STATEMENT OF DR. DAVID B. ALLMAN, MEMBER OF THE BOARD OF TRUSTEES AND CHAIRMAN OF THE COMMITTEE ON LEGISLA TION OF THE AMERICAN MEDICAL ASSOCIATION, ACCOMPANIED BY JOHN M. MARTIN, JR., LEGAL COUNSEL, AMERICAN MEDICAL ASSOCIATION

Dr. ALLMAN. I am Dr. David B. Allman, of Atlantic City, N. J.. and I have with me one of our legal counsel from the Chicago office, Mr. Martin.

Senator PURTELL. We are glad to have you with us, Mr. Martin. Dr. ALLMAN. I am engaged in the practice of medicine in Alantic City, N. J.

I am a member of the board of trustees and chairman of the committee on legislation of the American Medical Association, and am appearing here today as a representative of that association to testify on four specific bills which are pending before your committee.

Before discussing these measures, however, I should like to express the appreciation of myself, personally, and on behalf of the America Medical Association for the opportunity to appear and present our views.

In general, we agree with the stated purposes of these proposals, but we believe that considerable more study is necessary in determining the most desirable ways to accomplish these objectives. In this connec tion, I can assure you that our association is willing to assist, in any way possible, in devising sound approaches to the solution of the problems involved.

I shall proceed, Mr. Chairman, to a discussion of the specific proposals under consideration, beginning with S. 2778, the bill which would amend the Public Health Act, as amended, so as to extend and improve public-health services and to provide for a better use of Federal funds.

The American Medical Association, which has always promoted State and local health services, approves this purpose, and approve S. 2778 generally, although it has reservations as to the effect and the form of certain of its provisions.

For many years, our association has counseled with individuals and with various agencies of the Government relative to State and local public-health matters, and has consistently advocated greater responsibility and discretion at the local level in planning for and in solving public-health problems.

At the present time, section 314 of the Public Health Service Act authorizes separate appropriations for grants-in-aid to the States in connection with certain specifically enumerated diseases, such as tuberculosis, veneral disease, cancer, mental disease, and heart disease, as well as funds for public health services generally.

S. 2778 would, if enacted, authorize in lieu of the present "categori cal grants" three new types of grants for: (1) public health services in general: (2) extension and improvement of public health services: ard (3) unique projects.

We recommend that the extension and improvement or type 2 grants be eliminated from the bill as a separate category and that funds to be used for this purpose be considered an integral part of the basic or type 1 grant. Under such an arrangement, the decision with respect to the

extension and improvement of public health services would be the initial responsibility of the State health officer concerned and would be included by him in the plans submitted to the Surgeon General of the United States Public Health Service for approval.

It is noted with respect to type 3 grants that they may be made to "States and to public and other nonprofit organizations and agencies." In the context in which the term is used, and in view of the apparently unlimited authority of the Surgeon General with regard to the type 3 grants, this language should be clarified.

It also appears that there is little, if any, limitation on the authority of the Surgeon General with respect to the issuance of regulations and the allocation of money available for type 3 grants, since he is not required to seek the advice of State health authorities prior to issuing such regulations or allocating available money. The extent to which the authority of the Surgeon General in this respect can and should be limited, in view of the types of grants involved, we believe warrants additional consideration. We believe the Surgeon General should be required to consult with the appropriate State health authorities or an advisory council with respect to projects to be financed through type 3 grants.

Senator PURTELL. Doctor, do you have recommendations here for changes-not these general recommendations, but specific recommendations, embodied in your testimony?

Dr. ALLMAN. Yes, sir. They appear about the middle of the next page, sir.

Senator PURTELL. Thank you.

Dr. ALLMAN. One of the key provisions, in terms of the overall impact of this proposal on present programs and on the scope and effect of he new legislation is that which appears on page 2, as follows:

The portion of such sums which shall be available for each of such three types of grants shall be specified in the act appropriating such sums.

The extent to which this matter could or should be determined in advance of annual appropriations should be further explored.

