to finance medical care and bring it within reach of all the people of the United States. Accordingly it supported the health and medical features of the Wagner-Murray-Dingell bill of 1943. A detailed analysis of this part of the bill was made, and constructive criticisms for its improvement were offered to its sponsors. Many of the suggestions offered by the Physicians Forum and by other organizations that gave thoughtful consideration to the bill were incorporated in a subsequent draft.

A new bill, Senate bill 1606, has been introduced into the Senate by Senators Wagner and Murray, and into the House of Representative Dingell (H. R. 4730). The new bill is devoted to the establishment of a health insurance plan designed to supply nearly complete health and medical care to individuals and their families throughout the country. In addition, more funds are made available for public health services; for maternal and child health care, including services for crippeld children; and for medical care of needy persons.

Several important features of the bill warrant emphasis because of the fallacious statements that have been made about it.

A very adequate system of checks and balances in administration has been established. The Surgeon General is advised by a National Advisory Council representing the professions rendering services and the public. The decisions of the Surgeon General are subject to the approval of the Federal Security Administrator.

Local autonomy and control is strongly emphasized and provided for in the bill. Only financing and over-all policy are formulated on a strictly national basis. It is definitely stated in the provisions for all of the health programs called for in both titles of the bill that national administrators are to have no authority over the selection, tenure of office, or compensation of local personnel employed on a merit basis according to established standards. Nor shall there be any national control over the administration, personnel or operations of participating hospitals and institutions.

The administrative costs as well as the total costs would be small considering the benefits. Experience with the social security system has demonstrated the efficiency of operation and low administrative cost of this branch of the Government. The total money to be utilized for medical services assured in the bill is approximately the same as the American people spend today for these same services.

All people will have free choice of physicians, and physicians under the plan can accept or reject patients and can practice outside the plan as well as under it if they so choose. As a matter of fact, private practice will be greatly increased because millions of people now attending public clinics will, through health insurance, become private patients.

The Wagner-Murray-Dingell bill provides the best method for protecting and preserving the health of our nation. The passage of these provisions is essential to the well-being of the United States in the coming years.

The bill has two titles:

Title I: A. Public health services; B. Maternal and child health services; C. Medical care for needy persons.

Title II: Prepaid personal health service benefits.

TITLE I

Increased grants to States for public health services

This part of the bill is an amendment of section 314 of the Public Health Service Act of July 1, 1944. The subsections concerned with grants for the venereal disease and for the tuberculosis programs are unchanged. Those dealing with general public health work provide Federal cooperation with the States and coordination of various health programs to achieve as rapidly and as economically as practicable the development of adequate public health services in all parts of the country. The present authorization of $20,000,000 a year for grants to States is replaced by an authorization to appropriate a sum sufficient to carry out the purpose.

To receive Federal grants for public health services the States are required to develop their own plans and to submit these plans for approval. The proportion of grants to States is determined by an explicit formula, designed to give relatively more aid to the poorer States and less to the richer States. Federal grants range from 50 to 75 percent of the total expended under the approved State programs. Grants must be approved by the Surgeon General if they meet the requirements specified in the law. Programs must be State-wide in scope by 1949.

Comment

The present system of grants-in-aid and cooperation between the United States Public Health Service and the States in the promotion of public health services has been very successful, but limited in scope. Under the provisions of the bill it will be possible to expand these programs rapidly, and in particular to help those States that are in greatest need. We approve of this section.

Increased grants to States for maternal and child health services

This section makes more elastic and adequate provisions than the existing programs for each State to extend and improve services and facilities for mater nal and child health and for crippled children. As in the case of grants for pub lic health, States develop their own plans in accordance with their needs. These must conform to certain basic requirements to insure reasonable standards, 5tematic and efficient financing and administration, extension of the services to all parts of the States within 10 years and availability to all mothers and chil dren in the State. Demonstration services and personnel training are to be developed under the State plan. The Chief of the Children's Bureau is the re sponsible administrator who must approve all plans. Federal grants would be on a variable basis, so as to give special aid to the poorer States. Federal grants would range from 50 to 75 percent of the total expended under the ap proved State programs. Wide latitude is left to the States as to the scope and content of the programs. No specific appropriations are made, but expenditures necessary to carry out the program are authorized.

