The National Health Service Corps provides primary health care services to remote, rural, and overcrowded inner-city areas designated by the Department of Health, Education and Welfare as having critical health manpower shortages. This program is a relatively new one, but, I must add, a most worthwhile one thanks to the efforts of Senator Magnuson. At present, the National Health Service Corps has only 152 doctors, 20 dentists, and 116 other health personnel. Both of these corps are extremely important in providing our Nation with the additional health care it so desperately needs.

To illustrate this real need for more health care in the United States, there are 132 counties in this country which have no physicians and 225 counties with no dentists. Dr. H. McDonald Rimple, Director of the National Health Service Corps, stated in a May 24 press release of the Health Services and Mental Health Administration that there are approximately 5,000 communities without any health care services. As of May 24, only 122 communities had been designated as critical health manpower shortage areas.

My own State of Alaska is the only State which, in its entirety, has been given this classification. Although the national average ratio of non-Federal doctors to patients is 166 per 100,000, and New York State has a ratio of 193 per 100,000, Alaska has only 64 non-Federal doctors for every 100,000 people. Obviously, this is an unbearable load on any doctor, as well as an indication that many Alaskans are receiving a very minimum, if any, medical aid.

Most of the health care service to rural areas in my State is provided not by private physicians but by the Indian Health Service. In the State of Alaska, the IHS provides 68 physicians and 30 dentists. Sixty-two of the physicians and all 30 of the dentists are in the commissioned corps. Even with these Federal health service officials, Alaska is in dire need of additional health professionals. I cannot impress upon you enough the importance of the Indian Health Service to the people of my State. My amendment will contribute to assuring the continued availability of health personnel to the Indian Health Service which is imperative if Indian and Native people, not only in Alaska but throughout the United States, are to receive the delivery of essential comprehensive health services.

Realizing the importance of the Public Health Service and National Health Service Corps to the people of our Nation, I believe it is imperative that we do everything we can to assure its survival and flourishment. The most critical problem facing the PHS and NHS Corps today is the recruitment of qualified health personnel. The major cause of this problem is the reliance of the corps on the draft as a recruitment incentive. Since the Selective Service Act of 1949 provided that service in the Public Health Service Corps would fulfill the draft obligation, the corps has depended almost exclusively on this provision for recruitment. Approximately 99 percent of the physicians and 96 percent of all officers being recruited into the corps today are recruited through the use of this draft mechanism. With this dependence on the draft as a recruitment incentive, the voluntary recruitment machinery of the corps has drastically degenerated.

With the trend toward the abolishment of the draft to create an All-Volunteer Army, the corps is in serious trouble. One of the findings of the 1971 Report of the Secretary's Committee to Study the

Public Health Service Commissioned Corps, states that, "The recruitment and retention of physicians and dentists will constitute the critical problem following the end of using the draft mechanism, and plans to meet this problem must be developed."

My amendment will help alleviate this problem by offering a positive incentive to serve in the corps instead of relying almost totally on the negative incentive of the draft. An incentive such as this scholarship is most definitely needed to attract young men and women to HEW programs which service areas with a dire need for health services. It is quite obvious that the longrun needs of the Department of Health, Education, and Welfare's programs will be better served by such positive incentives for recruitment rather than by the negative incentives involved in the draft.

The corps not only needs new, positive recruitment incentives, but they must also have incentives which allow the corps to adequately compete with the Armed Forces. All branches of the Armed Forces have effective scholarship programs comparable to this one I am proposing and are planning to expand their present programs. H.R. 2, which has been passed by both the House of Representatives and the Senate, would increase the number of scholarships to 5,000 per year. We must make certain that the PHS and NHS Corps can also attract young men and women with a scholarship program which is as attractive to them as the programs now offered by the armed services. Another factor which could drastically affect the recruitment ability of the corps, if the draft is not abolished, is the possible elimination of undergraduate student deferments. With the elimination of this deferment, students entering college will either have completed their obligated service or have had their maximum exposure to the draft under the lottery system long before they enter medical or dental school. Either way, avoidance of the draft will no longer be an incentive for young men to join the PHS or NHS Corps. Thus, even if the draft were continued beyond the July 1, 1973, cutoff, the use of it to obtain health personnel will gradually phase out over a period of years.

