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would receive such care, subject to the limitations hereinafter discussed, without being concerned about the cost of the services to be received. The services would, of course, be paid for, but they would be paid for out of the personal health service ccount in the United States Treasury established by the bill.

Persons entitled to receive personal health service benefits

These rights to personal health service benefits would be vested in substantially ill employees in industry and commerce, agricultural and domestic workers, 'mployees of nonprofit institutions and, in addition, all persons self-employed in business or a profession. The benefits would be available not only to the emloyees and self-employed persons, but would be available also to their wives or lisabled husbands, their children under 18, or children of any age if disabled, and heir dependent parents.

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In addition, these benefits would also be available to all persons entitled to old-age and survivor benefits, under the Social Security Act, even if they do not qualify directly for personal health service benefits. Furthermore, the indigent persons in our country, who are at present dependent upon local and State public Assistance and relief (32 million persons in 1944) could be covered for personal health service benefits under the bill if the public agencies responsible for their are arranged to make payment for their personal health service benefits." Federal, State, and local government employees are excluded," but Federal, State, and local public agencies may, by arrangement with the Surgeon General, secure health service benefits for their employees by making working arrangements for reasonable reimbursement 16 to the trust fund.

Personal Health Service Benefits Provided

These benefits include general medical benefits," special medical benefits,18 general dental benefits," special dental benefits,20 home nursing benefits," laboraory benefits,22 and hospitalization benefits.23

Sec. 202, p. 35.

Sec. 209 (a), pp. 55-56. Under the bill the Federal Government would contribute up to 75 percent to the States for medical care of needy persons (pt. C, secs. 131-137, pp. 26-34). However, this is not mandatory, and if the public agency concerned does not nake the arrangements, the indigent under its jurisdiction will not be covered. The sick ndigent need medical care often more acutely than others. The inadequacies of medical are sometimes provided by some of the public-assistance and welfare agencies is well established. (NRPB, pp. 89, 203, 460, 461, 520, 521.)

15 Sec. 217 (b) (3) and (4), p. 74.

Sec. 209, pp. 55-56. This provision does not assure health service benefits to Governnent employees. On principle, there is no reason why the health of Government employees should not receive, as a matter of right, the protection available to the rest of he working population.

"The term 'general medical benefit' means services furnished by a legally qualified physician or by a group of such physicians, including all necessary services such as can be furnished by a physician engaged in the general or family practice of medicine, at the office, home, hospital, or elsewhere, including preventive, diagnostic, and therapeutic treatment and care, and periodic physical examination" (sec. 214 (b), p. 65).

38 The term 'special medical benefit' means necessary services, requiring special skill or experience, furnished at the office, home, hospital, or elsewhere by a legally qualified physician who is a specialist or consultant with respect to the class of service furnished, by a group of such physicians, or by a group of physicians including such specialists or consultants" (sec. 214 (c), pp. 65-66).

19 "The term 'general dental benefit' means services furnished by a legally qualified dentist or by a group of such dentists, including all necessary dental services such as can be furnished by a dentist engaged in the general practice of dentistry, with or without the aid of an assistant or hygienist under his direction, and including preventive, diagnostic, and therapeutic treatment, care and advice, and periodic examination" (sec. 214 (d), p. 66).

29 The term 'special dental benefit' means necessary services, requiring special skill or experience, furnished at the office, hospital, or elsewhere by a legally qualified dentist (with or with the aid of an assistant, a hygienist,, or anesthetist under his direction) who is a specialist or consultant with respect to the class of service furnished, by a group of such dentists, or by a group of dentists, including such specialists or consultants" (sec. 214 (e), p. 66).

"The term 'home-nursing benefit' means nursing care of the sick furnished in the home by (1) a registered professional nurse, or (2) a practical nurse" under special qualifications (sec. 214 (f), pp. 66-67).

"The term laboratory benefit' means such necessary laboratory or related services, supplies, or commodities as the Surgeon General may determine, including chemical, bacteriological, pathological, diagnostic and therapeutic X-ray, and related laboratory services, refractions, and other ophthalmic services furnished by a legally qualified practitioner other than a physician, physiotherapy, special appliances prescribed by a physician, and eyeglasses prescribed by a physician or other legally qualified practitioner

(sec. 214 (g), p. 67).

Sec. 214 (h), pp. 67-68, discussed in text below.

85907-46-pt. 1—16

There is no limitation to medical benefits and they are to be provided the extent to which they are necessary." They are to be provided by genera. practitioners and specialists, practicing individually and as groups, and a legally qualified physicians would entitled to be listed as general practitioners Patients would have free choice of selection from among the physicians listed and in the same way as they do now, physicians may decide what patients the will treat.

