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Miss ARNOLD. And for special purposes; yes.

Senator JOHNSON. I would like to ask just one question, Mr. Chairman, if I may.

The CHAIRMAN. Yes, Senator Johnson.

Senator JOHNSON. Should the Congress vote additional funds amounting to $8,500,000, as you have suggested, what would that mean in the way of State appropriations to match that money?

Miss ARNOLD. Under the present title V, part 3, of the Social Security Act, there is not a matching provision. It started out with only a $1,500,000.

Senator JOHNSON. In any degree?

Miss ARNOLD. It simply says that for the local services Federal funds should pay part of the cost. We have been rather flexible in interpreting that provision. Perhaps the Congress would want to consider whether, if funds were increased to $12,000,000, some kind of matching formula should be provided. When it was set up first, the matching formula was not put in.

Senator JOHNSON. But the present law views the Federal money as a part of the contribution.

Miss ARNOLD. For the local services, yes. It says it shall pay part of the cost.

Senator JOHNSON. Could you make an estimate, provided we do not change the law and change the formula, of what an increase of $8,500,000 would mean in the way of increased State appropriations? Miss ARNOLD. It would be difficult, but I think we could make an estimate, particularly with regard to local services.

Senator JOHNSON. That is all, Mr. Chairman.

The CHAIRMAN. Thank you very much, Miss Arnold, for your appearance and your contribution.

Miss ARNOLD. Thank you, Mr. Chairman.

The CHAIRMAN. Dr. Štarks?

We are calling Dr. Starks a little out of order on this list, because of the fact that one of the Senators at least may have to go to the floor.

You may be seated, Dr. Starks. Please identify yourself for the record, sir.

STATEMENT OF DR. C. ROBERT STARKS, SECRETARY, COLORADO OSTEOPATHIC ASSOCIATION, DENVER, COLO.

Dr. STARKS. My name is Dr. C. Robert Starks. My home is in Denver, Colo., where I am actively engaged in practice as an osteopathic physician licensed in medicine and surgery. I appear here oday as secretary of the Colorado Osteopathic Association and as past president of the American Osteopathic Association. My stateent has been prepared with the advice and assistance and is in onsonance with the policies of the department of public relations f the American Osteopathic Association, and of the State associaion which is a divisional society of the national organization.

There are upward of 200 osteopathic physicians in practice in Coloado. Osteopathic physicians or surgeons are legally licensed in all tates, to a total in excess of 11,000. More than 300 hospitals located roughout the country are staffed by doctors of osteopathy. The

members of the profession are engaged in general practice or in surgical or other specialty practice.

May I assure you that we greatly appreciate this privilege of dis cussing the medical provisions of H. R. 6000, an act to extend and improve the Federal old-age and survivors insurance system, to amend the public-assistance and child-welfare provisions of the Social Security Act, and for other purposes.

The primary objective of the Colorado and national associations is the promotion of the public health and it is in pursuance of that objective that we appear here today.

Disability insurance benefits: Title I, section 107, page 88 of the bill, amends title II of the Social Security Act to extend disability insurance benefits to qualifying individuals who are totally and permanently disabled. Insured persons who become totally and permanently disabled and remain so for a period of 6 months following determi nation of such disability are entitled to benefits. The Federal Security Administrator is authorized to provide for the determination and redetermination of disability by medical examinations to be performed by Government or private physicians. The Administrator is authorized to terminate disability benefits if the insured refuses to submit himself to examination or without good cause refuses to avail himself of rehabilitation services obtainable under the State-Federal program provided under the Vocational Rehabilitation Act.

There are perhaps good and bad features in all social-security programs and this one is no exception.

Among the good points of the program, is the fact that it should serve as a case finder for rehabilitation purposes. Many disabled persons who could be restored to employability have never heard of the State-Federal vocational rehabilitation programs, which operate under the act of Congress approved June 2, 1920, as amended, ertitled "An act to rovide for the promotion of vocational rehabilitation of persons disabled in industry or otherwise and their return to civil employment."

