cally all these resolutions give ample evidence of great interest in and sympathy for the desire of Congress to provide for the wives and infants of the men who are fighting this war for us. It is the way it is set up by Congress and administered by the Children's Bureau that draws their fire.

"FREE CHOICE"

The opponents assert that the emergency maternity and infant care program violates the right of the patient for free choice of doctors. Obviously when certain physicians refuse to cooperate under the program, the free choice of the wives is limited. But such a possible restriction of free choice pertains to ordinary medical practice where doctors cannot or do not wish to care for certain patients. It may also be limited by the qualification standards set by State health agencies or by State licensing laws as to what persons may participate in the care of maternity patients or as consultants or specialists. But surely standards are essential if the public's money is to be spent economically and effectively in the provision of medical care to these wives and infants. With these exceptions, free choice is in fact made a reality for these soldiers' and sailors' wives by the removal of the economic barrier between them and a doctor. Because she knows the physician and hospital will be paid, any wife may select a physician instead of feeling compelled to go to a midwife; she may choose the safety and comfort of a hospital delivery rather than one at home; and she may go freely and promptly to a physician when her baby shows the earliest signs of illness, instead of waiting in the hope that a doctor's bill will not be necessary.

"THIRD PARTY" BOGIE

The representatives of "organized medicine" repeatedly express the fear that the doctor-patient relationship is being jeopardized. The old bogie of a "third party" coming between the doctor and his patient is again given a leading role. Sometimes this third party is described as the State health agency which under the law administers the program locally, sets standards, and pays bills; sometimes it is the Children's Bureau in Washington. These representatives resent that the doctor cannot negotiate with his patient as to how much she will pay him, because the State health agency has fixed the amount to be paid within a national maximum and because the Children's Bureau has said the doctor may not charge, nor the wife pay, an amount above that paid by the State. They say physicians should be allowed to negotiate with the wives of servicemen as to how much they can afford to pay over and above the amounts paid by the State health agency or the wife should be permitted to offer, and the physician to accept, a "gift" or additional payment. The refusal of the Children's Bureau to allow such dickering is considered to be a threat to the established tradition of the "sliding scale" of fees.

CASH GRANTS

Fundamentally, it is this ruling that has caused "organized medicine" to rise up and demand cash grants to the wife on the pretext that this method alone would not disturb the existing doctor-patient relationship. With cash grants in operation, the physician would apply his own "means test" and could negotiate his fee with all wives, including those whose only income is their husband's allotment and the Government maintenance allowance. Such grants would also remove from the program any control over quality of medical care, as no agency would know how much or what kind of medicine was purchased with the grants. They would permit the expenditure of public monies without any assurance that they be used for the purpose for which Congress had voted them. The advocacy of such grants by physicians reflects an unbelievable disregard of responsibility and economy in Government spending, and a shocking lack of concern for standards of medical care.

Surely it is unthinkable that a physician would allow the consideration of a supplemental fee to interfere with the basic relationship between him and his patient in the matter of the kind of care he will give or the confidence that the patient has in him. So far as the attitude of the wife of a serviceman goes, the fact that she knows the physician and hospital are to be paid by the Government would tend to make her more willing to seek advice early and more receptive to it. She will not be restrained by an inability to meet the physician's bill; she will not have to accept charity if she cannot pay at all. She knows that the care is provided by the Government as her right, just as is her allowance for maintenance, because her husband is in the armed forces.

Congress purposely did not provide for medical-care grants or allowances to the wives of servicemen. It has been the clearly stated intention of Congress that the benefits of this program are to be regarded as the right of any wife or infant of an enlisted man in one of the specified grades. There is to be no "means test," no financial investigation of any sort, no discrimination under the program in respect to the kind of benefit because of the private financial resources of some wives. During the recent hearings and the debate on the appropriation for the fiscal year 1945, the Children's Bureau, has been told firmly by the congressional committee that administrative rulings, whether Federal or State, even though designed to get wives under care early, must not result in denial of the right of a wife or infant to benefits under the program when application is delayed because of lack of knowledge of the program or misunderstanding of procedures.