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The hospitalization benefit, which is limited to 60 days (although this ma be increased to 120 days in a year following the determination of the adequa of the fund to permit such increase), is an amount not less than $3 and more than $7 for each day of hospitalization for the first 30 days; not less tha $1.50 or more than $4.50 for days of hospitalization exceeding 30; and not less than $1.50 or more than $3.50 for each day of care in an institution for the ca of the chronic sick. Hospitalization benefits are not available for treatment a hospital or other institution for mental or nervous diseases or tuberculos although hospitalization benefits may be granted for tuberculosis or phychoss for 30 days following diagnosis thereof.26

Persons entitled to medical, hospitalization, and related benefits under ar workmen's compensation law are not entitled to personal health service benet's with respect to the same injury or disease."

Compensation of Physicians

The bill provides that the professional personnel furnishing medical care > entitled to assurance of adequate compensation, "especially in terms of an income or its equivalent and by reference to annual income customarily receives among physicians, dentists or nurses having regard for age, specialization, at type of community; and payments shall be commensurate with skill, experien and responsibility involved in furnishing service." 28 The Bill provides that 2compensation of physicians would be paid to them out of the insurance fu on: (1) a fee basis, according to a fee schedule approved by the Surgeon Gener. or (2) a per capita basis, according to the number of individuals on a fr titioner's list, or (3) a salary basis, for whole or part time service, or (41) combination or modification of these, as the Surgeon General may approve, `a cording in each local area as the majority of the general medical and far practitioners or of the general dental practitioners, respectively, to be paid for such services shall elect," provided that the Surgeon General may also mai payment by another of these methods to those doctors who do not elect method of the majority, and the Surgeon General may negotiate arrangem with hospitals or groups."

Administration

The responsibility for administering the medical and hospitalization benef1» is vested in the Surgeon General of the United States Public Health Service, br he must perform his duties under the supervision and direction of the Feder Security Administrator, after consultation with the National Advisory Medic Policy Council as to questions of general policy and administration, and furti~* in consultation with the Social Security Board as to the most effective metho

24 Sec. 210 (a), p. 57, authorizes the Surgeon General to require payment of a fee! benefits, if necessary "to prevent or reduce abuses." With respect to dental and he nursing benefits, it is provided that the Surgeon General may restrict the contents ther but after July 1, 1947, the restricted content of dental benefits shall include at least amination, including X-ray, diagnosis, prophylaxis, extraction of teeth that may be sidered injurious to the individual's health, and treatment of acute diseases. The det mination may fix an age above which the restriction of content shall apply. With respe to home nursing, restriction of content may be by providing part-time care on an ho or visit basis, or by limitation of amount of maximum service per case (sec. 210 p. 58).

25 Sec. 205, pp. 45-51.

28 Sec. 214 (h), pp. 67-68; sec. 210 (c), (d), p. 59. The question should be consider whether it would not be better to avoid limiting hospitalization benefits to specific mat mum and minimum money benefits. It should be noted that the bill permits the Surg General (1) to enter into contracts with hospitals for the payment of the reasonable of hospital service, within the specified minimum and maximum rates, and (2) to contr for the inclusive services of a hospital and its attending staff (sec. 214 (h), pp. 67-6 sec. 205 (g), pp. 48-49; sec. 203, pp. 35 fl).

27 However, a workmen's compensation agency may enter into contractual arrangement with the social-insurance system to have all medical benefits under the workmen's com pensation law provided through the social-insurance system (sec. 209 (b), pp. 56–57). 28 Sec. 205 (1), pp. 49-50.

29 Sec. 205 (g), pp. 48-49.

of providing benefits and as to legislation and methods of administration policy." Contracts for services and facilities made by the Surgeon General require approval of the Federal Security Administrator and consultation with the National Advisory Medical Policy Council." This Council is established to advise the Surgeon General with respect to questions of general policy and administration, professional standards, methods and arrangements for furnishing the services, and the establishment of special advisory, technical, local or regional boards, committees, or commissions. The Council is to consist of members selected by the Surgeon General, with the approval of the Federal Security Administrator, from panels of ames submitted by medical, professional and other organizations concerned with nedical services and education, the operation of hospitals, and public representatives in such proportion as is likely to provide fair representation to the principal interested groups that furnish and receive benefits. In his annual report the Surgeon General would be required to include a record of consultations with the Advisory Council and of its recommendations.33

The Surgeon General is required, insofar as practicable, to "give priority and preference to utilizing the facilities of State and local departments or agencies on the basis of mutual agreements with such departments and agencies." "

The bill declares explicitly in a section entitled "Methods and Policies for Administration," that the methods of administration, including the methods of making payments to practioners, shall

"(1) insure the prompt and efficient care of individuals entitled to personal health service benefits; (2) promote personal relationships between physician and patient; (3) provide professional and financial incentives for the professional advancement of practitioners and encourage high standards in the quality of servics furnished as benefits under this title through the adequacy of payments to practitioners, assistance in their use of opportunities for post-graduate study, coordination among the services furnished by general or family practitioners, specialists and consultants, laboratory, and other auxiliary services, coordination among the services furnished by practitioners, hospitals, public-health centers, educational, research, and other institutions, and between preventive and curative services, and otherwise; (4) aid in the prevention of disease, disability, and premature death; and (5) insure the provision of adequate service with the greatest economy consistent with high standards of quality."

