(b) Distribution of medical services as they exist will not improve the quality of medical care. It is indeed likely that the poor quality medical care, rather than the better, would be disseminated. (c) Population at large also requires much more education as to what may be considered adequate health practices. Public education must precede legislation in this respect. (d) Compulsory insurance would create huge sums of money for which there are inadequate means of effective use. (e) Insufficient authority is placed in the hands of medical personnel who are familiar with the needs in medical education and stable progress. (f) There is no differentiation between the patient who is able to pay for services in toto, the patient who can pay in part, and the patient who can pay nothing. (g) There are inadequate provisions for improvement of hospital facilities, health centers, and medical schools. 3. We would favor legislation which would: (a) Through State agency channels provide funds for medical care of the indigent. (b) Provide direct aid to hospitals and cooperate with well-managed hospital clinics so that the cost of medical care in such institutions could be materially reduced. (c) Provide direct aid to health centers which should be placed in strategic geographic areas. (d) Provide direct aid to medical schools for the improvement of their teaching facilities-possibly the most important consideration in any long-range view of this problem; with the result that- (1) Better teachers can devote more time to instruction. (2) Improved physical facilities, e. g., laboratories, hospitals, cooperating clinics, and health centers may be provided. (3) Postgraduate educational opportunities increased. (e) Setting up of medical districts in which the teaching institutions or larger hospitals would act as the hub of wider spread high-grade medical practice. In such areas residents in postgraduate training would act as one of the principal links between the peripheral medical units and the central teaching institution. 4. We suggest that legislation which is designed for the improvement of the medical care of infants and children be limited for the time being to obvious needs and that any policy of changing legislation be deferred at least until the completion of the survey of child-health service now being conducted under the joint auspices of the American Academy of Pediatrics, the United States Public Health Service, and the Children's Bureau. 5. Finally, we suggest that greater strides in the improvement of the state of health of infants and children, as well as women, can be achieved by measures designed to improve housing and sanitary conditions and nutrition, than by the effort to spread more widely (and incidentally more thinly) inadequately trained and inadequately manned health services. Sincerely yours, Hon. CLAUDE PEPPER, CHILDREN'S DENTAL CLINICS OF THE PHILADELPHIA MOUTH HYGIENE ASSOCIATION, United States Senate, Washington, D. C. MY DEAR MR. PEPPER: I am in receipt of your letter of October 24 relative to comment on bill S. 1318 which you have introduced in an effort to improve maternal and child health. It is evident that procedures which have been in vogue for a long time have not been generally effective-an ineffectiveness that is spotlighted by the appalling draft findings and the resulting physical deficiency corrections necessary to raising an adequate military force. It is equally evident that measures must be introduced to strengthen the health of our youth-a distinct contribution to a permanent national security. Being particularly interested in the dental phase of child health, I have given much study to this part of the problem. Using all available evidence, gathered from authentic and accepted studies, a method of procedure has gradually unfolded that, at least, offers an avenue of exploration that may reveal the answer. I presented the basis for such thinking to a conference on dental health at the Children's Bureau in February. Since that time I have been editing the report with a view to its publication. This job is now completed and I will be very glad to submit a copy, in the very near future, for incorporation in your record, if you so desire. I think you will be interested in the fact that I have attempted to show that it is entirely possible in a period of 7 years following a program inauguration, using less than 5 percent of the available dental manpower, to graduate every child in the United States into adult life with a maximum mouth health. This maximum can be attained at a cost of about $2.50 per child per year. It is of further interest to note that such a program can be made 80-percent self-sustaining that no encroachment will be made on private practice, it will in fact be helped-and that such dentists as are employed can be paid a yearly salary 35 percent above the average dental net income as reported by the Department of Commerce for the years 1929-39. Subsidy for the implementation of such a program must be forthcoming from some source and, of course, much preliminary study is necessary. Such study can be accompanied by proper demonstrations that will provide excellent service at a cost that is unbelievably low, once the initial installations are accomplished. I might add that the plan is in complete accord with the principles enunciated by the American Dental Association. As a matter of purely personal thought, I am convinced that every phase of maternal and child-health procedures must be completely integrated in a general over-all pattern. Thanking you for your letter and complimenting you for your vision and courage, Sincerely yours, EXHIBIT 34 WM. C. WEBB, Jr. Hon. CLAUDE PEPPER, CHILDREN'S DENTAL CLINICS OF THE PHILADELPHIA MOUTH HYGIENE ASSOCIATION, Philadelphia, Pa., June 24, 1946. United States Senate, Washington, D. C. MY DEAR SENATOR PEPPER: I am in receipt of your telegram of June 17 relative to a prepared statement regarding Maternal and Child Welfare Act of 1945, S. 1318. The Council of Social Agencies of the Community Fund of Philadelphia and vicinity of which