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DEAR SENATOR PEPPER: I regret very much that the engagements I have in St. Louis prevent my appearing before your committee. Enclosed is the statement covering my testimony. I hope it can be put to some use at the meeting. You can use the copies in any manner which you feel may be advantageous.

Sincerely,

ALLAN M. BUTLER, M. D.

STATEMENT OF ALLAN M. BUTLER, M. D., ASSOCIATE PROFESSOR OF PEDIATRICS, HARVARD MEDICAL SCHOOL, CHIEF OF THE CHILDREN'S MEDICAL SERVICE, MASSACHUSETTS GENERAL HOSPITAL, MEMBER OF THE AMERICAN PEDIATRIC SOCIETY, AMERICAN ACADEMY OF PEDIATRICS AND AMERICAN MEDICAL ASSOCIATION

I appreciate the invitation to come before this committee to add my testimony to your hearings on the Maternal and Child Welfare Act of 1945, S. 1318. As stated before this committee in my testimony favoring S. 1606, legislation pertaining to establishment of a national health program is not the product of New Deal politics or sentimental reform. It is reflection of the impact of science upon medicine. To avoid repetition may I refer you to that statement as to why I believe we must evolve some method of adequately financing medical care in an orderly and predictable manner, why a legislative medical-care program is a sounder way of meeting this need than reliance upon voluntary plans, and why your task requires imagination and boldness in creating a comprehensive program but conservatism in putting that program into operation. In that statement the reasons why you, in doing the required job, would encounter the opposition of so-called organized medicine were stated. Well, you have encountered that opposition. I trust you appreciate that it reflects the inevitable reactionary attitude of such organized groups and as such must not stop constructive conservative action.

Today I want to support S. 1318 amended as recommended by Senator Pepper and Dr. Martha Eliot as a logical way to take the first step in such a program, if you should feel that the program of S. 1606 is too broad and introduces too much too rapidly. S. 1318 is a logical first step because it provides a method of introducing a health program for maternal, infant, and child care gradually under controlled conditions. The need of improving such medical care is so generally recognized that there is no argument about it. These needs as recognized by the American Pediatric Society and American Academy of Pediatrics were presented in my testimony on this act before the Subcommittee on Aid to the Physically Handicapped of the House Committee on Labor June 7. That testimony also presents specific criticisms of the bill as written. It is, therefore, pertinent to submit it as part of my testimony this morning.

"I come before this committee under instructions of the president of the American Pediatric Society to act as a representative of that society. I am a practicing pediatrician and a teacher of pediatrics in Boston, Mass.; associate professor of pediatrics at Harvard University; and chief of the children's medical service, Massachusetts General Hospital. I am also a member of the American Academy of Pediatrics and the American Medical Association.

"The American Pediatric Society's interest is primarily in teaching, research, and standards pertaining to medical care of infants and children. I would like to submit as part of the record a report of a joint committee composed of representatives of the American Pediatric Society, the American Academy of Pedi

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atrics, and the Medical Advisory Board of the Children's Bureau. is stated as being

The objective ""To make available to all mothers and children in the United States of America all essential preventive, diagnostic, and curative medical services of high quality, which, used in cooperation with the other services for children, will make this country an ideal place for children to grow into responsible citizens.' This is also the objective of this bill (H. R. 3922).

"The reasons why large numbers of children do not receive preventive and curative care compatible with present-day standards are listed in this report in considerable detail. Included as reasons are:

1. Lack of and poor distribution of properly trained physicians.

2. Lack of facilities for training.

3. Lack of dentists.

4. Lack of nurses.

5. Lack of health officers.

6. Lack of hospital facilities.

7. Lack of health centers.

8. Lack of proper districting of health departments.

9. Need of more adequate support of research..

10. Need of adequate remuneration of persons providing professional care. "The report then recommends a survey whose purpose will be to see what total facilities and professional personnel actually are available in each State and local community in the country, so that there may be accurate data for indicating how and where improvement may be accomplished.

"As this report is the statement of needs and recommendations of physicians, it deserves particular consideration. I therefore submit it to you. [Report handed in.]

"If you have not had Dr. John Hubbard, who is conducting the survey recommended in the report, appear before this committee, I suggest that you do in order to learn exactly what information he might provide which would be pertinent to the work of this committee.

"I would now like to make a few general comments concerning such legislation as you are considering and then a few specific criticisms of the bill as now written.