2. MEDICAL EDUCATION AND RESEARCH

The Surgeon General is directed to administer grants-in-aid to nonprofit institutions engaged in medical research and professional education, providing for the education or training of persons to furnish medical, dental, nursing, hospital, laboratory and related benefits, "or to human knowledge with respect to the cost, prevention, mitigation or methods of diagnosis and treatment of disease and disability." During the first 5-year period, preference shall be given to projects to aid servicemen. For these purposes, there is to be available $10,000,000 for the year 1946, $15,000000 for the year 1947, and for each year thereafter an amount equal to 2 percent of the amount expended for medical care benefits in the last preceding year.

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3. FINANCING

A "Personal Health Services Account" is established in the Treasury. Sums sufficient to finance the benefits provided are authorized to be appropriated to this account. From these appropriations, there is to be credited to the account amounts equal to 3 percent of wages or remuneration received by employed and self-employed persons up to $3,600 per year in covered employment, the cost of dental and home nursing benefits, the amount expended for social security beneficiaries who become insured before the bill goes into effect, and, in addition, reimbursements to the account made on behalf of noninsured persons entitled to personal health service benefits, such as needy persons, specially provided for as hereinafter indicated."

Sec. 203 (a), pp. 35-36.

"Sec. 203 (c), pp. 36-37.
Sec. 204 (a), (b), pp. 41–44.

"Sec. 203 (1), p. 41.

Sec. 203 (e), pp. 37-38.

Sec. 205 (f), pp. 47-48.

Sec. 213, pp. 63-64.

*Sec. 212, pp. 61-63.

While no tax is imposed by this bill, it is probable that the bill's sponsors wi later propose a 3 percent pay-roll tax on wages of employed persons up to $3,60 per year (probably to be paid half by the employer and half by the employee and a tax on self-employed persons of 3 percent of their earnings up to $3,0* per year. The sponsors of the bill take the position that it is in the interest ( the national health and welfare that a system of medical, dental, nursing and hospital care be made available to substantially the working population of the United States. How the money is to be raised can be determined later. This leaves for subsequent consideration the question of whether the moneys are come out of general revenues, or out of ear-marked taxes; it leaves for late consideration the question as to whether financing should be on a pay-as-you-g basis, or whether reserves should be set up for future operations.

This is wholly sound. The Congress has, ever since the founding of our Natirt appropriated moneys urgently required in the public welfare without first deter mining upon the source of the funds. It would be unthinkable for the Congres to postpone appropriating moneys for military supplies for the waging of wa or for meeting any urgent national need until the sources of the funds were first determined. In the same spirit, the Congress should meet its responsibility: create an urgently needed national system of health care.

II. GRANTS TO STATES FOR HEALTH SERVICES AND FOR MEDICAL CARE FOR NEET

PERSONS

1. HEALTH SERVICES

In addition to the provision of medical care, it is a matter of urgent pub..... importance that Federal, State and local public health services be continued an largely expanded. It has been pointed out that there are still 40,000,000 pe: in this country who live in communities where there are either no local hea services at all or where such services are provided only by inexperienced, partime health officers. Most of these areas spend less than half of the $1 a pers: a year that is needed to pay for such essentials as collecting vital statist providing public health laboratory services, controlling communicable diseas securing decent sanitation, providing for the hygiene of mothers, infants, a: school children, and carrying out a necessary program of health education. A least $2 a person is needed for a really complete program, including necessar public health nursing service. We cannot rest satisfied until every one of 3,070 counties has an adequate local health service."

The bill proposes increased grants to the States for (a) public health servic and (b) maternal and child health services.

(a) Public health services.-The bill proposes to reenact two special pub health programs dealing with venereal diseases and tuberculosis. It also enlarge the general national public health program.

