1. EXPANSION OF PUBLIC HEALTH SERVICES AND ORGANIZATION

Through legislation enacted since 1935, the public health services of the Nation have been immensely improved. I refer particularly to the provisions of titles V and VI of the Social Security Act, the Venereal Disease Control Act, the National Cancer Institute Act, the Public Health Service Act of 1944, with its tuberculosis-control provisions, and in 1946 the Mental Health Act and the Hospital Survey and Construction Act. The several programs have materially advanced the health of our people.

There remains, however, a great need for extending and strengthening the local health units which are the foundation of our total health structure. For this purpose further Federal aid is needed. Over 1,000 counties-one-third of the counties of the Nation, and most of them rural counties-are without the benefits of full-time public health services.

In terms of life and health, this means that thousands of deaths and thousands of disabilities which occur today are preventable. If we are to reduce illness to a minimum, lessen the present burden of sickness care, prevent disease before it starts, build a more fit race, we must extend public-health services into all areas now without these services and intensify them everywhere. This weakness and even lack of local health structure already has proved a serious deterrent to the full effectiveness of the recently inaugurated mental-health and cancer-control programs.

Senator SMITH. I may say I agree with you fully in these paragraphs. I think that that is a recognized practical field which we can move toward, can move forward in, but it is this larger question of over-all health insurance which is the troublesome one.

Dr. PARRAN. I agree, Senator, and Congress has been generous in the authorization of funds, but we are nearly up to the ceiling in the amount of funds authorized under present laws.

2. CONSTRUCTION OF HOSPITALS AND HEALTH CENTERS

The Hospital Survey and Construction Act enunciates a national policy to deal with this sector of our total health problem. It represents a comprehensive approach to the provision of hospitals and related facilities. The current hospital survey and construction program has its limitations and imperfections. Further development and extension, probably along the lines of title III of S. 1320, undoubtedly will be required. I believe, however, that since it is so late in the present session amendments could well be deferred for another year so that we may gain more experience with the present terms of the Hospital Act.

3. EDUCATION OF PROFESSIONAL PERSONNEL

Present and prospective shortages of well-trained medical and related personnel pose an urgent problem demanding immediate attention. I view this as the greatest obstacle to improving the Nation's health. There are serious shortages in all categories of health workers today, aggravated by a serious maldistribution favoring the urban centers. Even the most conservative estimates indicate that these 64431-48-pt. 3-9

current shortages will become progressively more acute. These estimates are based upon present demands and do not take into consideration the added service which would be required by either S. 545 or S. 1320.

4. EXTENSION OF RESEARCH

In the field of research there has been considerable progress in recent years. Enactment of Public Law 410 by the Seventy-eighth Congress gave to the Public Health Service broad authority for research into the prevention, cause, and cure of the diseases of man. This legislation has been strengthened by the research provisions in regard to mental health and cancer control. With the additional legislation now pending before Congress, especially the bill to establish a National Science Foundation, the Federal Government will have created an adequate statutory basis for a strong, integrated program of research within and outside of Government which is essential to the advancement of national health.

5. ENVIRONMENTAL SANITATION

While great advances have been made in recent decades toward overcoming environmental health hazards, we are still far from the goal of providing a sanitary environment for all our people. One major sanitation hazard in early need of attention is the extent of pollution of our streams and waterways. Legislation sponsored by Senators Taft and Barkley and comparable bills in the House directed toward this specific problem is now being considered by the Congress. A further extension of Federal aid as contemplated by these bills is necessary if we are to round out this important element of our national health program.

6. IMPLEMENTATION OF A MEDICAL-CARE PROGRAM

Over many years, governments have assumed increasing responsibility for providing medical care for specific diseases and for specific groups within the population. Since Elizabethan times, AngloSaxon societies have accepted some degree of responsibility for the sick poor. In more recent years, care of the mentally ill and of the tuberculous has been recognized as a public function. Diagnosis and treatment for venereal disease is now offered in programs operated cooperatively by the Federal and State Governments. In addition, medical care is provided veterans and other categories of Federal beneficiaries at Federal expense.