For some 30 years, it has been the policy of Congress as set forth in that act, to make available vocational rehabilitation services, for the disabled. This bill should promote that vocational rehabilitation. program.

Section 107 does not increase the number of persons entitled to medical services at Government expense. The medical care would be available only under the Vocational Rehabilitation Act. Only needy persons otherwise eligible under that act could obtain physical restoration services. It does not increase the coverage of the Vocational Rehabilitation Act.

Among the bad features of the program under section 107 is the possibility of malingering. This is partially offset by the 6-montà waiting period. There can be no doubt that in many instances 3 would be extremely difficult to determine and certify the "medically demonstrable physical or mental impairment which is permanent Wherever there is a family physician he would be in the best posities to make the determination. It is noted on page 94 that the Adminis trator is authorized to secure the cooperation of local government and private groups for advice and assistance in securing efficient admis tration. The cooperation of these groups should serve to minimize

abuses, but inevitably the principal responsibility will rest on the examining physician.

If the Congress shall determine that the public good in such a program outweighs the potential abuses, the cooperation of the physicians of the country to make the system work will become a social responsibility.

Public assistance: The present Social Security Act limits Federal financial participation in public assistance payments to those which are paid to the recipient in money.

Title III of H. R. 6000 changes that. The term "public-assistance aid" (sec. 303, p. 173; sec. 323, p. 178; sec. 344, p. 185; and sec. 351, p. 194) is revised to mean "money payments with respect to or medical care in behalf of" a public-assistance recipient. Under this bill, then, all or any part of the federally matched assistance to the needy aged, dependent children, blind, and the newly added category of needy totally and permanently disabled, may be devoted to medical care and paid directly by the assistance agency to the supplier of medical care.

The Advisory Council on Social Security in its report to the Senate Committee on Finance, Senate Document 204, Eightieth Congress,

states:

It is frequently desirable to let recipients make their own arrangements for medical services. On the other hand, there are many circumstances in which the assistance agency finds it preferable to pay the doctor or other supplier of medical care directly.

In instances where the assistance agency finds it preferable to make the arrangements and pay for the medical care directly, there is no indication that the recipient has any choice of the type or quality of medical care tendered, except the possible choice of accepting that or nothing.

The bill does not define the term "medical care." On page 42 of the House report on the bill (House Report 1300, 81st Cong.) the term "medical care" is defined as "medical services." Defining a term with the term is not of much help. Letters from the chairman of the House Committee on Ways and Means and the Commissioner of Social Security, which I desire to make a part of the record, state that osteopathic services would be included within the term. There is, however, nothing to prevent their successors from reaching a different conclusion.

It is the Federal Security Administrator who is charged with the responsibility of prescribing regulations interpretative of the terms of the act. We ask that osteopathic inclusion be expressly provided for in the bill rather than left to the vagaries of administrative interpretation. Our request is urgently necessary because the Administrator has already, in other social-security grant-in-aid programs, administratively excluded osteopathic services from the definition of "medical care."

It is that fact which brings me to the next point in my discussion of that unfavorable precedent, and a request for its removal.

Crippled-children's services: Title V, part 2, of the Social Security Act authorizes Federal grants-in-aid to the States for

medical, surgical, corrective, and other services and care, and facilities for diagnosis, hospitalization, and aftercare, for children who are crippled or who are suffering from conditions which lead to crippling.

The program operates under State plans that require approval by the Federal Security Agency.

Colorado prepared a State plan for services for crippled children, and included services by licensed osteopathic physicians and hospitals. The Federal agency turned it down, refusing to approve the State plan so long as osteopathic participation remained a part of it.

In other words, according to the Federal agency, the terms "medical care" and "hospitalization" as used in the Social Security Act do not include services by doctors of osteopathy and hospitals.

