With you permission I will discuss certain provisions of S. 2337. Section 102 (a) (7) requires the State plan to establish standards for professional personnel and institutions furnishing care under the plan, but section 102 (a) (5) requires the State plan to provide such methods of administration as are necessary for the proper and efficient operation of the plan. Reading those two provisions together, we find that the States are required to establish such standards for participating professional personnel and institutions as the Children's Bureau shall deem necessary for the proper and efficient operation of the plan. That is indeed reminiscent of the law and practice under EMIC in World War II wherein the State plans were required by the law to be "developed and administered" by State health agencies and approved by the Chief of the Children's Bureau.

It was under such language that the Children's Bureau refused to approve State plans which permitted servicemen's wives and children to have the professional services of licensed osteopathic physicians.

The House Committee on Appropriations took cognizance of that discrimination, and in the course of House Report No. 450, Department of Labor appropriation bill, fiscal year 1944, in re Children's Bureau, stated in part as follows:

The States have established standards for licensing health practitioners and the Federal Government has never attempted to establish such standards. In the judgment of the committee, the Children's Bureau has not the power under law either to establish such standards or to question the standards established by the States. It is not the desire of the committee, of course, to permit the use of Federal funds to break down safeguards against the practice of healing arts by improperly and inadequately trained persons, but the committee does believe that the State laws and standards constitute the necessary protection for the public. Therefore, the committee has included in the bill a provision denying the use of the appropriation to promulgate or carry out any order, instruction, or regulation which has for its purpose the discrimination between persons licensed under State law to practice obstetrics.

Following the recommendation of the committee, Congress included the following limitation in the law:

Public Law 135, Seventy-eighth Congress, Labor-Federal Security Appropriation Act, 1944; approved July 12, 1943, title I, Department of Labor, Children's Bureau, Maternal and Child Welfare: "Provided, That no part of any appropriation contained in this title shall be used to promulgate or carry out any instruction, order, or regulation relating to the care of obstetrical cases which discriminates between persons licensed under State law to practice obstetrics: Provided further, That the foregoing proviso shall not be so construed as to prevent any patient from having the services of any practitioner of her own choice, paid for out of this fund, so long as State laws are complied with."

In other words, Congress provided against discrimination in the EMIC obstetric program, which constituted some 85 percent of the full program, and which the Children's Bureau said included the maternity period and until the child was 2 weeks old. Whereupon the Children's Bureau took the position that inasmuch as Congress prohibited discrimination in the obstetric program and did not say anything about the pediatric program, therefore it was all right to continue the discrimination against osteopathic patients in the pediatric program, and the Bureau instructed and required the States to so discriminate in their State plans.

Senator LEHMAN. Let me ask you, because it is not quite clear to me, did the Bureau direct the States to discriminate in the prenatal care of the mother and the delivery of the child, or only in the care of the child after birth?

Dr. SwOPE. You mean the law as it was finally administered?
Senator LEHMAN. Yes.

Dr. SwOPE. Only directed discrimination following the infant's first 2 weeks of life. The delivering osteopathic physician delivered the child, and he could take care of the child for 2 weeks under the fund, but after that period the child had to have care outlined by the Children's Bureau.

Senator LEHMAN. Thank you.

Dr. SwOPE. The States revised their plans to permit obstetric care by osteopathic physicians and pediatric care by such physicians during the first 2 weeks of the infant's life, but pursuant to Children's Bureau directives, the State plans then required the mother to switch to the services of a doctor of medicine for care of her child. The mother either complied or else she was deprived of the benefits of the program.

Some of the States actively demurred to this restriction by the Children's Bureau. For example, the Texas State health officer sought to include osteopathic pediatric services in his State plan. The Children's Bureau refused to approve, writing him in part as follows:

While the qualifications required of practitioners performing obstetrics services are established by each State health agency, and are left to its discretion, the Children's Bureau insists that for medical services, other than obstetric, payment may be authorized only to "graduates of medical schools approved (at the time of graduation, or subsequent to graduation) by the council of medical education and hospitals of the American Medical Association." The Children's Bureau in considering State plans for 1946 would not consider any modification or amendment to this provision.

