Page 2, line 13: For the fiscal year ending June 30, 1946, there is authorized the sum of $50,000,000, "and for each year thereafter a sum sufficient to carry out the purposes of this title." Practically, this same sum of $50,000,000 was authorized for carrying out the EMIC program, which reached approximately a million beneficiaries. The absurdity of expecting this amount of Government monies to cover the necessities of all who would embrace the benefits of the Pepper bill, an unpredictable portion of some 3,000,000 mothers and some 40,000,000 children under the age of 21, need not be dilated upon, except to remark that after the first year the appropriations have no limit but the stratosphere in arithmetical digits. In this respect the bill is patterned on many previous legislative acts, which are steered through the Congress in a manner similar to a poker game with a penny ante to begin with, but with an ultimate jack pot resembling a mountain of blue chips. The cost of this legislation would in the end enter the realms of billions, not millions, if its proponents have their way.

Page 2, lines 15 to 19: Herein appears one of the many inconsistencies in the bill. The individual States are authorized to prepare plans for developing such programs and providing such care and services (named hereafter) which must be approved by the chief of the Children's Bureau, but there are certain other "musts" associated therewith, the first and most emphatic "must" being admittedly the approval of the Children's Bureau.

The second "must" appearing in section 103 (a), as well as in 203 (a) and 303 (a), respectively, prescribes what the State plans shall embrace and, if complied with according to the letter of the law laid down in this section, page 8, lines 5, 6, and 7 (the concluding paragraph), "The Chief of the Children's Bureau shall approve any plan which fulfills the conditions specified in subsection (a)," in this respect, the history of the EMIC program is replete with the conflicts and disagreements arising from the apparent authority of the States to originate plans and of the Federal Government defining in detail the regulations under which such plans would have their birth and development.

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Furthermore, to pass ahead for the moment and to visualize confusion worse confounded, one reads on page 8, under the heading "Federal advisory committees," section 105, beginning on line 9, the following: "The Chief of the Children's Bureau shall formulate general policies for the administration of this title. * *." But previously in the bill (p. 4, line 9, (4), appears the directive that the State "provide for the administration of the plan by the State health agency *." Who wins the toss-up concerning this division of authority? What about the "administrative policies" of the Children's Bureau which will govern the proposed act? One might turn for an answer to experiences under the EMIC program and more especially to Information Circular No. 1, issued De cember 1943, the title of which on the front cover is "Administrative policies" but including within its covers what can only be construed as "regulations." The foreword states in part as follows:

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"The children's Bureau will use these policies as the basis for approval of the related portions of State emergency maternal and infant-care plans. "The administrative policies of the Children's Bureau have been developed within the framework of the congressional acts and the regulations of the Secretary of Labor, and in accordance with the intent of Congress as shown by the legislative history and as interpreted by the Bureau and by the Solicitor of the Department of Labor." In one section containing six pages of the EMIC Administrative Policies, Minimum Regulation for Hospitals Participating in the Program, the word "must" appears three times, "should", three times, and "shall" appears 47 times. Apparently, and in fact, the words "policies" and "regulations" are used conterminously by the administrative authorities of the Children's Bureau and the tremendous power of administrative fiats issued therefrom is admitted by the Associate Chief of the Bureau in a published statement entitled "The Children's Bureau and Postwar Planning for Child Health" (Journal of Pediatrics, vol. 25, No. 4, October 1944), to wit: "The regulations of the Secretary of Labor governing allotments of funds to States for the EMIC program are published in the Federal Register and have the force of law." Violation of such policies and regulations by a long-suffering State will not only violate the law (according to the above paragraph) but will instantly penalize the State by having the paternalistic purse snapped shut even if, in the administration of the plan (in theory formulated by the State) "there is a failure to comply substantially with any provision required by section 103, or section 203, or section 303, respectively, to be included in the plan, he (the Secretary of Labor) shall notify such State

agency that further payments will not be made to the State under such plan, or" * * * and here follows a provision that the State will be put in 4-F until it falls into line or has been rehabilitated (p. 27, line-24 et seq.).

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Let me return for the moment to the statement of the Associate Chief of The Children's Bureau above quoted, namely, that the policies of the Bureau have been developed within the framework of the congressional acts and the regulations of the Secretary of Labor, and in accordance with the intent of Congress and as interpreted by the Bureau and by the Solicitor of the Department of Labor." During the history of EMIC the writer has had occasion to bring to the attention of the Children's Bureau certain interpretations of its own and of the solicitors of the Department of Labor which were obviously at variance with the wording of the law as viewed by the mind of a layman and not through the spectacles of a lawyer clouded by the snarls of legal technicalities (Journal of Pediatrics, vol. 26, No. 1, January 1945, p. 93 and 94.)

