been constructed under this program, I think it is very significant to point out again that those projects cost $6.64 billion, of which the Federal participation was only $2.11 billion; in other words, only around 30 percent. I think it shows very clearly, as we have seen in many of our grant programs, what the Federal dollar can do to assist, to stimulate, and assist the States and communities in developing their health facilities and their health programs when it is properly used. And I think it has been exceedingly well used in this program.

Senator YARBOROUGH. I think it is well that you have pointed that out, Doctor. The same incentive is provided for through many other Federal programs, as in the field of education and other things. It is surprising how much the States will do, as in this instance, putting up about twice as much money as the Federal Government.

Surgeon General TERRY. That is right.

Senator YARBOROUGH. Sometimes we find that under the accelerated public works program and in the area redevelopment program, that the States themselves could not quite raise the total amount and the contribution of the Federal Government in the form of a grant or a loan of 20, 25, 30, 35, or 50 percent is often the added margin that enables a county, or city, or other community to get the improvement that means so much improvement in the kind of living the people have in that area of the country.

The CHAIRMAN. Senator Pell, do you have any questions?

Senator PELL. No questions except to endorse the comments of my colleague from Texas about your leadership, Senator.

The CHAIRMAN. Thank you, sir. Thank you.

Do you have anything you would like to add, General?
Surgeon General TERRY. I think that is all, Mr. Chairman.

The CHAIRMAN. Dr. Graning, is there anything you would like to add?

Dr. GRANING. No, thank you, Mr. Chairman.

The CHAIRMAN. Mr. Burleigh?

Mr. BURLEIGH. No, sir. I am very happy, sir.

The CHAIRMAN. Gentlemen, we want to thank you. As I said, Doctor and General, you have made a very fine statement, and we certainly appreciate that very, very much.

Surgeon General TERRY. It is always a pleasure to appear before this committee, Mr. Chairman.

The CHAIRMAN. Thank you. If you are not in too big a hurry or have too much compulsion to get somewhere else, we would like to have you stay, at least one of you, and hear the rest of the testimony of the witnesses.

Surgeon General TERRY. Yes, sir.

The CHAIRMAN. At this point there will appear in the record the table to which I referred earlier that was prepared by the Legislative Service of the Library of Congress.

(The table referred to follows:)

Number of hospital service areas which have met 100 percent of need for general hospital beds 1

1 All figures are from the fiscal year 1964 revisions of the State hospital and medical facilities construction plans, unless otherwise noted.

These figures are for general private hospitals. Louisiana has also designated 8 general charity hospitals of which 5 have met 100 percent of bed need.

This figure is an estimate for the year 1968.

The CHAIRMAN. Now I see our colleague, Senator Hruska, has come in.

Senator, we are happy to have you here with us and would be very glad to have you proceed, sir.

STATEMENT OF HON. ROMAN L. HRUSKA, A U.S. SENATOR FROM THE STATE OF NEBRASKA; ACCOMPANIED BY REX STURM, LEGISLATIVE ASSISTANT

Senator HRUSKA. Thank you very much, Mr. Chairman. For some time now, my staff has been working with members of the subcommittee staff on an amendment about which I would like to speak a little bit this morning. It has to do with the various categories and the flexibility of transfer from one to another of these categories under certain circumstances.

First I would like to say, Mr. Chairman, that the Hill-Burton program has been very well received in Nebraska as well as in the entire Nation. For this reason the Department of Health in Nebraska is very eager to have this program continued.

The extension of this program has very wisely foreseen the diversified needs of future medical facilities and promoted construction in needed areas by providing categorical controls. This is a good step to insure responsible use of the funds provided under the program. I am also pleased to see that in both the House bill and the Senate bill certain flexible features are included to allow the States to tailor their construction program to the most urgently needed categories.

In anticipation of the extension of this program and in reviewing their future needs, the Department of Health of Nebraska, as well as a number of other States, have found that they need another kind of flexibility. Assuming that either the House-passed bill or the pending Senate bill has sufficient flexibility for transferring allotments between categories, there is still a need for allowing States to decide when they should use their funds in each of these categories.

As an example, in a State receiving a relatively small allotment under this program, when assisting a large construction project, adequate funds may not be available to keep the project moving at its most efficient and expeditious pace. Under either of the bills, the House-passed bill or the pending Senate bill, a State may merely hold its allotment in one category over until the next year and use the 2-year total for a large project, but this would not solve the problem.

The need in one category may be very great in 1 year and much less pressing in another category during that year, and yet adequate funds for the urgent need would not be available for, say, 2 years.

The result would be to give financial assistance while dragging our feet on the actual construction of the project. In the meantime, other funds would be pushing ahead projects in which the need had not fully matured.

The purpose of the amendment which I have proposed would be to extend a degree of time flexibility to the States, allowing them to construct their most needed facilities first during the life of this act. Basically, this amendment would allow States to use as much as necessary of the total allotment in any urgently needed category for the overall 5-year life of the act in any one of 2 years of

the life of the act simply by deferring the use of funds from other less needed categories. These less urgent needs could then be provided for in subsequent years. The net effect at the end of the 5 years would be unchanged since the average spent in each category would be the same as allowed under the pending provisions. In the meantime the needed facilities would have been in use years earlier.