Certain members of the osteopathic profession in Texas promptly sued for a writ of mandamus against the State board of health. The lower court granted the writ, thereby invalidating the State plan unless and until osteopathic pediatric participation was included. The Texas Supreme Court reversed the lower court on the ground that the State board of health was merely agent of the Children's Bureau. So, pediatric services by osteopathic physicians after the first 2 weeks of the infant's life continued to be excluded from the EMIC program by the Children's Bureau dictation to the States.

The Children's Bureau followed the same line of dictation to the States in administering title V, part 2, of the Social Security Act relating to State plans for providing medical, surgical, corrective, and other services and care, and facilities for diagnosis, hospitalization, and after-care of crippled children. The States were prohibited from using osteopathic physicians or surgeons for services for crippled children under the State plans. Congress remedied that discrimination by amending the over-all definitions title of the Social Security Act (Social Security Act Amendments of 1950), Public Law 734, Eighty-first Congress, approved August 28, 1950, as follows:

Section 1101 (a) (7). The terms "physician" and "medical care" and "hospitalization" include osteopathic practitioners or the services of osteopathic practitioners and hospitals within the scope of their practice as defined by State law.

S. 2337 requires the establishment of national and State advisory councils composed of representatives of medical, nursing, and hospital groups and organizations. In an article entitled, "Four Years of the EMIC Program" published in the Yale Journal of Biology and Medi

cine, March 1947, one of the authors of which was Dr. Martha M. Eliot, then Associate Chief and now Chief of the Children's Bureau, the statement appears that:

Approximately 2,500 osteopaths participated in the program in those States where osteopaths were allowed to provide obstetric care under EMIC. Although the American Osteopathic Association requested a voice by way of representation on the EMIC advisory committees of the Children's Bureau, no representation was granted.

In the programs envisaged by S. 2337, both the American Osteopathic Association and the American Osteopathic Hospital Association ought to be represented on the advisory councils, and a directive to that effect should be included in the legislation.

It is observed that the bill contemplates that the services of voluntary nonprofit agencies or organizations in the health or medical field should be utilized for the purposes of this program where consistent with economy and efficiency. It is assumed that such organizations as Blue Cross and Blue Shield are intended. We respectfully suggest that the right of the patient to choice of physician or hospital should be preserved, regardless of the availability of such voluntary health or medical agencies. In other words, the patient's choice of physician, or hospital ought not to be confined to physicians or hospitals participating in such organizations.

In view of the foregoing, in order that the osteopathic profession and its institutions may fully cooperate and contribute to the success of the program involved, we respectfully request express provision that wherever medical or hospital care or the advice and cooperation of representative organizations of physicians or hospitals is contemplated under the legislation, the legalized services of osteopathic physicians and hospitals and the advice and cooperation of representative organizations thereof are included.

Senator LEHMAN. Thank you very much. As I interpret your statement, the Children's Bureau under the World War II EMIC program made a very definite distinction between obstetrical treatment and pediatric treatment after the first 2 weeks. You were not interfered with or prohibited from participating in the program, in those States which permitted the practice of osteopathy in connection with obstetrics?

Dr. SwOPE. There was no interference as far as obstetrics was concerned, after the 1944 appropriations act.

Senator LEHMAN. The prohibition to which you refer related exclusively to the care of the child after the first 2 weeks?

Dr. SwOPE. Yes, sir.

Senator LEHMAN. I notice in this one statement that the Bureau said that payment may be authorized only to graduates of medical schools approved at the time of graduation or subsequent by the council of medical education of the American Medical Association.

Have your schools and hospitals been approved by this council? Dr. SwOPE. We have our approving agency, just as the American Medical Association has their approving agency for their institutions. Senator LEHMAN. Are you a part of the American Medical Association?

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Dr. SwOPE. No, sir. We are members of the American Osteopathic Association.

Senator LEHMAN. Are any members of your association also members of the American Medical Association?

Dr. SWOPE. I think not.

Senator LEHMAN. Does the American Medical Association recognize in any way the validity of the claims of the osteopathic profession? Dr. SwOPE. I think not. Do I interpret your question whether or not they pass on the approval of any of our institutions?

Senator LEHMAN. I see they have not, according to what you have said. I was tying to develop the relationship now between the American Medical Association and the osteopathic practitioners, namely, whether there is any relationship, whether they recognize the practice of osteopathy on the same plane that they recognize the practice of the more conventional forms of medical treatment.