MISLEADING PROPAGANDA

This cry concerning the evils of a "third party" coming between doctor and patient and this charge that any modification of individualistic private practice will limit the "free choice of physician" have been used so loosely and misleadingly in regard to almost any group health plan as to suggest either dishonesty or lack of intelligence. This propaganda does not mention that the excellent medical care provided by the Mayo Clinic, the Lahey Clinic, the Baker Memorial Unit of the Massachusetts General Hospital, all the larger university teaching hospitals throughout the country, and by the efficient modern medical units of the Army, Navy, and Public Health Service include not the evil but the benefit of a "third party." The propaganda does not mention that a majority of the American people have no "free choice of physician" in any significant sense. And such propaganda concerning the present Wagner-Murray-Dingell national-health bill does not mention the fact that under that plan millions of people would be provided for the first time with the opportunity of choosing a family physician and thus the American public would experience a greater free choice of physician than has ever pertained under the present catch-as-catch-can system of medicine. Fortunately, events as outlined in the following paragraphs show that the people whose money and health are at stake see the issue clearly.

In June 1943, the house of delegates of the Aemrican Medical Association adopted a resolution introduced by the delegation from Oregon as follows: "That the action of the Federal Government in making funds available for maternity and infant care for the wives and infants of enlisted men be approved," and "that adoption be urged of a plan under which the Federal Government will provide for the wives of enlisted men a stated allotment for medical, hospital, maternity, and infant care, similar to the allotments already provided for the maintenance of dependents, leaving the actual arrangements with respect to fees to be fixed by mutual agreement with the wife and the physician of her choice." Once the attack was launched by the American Medical Association, many other State organizations joined up. By midsummer 1943 a test case was brought before the people of Ohio. The Ohio State health agency had submitted a plan to the Children's Bureau for putting EMIC into operation. While negotiations were going forward between the State and Federal agencies, the council of the State medical association disapproved the plan and recommended the adoption of a plan that would provide stated allotments for medical and nursing services and hospitalization on the basis of need. The Governor and the State health officer were deluged with demands that the EMIC program we put into operation without delay. Newspapers of all political affiliations joined in support of the program and in criticism of the medical society. Thus backed by popular support, the program was set under way and soon covered all parts of Ohio with the exception of a few places in which local organized medical groups held out by refusing to cooperate.

The effect of the Ohio test case was felt throughout the country. Notwithstanding the opposition of the State medical associations, State after State came into the program until by March 1944 all were in. No State association took the stand that individual members should not cooperate if they wished. Yet, in one State, individual members were warned that if they participated in the program it would be against the advice and opinion of the council of their State association. The last State to come in did so after an abortive attempt to get the Children's Bureau to accept a plan of cash payments to the wife on the showing of medical or hospital bills.

CONGRESSIONAL ACTION

The issue of cash allowances as payment for service was put up to Congress in September 1943 in the form of an amendment to a deficiency appropriation bill before the House of Representatives. The amendment was overwhelmingly defeated by a vote of 115 to 8. On the ground that this vote represented the attitude of but a small proportion of the total Members of the House, a number of State medical associations and the American Medical Association requested a hearing in the spring of 1944 before the subcommittee of the House Appropriations Committee that was in charge of the Department of Labor appropriations.

1

This hearing was granted and testimony was presented by representatives of the American Medical Association, the California, Minnesota, New York, Iowa, New Jersey, and Louisana State medical associations. Representatives also appeared from the Committee of Physicians for the Improvement of Medical Care and from many lay organizations. Among these were the American Legion, the National Congress of Parents and Teachers, the Congress of Industrial Organizations, the Young Women's Christian Association, and the Women's Trade Union League.

The published report of this and earlier hearings on the 1945 appropriation shows that the testimony covered all of the controversial issues thoroughly and included many criticisms on the part of the medical associations of the details of administration. The only testimony offered in favor of a plan of cash allowances to the wives or a change in the administrative regulations to permit physicians to charge a fee over and above that paid by the State agencies came from the American Medical Association and the State medical associations. The American Legion, basing its opinion on experience with the giving of aid to veterans over a period of 19 years, supported direct payments to physicians and hospitals and opposed cash allowances. So did the Committee of Physicians for the Improvement of Medical Care. A resolution of the board of trustees of the American Hospital Association endorsing the purchase of hospital care by direct payment to hospitals on a cost basis was introduced in the testimony later."