"1. The major danger of tax-supported medicine is its threat to medical education. If all the persons now being cared for by our teaching services throughout the country should, under a tax-supported plan, decide to obtain medical care from an individual physician, the teaching of medicine by specially qualified groups, such as teach today, might be seriously affected. That does not mean that we should perpetuate indigency, but it does mean that steps should be taken to protect teaching services as indigency is lessened. Good teaching determines the quality of our medical care to a very great extent. Therefore, a specific modification must be made in the bill under discussion to assure that an individual can seek medical care from a group of physicians or institution as well as from an individual. And groups of physicians or institutions must be permitted, under the bill, to compete for the provision of such care. Appropriate amendments to cover this could be readily made. Interestingly enough, no voluntary scheme operating on a State-wide basis has made any provision for protecting teaching services. The two chief aims of a national health program should be to improve, first, the quality and then the availability of medical care. Voluntary plans do not consider the former and make but a minor contribution to the latter. Moreover, voluntary schemes cannot coordinate medical with other health services required by children.

"2. This bill provides the funds necessary for its purposes from general tax funds. The question as to whether this is correct or whether individual prepayments for medical care should be made by those who can afford it, as provided under title II of the Wagner-Murray-Dingell bill, deserves very careful consideration. Administratively, it is simpler to draw from general tax funds because the care of the so-called medically indigent will have to be financed in this manner, anyway. So why not cover the costs of all people this way? On the other hand, it is psychologically and perhaps economically sound to insist upon individual contribution for health services wherever possible. The WagnerMurray-Dingell bill resorts to this in spite of the administrative difficulties.

"3. One of the dangers of a Government program for medical care such as this is that it is 'big' and may be put into effect more rapidly than is consistent with available administrative and professional personnel and facilities. On the other hand, a Government program provides a better opportunity than does a volun

tary plan for setting up a well-conceivaed progrm that can be put into effect slowly and gradually in an orderly manner. There appears to be nothing in this bill that justifies Dr. Wall's use of the phrase 'revolutionary changes in the practice of obstetrics and pediatrics.' There is nothing in the bill that changes the doctor's role or independence in the performance of professional duties or his relation to patients, other than the fact that his payment is assured by a public agency instead of being dependent upon the economic status of the patient. Health and medical care to the extent of $900,000,000 per year is now being financed by Government moneys. Much of what Dr. Wall has said represents fantastic interpretations. As a member of the American Academy of Pediatrics, for which Dr. Wall appeared this morning, I wish to record with this committee the fact that a large number of the members of the academy do not endorse Dr. Wall's statement. His statement represents personal rather than academy interpretation of the bill. This is evidenced by an article written by Dr. Edwards A. Park, of Johns Hopkins, in the March 1946 issue of the Journal of Pediatrics, entitled 'Social Aspects of Medicine.' This statement of Dr. Park has been highly praised by not only a larger number of the members of the academy but possibly by a majority of the members.

"The academy, in its statement concerning S. 1318, stated, 'For these reasons the American Academy of Pediatrics believes that the Maternal and Child Welfare Act of 1945 (S. 1318) does not represent the best form of legislation for the purpose for which it was written.' This statement is hardly one of 'unanimous disapproval' as stated by Dr. Wall.

"The bill before you could, with but slight modification, initiate the first step in a legislative-health program in a logical way. The first way would be to limit the children who are covered by this legislation on the basis of age, as suggested by Dr. Getting. In other words, children up to 2 years of age might be provided the services designated in the bill the first year, children of 3 years of age or 4 years of age so covered in the second year, the expansion in coverage according to age being determined by the capacity for adequately handling an expanded program. The second way of putting this legislation into effect gradually would be by starting the program on an area basis-again with expansion determined as the capacity for so doing warrants.

"There are those that object to covering only a portion of the people in a Government program. I do not see the validity of this objection so long as the program is to be extended, as capacity for extension permits. Such a gradual extension is not unfairly discriminatory. It appears to me to be the logical way of avoiding a serious danger in a legislated medical-care program, namely, too big a program too suddenly.

"Now, very briefly, a few specific amendments.

"I especially endorse the following criticisms of the bill made by the American Academy of Pediatrics:

1. The bill excludes fee-for-service as a means of paying practitioners for service rendered.

"2. The bill makes inadequate provision for paying groups of physicians or institutions for professional services rendered.

"3. The bill does not specify that professional personnel, groups, or institutions do not accept supplemental payments.