Now comes forward a champion of justice and right thinking who has much the same views and dares to express them in no uncertain terms. He is the Honorable Lewis B. Schwellenbach, recently appointed as Secretary of Labor, formerly a Senator in the Congress and latterly a judge of the United States district court of the State of Washington. Three days after taking office on July 1, 1945, he issued the following statement after conference with President Truman, who gave to it the Presidential blessing, as indicated in the closing paragraph of the press release, to wit: "The President indicated considerable interest and told him (the Secretary) that he would issue it (the order) from the White House."

SCHWELLENBACH TELLS EMPLOYEES THEY CANNOT "CIRCUMVENT" LAWS

Lewis B. Schwellenbach, the new Secretary of Labor, in an unusual move today served notice on his Department associates that he expected them "to execute the laws" and not to ignore or attempt to circumvent them because they thought these statutes should have been written or interpreted differently by Congress and the courts.

The Secretary's action was disclosed in a White House statement which said that "with the approval of the President" Mr. Schwellenbach "has issued following general order No. 1":

"I am issuing this order now before any specific instance arises so as not to subject anyone to embarrassment. Perhaps because my previous experience has been in the legislative and judicial branches of the Government, I am peculiarly sensitive to the importance of this question.

"I must insist that in this Department there is given full recognition to the fact that it is the function of this Department to execute the laws. The duty of an officer in this Department is to accept the laws as Congress has written them and as the courts have interpreted them.

"The fact that he may think the Congress should have written or the courts should have interpreted a law differently in no case justifies him in ignoring or attempting to circumvent the law. I will expect full cooperation in this policy."

Mr. Schwellenbach told reporters he had no particular instances of misinterpretation in mind, but that he knew from past experience it was "an old Washington custom" for the executive department to interpret congressional legislation in any way it saw fit. He added that while he was in the Senate he was interested in laws that "I wouldn't have recognized after some of the departments got through with them" (Washington Evening Star, Tuesday, July 3, 1945).

The writer has quoted at length the Secretary of Labor's criticism of the practices of some Federal departments in evidence of the fact that legislation is often subjected to the whims and fancies of those in authority in subordinate positions with evil results and would venture the observation that of such stuff is bureaucratic government by regulation and regimentation composed.

To return to the regular order.

When

Page 2, line 25, appears the wording "children under 21 years of age." is a child not a child? Should the Congress so specify this designation of the word "child," it would expose itself to sharp criticism of having abducted, through the draft, and perchance in some possible future military-service law, mere children of 18 and 19 in defiance of the principles of the Society for the Prevention of Cruelty to Children; child-labor laws must need be expanded in scope; the "age of consent" ws promptly revamped, while the study and practice of pediatrics male #y be enlarged to embrace a portion of geriatrics.

Page 3, line 15, (2): One may wonder what are "the special problems of maternal and child health," how are they to be ascertained and how qualified?

Page 5, line 19, section 103: Delineates the necessary attributes of a State plan in order to qualify for the receipt of Federal monies, subject to the limitation that they must be approved by the Chief of the Children's Bureau, although the latter shall approve such plans if in accordance with the requirements of this section 103, whether the Chief likes them or not, all of which constitutes a sort of Washington merry-go-round.

Now witness the beginnings of socialized Federal and State medicine. Page 4, line 3: Following the phrase containing a directive that the State provide facilities (although not a constructive program in the opinion of the framers of the bill) appear the words that services and facilities "furnished under the plan *** shall be available to all mothers and children who elect to participate in the program." It is obvious that this feature of free Federal medical services extended to all who would embrace them constitutes a pilot exploration, insidious, revolutionary, and devastating in its effects upon the private practice of obstetrics and pediatrics, which, if enacted into law, would mean annihilation of both special branches of medicine and the liquidation of their adherents upon whose services the Government depends for the distribution of its beneficences.

Herein goes into the discard any means test or financial qualification as to need which sets apart this proposed act as one of startling novelty in the annals of congressional legislation. Even the EMIC program was qualified by a general means test in that its benefits accrued only to the wives and infants of servicemen of the fourth, fifth, sixth, and seventh grades and to aviation cadets, the lowest-paid classes in the armed forces. The legislative history of EMIC shows, also, that some appropriations committeemen questioned sharply the omission of a means test in this measure.

Congress, together with the American people, believe in a means test. As a matter of fact, the Federal Government insists upon the most widespread application of the means test ever required, namely, the income tax which is based directly upon the financial situation of the individual.