Except for such groups, however, there is as yet no Nation-wide program to aid in providing adequate personal health services. This is a conspicuous weakness in our total health program. There is general agreement that a solution to this problem is fundamental to the health of the Nation. There is similar agreement that the cost of adequate medical care is beyond the means of a large proportion of the sick and disabled.

This brief review of our present situation, I believe, highlights three areas of urgent need: First, there is a lack of public health services in many parts of the country and particularly in our rural regions; second, there are not enough physicians, dentists, nurses,

and other health personnel; third, there is a substantial part of our population which does not receive adequate medical care. The Congress, in my view, should direct its attention simultaneously to these three areas.

The success of a medical-care program, whether as contemplated in S. 1320 or in S. 545, will depend in large part on a strong local health organization. It is axiomatic that the preventive and curative aspects of medical care are inseparable. The relationship between the provision of medical care and adequate numbers of health personnel is obvious. If more people are to get more medical care, we shall need more doctors, dentists, and nurses to give this care.

I should like now to turn to the legislative steps which I believe should be taken to meet these three needs.

The

(1) We should ensure adequate health services in every community. This can be accomplished by increasing the amounts of Federal grants to States and by weighting the aid in proportion to the need, with special consideration for rural areas. The pattern of Federal-State-local cooperation already is well established. current methods of granting aid to the States furnish a sound basis. The statutory foundation for necessary expansion of public health services could be provided by amending the provisions of section 314 (c) of the Public Health Service Act of 1944 along the lines indicated in title III (A) of S. 1320.

(2) We should develop a national program of aid for the training of health personnel. Such aid probably will be needed both by institutions and individuals. As a first step in developing such a program, detailed surveys should be made-State by State. The Public Health Service, with the assistance of a competent advisory group broadly representative of the public, the professions, and the educational institutions, would be prepared to cooperate in such surveys, analyze, and appraise the findings, and submit specific recommendations to the Congress.

The Public Health Service already has begun studies of this problem. These studies are being undertaken jointly with the appropriate Council of the American Medical Association. In addition, we have had informal discussions with the dental profession. Also, as a result of our wartime experience in nurse education, we are continuing to consult with the nursing, hospital and educational groups concerned with nurse training with a view to developing a satisfactory program for the future.

The Congress could facilitate a definite program for professional education and training in the health sciences through a relatively modest appropriation to meet the Federal share of the cost of surveys conferences and reports. A statement of the interest of this committee in such studies and reports would be helpful as a basis for submitting an appropriation estimate.

(3) At least a start should be made in providing funds through taxation insurance or both toward the goal of making available adequate medical care for all the people. S. 545 represents a modest approach toward this goal, S. 1320 a comprehensive approach. The choice of approach is a matter for Congress to determine; but 1, for one, believe there should be no undue delay in the full attainment of this goal.

If the Congress elects initially to provide only a limited approach to a medical-care program, most of the concepts of title II of S. 545, which would create a new title VII in the Public Health Service Act, seem to me to be sound, with some modifications which I shall specify.

State surveys as contemplated in S. 545 obviously are necessary. Their usefulness would be enhanced, if they were to include the three areas in which I have recommended simultaneous action and if they were directed also toward the determination on a State basis of the relative urgency of need.

A limited program should attempt to meet first needs first. In some cases, incomes may not be the most reliable index of urgent need. There are many areas in our country, particularly rural areas, where few, regardless of incomes, have ready access to adequate medical care. Likewise in some serious illnesses, including the chronic diseases, the cost of adequate care is prohibitive even to persons in the middle- or higher-income brackets. Also, the most effective way to attack our dental health problem may be to concentrate on dental care for children. In this case, age provides a better index of priority than income. Any Federal legislation should make it clear that each State would be permitted to develop a health program more comprehensive than the minimum required and to operate it in a single administrative pattern, using its share of the Federal grant in any appropriate way. Obviously, it would add to the complexity and cost of administration to have one program for persons of low income and another for other

persons.

