EXHIBIT II.-U. S. Department of Labor, Bureau of Labor Statistics-Indexes of the cost of goods purchased by wage earners and lower-salaried workers for large cities of the United States-Continued EXHIBIT III.-Estimated distribution, by net income classes, of income recipients, income payments, and personal taxes paid in the calendar year 1944 The classification by net income brackets is in accordance with net income as determined by the Current Tax Payment Act of 1943. ? Includes only the income recipients who would be potential income tax paying units if there were no exemptions and if the present advantage to filing separate returns were retained. The income of income recipients who are dependents for purpose of the Federal individual income tax is included, although the number of such income recipients is excluded. Income payments are as defined by the Department of Commerce. 4 Refers to the personal taxes paid under present law in the calendar year rather than liability for personal taxes incurred in the calendar year. Personal taxes consist of Federal, State, and local individual income taxes, estate, inheritance, and gift taxes, property taxes (excluding taxes on business property and rented houses), taxes and licenses on motor vehicles not used in business, miscellaneous personal taxes, and nontax payments to Government. The portion of the Federal individual income tax withheld is considered paid by the individual when withheld rather than when received by the U. S. Treasury. NOTE.-Figures are rounded and will not necessarily add to totals. Source: Treasury Department, Division of Research and Statistics, Oct. 19, 1943. EXHIBIT IV-Estimated distribution by $500 net income classes under $5,000 of income recipients classified according to marital status, and of income payments in the calendar year 19441 [Number of income recipients in thousands; dollar amounts in millions] 1 This table presents in greater refinement the same estimates contained as a part of the table appearing on p. 21 of the revised hearings before the Committee on Ways and Means of the House of Representatives on revenue revision of 1943, Öct. 4, 1943. The classification by net income brackets is in accordance with net income as determined by the Current Tax Payment Act of 1943. Includes only the income recipients who would be potential income-tax paying units if there were no exemptions and if the present advantage to filing separate returns were retained. The income of income recipients who are dependents for purposes of the Federal individual income tax is included, although the number of such income recipients is excluded. Income payments are as defined by the Department of Commerce. NOTE.-Figures are rounded and will not necessarily add to totals. Source: Treasury Department, Division of Research and Statistics, Jan. 17, 1944. EXHIBIT VI The operation of the 1944 law with respect to exemptions and credits for dependents may be seen in the following table: Earnings here mean adjusted gross income within the definition of that term in sec. 22 (n) of the Internal Revenue Code. It is also assumed in the above table that the children qualify as dependents as defined in sec. 25 (b) (3) of the code, who are not dependent upon another taxpayer. EXHIBIT V The following is a record of the changes that have been made in the personal exemptions and credits for dependent under the several revenue acts from 1913 to date for individual income-tax purposes: 1 The Individual Income Tax Act of 1944 inaugurated a system of per capita exemptions and credits for dependents as a step toward simplification of the personal income tax system. For surtax purposes the per capita system calls for a uniform exemption of $500 per person, that is the taxpayer receives a $500 exemption, his wife $500 and there is a $500 allowance for each dependent. For normal tax purposes each taxpayer is given a normal tax exemption of $500 with no credits for dependents. In a joint return by a husband and wife the normal tax exemption amounts to $500 plus the lesser income of the 2 spouses, not exceeding in the aggregate for both taxpayers the sum of $1,000. EXHIBIT 85 Hon. CLAUDE PEPPER, THE SOCIETY OF THE NEW YORK HOSPITAL, United States Senate, Washington, D. C. MY DEAR SENATOR: I am writing this letter in response to your telegram of June 17, 1946, requesting a statement of my views concerning S. 1318. * * There can be no question of the need for improvement and extension of services for mothers and children. The disparity between mortality rates for infants and mothers in the various States and the differences in the quality and quantity of various types of care available in urban and rural areas indicate that we cannot rest on the laurels of past achievements. The American Academy of Pediatrics recognized these facts in passing two resolutions at its annual meeting in January 1946 (Journal of Pediatrics, 28; 384, 390, 391, March 1946). The first of these favored "the use of public funds to provide such service to those groups of the population unable to pay for medical services. Pending completion of the academy study of child health services in the various States, the acedemy recommended that additional Federal funds be made available under title V of the Social Security Act to meet urgent needs which existed in some States. The second resolution cited 13 specific criticisms of S. 1318 which if met would presumably make this bill a more satisfactory form of legislation for meeting the needs for which it was designed. Since one of the factors which will determine the quality of care given is the willing cooperation of the purveyors of that care, it is important that an attempt be made to meet the objections raised. I should like to coment on some of the 13 points: Point 1 implies that a means test should be included in the bill because its exclusion would be a violation of States' rights. Actually, the question is hardly a matter of States' rights. On principle, proponents of a means test say that no one should get medical care in a public program who can afford to pay a private fee, and opponents say that no one who pays taxes should be excluded from a public program if he chooses to use it. These arguments can both be considered valid American thinking and one has to look for other reasons for including or excluding the test. Proponents of its inclusion consider it necessary to obtain the cooperation of private physicians because of the danger that private practice may suffer. For full time salaried members of university or other groups, this would not be a consideration. The inclusion of a means test might therefore well be a subject for local option where neecssary to insure the cooperation of the physicians who