we are a member agency, has compiled and forwarded to you a prepared statement which is a condensation of all interested agencies official statements relative to the bill. I trust this expression of opinion will be satisfactory to all concerned. Respectfully, EXHIBIT 35 WM. C. WEBB, Jr. Senator CLAUDE PEPPER, COMMITTEE FOR THE NATION'S HEALTH, Senate Office Building, Washington, D. C. DEAR SENATOR PEPPER: I write with reference to your maternal and child. care bill, S. 1318, on which I understand you are opening hearings in the near future. The Committee for the Nation's Health is formally on record in favor of a general national health program, of which provision for care of children and mothers is an important part. Thus we recognize the need for making good medical care and preventive measures more fully available to mothers and children, and are heartily in favor of the prompt passage of legislation to this end. S. 1318 would provide for the care of all persons under 21 and of women at the time of maternity. This care would be supported mainly by Federal funds derived from general revenues. The cost of such a program if fully carried out would be about $1,000,000,000 a year. We do not believe that this proposal is practicable or that it is necessary to accomplish the end in view. It is not practicable because appropriations on the scale necessary to effectuate the program would be unlikely, and insufficient appropriations would probably lead to the establishment of a means test, to restrict the number eligible for care. The measure is not necessary because a better alternative is already before Congress, namely the use of the insurance principle as the main base of support for medical care for the bulk of the population, including children and mothers. The insurance principle utilizes and organizes the existing expenditures for medical care by individuals and families. Appropriations from general revenues in relatively small amounts must supplement insurance payments for special purposes or for special groups of the population. The purposes of S. 1318 can best be accomplished by enacting H. R. 4730 and S. 1606, with amendments already proposed that would strengthen the maternal and child health provisions now in these bills. I appreciate that there may be delay in the passage of the general national health program. Meanwhile progress may nevertheless be made. The interim might best be covered by legislation enlarging the annual appropriations now made available to the United States Children's Bureau for maternal and child health services. Sincerely yours, MICHAEL M. DAVIS, Chairman, Executive Committee. EXHIBIT 36 Hon. CLAUDE PEPPER, THE AMERICAN PUBLIC HEALTH ASSOCIATION, Senate Office Building, Washington, D. C. DEAR SENATOR PEPPER: The American Public Health Association welcomes the opportunity to present a statement bearing on the maternal and child-welfare bill, S. 1318. By order of my board I present for your information and that of the committee, with the request that it be included in the record, a statement of the principles which the association has adopted bearing on this subject. We think it appropriate to state our opinion in this form because we are aware of pending amendments to this bill which may bring it more fully into accord with our principles and we recognize that there are potential changes to be brought about by the proposed reorganization of Federal agencies which may have a large effect on the extent to which this bill conforms to our declared principles. Very respectfully yours, REGINALD M. ATWATER, M. D., [Reprinted from American Journal of Public Health, vol. 34, No. 12, December 1944. Published by the American Public Health Association, New York, N. Y.] MEDICAL CARE IN A NATIONAL HEALTH PROGRAM AN OFFICIAL STATEMENT OF THE AMERICAN PUBLIC HEALTH ASSOCIATION, At the annual meeting of the committee on administrative practice of the American Public Health Association, October 9, 1943, the committee directed its subcommittee on medical care to draft a set of principles expressing the desir able content of a comprehensive program of medical care, the methods of its administration, and the part which public health agencies should take in its operation. In pursuit of this assignment, the subcommittee completed a tentative draft, which was considered and adopted by the committee on administrative practice at its meeting, October 1, 1944. The report was then transmitted to the governing council of the association where, afer certain revisions, it was adopted as a statement of association policy. Because of its composition and charge, the subcommittee has limited its considerations to one sector of a comprehensive national health program, namely, medical care. In preparing the report, the subcommittee has considered (a) The needs for a national program for medical care. (b) The objectives of such a program. (b) Recommendations for immediate action. The American Public Health Association through its national organization and its constituent societies stands ready to collaborate with the various professional bodies and civic organizations which may be concerned with either the provision or receipt of medical service with a view to implementing the following general principles: A. THE NEEDS I. A large portion of the population receives insufficient and inadequate medical care, chiefly because persons are unable to pay the costs of services on an individual-payment basis when they are needed, or because the services are not available. II. There are extensive deficiencies in the physical facilities needed to provide reasonably adequate services. Such facilities include hospitals, health centers, and laboratories. The needs are most acute in poor communities, in rural areas, and in urban areas where the population has increased rapidly or where the development of facilities has been haphazard or the financial support inadequate. III. There are extensive deficiencies in the number and the distribution of personnel needed to provide the services. Here again, the needs vary according to categories