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tary plan for setting up a well-conceivaed progrm that can be put into effect slowly and gradually in an orderly manner, There appears to be nothing in this bill that justifies Dr. Wall's use of the phrase 'revolutionary changes in the practice of obstetrics and pediatrics. There is nothing in the bill that changes the doctor's role or independence in the performance of professional duties or his relation to patients, other than the fact that his payment is assured by a public agency instead of being dependent upon the economic status of the patient. Health and medical care to the extent of $900,000,000 per year is now being financed by Government moneys.
Much of what Dr. Wall has said represents fantastic interpretations. As a member of the American Academy of Pediatrics, for which Dr. Wall appeared this morning, I wish to record with this committee the fact that a large number of the members of the academy do not endorse Dr. Wall's statement. His statement represents personal rather than academy interpretation of the bill. This is evidenced by an article written by Dr. Edwards A. Park, of Johns Hopkins, in the March 1946 issue of the Journal of Pediatrics, entitled 'Social Aspects of Medicine.' This statement of Dr. Park has been highly praised by not only a larger number of the members of the academy but possibly by a majority of the members.
“The academy, in its statement concerning S. 1318, stated, 'For these reasons the American Academy of Pediatrics believes that the Maternal and Child Wel. fare Act of 1945 (S. 1318) does not represent the best form of legislation for the purpose for which it was written.' This statement is hardly one of 'unanimous disapproval’ as stated by Dr. Wall.
"The bill before you could, with but slight modification, initiate the first step in a legislative-health program in a logical way. The first way would be to limit the children who are covered by this legislation on the basis of age, as suggested by Dr. Getting. In other words, children up to 2 years of age might be provided the services designated in the bill the first year, children of 3 years of age or 4 years of age so covered in the second year, the expansion in coverage according to age being determined by the capacity for adequately handling an expanded program. The second way of putting this legislation into effect gradually would be by starting the program on an area basis—again with expansion determined as the capacity for so doing warrants.
“There are those that object to covering only a portion of the people in a Government program. I do not see the validity of this objection so long as the program is to be extended, as capacity for extension permits. Such a gradual extension is not unfairly discriminatory. It appears to me to be the logical way of avoiding a serious danger in a legislated medical-care program, namely, too big a program too suddenly.
“Now, very briefly, a few specific amendments.
"I especially endorse the following criticisms of the bill made by the American Academy of Pediatrics :
1. The bill excludes fee-for-service as a means of paying practitioners for service rendered.
“2. The bill makes inadequate provision for paying groups of physicians or institutions for professional services rendered.
"3. The bill does not specify that professional personnel, groups, or institutions do not accept supplemental payments.
“4. The bill endorses the Children's Bureau as the most suitable administrative agency of this major step in a national health program without assuring integration of the administrative functions and health services under this bill with other health activities of the Government. However, the recent reorganization of health services under plan 2 as ordered by the President may accomplish this integration.
“5. The bill does not satisfactorily define the Federal or State advisory committees as regards personnel, method of appointment, advisory and policy-making roles, or manner of giving authority to the record of consultations with and recommendations to the administrators at Federal and State levels. This is done excellently in S. 1606.
“6. The bill makes no provision for variation in remuneration for service according to the differing costs pertaining in various States.
57. The bill makes no provision for the prevention of arbitrary requests on short notice by the Federal administrative agency for reports from the State health agencies and similarly arbitrary requests by the State health agencies for reports from those rendering services.
"8. The provisions for handling claims are unsatisfactory.
“9. The bill fails to adequately specify reference to coverage of dental care in appropriate portions of the bill.
“10. The bill makes no adequate provision for the protection of the wellorganized and integrated teaching services on which the future quality of medical care is so dependent.
"11. The bill makes inadequate provision for the support and encouragement of research pertaining to the improvement of maternal and child-health services and medical care.
“12. The bill makes no provision for assuring 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.
"A letter which I wrote to Senator Pepper in December 1945 comments more fully on these and other points. I would like to submit excerpts from this letter as part of my testimony. [Attached.]