Appropriations for the care of well children of working mothers under the Lanham Act are based upon a sliding scale of the means test and contributions are insisted upon from the parent embracing the facilities of these day nurseries.

Page 4, line 9, (4) Note the words "provide for the administration of the plan by the State Health agency *** and for appropriate coordination of the plan with the general public-health and medical-care program of the State health agency: Provided, That in carrying out the purposes of this title, the State health agency may develop agreements or cooperative arrangements with other State or local public agencies whose functions include the provision of services similar or related to the services furnished under the State plan." The word "public" used in this section is not akin to the old tie schools of England called public, but in reality private, but means governmental as opposed to private a differentiation recognized on page 23, lines 16 to 19, also relating to cooperation "with State and local agencies, public and private, concerned with child health, education, child welfare, and related subjects."

This directive first quoted constitutes a prohibition (by omission) of agreements or cooperative arrangements with such private agencies as the Blue Cross, industrial indemnity sick-benefit plans, prepayment plans of private organizations medically or otherwise initiated, but is at variance with and constitutes an inconsistency with the directive on page 6, line 3 et seq., stating that State plans will provide "such use of health centers, hospitals, clinics, and health-service agencies, public and voluntary, as will achieve the satisfactory distribution and coordination of preventive, diagnostic, consultative, and curative services for mothers and children, furnished by general practitioners, specialists, public health personnel, laboratories and others." The first directive is prohibitive of agreements with private (voluntary) agencies, the second would seem permissive, but who knows what is meant by either except, perhaps, the interpretive ruling of a solicitor of the Department of Labor, which may later appear as a Federal fiat in the columns of the Federal Register.

Page 4, line 20: "be made part of the State plan for maternal and child health services submitted in accordance with the provisions of title V, part 1, of the Social Security Act." Senator Pepper in his speech (p. 3, par. 5) says: "The bill, which I hope will receive early consideration by the Congress, provides for

gradual yet substantial expansion of existing State programs of child health and welfare initiated a decade ago under the Social Security Act."

If that be the purpose of the bill, what is the necessity of usurping by new, over-all legislation, strikingly revolutionary in character, the orderly, legal functions of established governmental agencies which have accomplished much acknowledged good in aid of maternal and child interests throughout the States, but which have done so under careful, yearly scrutiny of regularly ordained appropriation committees of Congress after convincing justification of needs presented by officials of the bureaus involved.

Page 4, line 6: The State is commanded to provide "such methods of administration as are necessary for the proper and efficient operation of the plan" while on page 29, line 8 (sec. 501) "The Chief of the Children's Bureau, with the approval of the Secretary of Labor, shall make (note the word "make") and publish (it is presumed in the Federal Register, thereby having the force of law) such rules and regulations as may be necessary to the efficient administration of this act." One might with unquestioned propriety ask who's who, under such ambiguous phraseology.

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Page 5, line 7, (B): The State is commanded to construct "standards for professional personnel rendering medical, dental, nursing, and related types of care or services, such standards to be established by the State health agency. EMIC and other experiences prove beyond peradventure that the Children's Bureau and not the State agencies have heretofore established such standards for professional personnel and for hospitals, in evidence of which we have quoted above EMIC Circular of Information No. 1 with its array of "shoulds," "musts," and "shalls." This would answer the question who's who. Page 5, line 13: The State is directed to provide "such methods of administration of medical care as will insure the right of mothers and children, or persons acting in their behalf, "to select from among those meetings standards prescribed by the State health agency in accordance with methods set forth in the State plan, the physicians, hospital, clinic, or health service agency of their choice (provided that the physician, hospital, clinic, or health service agency selected may refuse to accept the case), and where no such selection is made, the State plan shall set forth the method by which care will be made available." Herein, according to the proponents of the measure, lies the great virtue of the bill in possessing choice of physician, hospital, or clinic, but what are the limitations of such choice?

They are (1), only from among those meeting "standards" theoretically prescribed by the State health agency, but in the light of past experiences in the administration of EMIC and Social Security title V, established by remote control in Washington by regulations alive with "shoulds," "musts," and "shalls," which have the force of law.

(2) The bill graciously concedes that a physician, hospital, or clinic, may refuse to accept the case, i. e., not enter the "panel" of preferred and acceptable functionaries. What if the majority of physicians, in the language of Calvin Coolidge, do not choose to run the gamut of the slings and arrows of outrageous fortune inherent in the bill? They are without the pale and so are the beneficiaries of Government largess if their chosen ministers of health, whom they may have always sought in times of illness, are not included among the elect. (3) If the mother or child is thus bereft of medical aid from one of their choice, or if they fail to make a choice, the State will provide it, willy-nillythe element of choice having disappeared and that of compulsion by the State taking its place.