In addition an appropriation of $5,000,000 is made to the Children's Bureau during the first year to make special studies and investigations to promote ciency in this program, to establish policies in consulation with advisory com mittees, to make and publish rules and regulations and to coordinate Children's Bureau activities with those of the Public Health Service and the Social Security Board. In subsequent years the appropriation is to be a sum sufficient for these purposes.

Comment

The purpose of this section of the bill is admirable, and the forum approves an expansion of services. However, if we are to have a national health insur ance program, as called for in title II of this bill, care should be taken to prevent any overlapping of services. As President Truman pointed out in his message to Congress: "Federal aid for community health services-for general public health and for mothers and children-should complement and not dup cate prepaid medical services for individuals." Maternal and child health serv ices should be limited to community-wide services on the basis of filling a′′f need not covered by national health insurance, and the program should be care fully integrated with the over-all plans for health and medical services. De spite the Children's Bureau's enviable record of solid achievement in its present maternal and child health program, it would nevertheless seem desirable to coordinate this program with the general health services under the direction of the Federal Security Agency.

Medical care of needy persons

This section provides Federal grants-in-aid to States for medical care of needy persons. The grants range from 50 to 75 percent of the total expended, depending on the State's per capita income. An appropriation of $10,000,000 is made for the first year, and for each year thereafter a sum sufficient for the purposes Federal grants are made after approval by the Social Security Board. State plans to be approved by the Board must be in effect in all parts of the State, must be efficiently administered by a single State public assistance agency and must include no citizenship or residence requirement.

Medical care may be provided through money payments to claimants or through payments to those furnishing the care or by direct provision of such care. The State may arrange with the Surgeon General to make equitable payments ints the personal health services account and thus supply medical care to the needs under the national health insurance plan as set up under title II of this bill Comment

At present States receive no grants for medical aid for general relief cases. Federal grants of 50 percent of the State and local expenditures, up to a fred maximum regardless of the financial capacity of the State and the locality, are at present provided in assistance for the needy aged, the needy blind, and dependent

children. More specifically, Federal grants are made only for amounts paid unconditionally to the relief recipient or his guardian. The requirement of a direct grant and a monthly maximum limit greatly the effective provision of medical services for indigent groups.

The new bill removes these limitations. It permits Federal grants for all indigent groups, it removes the maximum, it makes larger grants to States with per capita income below the national average, it provides grants for medical care whether it is paid for by cash grants to the recipient or directly to those furnishing these services. In fact, it allows the States and localities to contract with the insurance program to provide medical services to indigent individuals— who are not insured under the prepaid medical service plan-on the same basis as for the insured and their dependents. If the latter course is followed the invidious distinction of charity patients will be abolished, physicians will give the same care to all and will receive like compensation for all groups of patients from the insurance fund. The number of pay patients to be cared for by private physicians will thus be increased.

The forum strongly disapproves of the use of Federal grants-in-aid for direct payments to patients for medical care-a method too easily abused, perhaps by inadequate payments, perhaps by failure of the patient to use the payment for medical purposes. The only sound method of supplying medical care to relief cases is by grants the proceeds of which are used to insure such people under the national health insurance fund.

TITLE II-PREPAID PERSONAL HEALTH SERVICE BENEFITS-NATIONAL HEALTH

Coverage

INSURANCE

All individuals are to be considered insured for medical care if they have been employed and have been paid not less than $150 in the base year. Coverage is also extended to all legal dependents of such employed persons. All retired and survivor beneficiaries under the Social Security Act are entitled to receive personal health service benefits. Employed persons are to be considered insured irrespective of citizenship or residence. Coverage for medical care under this ill extends beyond the groups now benefiting from the Social Security Act. Included are all persons in industry and commerce, agricultural and domestic workers, seamen, employees of nonprofit institutions (except ministers and members of religious orders), and self-employed persons such as small businessmen, farmers and professional persons. Not included are those employed-and covered by existing pension systems-by the United States Government, by a State or in any service exempt from income tax. States may enter into contracts with the Surgeon General to make the medical care program available to the unemployed needy.