The time to act on this recruitment problem is now, before it becomes too critical to correct and before one of our most valued governmental services is lost. By enacting this scholarship program now, we will begin to build in the incentives urgently needed to maintain the corps and will work toward avoiding a last-minute personnel manpower crisis when and if we abolish the draft.

But regardless of this motivation, I also believe this is good legislation in its own right for today's situation. It gives the PHS and the NHS Corps a strong scholarship recruitment vehicle such as the military has had for years. The Department of Health, Education, and Welfare's programs provide health care for some of our most needy areas through the Public Health Service and National Health Service Corps and are, I believe, extremely important to the health system of our Nation. They need and deserve a recruitment program of the highest caliber to attract our citizens who wish to enter the health field, through their ranks, so these important health delivery programs of HEW will be adequately staffed and well operated.

I understand, Mr. Chairman, that S. 3858, which you recently introduced, already has a scholarship program in it. I would like to

point out a few of the differences between this bill and the one which I introduced. One major difference between the two proposals is in the payback time required of an individual. S. 3858, requires only 6 months of active duty service in the corps for each year of academic training received. I admit that this lesser amount of required service time would be an added incentive, but I also believe that this is not a long enough period for the needs of HEW's programs. My amendment would increase the amount of time the health professional would be spending in the community in which he is serving. The impact on the community would be that of increasing quality care by extending the continuity of the relationship between the patient and the health professionals. Many areas that are services by the PHS and NHS Corps have a culture and a way of life totally different than what most of us are accustomed to. The Indian Health Service and Public Health Service facilities in my State are a prime example of this. It is very important that an individual remains in one area long enough to grow accustomed to the people he is serving.

A second major difference between the two scholarship programs is the amount of money provided each student. As I stated earlier, my amendment provides tuition, salary, and all educational expenses, whereas S. 3858, sets a maximum of $5,000 per year. I feel that offering not only tuition and educational supplies but also a regular salary opens this scholarship program up to any individual regardless of income level. A lower income student could readily take advantage of the program offered by my amendemnt but would have dificulty affording additional expenses not covered by the other programs. One benefit of attracting lower income individuals is that they are more likely to return to the areas they came from to practice and more likely to remain there on a permanent basis. A recent American Medical Association survey revealed that 49 percent of the physicians raised in small towns were practicing in communities of 2,500 or less. Since a majority of the health manpower shortage areas, approximately 80 percent, are rural, attracting rural, lower income individuals into this program-who would be more likely to remain in the area— would have a lasting effect on the Public Health Service and National Health Service Corps.

The Public Health Service and National Health Service Corps definitely need a strong scholarship program with positive incentives. They have relied in the past on the draft as an incentive but will very likely have to depend on positive incentives such as this program in the near future. The corps needs a scholarship program that is at least as good as that offered by the Armed Forces so it may compete for doctors, dentists, and other health professionals. Considering the vital services provided by the Department of Health, Education, and Welfare, I firmly believe that they are entitled to a recruitment program which is as strong and comprehensive as that of the military. My amendment would provide just such a scholarship program.

Senator KENNEDY. Thank you, Senator, for your most informative statement.

We are pleased to welcome as our next witnesses Dr. Merlin K. DuVal, Assistant Secretary for Health and Scientific Affairs, accompanied by Dr. Vernon E. Wilson, Administrator, HSMHA, and Dr. H. MacDonald Rimple, Director, National Health Service Corps.

STATEMENT OF MERLIN K. DuVAL, M.D., ASSISTANT SECRETARY FOR HEALTH AND SCIENTIFIC AFFAIRS, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; ACCOMPANIED BY DR. VERNON E. WILSON, ADMINISTRATOR, HSMHA, AND DR. H MacDONALD RIMPLE, DIRECTOR, NATIONAL HEALTH SERVICE CORPS

Dr. DUVAL. Mr. Chairman and members of the subcommittee.

It is a pleasure for me to be here today and discuss with you the program of National Health Service Corps and S. 3858, a bill to amend and extend section 329 of the PHS Act.

