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Being particularly interested in the dental phase of child health, I have given much study to this part of the problem. Using all available evidence, gathered from authentic and accepted studies, a method of procedure has gradually unfolded that, at least, offers an avenue of exploration that may reveal the answer. I presented the basis for such thinking to a conference on dental health at the Children's Bureau in February. Since that time I have been editing the report with a view to its publication. This job is now completed and I will be very glad to submit a copy, in the very near future, for incorporatiou in your record, if you so desire.
I think you will be interested in the fact that I have attempted to show that it is entirely possible in a period of 7 years following a program inauguration, using less than 5 percent of the available dental manpower, to graduate every child in the United States into adult life with a maximum mouth health. This maximum can be attained at a cost of about $2.50 per child per year. It is of further interest to note that such a program can be made 8h-percent self-sustaining—that no encroachment will be made on private practice, it will in fact be helped—and that such dentists as are employed can be paid a yearly salary 35 percent above the average dental net income as reported by the Department of Commerce for the years 1929-39.
Subsidy for the implementation of such a program must be forthcoming from some source and, of course, much preliminary study is necessary. Such study can be accompanied by proper demonstrations that will provide excellent service at a cost that is unbelievably low, once the initial installations are accomplished.
I might add that the plan is in complete accord with the principles enunciated by the American Dental Association.
As a matter of purely personal thought, I am convinced that every phase of maternal and child-health procedures must be completely integrated in a general over-all pattern.
Thanking you for your letter and complimenting you for your vision and courage, Sincerely yours,
WM. C. WERB, Jr.
CaILDREN'S DENTAL CLINICS OF THE
Philadelphia, Pa., June 24, 1946. Hon. CLAUDE PEPPER,
United States Senate, Washington, D. C. MY DEAR SENATOR PEPPER: I am in receipt of your telegram of June 17 relative to a prepared statement regarding Maternal and Child Welfare Act of 1945, S. 1318.
The Council of Social Agencies of the Community Fund of Philadelphia and vicinity of which we are a member agency, has compiled and forwarded to you a prepared statement which is a condensation of all interested agencies official statements relative to the bill. I trust this expression of opinion will be satisfactory to all concerned. Respectfully,
WM. C. WEBB, Jr.
COMMITTEE FOR THE NATION'S HEALTH,
Washington 1, D. C., June 19, 1946. Senator CLAUDE PEPPER,
Senate Office Building, Washington, D. C. DEAR SENATOR PEPPER: I write with reference to your maternal and child. care bill, S. 1318, on which I understand you are opening hearings in the near future.
The Committee for the Nation's Health is formally on record in favor of a general national health program, of which provision for care of children and mothers is an important part. Thus we recognize the need for making good medical care and preventive measures more fully available to mothers and children, and are heartily in favor of the prompt passage of legislation to this end.
S. 1318 would provide for the care of all persons under 21 and of women at the time of maternity. This care would be supported mainly by Federal funds derived from general revenues. The cost of such a program if fully carried out would be about $1,000,000,000 a year.
We do not believe that this proposal is practicable or that it is necessary to accomplish the end in view.
It is not practicable because appropriations on the scale necessary to effectuate the program would be unlikely, and insufficient appropriations would probably lead to the establishment of a means test, to restrict the number eligible for care.
The measure is not necessary because a better alternative is already before Congress, namely the use of the insurance principle as the main base of support for medical care for the bulk of the population, including children and mothers. The insurance principle utilizes and organizes the existing expenditures for medical care by individuals and families. Appropriations from general revenues in relatively small amounts must supplement insurance payments for special purposes or for special groups of the population.
The purposes of S. 1318 can best be accomplished by enacting H. R. 4730 and S. 1606, with amendments already proposed that would strengthen the maternal and child health provisions now in these bills.
I appreciate that there may be delay in the passage of the general national health program. Meanwhile progress may nevertheless be made. The interim might best be covered by legislation enlarging the annual appropriations now made available to the United States Children's Bureau for maternal and child health services. Sincerely yours,
MICHAEL M. DAVIS, Chairman, Executive Committee.
THE AMERICAN PUBLIC HEALTH ASSOCIATION,
New York 19, N. Y., June 19, 1946. Hon. CLAUDE PEPPER,
Senate Office Building, Washington, D. C. DEAR SENATOR PEPPER: The American Public Health Association welcomes the opportunity to present a statement bearing on the maternal and child-welfare bill, S. 1318.
By order of my board I present for your information and that of the committee, with the request that it be included in the record, a statement of the principles which the association has adopted bearing on this subject.