With respect to the special venereal diseases program, the bill would reena existing legislation which appropriates a sum sufficient to enable the Surge General to assist the States and localities to establish and maintain adequatmeasures for the prevention, treatment and control of these diseases." W respect to the special tuberculosis program, $10,000,000 is appropriated for t first year and thereafter yearly a sum sufficient to enable the Surgeon Gener to assist the States and localities in establishing and maintaining adequa measures for dealing with this disease." The appropriations for these prograc are to be allotted among the several States on the basis of their respective pep lations, the size of their problems and their financial needs.“

With respect to the general national public health program, the present authen zation of $20,000,000 per year is replaced by authorization of an appropriat ** of a sum sufficient to extend and improve public health work, especially in rur. communities, in economically depressed areas and in other communities whe such services are below nationally accepted standards of adequate public hest

38 Winslow, op. cit., p. 20.

30Sec. 314 (a), Public Health Service Act, as amended by sec. 101, p. 2.

40 Id., sec. 314 (b), pp. 2-3.

41 Id., sec. 314 (c), pp. 3-4. The 1939 Report of the Interdepartmental Committee * Coordinate Health and Welfare Activities urged that Federal grant-in-aid should expanded for special programs dealing with penumonia, cancer, malaria, mental hygie and industrial hygiene in the domain of public-health service work, in addition to speci programs dealing with venereal diseases and tuberculosis. It is to be regretted that the bill limits special grants to the two fields of venereal diseases and tuberculosis.

services. In order to receive the Federal grants, States are required to develop their own plans in accordance with their own needs and to submit these plans for pproval by the Surgeon General. The amounts of the grants range from 50 to 15 percent of the total public funds expended under approved State programs inder a formula based upon the relationship of the per capita income of the State to the national per capita income, the States with lower relative per capita ncome receiving the larger grants.**

(b) Maternal and child health services.-Two programs are here involved: (1) maternal and child health services and (2) services for crippled or othervise physically handicapped children. For each of the two services, State plans must be submitted to and approved by the Chief of the Children's Bu'eau. The State plans must provide that the services and facilties will be vailable to all mothers and children in the State or locality who elect to participate in the respective programs." Federal grants for each of the programs are from 50 to 75 percent of the total public funds expended under the espective State programs. The formula for determining the amount of the grant is the same as for public health services, giving greater aid to the poor States." For the maternal and child health services and for the crippled and handicapped children a sum sufficient is authorized to be appropriated each year, nstead of present appropriations of $5,820,000 annually for maternal and child health services and $3,870,000 annually for crippled children's services."

2. GRANTS TO STATES FOR MEDICAL CARE OF NEEDY PERSONS

The Wagner-Murray-Dingell Social Security bill proposed a new complete Federal-State comprehensive public assistance prograin by grants-in-aid to States of between 50 and 75 percent of the cost of State plans for public assistince." It was intended that such State comprehensive public assistance plans should include medical care for needy persons. The proposed new National Health Act would adapt these public assistance provisions of the former bill to provisions for medical care for the needy by establishing grants-in-aid to States of 50 to 75 percent of the cost of State plans for medical care of needy persons." Such medical care could be provided (1) by the State or local public assistance agency through money payments to individuals, payments to persons or instiutions furnishing care or direct provision of such care, (2) by other agencies of the State, (3) through arrangements with the Surgeon-General to furnish services under the medical care system established by this hill, or (4) through 1 combination or modification of these methods.18

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The need for providing medical care for needy persons who would not be covered by the medical care insurance provisions of the bill is as essential as the provision of such assistance to persons not protected by social insurance. The bill's proposals to provide such medical care would meet an urgent need for those who are altogether unable to meet its cost and whose medical needs are greatest.

III. THE OBJECTIONS TO THE NATIONAL HEALTH PROGRAM ARE WITHOUT MERIT

The bill has been subjected to violent attack." Generally, only the medical care portion of the health program of the bill has been the object of the attack. Those who have attacked the bill have generally ignored the beneficent and desperately needed health proposals of the bill other than its proposals for medical care.

In essence, the argument of the opponents is that these provisions would bring about a system of State medicine or socialized medicine and would destroy the private practice of medicine in the United States. These contentions

Id., sec. 314 (f), pp. 4-10.

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Secs. 122 (a) (8), 124 (a) (5), pp. 16, 18. The maternal and child-health services are to be administered by the State health agency.

Sec. 125, pp. 19-21.

Sec. 121 (a), pp. 13-14; cf. Social Security Act, as amended, secs. 501, 511. Under the present title V of the Social Security Act there is a 50-50 matching of State expenditures on services for crippled children (sec. 514) and on part of the funds for maternal and child-health services (sec. 504a, referring to sec. 502a).

S. 1050, pp. 56-65.

47 Pt. C. pp. 26-34.

48 Sec. 136 (b), p. 34.

See literature by John M. Pratt, published by the National Physicians' Committee for Extension of Medical Service, Chicago.

Kingsbury, Health in Handcuffs (supra, note 5), p. 18; Need for Medical-Care Insurance (supra, note 3), p. 23.

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