This amendment provides for supervision of these transfers by the Surgeon General to carry through the control features. As a formula which avoids the necessity for some projects to be delayed, awaiting adequate assistance, it will prevent waste not only in terms of money but also from the standpoint of those needing the required facilities. It is felt that this amendment will help to more closely achieve the purposes of the Hill-Burton program by meeting the needs of the individual States while retaining the control and assistance of the Surgeon General, who is responsible to the Congress for the administration of these funds.

There are several States that have indicated their support of this amendment, primarily States where the allocation is rather limited, Mr. Chairman. In fact, in some of the letters from States, it is suggested that this amendment apply only to States having $2.5 million or less, where this problem is particularly acute. I do not know what the committee's thinking on that might be.

I would like to give one example of where this would really apply. One of the problems of Federal grants-in-aid to specific categories is that in order for a State to participate, they must build the specific type of facility, whether or not it is a first priority in that State.

For example, a State's principal problem may be to obtain mental retardation facilities, but when the Hill-Burton Act provides only a limited amount for such facilities, and a much larger sum for, say, general hospitals, the primary need of that State is not met in timely fashion. In other words, they would have to spread over several years the construction of the much-needed mental retardation facilities, and at the same time be building general hospital facilities which are not nearly as urgent at this particular time.

Now, we have no pride of authorship in the amendment. I would be just as anxious as any other Member of the Senate to see that there were proper safeguards there to achieve the ultimate spread of those funds among the categories. But it is simply that flexibility within that 5-year period that we would ask for this amendment.

The CHAIRMAN. Senator, of course, you recall the mental retardation and mental health act, that makes special provision for the construction of facilities for the mentally retarded?

Senator HRUSKA. Yes, I understand. It is a preferred category. The CHAIRMAN. Yes.

Senator HRUSKA. But that example could be extended to any one of the other categories, Mr. Chairman, and I would certainly ask the committee to take it under consideration to see if there would not be some merit in it from the standpoint of those small States where each of those pigeonholes is so small that they have to pass up the necessities of the moment and stretch them out. In many of these it really causes the shoe to pinch severely.

This could be overcome by the good judgment and discretion of the Surgeon General and the department of health in each respective State.

35-281 0-64——11

The

CHAIRMAN. Are there any more

Yarborough?

Senator YARBOROUGH. No questions.

questions? Senator

The CHAIRMAN. Do you have any more questions, Senator Pell? Senator PELL. No, Mr. Chairman.

The CHAIRMAN. Well, Senator, I certainly want to thank you very much for your statement. We assure you that we will consider it carefully, sir.

Senator HRUSKA. I believe the subcommittee staff has the amendment and the other supporting papers. But if there is anything further you need, we would be happy to supply it.

The CHAIRMAN. Do you want the amendment printed in the record, Senator?

Senator HRUSKA. Yes, sir.

The CHAIRMAN. Fine. We will be very happy to put it in the record.

(The document referred to follows:)

AMENDMENT INTENDED TO BE PROPOSED BY MR. HRUSKA TO H.R. 10041

An act to improve the public health through revising, consolidating, and improving the hospital and other medical facilities provisions of the Public Health Service Act, viz: On page 12, between lines 12 and 13, insert the following:

"(g) (1) In addition to the amounts, if any, which a State is authorized under subsection (e) to have transferred from one allotment of such State under subparagraph (1) or (2) of subsection (a) to another such allotment, any State shall, upon request to the Surgeon General, be entitled to have such amounts as it may specify transferred from one such allotment to another such allotment, if such request is accompanied by a certification of the State agency of such State that a transfer of the amounts made in accordance with such request will more effectively serve the needs of the people of such State than if such transfer were not made.

"(2) Transfers under paragraph (1) to any allotment of a State under subparagraph (1) or (2) of subsection (a) shall be made only to the extent that the aggregate, for the period beginning with the fiscal year ending June 30, 1965, and ending June 30, 1969, of the amounts of such allotment plus all amounts transferred thereto under paragraph (1) and subsection (e) does not exceed the aggregate, for such period, of the amounts which would, without regard to the provisions of paragraph (1) and of subsection (e), have been available for such allotment for such period. The Surgeon General, in applying the provisions of the preceding sentence to any allotment of a State, shall assume that, with respect to any future fiscal year within such a period, there will be appropriated the maximum amount authorized in this part for such year for purposes of making allotments of the type of such allotment and that there will be no change in the population of such State or in the allotment percentage of such State.

The CHAIRMAN. Thank you again for your statement, sir. Now, Mr. Williamson of the American Hospital Association. You have been with us many times in the past, Mr. Williamson. We are happy to have you here, and we welcome you back, sir. Mr. WILLIAMSON. Thank you, sir.

STATEMENT OF KENNETH WILLIAMSON, ASSOCIATE DIRECTOR, AMERICAN HOSPITAL ASSOCIATION, WASHINGTON, D.C.

Mr. WILLIAMSON. On behalf of the American Hospital Association, I would first wish to express our appreciation for the opportunity to discuss with you the operation and accomplishments of the Hospital Survey and Construction Act and our views with respect to the Hos