We think it appropriate to state our opinion in this form because we are aware of pending amendments to this bill which may bring it more fully into accord with our principles and we recognize that there are potential changes to be brought about by the proposed reorganization of Federal agencies which may have a large effect on the extent to which this bill conforms to our declared principles. Very respectfully yours,
REGINALD M. ATWATER, M. D.,
Executive Secretary. [Reprinted from American Journal of Public Health, vol. 34, No. 12, December 1944.
Published by the American Public Health Association, New York, N. Y.]
MEDICAL CARE IN A NATIONAL HEALTH PROGRAM
AN OFFICIAL STATEMENT OF THE AMERICAN PUBLIC HEALTH ASSOCIATION,
ADOPTED OCTOBER 4, 1944
At the annual meeting of the committee on administrative practice of the American Public Health Association, October 9, 1943, the committee directed its subcommittee on medical care to draft a set of principles expressing the desir
able content of a comprehensive program of medical care, the methods of its administration, and the part which public health agencies should take in its operation. In pursuit of this assignment, the subcommittee completed a tentative draft, which was considered and adopted by the committee on administrative practice at its meeting, October 1, 1944. The report was then transmitted to the governing council of the association where, afer certain revisions, it was adopted as a statement of association policy.
Because of its composition and charge, the subcommittee has limited its considerations to one sector of a comprehensive national health program, namely, medical care. In preparing the report, the subcommittee has considered (a) The needs for a national program for medical care. (6) The objectives of such a program. (b) Recommendations for immediate action. The American Public Health Association through its national organization and its constituent societies stands ready to collaborate with the various professional bodies and civic organizations which may be concerned with either the provision or receipt of medical service with a view to implementing the following general principles :
A. THE NEEDS
I. A large portion of the population receives insufficient and inadequate medical care, chiefly because persons are unable to pay the costs of services on an individual-payment basis when they are needed, or because the services are not available.
II. There are extensive deficiencies in the physical facilities needed to provide reasonably adequate services. Such facilities include hospitals, health centers, and laboratories. The needs are most acute in poor communities, in rural areas, and in urban areas where the population has increased rapidly or where the development of facilities has been haphazard or the financial support inadequate.
III. There are extensive deficiencies in the number and the distribution of personnel needed to provide the services. Here again, the needs vary according to categories of personnel and to characteristics of communities.
IV. There are extensive deficiencies in the number and categories of personnel qualified to administer facilities and services.
V. Many communities still are not served by public health departments; others inadequately maintain such departments. Thus, some communities have never utilized organized health work to reduce the burden of illness, and others share its benefits only in part. In these communities especially, people lack information on the benefits of modern medical care.
VI. Expansion of scientific research is urgently needed. Despite past and current scientific advances, knowledge as to the prevention, control, or cure of many diseases is lacking.
Each of the six conditions defined above can be broken down into many component parts representing specific needs. In general, however, solutions of these broad problems require simultaneous attack on four frontsnamely, the distribution of costs, construction of facilities, training of personnel, and expansion of knowledge.
B. THE OBJECTIVES I. A national program for medical care should make available to the entire population all essential preventive, diagnostic, and curative services.
II. Such a program should insure that the services provided be of the highest standard, and that they be rendered under conditions satisfactory both to the public and to the professions.
III. Such a program should include the constant evaluation of practices and the extension of scientific knowledge.
C. RECOMMENDATIONS The recommendations presented in this report represent guides to the formulation of a policy of action. It is believed that study of these recommendations by the professions and others concerned in the States and localities will produce new and more specific recommendations for the attainment of the objectives of a national-health program.
Recommendation 1. The services
(a) A national plan should aim to provide comprehensive services for all the people in all areas of the country. In light of present-day knowledge, the services should include hospital care, the services of physicians (general practitioners and specialists), supplementary laboratory and diagnostic services, nursing care, essential dental services, and prescribed medicines and appliances. These details of content must remain subject to alteration according to changes in knowledge, practices, and organization of services.
Because of inadequacies in personnel and facilities, this goal cannot be attained at once; but it should be attained within 10 years. At the outset as many of the services as possible should be provided for the Nation as a whole, having regard for resources in personnel and facilities in local areas. The scope of service should then be extended as rapidly as possible, accelerated by provisions to insure the training of needed personnel, and the development of facilities and organizations.
(b) It is imperative that the plan include and emphasize the provision of preventive services for the whole population. Such services include maternity and child hygiene, school-health services, control of communicable diseases, special provisions for tuberculosis, venereal diseases, and other preventable diseases, laboratory diagnosis, nutrition, health education, vital records, and other accepted functions of public health agencies, which are now provided for a part of the population.