Dr. SwOPE. As an association, I would not be able to answer that, but the State health officer of Texas, that I quoted here, in his desire to include the osteopathic profession in their program for the practice of pediatrics, is a doctor of medicine and a member, as far as I know, of the American Medical Association.

Senator LEHMAN. I remember at the time I was Governor of my State of New York, there was for a number of years a great deal of debate with regard to the position of osteopaths in the medical profession.

Dr. SWOPE. Yes, sir.

Senator LEHMAN. That is a good many years ago. My recollection may not be accurate, but my impression is that the practice of osteopathy is recognized in New York State without limitation save in the practice of surgery. I think there are some limitations in the practice of surgery, is that not right?

Dr. SwOPE. No, sir. I am happy to inform you, Senator, that they have been removed, and there is an unlimited practice for the two professions.

Senator LEHMAN. I know for a long time the practice of minor surgery was permitted.

Dr. SwOPE. That is right.

Senator LEHMAN. But major surgery was under discussion for a great many years.

Dr. SwOPE. That is right. That has now been relieved, and the osteopathic profession has unlimited practice rights in the State of New York.

Senator LEHMAN. In how many States is the practice of major surgery not permitted?

Dr. SwOPE. I am only speaking now from memory, but certainly less than a dozen.

Senator LEHMAN. Is there a prohibition in any State on the practice of general medicine, including pediatrics?

Dr. SwOPE. For the osteopathic profession?

Senator LEHMAN. Yes.

Dr. SwOPE. So far as the osteopathic profession is concerned, there is no prohibition against pediatrics in any State.

Senator LEHMAN. Is it true that in all States the osteopath can prescribe drugs or give treatment, let us say for typhoid fever or diabetes or syphillis, or are there any prohibitions?

Dr. SwOPE. There are some prohibitions in a few States, and again they are of a limited number. At least two-thirds of the States permit internal medication for the ailments you mention.

Senator LEHMAN. In your opinion, would a provision similar to that in the 1944 appropriation act applicable to medical care generally meet the point raised by your association?

Dr. SwOPE. It would, Mr. Chairman, because that would include pediatrics as well as obstetrics.

Senator LEHMAN. Thank you very much.

Dr. SwOPE. Thank you, sir.

Mr. MEIKLEJOHN. May I ask one question?

Dr. Swope, is it your position that the requirements should be binding on the Chilidren's Bureau or binding on the States, as well, or would you have that left up to the States?

Dr. SwOPE. I would leave that up to the States, because we feel that the State agency is better equipped to know the conditions in the State regarding the practitioners in that State, rather than the Federal bureau.

Mr. MEIKLEJOHN. So the State law in the particular State would govern?

Dr. SwOPE. Yes, sir; that would be the deciding factor.

Senator LEHMAN. Take the State of New York; is the examination for licensing identical with that given to a medical practitioner? Dr. SwOPE. They take the same examination, Senator.

Senator LEHMAN. Is the course of study that is required of the same length and the same quality?

Dr. SwOPE. Yes, sir.

Senator LEHMAN. Thank you very much.

Dr. SwOPE. If it would be of interest to the commiteee, we submit for the record this educational supplement which among other things includes a partial list of the osteopathic hospitals.

Senator LEHMAN. By whom are those approved?

Dr. SwOPE. These are approved by the American Osteopathic Association, approving authority.

Senator LEHMAN. Are those subject to State laws as to standards and quality of training and maintenance?

Dr. SwOPE. Yes, sir.

Senator LEHMAN. If you will submit it, we will be glad to accept the supplement for our files.

(The information referred to is on file with the subcommittee.) Senator LEHMAN. Miss Elizabeth Smart.

STATEMENT OF ELIZABETH A. SMART, NATIONAL DIRECTOR, DEPARTMENT OF LEGISLATION, NATIONAL WOMEN'S CHRISTIAN TEMPERANCE UNION

Miss SMART. Mr. Chairman, I am Miss Elizabeth A. Smart, national director of the department of legislation of the National Woman's Christian Temperance Union. My address is 100 Maryland Avenue NE, Washington, D. C.

My organization favors the passage of S. 2337. Title I of the bill is the same bill that inaugurated the EMIC program in World War II. It has borne the test of legislation. It was worked out by the com