"Modifications could easily be incorporated in the present bill that would cover the points I have raised. If such were the case, I as an individual would heartily endorse the bill as the first logical and practical step in a national health program.
“Mrs. Meyer yesterday, as quoted in the morning paper, said that this bill 'cut across the President's reorganization plan. I see no justification in this charge. The preambles to the bill by both your chairman and Senator Pepper make adequate provision for coordination of this program with any further expansion of a national health program. The President's reorganization plan, if carried out wisely, would facilitate such coordination. Incidentally, Mrs. Meyer's attack on the Children's Bureau's activities during the war was most surprising. The record of the manner in which the Bureau carried out its emergency assignments and regular duties provide adequate answer to Mrs. Meyer's criticism.
“I see no reason why legislation should not be enacted now that would outline as I have mentioned the initiation of a program that could be expanded as the capacity of the country to administer and provide service is demonstrated.
"The opportunity at this committee has to initiate constructive and conservative action places a grave responsibility upon you. With the cooperation of doctors and public I see no reason why this Congress, under the leadership of this committee, should not meet that responsibility this year.”
In addition I would like to stress the weakness of arguments commonly used against such legislation; namely, that the same arguments apply equally if not more against voluntary plans. For example, the argument is used that the cost of a legislative prog-am administered by Federal and State agencies would be prohibitive. Yet the people who use this argument never state the cost of a voluntary plan which would give the same medical coverage to the same number of people. Should voluntary insurance be extended to cover what Government insurance under such a plan as the Wagner-Murray-Dingell bill will cover, the cost of the former would be as great if not greater than the latter. The competition of the voluntary schemes, except as it results in underpaying doctors or regimenting them, would be costly. The total number of people in all the voluntary administrative agencies would exceed those needed under a Government scheme. For under a Government scheme agencies could be used that exist and are functioning well today and must function tomorrow in order to administer the tax-supported medical care that must be administered by Government for the needy. Why not use these agencies instead of extravagantly creating new voluntary ones? Moreover, the performance of these Government agencies each year is critically reviewed by the Bureau of the Budget, the Congress, and the President before the Budget for the ensuing year is granted. This automatically assures a yearly check and public hearing, which it would be difficult if not impossible to assure for voluntary schemes.
The opposition also says that the people would tend to abuse a Government plan forgetting that the people already abuse every voluntary insurance agency by trying to collect everything possible. Indeed, a little thought indicates that most of the objections to a Government plan are not equally valid arguments against voluntary plans only if voluntary plans do not include as many people and as much care; that is, only if voluntary plans are not successful in meeting the need. The arguments of the opposition boil down to strangely indefinite statements such as the following:
1. A legislative program would be ill-conceived because Congress could not devise wise legislation. Legislation means politics and politics means graft.
2. A plan administered by. Federal and State agencies would be badly administered because all such agencies are incompetent.
3. The doctors and public would not respect such a service because all Government services reak with graft and are outrageously inefficient.
You should know better than I if these arguments are fair or insulting. If the former, why are we proud of our representative democracy? If the latter, why do people use them or permit their use by others?
For example, the testimony which Dr. Joseph Wall submitted to this committee concerning S. 1606 and concerning. S. 1318 to the Subcommittee on Aid to the Physically Handicapped of the House Committee on Labor, to which I referred in my statement before that committee, is an extraordinary reflection of a respectable and intelligent citizen's respect for his government. To acquiesce in his condemnation of your and public agencies' integrity and intelligence and his fantastic insinuations of your and their intent is not only a gross injustice to you and all the other individuals concerned but also a shocking commentary on the state of the Nation and the future promise of democracy. I am sure Ahis personal statement does not reflect the considered opinion of the American Academy of Pediatrics. I am equally sure that much of the similar testimony presented by physicians does not represent the considered opinion of the majority of American physicians. Instead, it must be a reflection of a group response to emotions aroused by the propaganda cleverly presented by leaders who dominate the group.