(c) Insofar as may be consistent with the requirements of a national plan, States and communities should have wide latitude in adapting their services and methods of administration to local needs and conditions. Recommendation II. Financing the services
(a) Services should be adequately and securely financed through social insurance supplemented by general taxation, or by general taxation alone. Financing through social insurance alone would result in the exclusion of certain economic groups and might possibly exclude certain occupational segments of the population.
(6) The services should be financed on a Nation-wide basis, in accordance with ability to pay, with Federal and State participation, and under conditions which will permit the Federal Government to equalize the burdens of cost among the States. Recommendation III. Organization and administration of services
(a) A single responsible agency is a fundamental requisite to effective administration at all levels, Federal, State, and local. The public health agencies—Federal, State, and local-should carry major responsibilities in administering the health services of the future. Because of administrative experience, and accustomed responsibility for a public trust, they are uniquely fitted among public agencies to assume larger responsibilities and to discharge their duties to the public with integrity and skill. The existing public-health agencies, as now constituted, may not be ready and may not be suitably constituted and organized, in all cases, to assume all of the administrative tasks implicit in an expanded national health service. Public-health officials, however, should be planning to discharge these larger responsibilities, and should be training themselves and their staffs. This preparation should be undertaken now because, when the public comes to consider where administrative responsibilities shall be lodged, it will be influenced in large measure by the readiness for such duties displayed by publichealth officers and by the initiative they have taken in fitting themselves for the task.
(6) The agency authorized to administer such a program should have the advice and counsel of a body representing the professions, other sources of services, and the recipients of services.
(c) Private practitioners in each local administrative area should be paid according to the method they prefer, i. e., free for service, capitation, salary, or any combination of these. None of the methods is perfect; but attention is called to the fact that fee for service alone is not well adapted to a system of wide coverage.
(d) The principle of free choice should be preserved to the population and the professions.
(e) State departments of health and other health agencies are urged to initiate studies to determine the logical and practical administrative areas for a national medical care plan. Recommendation IV. Physical facilities
(a) Preceding, or accompanying, the development of a plan to finance and administer services, a program should be developed for the construction of needed hospitals, health centers, and related facilities, including modernization and expansion of existing structures. This program should be based on Federal aid to the States and allow for participation by voluntary as well as public agencies, with suitable controls to insure the economical and community-wide use of public funds. The desirability of combining hospital facilities with the housing of physicians' offices, clinics, and health departments should be stressed.
(6) Federal aid to the States should be given on a variable matching basis in accordance with the economic status of each State.
(c) Because of its record of experience and accomplishment in this field, the United States Public Health Service should administer the construction program at the Federal level, in cooperation with the Federal agencies responsible for health services and construction.
(d) Funds available under this program should be granted only if :
(1) The State administrative agency has surveyed the needs of the State for hospitals, health centers, and related facilities, and has drawn up a master plan for the development of the needed facilities (taking account of facilities in adjacent States) ; or, in the absence of a State plan, the project is consistent with surveys of construction needs made by the United States Public Health Service;
(2) The proposed individual project is consistent with the master plan for the State; its architectural and engineering plans and specifications have been approved by the State agency and/or the United States Public Health Service; and there is reasonable assurance of support and maintenance of the project in accordance with adequate standards.
(e) State health departments are urged to conduct studies to develop State plans for the construction of needed hospitals, health centers, and related facilities. Such studies should be made in cooperation with official health agencies, with State hospital associations, and other groups having special knowledge or interests. Recommendation V. Coordination and organization of official health agencies
(a) The activities of the multiple National, State, and local health agencies should be coordinated with the services provided by a national program. There is no functional or administrative justification for dividing human beings or illnesses into many categories to be dealt with by numerous independent adminis. trations. It is difficult to reorganize agencies or to combine activities and this cannot be accomplished hurriedly. Therefore studies and conferences should be undertaken without delay at the Federal level, and in those States and communities where the health structure is already unnecessarily complex.
(6) The Federal and State Governments should provide increased grants for the extension of adequate public health organization to all areas in all States. Increased Federal grants should be made conditional upon the requirement that public health services of at least a specified minimum content shall be available in all areas of that State. Recommendation VI. Training and distribution of service personnel
(a) Within the resources of the program, financial provisions should be made to assist qualified professional and technical personnel in obtaining postgraduate education and training.
(6) The plan should provide for the study of more effective use of auxiliary personnel (such as dental hygienists, nursing aides, and technicians), and should furnish financial assistance for their training utiliza n.
(c) Professional and financial stimuli should be devised to encourage physicians, dentists, nurses, and others to practice in rural areas. Plans to encourage the rational distribution of personnel, especially physicians, should be developed as quickly as possible, in view of the coming demobilization of the armed forces. Such plans should be integrated with the whole scheme of services and the establishment of more adequate physical facilities.