"4. The bill endorses the Children's Bureau as the most suitable administrative agency of this major step in a national health program without assuring integration of the administrative functions and health services under this bill with other health activities of the Government. However, the recent reorganization of health services under plan 2 as ordered by the President may accomplish this integration.

"5. The bill does not satisfactorily define the Federal or State advisory committees as regards personnel, method of appointment, advisory and policy-making roles, or manner of giving authority to the record of consultations with and recommendations to the administrators at Federal and State levels. This is done excellently in S. 1606.

"6. The bill makes no provision for variation in remuneration for service according to the differing costs pertaining in various States.

"7. The bill makes no provision for the prevention of arbitrary requests on short notice by the Federal administrative agency for reports from the State health agencies and similarly arbitrary requests by the State health agencies for reports from those rendering services.

"8. The provisions for handling claims are unsatisfactory.

"9. The bill fails to adequately specify reference to coverage of dental care in appropriate portions of the bill.

"10. The bill makes no adequate provision for the protection of the wellorganized and integrated teaching services on which the future quality of medical care is so dependent.

"11. The bill makes inadequate provision for the support and encouragement of research pertaining to the improvement of maternal and child-health services and medical care.

"12. The bill makes no provision for assuring that State plans be expanded at rates that do not exceed available administrative and professional personnel and resources and that assurance against too rapid expansion be considered as one of the criteria of approval of a State plan by the Federal agency.

"A letter which I wrote to Senator Pepper in December 1945 comments more fully on these and other points. I would like to submit excerpts from this letter as part of my testimony. [Attached.]

"Modifications could easily be incorporated in the present bill that would cover the points I have raised. If such were the case, I as an individual would heartily endorse the bill as the first logical and practical step in a national health program. "Mrs. Meyer yesterday, as quoted in the morning paper, said that this bill 'cut across the President's reorganization plan.' I see no justification in this charge. The preambles to the bill by both your chairman and Senator Pepper make adequate provision for coordination of this program with any further expansion of a national health program. The President's reorganization plan, if carried out wisely, would facilitate such coordination. Incidentally, Mrs. Meyer's attack on the Children's Bureau's activities during the war was most surprising. The record of the manner in which the Bureau carried out its emergency assignments and regular duties provide adequate answer to Mrs. Meyer's criticism.

"I see no reason why legislation should not be enacted now that would outline as I have mentioned the initiation of a program that could be expanded as the capacity of the country to administer and provide service is demonstrated.

"The opportunity that this committee has to initiate constructive and conservative action places a grave responsibility upon you. With the cooperation of doctors and public I see no reason why this Congress, under the leadership of this committee, should not meet that responsibility this year."

In addition I would like to stress the weakness of arguments commonly used against such legislation; namely, that the same arguments apply equally if not more against voluntary plans. For example, the argument is used that the cost of a legislative program administered by Federal and State agencies would be prohibitive. Yet the people who use this argument never state the cost of a voluntary plan which would give the same medical coverage to the same number of people. Should voluntary insurance be extended to cover what Government insurance under such a plan as the Wagner-Murray-Dingell bill will cover, the cost of the former would be as great if not greater than the latter. The competition of the voluntary schemes, except as it results in underpaying doctors or regimenting them, would be costly. The total number of people in all the voluntary administrative agencies would exceed those needed under a Government scheme. For under a Government scheme agencies could be used that exist and are functioning well today and must function tomorrow in order to administer the tax-supported medical care that must be administered by Government for the needy. Why not use these agencies instead of extravagantly creating new voluntary ones? Moreover, the performance of these Government agencies each year is critically reviewed by the Bureau of the Budget, the Congress, and the President before the Budget for the ensuing year is granted. This automatically assures a yearly check and public hearing, which it would be difficult if not impossible to assure for voluntary schemes.

The opposition also says that the people would tend to abuse a Government plan forgetting that the people already abuse every voluntary insurance agency by trying to collect everything possible. Indeed, a little thought indicates that most of the objections to a Government plan are not equally valid arguments against voluntary plans only if voluntary plans do not include as many people and as much care; that is, only if voluntary plans are not successful in meeting the need. The arguments of the opposition boil down to strangely indefinite statements such as the following:

1. A legislative program would be ill-conceived because Congress could not devise wise legislation. Legislation means politics and politics means graft. 2. A plan administered by Federal and State agencies would be badly administered because all such agencies are incompetent.

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