Page 5, line 24: The question of adequate remuneration "for persons and institutions providing medical care and related services." Who is to establish what is to be considered as "adequate remuneration?" Past experiences with governmental experimental medical practice indicates that remuneration will be far from adequate and that the fee schedules will be established by bureaucratic edicts which will remain as immutable as the laws of the Medes and Persians and that they will be fixed by remote control almost as distant from some State localities as Iran itself.

Page 6, line 9: "Payments to individual physicians for care furnished under this title (shall be) on a per capita, salary, per case, or per session basis, or, in the case of consultations or emergency visits on a fee-for-service basis."

In the opinion of the majority of pediatricians (as ascertained by poll) and probably of most physicians, the four methods first named are repugnant to the principles of medical practice and destructive of the sound policy that the laborer is worthy of his hire.

Page 6, line 13 (4): The key to the question of "ample remuneration" from governmental agencies, fully demonstrated throughout the years in their financial relationship to physicians and hospitals with which we are all familiar, is discovered in the wording of this paragraph, to wit: "Purchase of care from public or voluntary hospitals and other health service agencies included under the State plan (shall be) on a basis related to cost for providing such care." The same relationship, to judge from experiences under the administration of the EMIC program, will be applied to remuneration of physicians under S. 1318, namely, on a basis of relationship only to the value of the services they render— perhaps even to that of a second cousin twice removed.

Page 6, line 20 (8): From past experiences, our compassionate sympathy should be extended to the State agencies who are required under this provision to "make reports (paper work) in such form and containing such information as the Chief of the Children's Bureau may from time to time require, and comply with such provisions as the Chief of the Children's Bureau may from time to time find necessary to assure the correctness and verification of such reports."

Page 7, line 3, (9): The State plan must "provide 'cooperation' (of what nature the legislative proponent sayeth not) with medical, health, hopsital, nursing, education, and welfare groups and organizations in the State."

Page 7, line 6, et. seq. Herein, as in most medico-social legislation proposed or in operation, commandeering and confiscating the intellectual ability of physicians, appears the red herring commonly dragged across the trail, to wit: The advisory council and the technical advisory committees, both appointed by the State health agency while both are sufficiently and well diluted with "other persons" or "other professional groups" to insure the physician membership a diminutive and ineffective minority.

There is lacking an important explanatory phrase preceding the word "advisory" in each instance in the above provisions, namely, the words "hand picked," which should have been inserted in the interest of truth and veracity. The bill does not even possess the modest controlling interest vested in the selection of members from a "panel," as in the Wagner-Murray-Dingell bill, nor of the indulgence that any three members may demand a meeting of the advisory council as provided in the Hill-Burton bill, S. 191.

Time will not permit a discussion of the failures of "advisory committees," whose advice is eagerly sought when its presence in the administrative picture needs be painted large upon the canvas of cooperation, but in the passage of time such advice is usually relegated to an oblivion wherein its still, small voice disappears in the mist of remembrance only.

These same observations are equally pertinent to the Federal advisory committees (p. 10, line 8) appointed by the Chief of the Children's Bureau.

Page 8, line 5, paragraph (b): The bill directs that "The Chief of the Children's Bureau shall aprove any plan which fulfills the conditions specified in subsection (a), which we have just analyzed above. The Chief is unfortunately vested throughout other remaining sections of the bill with the right and prerogative of wielding an administrative tomahawk to effectively decapitate this particular directive in paragraph (b) relating to obligatory approval of State plans.

Page 8, line 8: Under the title "Payment to States." Methods of computing and paying Federal subsidies are outlined under the direction of the Secretary of Labor who will estimate such sums as are to be paid to the States on the basis of (a) reports and (b) "such other data as to such estimated expenditures, and such investigation as he may find necessary." Evidently the lengthy reports required from the State agency may not receive full credence. Page 10, line 8, Federal advisory committees: The Chief of the Children's Bureau shall formulate general policies (note the conterminous meaning of the words "policies" and "regulations" to which we have called attention above) for the administration of this title after "consultation with (1) a conference of State health officers, and (2) an advisory committee composed of professional and public members." The dilution of an advisory committee by such public members who participate in the discussion of policies which are largely or purely medical in nature is certainly open to question, to judge by past performances of similar groups within the knowledge of the writer.

Page 10, line 21: Here begins Title II-Services For Crippled Children. In wording and phraseology, both title II and title III (relating to child-welfare services) are quite similar to title I just considered.

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