We believe that only a small percentage of the funds appropriated should be allocated to other than type 1 grants.

Finally, in connection with this and other bills concerning grants-inaid to the States, it appears appropriate to invite the committee's attention to the scope of the duties assigned to the Commission on Intergovernmental Relations, which was created during the 1st session of the 83d Congress, and the desirability of having the benefit of its findings and recommendations in this highly important field prior to extensive legislation changing present public health grant-in-aid policies and requirements.

To sum up, the American Medical Association approves S. 2778 with the following recommended amendments:

(1) Type 1 and type 2 grants should be lumped together in a single

category.

Senator PURTELL. In other words, Doctor, you want no category No. 2 at all?

Dr. ALLMAN. That is correct, sir.

Senator PURTELL. Regardless of the amount assigned to it or the formula that might be employed?

Dr. ALLMAN. That is right. The purposes in type 2 can be carried out in type 1. We don't object to the purposes, and so on, but we think it should be all under the type 1 grant.

(2) The purpose and terms used in connection with type 3 grants should be more clearly defined;

(3) The Surgeon General should be required to consult with State health authorities or an advisory committee in connection with type 3 grants; and

(4) This legislation should spell out the proportion of the total Federal funds appropriated to be used on each type of grant with only a small percentage allocated to other than type 1 grants.

In other words, our position is that the type 1 grant is the important grant.

The type 3 grant will be used by the Attorney General and, in the opinion of some of us, is already covered by section 301.

Senator PURTELL. You wish to change that, do you not?

You don't mean the Attorney General; you mean the Surgeon General?

Dr. ALLMAN. Yes.

Mr. MARTIN. The Surgeon General.

Dr. ALLMAN. Thank you.

Senator PURTELL. We hope the Attorney General will not be in on this thing.

Dr. ALLMAN. Now, the next bill which I shall discuss is S. 2758. which proposes to amend the Hospital Survey and Construction Act, as amended, so as to provide assistance to the States in surveying the need for, and in constructing diagnostic or treatment centers, hospitals for the chronically ill, rehabilitation facilities, and nursing homes. When the Hospital Survey and Construction Act, familiarly known as the Hill-Burton Act, was before the 79th Congress, it was studied very carefully by the house of delegates, the board of trustees and by several councils of the American Medical Association. As a result of such study, the intent and purposes of the legislation received our approval. The association has continued to support the law since its enactment.

We are gratified to note that since the approval of the first project in fiscal year 1948, approximately 50,000 hospital beds have been constructed under this program. In addition, approximately 45,000 hospital beds are now under construction. Apparently rapid progress has been made; projects have been allocated for areas where they are most needed and are being put into service with commendable promptness.

There are certain differences in the House and Senate version of this proposal which we consider to be important. For example, the House bill, H. R. 8149, contains a declration of purpose, similar to that contained in the original Hill-Burton Act, while S. 2758 does not. We consider it desirable to reaffirm the original intent of the act, and. therefore, favor the inclusion of a restatement of the purpose as contained in H. R. 8149.

It should be observed that the purpose of the original act was that facilities constructed pursuant to its provisions should be available to all the people of a State, the entire community, rather than just to one particular segment of the population. The declaration of purpose

contained in H. R. 8149 conforms to the original declaration in this respect.

We also consider it important that it be made clear in the purpose section whether it is the intention of the bill to establish priorities in construction of facilities as between those covered in the bill and those covered in the existing Hospital Survey and Construction Act, since there appears to be a duplication of authorization with regard to certain of the named facilities.

It is our view that facilities for the chronically ill and impaired should be part of or near a conventional hospital. S. 2758 does not include such a requirement; H. R. 8149 does include such a requirement, as an alternative, as part of the definition of diagnostic or treatment center, rehabilitation facility, and nursing home, but not in connection with hospitals for the chronically ill and impaired. It is recommended that such a requirement be added.