In considering this legislation we must rely on such facts as are available.
The record shows that the progress and manner of developing voluntary medical (not hospital) insurance is unpredictable. A Government medical-care program on the other hand can be carried out according to a well-devised plan, the expansion along that plan being taken step by step over a period of 10 or more years as administrative experience and personnel and medical facilities warrant.
I, therefore, because of the record favor definite, carefully planned legislative insurance introduced conservatively and under the control of experienced administrative agencies, the Bureau of the Budget, the Congress, and the people instead of voluntary plans that may be run by we know not whom and give we know not what kind of service at an unpredictable cost and an unpredictable future time.
ROCHESTER, MINN., June 21, 1946. Senator CLAUDE PEPPER,
United Stutes Senate, Washington, D. C.: I sincerely regret that absence of two of my associates makes it absolutely impossible for me to get away at this time. In answer to your request to submit a statement, I wish merely to point out what I consider the most fundamental section of bill s. 1318 and the one that has received the most adverse criticism from the medical profession. I refer to subsection 3, section 103, title 1, which provides that as services and facilities are furnished under the plan they shall be made available to all mothers and children in the State or locality who elect to participate in the benefits of the program and that there will be no discrimination because of race, creed, color, or national origin and no residence requirement.
This is the first time that a bill has carried this broad concept of national interest in the health of children that will make available to all children the best of preventive and curative medical care.
The present study of child-health services now being conducted by the American Academy of Pediatrics with the help of the Public Health Service and the Children's Bureau had as its objective to make available to all mothers and children in the United States of American all essential preventive, diagnostic, and curative medical service of high quality which, used in cooperation with the other services for children, will make this country an ideal place for children to grow into responsible citizens. This survey should show what and where personnel and facilities are needed and s. 1318 should make it possible to meet these State and local needs by Federal grants-in-aid to the States that need help. The right of every child to an education has been accepted universally for many years, but let no one suppose it did not raise tremendous opposition from the private school at the time of its introduction. Just as every American child has a right to an education, so S. 1318 states for the first time that every American child has a right to health.
The idea is not entirely new. As early as 1913 the eminent pediatrician, Dr. Emmett Holt, Sr., said in an address : "We are coming to see that the child belongs to the State in respect to health also and the right of a mother to neglect her child may come to be regarded as an offense against society much as we now regard absence from school. What parents will not do voluntarily, the State will compel them to do or will step in and do for them."
More recently Dr. Borden Veeder, a former president of the American Academy of Pediatrics, said in an address :
"I can see no way in which the promise that if an American child is entitled to an education he is entitled to health can be refuted."
The acceptance of the fundamental principle of the national interest in the health and welfare of all children places S. 1318 in the forefront of the progressive health legislation.
HENRY F. HELMHOLZ.
MARGAREE, Nova SCOTIA, June 19, 1946. CLAUDE PEPPER,
United States Senate: Am unable at this great distance where all data are lacking to reply to your request as you wish. In general am in favor of bill S. 1318 with certain modifications as suggested in the resolution of the Pepper bill passed at the last meeting of the Academy of Pediatrics.
E. A. PARK.
YALE UNIVERSITY SCHOOL OF MEDICINE,
DEPARTMENT OF PEDIATRICS,
New Haven 4, Conn., May 23, 1946. Hon. CLAUDE PEPPER,
United States Senate, Washington, D. C. MY DEAR MR. PEPPER: On March 18, 1946, I sent a letter to President Truman, a copy of which is enclosed. This letter explains my convictions upon the very important matter of preserving the Children's Bureau intact, regardless of the particular executive department in which the Bureau might be placed. Therefore, I view with grave concern the announcement of Reorganization Plan No. 2, in which it is proposed to transfer the Children's Bureau to the Federal Security Agency in such manner that the integrity and present powers of the Bureau are not safeguarded and protected. There is nothing in the proposed plan which prevents dismemberment of the Bureau; we should then have a Federal Government without a single, strong, unified organization representing and focusing all our interests and services for the children of this country.