Colorado had obviously thought otherwise. So had other States. They knuckled down. The osteopathic profession also knuckled down. But it was not a supine submission. The profession in Texas sought to enjoin the State agency from complying with the edict of the Federal agency requiring the State to exclude osteopathic services under a similar State plan (EMIC). The lower court granted the injunction, but the appeals court of the State held that the State agency was merely acting as the agent of the Federal agency and had to abide by the conditions imposed by the Federal agency. Wilson v. State Board of Health (188 S. W. 2d. 999).

A representative of the Federal agency, testifying before the Senate Committee on Education and Labor on June 22, 1946, on a bill for Federal aid for medical services for all children under 21 years of age, took the position that Congress apparently had acquiesced in the policy by which the Federal agency prevents the States from using the facilities of the osteopathic profession and institutions in carrying out the programs involving medical services under the Social Security

Act.

Senator MILLIKIN. Is anyone connected with the Social Security Administration present who can say why the osteopaths were excluded? The CHAIRMAN. There does not seem to be any representative here at this time.

Dr. STARKS. We put in our program, in Colorado, of course, then this question came up that the Federal agency was the one who said that, because of the definition in the law.

Senator MILLIKIN. Under the law, as you have quoted it, I just cannot understand why osteopaths would be excluded.

Dr. STARKS. Well, we could not, either.

Senator MILLIKIN. You give medical service.

Dr. STARKS. That is right.

I sought legal aid and advice on that matter of acquiescence by Congress, and was informed that Congress cannot be said to acquiesce, or demur, to an administrative interpretation unless and until the interpretation has been properly brought to the attention of Congress. Lukens Steel Company v. Perkins (60 S. Ct. 869; 310 U. S. 113).

That is a principal reason why I am here today-to bring to the attention of this congressional committee which has jurisdiction over social-security legislation, this policy of the Federal Security Agency which tortures the language of the Social Security Act to deny to the States the right to help crippled children by utilizing osteopathie services under the social-security program.

I said the States knuckled down. An impasse is apparently in the making in Kansas. The Kansas Legislature passed a law, approved April 2, 1949, expressly including doctors of osteopathy as physicians

qualified to render medical services under the crippled-children's program in that State.

Who is better able to judge the qualifications of the suppliers of medical care in such programs, the States or the Federal agency?

The House Appropriations Committee Report No. 450, recommending appropriations for the fiscal year 1944, sheds luminous light on that question 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 State. 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.

In Colorado, and a number of other States, osteopathic and medical candidates take the same examination before the same State board and receive the same State license to practice medicine and surgery. In more than half the States the scope of the osteopathic license is equivalent to that of doctors of medicine. Most States license the practice of major operative surgery.

The American Osteopathic Association is the generally recognized agency for accrediting schools of osteopathy and surgery. However, several State medical boards have made personal inspections of all osteopathic schools preliminary to examinations of osteopathic applicants for unlimited licenses to practice and found them to be institutions furnishing training of comparable scope and quality to that provided in recognized medical schools.

Evidence that Congress has considered the training accorded in Osteopathic and medical institutions as comparable is furnished in the act regulating the practice of the healing art in the District of Columbia which states:

The degrees, doctor of medicine and doctor of osteopathy, shall be accorded the same rights and privileges under governmental regulations.

The Congress, as you know, included that in the act of February 27, 1929 (45 Stat. 1329).

Another example of the recognized comparable quality of training in medical and osteopathic colleges is to be found in the Medical Service of the Veterans' Administration. In 1946 Congress prescribed that to be eligible for appointment in the Medical Service of the VA Department of Medicine and Surgery an applicant must

hold the degree of doctor of medicine or of doctor of osteopathy from a college or university approved by the Administrator, and have completed an internship satisfactory to the Administrator, and be licensed to practice medicine, surgery, or osteopathy in one of the States or Territories of the United States or in the District of Columbia.

In administering that law, Gen. Paul R. Hawley, then Chief Medical Director of the Veterans' Administration, took the position that there could not be two standards of proficiency in the Medical Service; and that as soon as he should become satisfied of the equivalence of osteopathic and medical education he would recommend appointment of osteopathic applicants. He was so satisfied. All osteopathic colleges and all intern-training hospitals approved by the American

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