More important than these differences in the bill, however, are certain considerations which go to the fundamentals of the proposal. It appears from the language of the pending bills that the proposed extension of Federal assistance to the States in connection with the construction of medical facilities other than hospitals will be experimental in nature. However, even considered in that light, the definitions of diagnostic or treatment centers, rehabilitation facilities, and nursing homes contained in each of the bills are too general in nature. In particular, the definition of diagnostic and treatment centers is vague and ambiguous. It is not clear whether a diagnostic or treatment center will include an individual physician's office, a group clinic operated by physicians, or any hospital.

How will the inventory be made by the States under vague terminology of this type?

We consider the language of this part of the bill to be an unwise amendment to an act which has been highly successful to date.

Also, neither S. 2758 nor H. R. 8149 includes a comprehensive definition of the term "hospital for the chronically ill and impaired,' except that it is stated the term shall not include any hospital primarily for the care and treatment of mentally ill or tuberculous patients.

The committee report accompanying the House bill, House Report No. 1268 of the 83d Congress, states on page 14 that the House bill "proposes no change" in the definition of "hospital" appearing in section 631 (e) of the Public Health Service Act, which states:

(e) the term "hospital" (except as used in section 622 (a) and (b) includes health centers and general, tuberculosis, mental, chronic disease, and other types of hospitals, and related facilities, such as laboratories, outpatient departments, nurses' home and training facilities, and central service facilities operated in connection with hospitals, but does not include any hospital furnishing primarily domiciliary care;

It

While it may be assumed that this is also the intention of the Senate bill, it is a matter which should be clarified prior to passage. appears to us that the above-quoted definition clearly includes hospitals for the chronically ill. If so, the question naturally arises as to the necessity for including this category in the proposed amendment, unless it is to establish a priority for such facilities. If this is the purpose, it should be so stated.

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To summarize, we approve this proposal subject to the following amendments and recommendations:

(1) That a purpose section be included and that such section be clearly written, particularly with regard to the possible matter of priorities; and

(2) That the terms used in the bill be defined more clearly, and that the relationship of such facilities to conventional hospitals be specified.

The next bill, S. 2759, proposes an amendment to the Vocational Rehabilitation Act. On this bill, Mr. Chairman, we are not prepared to take a definite position. We have considered the proposal generally; however, we have not received a sufficiently clear explanation of the measure to permit the formulation of a final opinion on the bill. While it may well be desirable to amend certain provisions of the Vocational Rehabilitation Act in order to facilitate improved administration, we consider that this bill goes beyond the correction of technical administrative provisions. Further, while it may be appealing to streamline statutory phraseology by dividing all types of grantsin-aid to the States in the health field into three categories, we see no need for making artificial groupings just for the sake of that type of streamlining.

Beyond these general observations, Mr. Chairman, we take no posi tion on the proposal at this time.

Senator PURTELL. Is it your intention perhaps to express an opinion later as an organization?

You say "at this time."

Dr. ALLMAN. We attempted to get all the information we could and, if I may, I would like to make a statement off the record. Senator PURTELL. All right.

(Off the record.)

Dr. ALLMAN. The next and last bill to be discussed is the reinsurance proposal, S. 3114. On March 31 a joint meeting of our committee on legislation and executive committee of the board of trustees of the association met to formulate a position on this bill.

As in the case of two of the proposals already discussed, the Amer ican Medical Association is in complete accord with the stated purpose of S. 3114, which is to promote the best possible medical care on reasonable terms. Our association has for many years adhered to a policy which parallels this purpose and has long been in agreement that the most feasible method of accomplishing this result for most of the people is through voluntary health insurance.

While it is reassuring to the medical profession to find that the official position of the Government is one of trust and confidence in the ability of private initiative to solve existing problems in the field of medical care, it is questionable whether the mechanism suggested in S. 3114 is essential, and whether it will, in fact, accomplish the desired results.

In determining its essentiality we believe that it is necessary to give full and complete consideration to the tremendous strides which voluntary health insurance has made in this country and the simultaneous improvement in benefits provided to meet the desire of the public for more adequate protection. The expansion of coverage and the improvement of benefits to cushion the economic shock of hospital.