The concept of meeting the health needs of residents of areas critically short of health personnel through the provision of direct Federal medical services has been debated as far back as the 1930's.

The majority of heavily populated and economically secure areas of America have adequate access to medical services. However, there are segments of the American population, especially those who live in rural and inner-city urban areas, who receive little or inadequate medical

care.

To help meet this problem, on December 31, 1970, the President signed the Emergency Health Personnel Act of 1970, Public Law 91-623.

In his health message of February 18, 1972, the President indicated that meeting the special needs of scarcity areas was a key objective of his six point health program and that a National Health Service Corps would be mobilized to provide health professionals to critical manpower shortage areas.

For the fiscal year 1972, the administration requested $10 million to staff the corps with doctors, nurses, dentists, and other allied health professionals who would provide Federal medical personnel on a temporary basis to alleviate the crisis in some of these areas.

In mid-June 1971, the National Health Service Corps was created as a distinct program within the Health Services and Mental Health Administration.

Regulations and guidelines which were circulated to a large number of groups and individuals outside DHEW for comment prior to final preparation, were published on December 16, 1971.

Also during this period, selections were being made and confirmed for the National Advisory Council required by the act.

The first corps members were assigned to and deployed in medically underserved areas in January of 1972.

To date, the corps has selected 143 communities to receive corps assignees. And 407 PHS personnel have been or will be assigned to staff these 143 communities; 30 communities are located in urban and 113 in rural areas.

Of these 407 positions, 223 have been allocated for physicians, 34 for dentists, 86 for RN's, and 64 for other allied health professionals. As of August 1, the approximate number of personnel in the field providing services will total 210; of these 159 are physicians, 10 dentists, 28 RN's, and four allied health personnel. The remaining personnel are being recruited and will be assigned as soon as possible. The National Health Service Corps receives applications from

communities requesting medical personnel. If the Administrator of the Health Services and Mental Health Administration approves these communities, the previously recruited personnel are assigned to these communities.

Section 329 of the PHS Act, the operational authority for the corps, provides that the need for services in a given area must be certified to by the State and district medical, or dental, or other appropriate health societies, as well as the local government.

Besides the certification process, recommendations are obtained from State and area wide comprehensive health planning agencies. The procedure for implementing this requirement has been to obtain the signoff by the appropriate society representatives to an application submitted to the corps. This procedure has worked well in most cases, insuring an effective input by the health professionals who are most familiar with the needs of the area.

The law also requires that a fee be charged to recover the reasonable cost of providing the services, except for those who are unable to pay. Third-party payers, including Federal and State health insurance and payment programs, are liable to be billed by the corps exactly as if the services had been provided by private health providers.

S. 3858 would extend and substantively change the corps' authority for 3 years with authorizations of $25 million in fiscal year 1974, $30 million in fiscal year 1975, and $35 million in fiscal year 1976.

At the present time, we are reviewing the existing National Health Service Corps authority to determine what, if any, changes need to be made.

The program is relatively new, and careful analysis of the experience to date is required for this review to be truly effective.

For this reason, we urge the Congress not to act on the bill at this time. S. 3858 contains a number of provisions which are not related to the basic enabling authority for National Health Service Corps activities which we believe are particularly inappropriate for consideration in this context.

S. 3858 would amend section 741 (f) of the Public Health Service Act, which authorizes loan repayment and forgiveness for physicians, dentists, and other health professionals who enter into an agreement with the Secretary to practice their profession in an area determined by the Secretary, after consultation with the appropriate State health authority, to have a shortage of and need for personnel trained in their professions.

It would provide for loan forgiveness to persons serving in the National Health Service Corps at a rate of 50 percent of principal and interest for the first year of service and 50 percent for the second year.

As you know, Mr. Chairman, this administration fully supports the principle of loan forgiveness as a means of providing incentives to practice in underserved areas. Existing provisions of section 741 authorizing loan forgiveness and repayment in return for service of health professionals in such a shortage area at the rate of 30 percent for the first year of practice, 30 percent for the second year, and 25 percent for the third were only recently enacted, in 1971, and represent a significant broadening of earlier authorities.

While it is too soon to assess the impact of these broadened loan forgiveness authorities, we are hopeful that increasing numbers of phy