Jomment

Under the provisions of the bill, medical coverage would include upward of 10 percent or more of the entire population in one medical care program. This is as it should be, for the need for health insurance arises from the fact that the Fast majority cannot afford to pay individually for adequate medical care. American Medical Association figures show that 75 percent of all American families need financial assistance to pay for any serious illness.

It has been suggested by some that initially the coverage should be limited to a 'raction of the population and that the benefits should be extended gradually as xperience accumulates. Limitation of coverage to certain occupational groups or to geographic areas would be inequitable. Limitation by setting an income eiling eligibility, say an income of $3,500, would exclude only a small fraction of the population and would make administration of the act more difficult, not asier. The forum approves the broad coverage proposed in the bill. Personal health services account

The bill calls for the creation, by the United States Treasury, of a personal health services account and authorizes appropriations to finance the medical are benefits. From the appropriations, the Secretary of the Treasury is to redit to the account the equivalent of 3 percent of all wages up to $3,600 a year, Is well as certain additional amounts spent for special health benefits and for administration. The bill does not state how these sums are to be raised, but eaves this decision up to Congress. Previous drafts of the bill, however, have

called for equal payments by employer and employee on a social-security basis. with supplementation from general tax funds.

Comment

Today the Nation as a whole spends $4,000,000,000 a year on medical care. The total amount expended for compulsory health insurance will not be significantly higher than this aggregate amount. The advantage would be that persons woul not be called upon as individuals to meet the heavy obligations imposed by the need for medical care, and they would feel free to seek medical services as soe as needed.

The forum believes that it would be sound policy for Congress to legislate a distribution of national health insurance costs between employer and employee. with supplementation from general tax funds, as called for in earlier drafts of this bill. With the worker and employer contributing directly to the cost of social insurance they would be more apt to take an interest in the proper admir istration of the whole program. Such direct payment by the persons benefiting would take medical care out of the realm of charity, with which public medicine has been stigmatized, and would make it a right. As in existing social security legislation the employer would contribute an equal amount. The benefits to the employer, derived from proper care for the health of his employee, are wel recognized. If additional provision were made for appropriations by the Federa Government out of general tax funds, it would safeguard the program, give it a certain elasticity and allow for some experimentation.

Benefits

All insured persons and their dependents are entitled to the service of a generai practitioner in home, office, or hospital; services of specialists and consultants complete laboratory services including X-ray and physiotherapy; special med cal appliances, including eyeglasses; hospitalization; general and special denta. services, and home nursing.

Limitation on benefits.-The Surgeon General, after consultation with the National Advisory Medical Policy Council and with the approval of the Federa Security Administrator, may require that for any calendar year the patient pay the physician, dentist or nurse a fee for the first service or for each service in a period of sickness. Such decision shall be made only when it becomes necessary to prevent or reduce abuses, but the maximum size of such a fee shall not be great as to interpose a substantial financial restraint on proper care. Such feer may be limited to home calls, to office visits or to both. Each such determination shall be withdrawn as rapidly as practical.

In the same manner, if personnel is inadequate the dental benefits may be restricted provided that after July 1, 1947 they shall include at least: (1) examination including X-ray and diagnosis; (2) prophylaxis; (3) extraction ." teeth which may be injurious to the general health of the individual; (4) treatment of acute diseases of the teeth, their supporting structures and adjacent parts, including fractures of the teeth or jaws. Complete dental care may provided to children under a specified age. Home-nursing benefits may be : ited to part-time care, or by limitation of cases, or by limitation of maxi service per case as may be practicable and necessary. Similarly the laboratory benefits may be curtailed if funds become inadequate.