Before completing its hearings, the appropriation committee received further testimony from the Federal administrative agency (the Children's Bureau)' reviewing fully the principal questions under discussion and many of the details of administration. Without question careful consideration was given to the issues raised by the representatives of organized medicine and others. It is of considerable significance, then, that the language of the act ap propriating funds for the fiscal year 1945 remains the same as that in former acts, with the exception of the addition of a clause to broaden the group of beneficiaries to include Army aviation cadets and a provision to allow the use of part of the grants to States for State administration. Neither in the House or Senate Appropriation Committee reports, nor in the debate on the floor of either House" were the questions of cash grants or supplemental fees to physicians even raised. In other words the Congress, having reviewed the issues, silently but explicitly reaffirmed its original purpose, that payments for medical care should be made directly to physicians, hospitals, nurses, or others and gave tacit support to the general policies of the Children's Bureau.

THE AMERICAN MEDICAL ASSOCIATION

From June 12 to 15, 1944, the house of delegates of the American Medical Association met. The emergency maternity and infant care program was clearly a matter of concern, but the printed record, as is customary, gives none of the discussion in the reference committees that considered the various resolutions and those portions of the reports of the bureau of health education, the bureau of

1 Hearings before the subcommittee of the Committee on Appropriations, House of Representatives. 78th Cong., 2d sess., on the Department of Labor-Federal Security Agency appropriation bill for 1945. Pt. 1, pp. 485-570 (April 27, 1944). 2 Ibid., p. 458 (May 3, 1944).

3 Ibid., p. 444-470 (May 3, 1944).

4 House of Representatives, Rept. No. 1526, 78th Cong., 2d sess. Senate Rept. No. 965, 78th Cong., 2d sess.

Congressional Record, vol. 90; No. 97, May 29, 1944; No. 99, June 1, 1944; No. 111, June 15, 1944.

6 Report of Bureau of Health Education, Journal of the American Medical Association, April 29, 1944, pp. 1273-1275.

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"11

legal medicine and legislation,' and the council on medical service and public relations that related to the EMIC program. The report of the reference committee on legislation and public relations as adopted by the house of delegates approved (among other things) (1) "the bill introduced by Congressman A. L. Miller, of Nebraska, which would transfer all Government agencies dealing with health to the United States Public Health Service," (2) "the resolution to transfer the emergency maternal and infant care program to the Department of Public Health," and (3) the report of the council on medical service and public relations. The latter report referred to a verbatim report of a conference on EMIC with Dr. Martha Eliot of the Children's Bureau which has never been published.12 The house of delegates adopted the reports of the bureau of health education and the bureau of legal medicine and legislation, through approving the reports of the respective reference committees. Thus the house apparently continued its support of converting the EMIC program from one of payment to physicians and hospitals to one of cash grants to the wives of servicemen.

The report of the bureau of health education said that EMIC is "a possible trial balloon, bridgehead, or entering wedge looking toward the extension of medical service in point of time beyond the duration of the war and in breadth of scope, both as to kinds of service and as to groups served.”

THE MAJOR ATTACK

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19 13

It would appear, however, from the supplemental report of the council on medical service and public relations that the major attack on the EMIC program would now take the form of an effort to transfer the whole EMIC program and the Children's Bureau (or in accordance with the provisions of the Miller bill, that part of the Bureau that has to do with maternal and child health) to the United States Public Health Service where the "aims of the Children's Bureau can be curbed." To quote this supplemental report:

“Among other things it [the Miller bill] would remove the Children's Bureau from the Department of Labor to a place where it more properly belongs, and the council feels that such a transfer might aid in curbing the present aim of the Children's Bureau, which apparently seems to be chiefly the socialization of medicine in this country. Furthermore, the Children's Bureau has never been willing to accept good scientific opinion in the conduct of its affairs but has relied on a hand-picked committee, many of the members of which have been powerless to prevent actions of which they did not approve."

It is well to have this issue out in the open.

Once again organized medicine

is "curbing" the needed provision of medical care. Once again it is misleadingly characterizing an intelligent and honest endeavor to extend medical care and protect medical standards as "the socialization of medicine." In so doing, an opportunity is being lost and little good is being served. Organized medicine might instead have constructively stated:

"We recognize the emergency need of the EMIC program. As such we shall support it, but we insist that

"1. Payments of cash benefits to mothers be disapproved because such payments (a) do not prevent the expenditure of the public's money for purposes other than intended by Congress; (b) do not assure adequate remuneration to physicians for services they are asked by Congress to render; (c) make it

7 Report of Bureau of Legal Medicine and Legislation, Journal of the American Medical Association, April 29, 1944, pp. 1278-1279.