I have sent the following telegram in protest to President Truman: "Strongly urge modification of Reorganization Plan 2 regarding permissive dispersion of Children's Bureau functions. Absolutely vital to welfare of Nation's children that all activities in their behalf be integrated in one Federal organization. Request you maintain by law authority of Children's Bureau in all respects as at present including powers granted under title V of Social Security Act.”
I hope you will strive to have Reorganization Plan No. 2 modified in the manner I have indicated as regards the Children's Bureau. Your very truly,
GROVER F. POWERS, M. D.,
Professor of Pediatrics.
MARCH 18, 1946. The PRESIDENT,
The White House, Washington, D. O. DEAR MR. PRESIDENT: I am writing to you concerning the Children's Bureau of the Department of Labor. For many years I have been familiar with the work of the Bureau not only
with my personal work as a children's physician and as a teacher
of pediatrics, but also as a member of long standing of one of the advisory committees of the Children's Bureau.
My view of pedictrics is that this medical specialty is concerned with the whole child. One cannot wisely assume responsibility for the treatment of sick children without being concerned with disease prevention, mental hygiene, education, and socio-economic status. This point of view the Children's Bureau, to its great credit, has always stoutly supported.
In my opinion there are good reasons for retaining the relationships which the Children's Bureau shares in and with the Department of Labor. There are also good reasons-perhaps decisive at this particular time when medicalcare programs are being developed—for coordinating the Children's Bureau as an entity with the Public Health Service, the Department of Education, and kindred health and welfare services into a new executive department of Cabinet rank. The fundamental point I wish to emphasize is the importance of keeping intact the broad facilities and responsibilities of the Children's Burean as now organized-responsibilities and services which take into account all important phases of child life. I would add that because of traditional orientation, interest, and experience no agency of the Federal Government except the Children's Bureau is well equipped to administer these broad services in behalf of children. Admitting faults unavoidable in a new and wartime undertaking, the emergency maternity and infant-care program was successful in its main objective and has furnished the administrators in the Children's Bureau with a wealth of experience not possessed by any other group in this country at this time.
I trust, therefore, that if a new executive department is established, the enabling order or legislation will stipulate specifically that the integrity of the Children's Bureau as now organized is to be retained. In this way there will continue to be recognition of the essentiality of an administrative unit which guards and cherishes all of the broad interests of children and serves as the channel through which these interests find national focus, expression, and action. Respectfully yours,
GROVER F. POWERS, M. D.,
Professor of Pediatrics.
YALE UNIVERSITY SCHOOL OF MEDICINE,
DEPARTMENT OF PEDIATRICS,
New Haven 4, Conn., June 19, 1946. Hon. CLAUDE PEPPER,
United States Senate, Washington D. C. MY DEAR MR. PEPPER: I have your telegram of June 17 inviting me to testify at the hearings on S. 1318. A previous engagement in St. Louis prevented my accepting your invitation. I wish, however, to be recorded as one of those supporting S. 1318 as an important piece of legislation furthering improvement in maternal and child health and welfare in this country.
I do not believe in the application of the means test in the furtherance of medical services to women and children. I am well aware of the fact that many of my pediatric colleagues feel differently on this subject, but it seems clear to me that if we are going all-out to achieve the optimum in maternal and child care, there should be no limitations on the opportunity to receive and render service.
I have already written to you specifically on the subject of the preservation of the integrity of the United States Children's Bureau. In S. 1318 it seems to me the Children's Bureau is admirably and worthily recognized as the exponent in the Federal Government of all that pertains to the health and welfare of mothers and children. This is a very strong reason for my support for S. 1318.
I hope there will be favorable action on S. 1318 by the Congress at this session.
I wish to express my appreciation of your strong support of the Children's Bureau and for your sponsorship of legislation for the improvement of maternal and child health and welfare. Sincerely yours,
GROVER F. POWERS, M. D.