think the mistake we made is removing the Surgeon General from line authority over our health programs and our professional programs of the service, and putting in essentially a staff function for him.

Europeans have a minister of health and a policy similar to what I have just described, and the Surgeon General has urged a reconsideration in our setup, and the consideration of this kind of model, and we see good reason for the administration to have somebody who is a member of the administration, directly a member of the Cabinet, a department member, an individual who can look at the priorities of the problems of the country and can help set policy, but to keep an ongoing continuity of a line professional authority within the health structure of the Government.

Mr. Chairman, these are mixed personal and association comments. Thank you, sir.

The CHAIRMAN. I think they are very valuable. I wish you would write me a letter which I would ask to be printed in the record, a letter setting those comments out. I would like to get broader comments and then put those in the Congressional Record, and I might state that 45,000 copies are printed every day and they are not generally available in the streets as a tabloid, but they do go to the libraries of the Government and to the departments of the Government, so that everyone concerned can see if they desire, and so that everyone in the White House can see what the comments are, and the major libraries are able to put that material into relevant files so that people doing research in medical schools and different universities and different departments of medicine can see what is happening in medicine in America.

I think your contribution is very valuable, and I want to put it in the Record to give it a broader distribution than just this hearing. Dr. KIMMEY. With your permission, I would like to submit a copy of the editorial of the New England Journal of Medicine, and a copy of an article by Dr. Albert Snoke appearing in a journal of the American Public Health Association which deals with the problem in detail.

The CHAIRMAN. What is the circulation of the journal of the APHA?

Dr. KIMMEY. Well, I took this job about 3 weeks ago, and I have not gotten acquainted enough yet to get to the circulation.

The CHAIRMAN. All right, what is the circulation of the medical journal you mentioned?

Dr. KIMMEY. The New England Journal of Medicine is one of the major medical journals, and very widely circulated. This editorial appeared a few months ago and has been well received and has not yet been circulated in all libraries or throughout the administration. The CHAIRMAN. Well, I would like to review that, but the time here is getting short for this session, as you know.

Now you mentioned legislation on S. 4296 was introduced yesterday, and I concurred in the opinion of the author as far as an authorization of $45 million ending next June 30, when it goes up to $75 million.

Yet Senator Magnuson, in offering this bill, lends to it his great experience and great legislative expertise. I have watched him for 13 years. He was committee chairman when I came here, and, if you will note, this bill had a very modest beginning, only $5 million, and he mentioned the fact it is a mere pilot project level, but the principle is established.

So here you have a $5 million bill and in 3 years it is $15 million. Well, this totals up, as I get it by rapid mental calculation, to about $330 million in the other bill, and I am afraid that $330 million would be so heavy it would pull the $15 million under the surface with it.

Dr. KIMMEY. I mentioned that bill, possibly another approach to the broad problem, but certainly not as a kind of substitute for S. 4106, but I might add, in closing, that those of us who have been active in supporting health legislation, health administration, and so forth, have often referred to the 89th Congress as the "Health" Congress, there being a great volume of health legislation coming out of that Congress. I think the bills introduced in the last couple of months here in the 91st Congress would show that you are running for the title now.

The CHAIRMAN. Thank you very much for your excellent statement. Dr. KIMMEY. Thank you, Mr. Chairman.

The CHAIRMAN. The next witness is Mr. Bill Lucca, executive director of the Commissioned Officers Association of the U.S. Public Health Service.

Come around, please, Mr. Lucca.

STATEMENT OF WILLIAM J. LUCCA, EXECUTIVE DIRECTOR, COMMISSIONED OFFICERS ASSOCIATION OF THE U.S. PUBLIC HEALTH SERVICE

Mr. LUCCA. Thank you, Mr. Chairman.

My name is William J. Lucca, and I am executive director of the Commissioned Officers Association of the U.S. Public Health Service. I am, indeed, grateful to you, Mr. Chairman, and the members of this subcommittee, for giving the Commissioner Officers Association the opportunity to present their views on S. 4106, a bill which would establish a National Health Service Corps.

The Commissioned Officers Association of the U.S. Public Health Service represents approximately 4,600 members, which number includes 87 percent of the career active duty personnel of that Service. These members are physicians, dentists, scientists, engineers, pharmacists, nurses, veterinarians, dietitians, and others in the Commissioned Corps of the Public Health Service. The Corps is unique in that its entire personnel is derived exclusively from professions in which individuals are trained outside the service and qualified prior to commissioning.

The Commissioned Officers Association supports S. 4106 and recommends its enactment. We do, however, have some suggested changes which I will outline a little later in my statement.

The basic purposes of S. 4106, as we understand them, are:

1. To demonstrate how the quantity and quality of health care can be improved in areas deprived of that care at the present time;

2. To revitalize the Public Health Service and its Commissioned Corps by broadening its mission;

3. To satisfy the social motivation of young health professionals. The funding of $5 million annually for fiscal year 1971-72 and 1973 would necessarily limit the scope of the program and, in effect, make it a pilot or demonstration project.

Mr. Chairman, the present authorities under the Public Health Service Act now permit the use of employees both Corps and civil service-in carrying out demonstration projects such as kidney dialysis projects. Public Health Service professional personnel, including draft obligated officers, may be used in these projects. The establishment of the National Health Service Corps, however, would give stature and visibility to the program and emphasize the importance it deserves.

The Commissioned Officers Association believes that the enactment of this legislation would accomplish the following objectives:

1. It would provide care to groups now being deprived of adequate health services;

2. It would utilize PHS facilities more broadly and make their activities an integral part of the health resources of the communities in which they exist;

3. It would enhance the potential of additional people in health careers;

4. It would provide a laboratory for health delivery research;

5. It would provide an opportunity to effectively utilize ancillary health personnel;

6. It would broaden the mission of PHS and meet motivation of many young professionals thereby making more attractive, service ca

reers.

Mr. Chairman, we have several suggestions that we feel would strengthen the legislation and we recommend them for your, and your committee's, consideration:

1. The appointment of a Director by the President by and with the consent of the Senate appears unnecessary. This official, according to section 399j, is subject to the supervision and control of the Surgeon General. The appointment of the Director should, therefore, be the responsibility of the Surgeon General.

2. Provision should be made for coordinating this program with the Health Services and Mental Health Administration which has responsibility for direct care services and health service research.

3. Provision should be made for increased funding in fiscal year 1972 and 1973 for expansion of the program.

4. A substitute for the word "Corps" should be considered since this term could easily be confused with the present Commissioned Corps personnel system.

Mr. Chairman, there is a segment of the population that desperately needs direct health care and that is being inadequately served at the present time. The Commissioned Officers Association believes that the Public Health Service is the most logical agency to meet this need. We further believe that the dedication, the enthusiasm, and the expertise of Public Health Service commissioned officers make them the ideal professionals to be utilized for the delivery of health care to our underserved areas. The Commissioned Corps has a long and