Comment

The provision that, if it should become necessary to prevent abuses, the patient may be required to pay a fee for the first service or for each service in a period of sickness is unfortunate. Should this ever be applied it would set up a finan cial barrier between the insured person and the doctor, a barrier which health, insurance is supposed to remove. It would tend to delay early recognition treatment of disease. It would offer financial inducement to the physician increase the number of his visits. If abuses arise that threaten the integrity the insurance fund, it is better that they be regulated by the operation of los committees on which physicians are fully represented. A possible limitation laboratory, dental and nursing benefits is also unfortunate, but may become necessary until more administrative and actuarial experience has become at cumulated and more professional personnel is available.

Administration of personal health benefits

The Surgeon General of the United States Public Health Service admiste the technical and professional aspects of the program, under the supervis and direction of the Federal Security Administrator. He is required to cons? I

with the National Advisory Medical Policy Council as to questions of general policy and administration, and with the Social Security Board in regard to health legislation and methods of providing personal health service benefits most effectively.

The National Advisory Medical Policy Council consists of the Surgeon General as Chairman, and 16 members to be appointed by the Surgeon General with the approval of the Federal Security Administrator. The members shall be selected from panels of names submitted by professional and other agencies and organizations concerned with medical, dental and nursing services and education and with the operation of hospitals and laboratories and from among other persons, agencies or organizations informed in the need for medical, dental, nursing, hospital, laboratory, or related services. It is to include medical and other professional representatives, and public representatives in fair proportions. Members are appointed for a term of 4 years and are arranged in four classes so that four members are appointed every year. Members receive compensation at the rate of not more than $25 a day and travel and subsistence expenses for the time devoted to official business.

The advisory council shall meet at least twice a year and whenever at least four members request a meeting. It and its members shall be provided with adequate clerical and secretarial assistance. It shall advise the Surgeon General with reference to questions of general policy and administration including: (1) professional standards of quality; (2) designation of specialists and consultants; (3) methods to encourage the attainment of high standards through coordination of the services of physicians and dentists with those of educational and research institutions, hospitals and public health centers; (4) standards for hospitals, coordination among hospitals and the establishment of a list of participating hospitals; (5) suitable methods of paying for personal health service benefits; (6) studies of the quality and adequacy of personal health services; (7) grants-in-aid for professional education and research.

In regard to most questions of policy the bill directs that the Surgeon General must consult the advisory council before taking action. Also the Surgeon General, in his report to each session of the Congress, must include a report of consultations with the advisory council, recommendations of the council and his comments thereon. This assures that there will be public information as to whether the Surgeon General is or is not consulting and taking the council's advice and makes public what its recommendations are.

The advisory council may establish similar advisory and technical committees on regional and local levels.

Organization.-In the administration of the personal health benefits the Surgeon General shall, insofar as practicable, give priority and preference to utilizing the facilities and services of State and local governmental departments and agencies on the basis of mutual agreements. Local area committees, selected from panels submitted from the professional and other agencies for health services, shall be appointed to aid in administration. Such committees shall include representatives of insured persons and medical and other professional representatives. These committees shall be consulted frequently and shall be kept informed by Public Health Service officers with respect to policies and the availability of benefits. They are authorized to make annual and special reports with recommendations either to the local aréa officers or to the Surgeon General through the State or regional officers. Wherever the State is the local cooperating agency, the State shall appoint such committees.

Policies and methods for administration.-Any physician, dentist or nurse legally qualified by a State may furnish services under this bill. Specialists or consultants who are to be entitled to special rates of payment are, however, to be designated by the Surgeon General from among qualified practitioners. Such specialists or consultants shall be chosen in accordance with general standards prescribed after consultation with the advisory council, and after taking into account their profession experience and skill. A group of qualified physicians, dentists or nurses may furnish services.

Beneficiaries may freely choose their physicians and dentists, or groups of physicians and dentists, and they have the right to change their selection. Physicians have the right to refuse patients. The services of a specialist or consultant shall ordinarily be available only upon the advice of the general practitioner. They shall also be available when requested by the individual and approved by the medical administrative officer. Lists of qualified practitioners and groups of practitioners, and of specialists and consultants shall be published and made available to the beneficiaries by the Surgeon General. Doctors who