of personnel and to characteristics of communities. IV. There are extensive deficiencies in the number and categories of personnel qualified to administer facilities and services. V. Many communities still are not served by public-health departments; others inadequately maintain such departments. Thus, some communities have never utilized organized health work to reduce the burden of illness, and others share its benefits only in part. In these communities especially, people lack information on the benefits of modern medical care. VI. Expansion of scientific research is urgently needed. Despite past and current scientific advances, knowledge as to the prevention, control, or cure of many diseases is lacking. Each of the six conditions defined above can be broken down into many component parts representing specific needs. In general, however, solutions of these broad problems require simultaneous attack on four fronts-namely, the distribution of costs, construction of facilities, training of personnel, and expansion of knowledge. B. THE OBJECTIVES I. A national program for medical care should make available to the entire population all essential preventive, diagnostic, and curative services. II. Such a program should insure that the services provided be of the highest standard, and that they be rendered under conditions satisfactory both to the public and to the professions. III. Such a program should include the constant evaluation of practices and the extension of scientific knowledge. C. RECOMMENDATIONS The recommendations presented in this report represent guides to the formulation of a policy of action. It is believed that study of these recommendations by the professions and others concerned in the States and localities will produce new and more specific recommendations for the attainment of the objectives of a national-health program. Recommendation I. The services (a) A national plan should aim to provide comprehensive services for all the people in all areas of the country. In light of present-day knowledge, the services should include hospital care, the services of physicians (general practitioners and specialists), supplementary laboratory and diagnostic services, nursing care, essential dental services, and prescribed medicines and appliances. These details of content must remain subject to alteration according to changes in knowledge, practices, and organization of services. Because of inadequacies in personnel and facilities, this goal cannot be attained at once; but it should be attained within 10 years. At the outset as many of the services as possible should be provided for the Nation as a whole, having regard for resources in personnel and facilities in local areas. The scope of service should then be extended as rapidly as possible, accelerated by provisions to insure the training of needed personnel, and the development of facilities and organizations. (b) It is imperative that the plan include and emphasize the provision of preventive services for the whole population. Such services include maternity and child hygiene, school-health services, control of communicable diseases, special provisions for tuberculosis, venereal diseases, and other preventable diseases, laboratory diagnosis, nutrition, health education, vital records, and other accepted functions of public-health agencies, which are now provided for a part of the population. (c) Insofar as may be consistent with the requirements of a national plan, States and communities should have wide latitude in adapting their services and methods of administration to local needs and conditions. Recommendation II. Financing the services (a) Services should be adequately and securely financed through social insurance supplemented by general taxation, or by general taxation alone. Financing through social insurance alone would result in the exclusion of certain economic groups and might possibly exclude certain occupational segments of the population. (b) The services should be financed on a Nation-wide basis, in accordance with ability to pay, with Federal and State participation, and under conditions which will permit the Federal Government to equalize the burdens of cost among the States. Recommendation III. Organization and administration of services (a) A single responsible agency is a fundamental requisite to effective administration at all levels, Federal, State, and local. The public-health agencies-Federal, State, and local-should carry major responsibilities in administering the health services of the future. Because of administrative experience, and accustomed responsibility for a public trust, they are uniquely fitted among public agencies to assume larger responsibilities and to discharge their duties to the public with integrity and skill. The existing public-health agencies, as now constituted, may not be ready and may not be suitably constituted and organized, in all cases, to assume all of the administrative tasks implicit in an expanded national health service. Public-health officials, however, should be planning to discharge these larger responsibilities, and should be training themselves and their staffs. This preparation should be undertaken now because, when the public comes to consider where administrative responsibilities shall be lodged, it will be influenced in large measure by the readiness for such duties displayed by publichealth officers and by the initiative they have taken in fitting themselves for the task. (b) The agency authorized to administer such a program should have the advice and counsel of a body representing the professions, other sources of services, and the recipients of services. (c) Private practitioners in each local administrative area should be paid according to the method they prefer, i. e., free for service, capitation, salary, or any combination of these. None of the methods is perfect; but attention is called to the fact that fee for service alone is not well adapted to a system of wide coverage. (d) The principle of free choice should be preserved to the population and the professions. |