S. 545 very wisely assigns primary responsibility for the administration of the program to the State and local governments. As I have already indicated, I believe that Federal legislation should give the States even wider latitude on program content, subject to minimum Federal standards. I agree with the New York Academy of Medicine that enabling legislation should clearly authorize and promote the provision of comprehensive, as opposed to limited, medical-care services.

The authors of S. 545 have repeatedly emphasized that one of its principal objectives is to establish 48 "State laboratories" for practical experimentation in new and improved methods of providing or assuring medical-care services to all our people. I should like to suggest three important areas of fruitful exploration:

(1) Further experimentation is needed in new and improved methods of making high-quality medical care available in a more efficient and economical manner. I should like to endorse the emphasis which the New York Academy of Medicine has placed on the organization of group practice and special diagnostic centers. This was one of the two principal recommendations of the Committee on the Costs of Medical Care, under the chairmanship of Dr. Ray Lyman Wilbur, distinguished Secretary of the Interior under President Hoover, past president of the American Medical Association, and chancelor of Leland Stanford University. The other was for voluntary health

insurance.

Senator DONNELL. May I interrupt there?
Dr. PARRAN. Yes, sir.

Senator DONNELL. You say this:

I should like to endorse the emphasis which the New York Academy of Medicine has placed on the organization of group practice and special diagnostic centers.

Do you likewise endorse the last sentence appearing on page 11 of your mimeographed paper? Do you endorse the New York Academy of Medicine's recommendation?

Dr. PARRAN. The other recommendation was made by Dr. Wilbur. I was fully in accord with the recommendations of the committee when the recommendation was made.

Perhaps I can clarify my position by saying I am not a person who believes in all or nothing. I believe sooner or later we shall need a system of health insurance and taxation, or a combination of both.

The ways we attain that goal are something for Congress to determine. I am sure from experience that voluntary prepaid medical care would be a step in the direction of the total goal I have stated. Senator SMITHI. You think from your observation those voluntary plans have been reasonably successful-the Blue Cross?

Dr. PARRAN. The Blue Cross particularly, and the Blue Shield. Senator SMITH. I just wonder whether your over-all feeling is they have done good work in that field?

Dr. PARRAN. I think it was a great forward step, Mr. Chairman, when the medical profession finally, after years of opposition, endorsed the principle of the voluntary health insurance.

I think all of the experience we can gain will be of value to Congress and to the people in charting a future course.

(2) We need to learn better how to coordinate the activities of medical research and teaching institutions with the administration of medical care services, in order to improve standards through leadership in this dynamic science.

(3) I believe the bill should contain some specific provision for reviewing and evaluating State experience with various methods of providing medical care and for making results of such an evaluation available to all of the States.

It would be well if the bill clearly authorized experimentation along these three lines.

S. 545 wisely recognizes the need for some equalization in the allocation of funds among the States. I would suggest also that provision be made for a variable matching ratio to enable the poorest States to raise the necessary matching funds. Again, I would emphasize special consideration of the needs of disadvantaged rural areas.

While the $200,000,000 annual appropriation authorized for the financing of this program would, together with State funds, permit a substantial program to be inaugurated, there can be little doubt that this amount would need to be increased once the program is under way. I would, therefore, prefer to see the bill authorize increased appropriations after the first year or two of operation.

Senator SMITH. I think the authors of the bill-that is, S. 545-I for one, thought we would feel our way and get a lot of information during that period to determine whether that was a sound program. Dr. PARRAN. Yes; my statement says "after the first year or two." I would agree to changing the language to "after the first few years of operation.

Senator SMITH. I thought we could test it and see how much further we could go.

DR. PARRAN. Yes, sir.

The promotion of health and treatment of disease are integral parts of one problem. It is the total health of a single individual, the total