Report of the Council on Medical Service and Public Relations, Journal of the American Medical Association, April 29, 1944, pp. 1304-1306.

Supplement report of Council on Medical Service and Public Relations, Journal of the American Medical Association, June 24, 1944. p. 573.

10 Report of Reference Committee on Legislation and Public Relations, Journal of the American Medical Association, July 1. 1944, pp. 651-652.

11 The Miller hill, H. R. 4663, provides for "the transfer to the Federal Security Administrator and the Public Health Service, respectively, the functions of the Secretary of Labor and the Children's Bureau of the Department of Labor with respect to health and for other purnoses." The bill does not provide for the transfer of the entire Children's Bureau but would divide up its functions, transferring only those related to health; nor does it provide for the transfer of "all Government agencies dealing with health" as the report of the American Medical Association reference committee states.

12 The verbatim report of this conference has not vet appeared in the Journal of the American Medical Association, though the report of the council stated that it "will have anneared in the Journal of the American Medical Association prior to the publication of this report."

13 Renort of Bureau of Health Education, Journal of the American Medical Association, April 29. 1944. p. 1275.

doubly difficult to protect the quality of the medical service purchased; and (d) negate the primary intent of Congress that the wives and infants of our enlisted men receive the medical care they deserve without being subjected to either a means test or financial stress.

"2. Every effort be made to foster economy in administration by avoiding unnecessary paper work and bureaucracy, and to this end payment to physicians be made in a manner requiring a minimum of reports and accounts; i. e., on a capitation or annual basis except for such consultation or special services as are more easily dealt with on a fee basis.

"3. Because of the shortage of physicians and the heavy burden already placed upon them, this new load be made as light as possible by the organization whereever possible of clinic services associated with hospital facilities and nursing, public health and social service personnel.

"4. It should be clearly understood that physicians are willing to accept moderate rates of payment under this program because of the contribution these men and their wives are making to the Nation. The payments pertaining under the program are not to be regarded as standards accepted as adequate by the medical profession."

Even such a simple and practical statement of policy remains a visionary's dream as long as reactionary elements within organized medicine dominate the actions of the national body.

Many times during its 32 years of existence the Children's Bureau has been under attack by organized medicine for its progressive and courageous stand in behalf of the mothers and children of the United States. It has withstood attack because the people of the country (including many physicians) have recognized the contributions that it has made to bettering the conditions of children. It is one of the organizations that has done an outstanding job in trying to lessen the physical handicaps that the draft has revealed to be so shockingly prevalent in this Nation, and regarding which organized medicine has been so complacent and indeed so blatantly proud of our national health, The people know, that to attain better national health, all aspects of child life, the economic and social as well as the medical, must be considered together.

The statement that the Children's Bureau has never been willing to accept good scientific opinion in the conduct of its affairs needs little comment. Members of its advisory committees include eminent members of the medical profession who have given guidance and advice to the Bureau in its research as well as its administrative activities for 25 years. In addition, individual physicians, economists, scientists of many types, all experts in their own fields, have been consulted freely. It is obvious that a Government agency, representing and protecting the public as it does, must assume final responsibility for its policies and actions in carrying out the intent of Congress and that it cannot delegate this responsibility to any private group. It is equally obvious that a conscientious agency in carrying out the intent of Congress in extending efficiently organized medical care in an emergency may incur the opposition of those that want no extension of federally financed medicine and no modification of individualistic private practice.

But the people and the Congress should not be misled by such expected opposition. The decision as to what sort of maternity and medical care the wives and children of our soldiers and sailors are going to have, and how it will be paid for, rests with the people and their elected representatives in legislative bodies.

EXHIBIT 76

UNITED STATES DEPARTMENT OF LABOR

CHILDREN'S BUREAU, DIVISION OF STATISTICAL RESEARCH, MAY 17, 1946 PRELIMINARY MONTHLY STATISTICAL REPORT ON THE EMIC PROGRAM, APRIL 1946 The emergency maternity and infant-care program provides medical and hospital care to wives and infants of enlisted servicemen in the four lowest pay grades. Complete maternity care, including medical and hospital service, is provided for wives of servicemen, and medical and hospital care is available for their infants until they are 1 year of age.