will supply medical care. This may give an opportunity to study the effect of a means test on the quality of care given. Point 2 calls attention to the desirability of including fee-for-service as a mens of paying practitioners. Since it is not the purpose of S. 1318 to change prevailing modes of practice, it is obvious that where fee-for-service will purchase adequate care it should be used as a means of doing so. It is important, however, both for individual physicians as well as for groups or institutions (point 3), that the fees paid should be high enough to permit physicians to give adequate time to their patients. During the war years, the shortage of physicians frequently led to hurried care in both private doctors' offices and in clinics, and although adequate remuneration will not in itself insure adequate time for care, it is a step in the right direction. Point 5 requests integration of the administrative functions and health services under this bill with other health activities of the Government. No one will argue the desirability of this point, but it is important that the Children's Bureau guide any program for mothers and children. Its record of pioneering achievement for a period of over 30 years and its intimate knowledge of the diverse problems in the whole Nation far outbalances the harmful effects of any disagreements which have arisen during the past few years. Hard feeling has been engendered by administrative complexities which plagued the EMIC program. Some of these perhaps could have been avoided, but when one remembers the urgency of initiation of the program, the difficult conditions around many military posts, the shortages of administrative help in local, State, and Federal agencies concerned, and the ridiculously small initial Federal appropriation for administration, one can only be thankful that the wives and babies of so many enlisted men received medical care. The EMIC program was an emergency war program from which lessons have been learned by administrators at all levels. To refuse to work now with the Children's Bureau in peacetime pursual of worthy goals is as unreasonable as declining to eat in a Pullman diner because of wartime traveling experiences. Furthermore, the contemplated transfer of the Children's Bureau to the Federal Security Agency and ultimately to a full cabinet Department of Health and Welfare, as outlined in President Truman's reorganization plan, will make for uniformity | in administrative procedures as desired by State health departments. In university as well as other hospitals, it has long been recognized that the best interests of children are served by autonomous departments of pediatrics. It would be a mistake to submerge this principle because of the desire for administrative improvements. Increased efficiency can never be obtained at the expense of quality of service. The past record of the Children's Bureau with respect to the quality of care it desires for mothers and children makes it vital that the present Bureau guide the program while simplifying administrative procedures. Point 11 calls for provision for the protection of teaching services. An aggressive approach to this problem seems indicated at once. The National Board of Medical Examiners finds marked variation in the quality of answers to pediatric questions among students from different medical schools, thus indicating considerable variation in the caliber of the teaching of undergraduate students. Since the major portion of the care supplied under S. 1318 will be provided by general practitioners, there is great need for improvement of the teaching of pediatrics at both undergraduate and postgraduate levels. Dr. James L. Wilson has outlined a plan for such expansion (Journal of Pediatrics, 28: 231, 1946), which could be started immediately without becoming embroiled in the arguments over methods of supplying direct medical care. Furthermore, under his direction, a study has been initiated in association with the American Academy of Pediatrics which will yield basic data concerning the teaching of pediatrics in American medical schools. Point 13 is perhaps the most important of all the objections which have been raised. It calls for assurance 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." Many physicians have recently had personal experiences in military service with the difficulties encountered in supplying a high caliber of individualized care when personnel and facilities were swamped by the urgencies of mobilization, training, actual warfare, and, finally, demobilization. The same situation has existed in peacetime, although not as acutely, in civilian hospitals and clinics for the indigent. The problem of supplying individualized care on a mass basis is complex, and will require wisdom and experimentation, lack of haste in the development of administrative and professional policies, and the unhurried efforts of many physicians, medical social workers, public-health nurses, and medical administrators. The following statements from War Department Circular No. 387, dated December 29, 1945, are quoted, for with slight paraphrasing they apply to the problem of supplying mass care: "It must be clearly understood that the great majority of individuals seeking medical care do not suffer from serious conditions requiring hospital treatment, but from relatively minor sickness and injuries and from concern over personal health and welfare. If these individuals are returned [to duty] from the dispensary level without adequate examination, treatment, and reassurance, they continue to worry about their health, lose a degree of confidence [in the Medical Department], and become less effective [in their assignments]. On the other hand, if they are unnecessarily referred to the hospital consultation services or unnecessarily hospitalized, the seriousness of their conditions becomes exaggerated in their own minds and there is unnecessary loss of [duty] time and unnecessary use of hospital personnel and facilities." These statements point up the need of supplying at the initial level of care adequate numbers of well-trained physicians, medical social workers, and publichealth nurses to really give individualized care to patients. In view of shortages which will certainly exist if an extensive system is immediately established, there should be, first, an increase in the number and improvement of the training of physicians, medical social workers, and ancillary workers in the field, and, second, establishment of plans only as rapidly as local facilities and personnel permit. If, because of shortages or for other reasons, care of a low quality is supplied initially, it will lead to poor morale with further deterioration of the service. |