part of any health program and should have precedence over medical

care.

3. Medical care should be extended as needed but should be limited to individuals unable to provide such care for themselves.

The Pepper bill does not meet the cardinal need, namely, the extension of public health facilities and programs into communities not served at the present time. As Haven Emerson pointed out in the book entitled "Local Health Units for the Nation" which was prepared in 1945 under the auspices of the commonwealth fund for the subcommittee of local health units of the committee on administrative practice of the American Public Health Association; approximately 40,000,000 of the people of the continental United States are living in communities where local health services have either not been undertaken at all, or, if provided for, are under the direction of part-time and generally untrained or experienced health officers. It seems apparent, therefore, that the basic need of this country is the expansion of present public health facilities so that the benefits of preventive medicine may be available to all, rather than the provision of medical care for a selected group of the population. To us, the Association of State and Territorial Health Officers, it appears to be poor administrative practice to set up a medical-care program for the treatment of the sick before adequate measures have been undertaken to reduce the extent of preventable illness. Curative medicine assumes its proper role only after public health facilities have been made available to insure, insofar as is possible, optimal health for the people. It is, moreover, a fundamental policy of the association that medical care is primarily the responsibility of the family which the Government should assume only when the family is otherwise unable to secure it. Since this bill is not based upon a prepayment plan comparable to the Blue Cross, in which participants pay on an insurance basis for medical or hospital care, it cannot provide for universal coverage unless the Government assumes the responsibility for medical care of all persons in the special classes listed regardless of economic status. Because of the vital importance of this point, I repeat that while in favor of its objectives, the association cannot approve S. 1313 in its present form inasmuch as it does not limit the extension of medical care to the medically indigent, as defined by the several individual States.

1. It is the opinion of the Association of State and Territorial Health Officers that State health departments are not prepared to undertake a medical-care program for maternal and child health unless consideration is given to their ability to expand and participate. The association, therefore, recommends that the bill be modified to permit a gradual development of the program over a period of years, limiting it in the first year to children under 1 year of age and extending it by the tenth year of operation to include all children up to the age of 18 years. Preventive, diagnostic, school health, and related facilities would necessarily be made available to all children.

2. The association has recommended that the age limit be reduced from 21 to 18 years, since in the opinion of the members, and individual who has reached his eighteenth birthday can no longer be considered a child. The reasons are self-evident. He has matured sufficiently

both mentally and physically to assume responsibility for himself; he is eligible for draft; and in some States he may vote. Moreover, at this age some individuals are married and raising families of their own. Finally, if the age were left at 21 years, it would be possible for a returning veteran to receive care under this program which is intended for children.

3. State-administered programs: Experience with the emergency maternal and infant care program has shown that in order to administer medical care programs efficiently for the benefit of the public, they must be designed and operated by the States rather by the Federal Government. (a) The States should be able to determine domicile and financial eligibility. (b) They must be able to administer the program in accordance with State laws and to formulate major policies and administrative procedures. It is impossible for 1 pair of shoes to fit 48 pairs of feet. Similarly, it is impossible for a Federal program designed on a national level to meet the needs of the various States and Territories. (c) The States should have authority to establish rates of remuneration for services rendered under their programs by the following means:

The Federal agency should annually establish a stipulated remuneration schedule for each type of medical care rendered by physician, dentist, and other professional personnel or organizations thereof and should match dollar for dollar additional funds appropriated by the States for such professional services rendered, provided that such Federal matching funds shall in no instance exceed 50 percent of those stipulated in the original Federal schedule. Remuneration schedules should be established by the Federal agency only after conferences with the association of State and Territorial Health Officers and with representatives of the professions rendering such services, in order that adequate payment may be furnished to physicians and others in those States in which additional funds are not available to increase the fees paid for professional services. This administration of the medical care program would enable a differential rate of payment from one State to another, based upon the appropriation of funds by the State legislatures to supplement funds made available as grantsin-aid from the Federal Government. Moreover, a State should not be required to include financial participation for the medical and other professional care aspects of the program. Methods of payment to physicians or groups of physicians should be determined by the States. (d) The administration of this program should not be so circumscribed by regulations formulated by the Federal Government as to impose upon the various States standards of procedure which in their opinion are neither desirable nor for the benefit of the people. The Federal agency should require reports based only on such data as are necessary for the operation of the plan. Requests for additional reports other than those specified in the rules and regulations approved by the Association of State and Territorial Health Officers should be made known to the State health agencies at least three months prior to the period to be covered by such reports. Moreover, the State health agency should be informed at least three months prior to the setting up of additional regulations-such regulations not to be made more frequently than once each quarter. Similarly State health departments should give notice in advance to the professions of any

changes in regulations. (e) The Federal agency should not require the State health agency to furnish it with a line-by-line detail regarding the State budget. Moreover, all new regulations, changes in reports, plans, etc., should be submitted in advance, whenever practical, to the Association of State and Territorial Health Officers.

4. Advisory committees: The bill does not provide the professions with a continuous, authoritative voice in the formulation of policies and plans: (a) On the State level, professional advisory committees including such representatives of the medical, dental, hospital, nursing, and public health associations, as are recommended by them. should be appointed by the State health agency with the understanding that such professional advisory committees be given the right and the facilities to make public their recommendations; (b) similarly. on the Federal level, general advisory as well as technical committees should be set up representing the professional organizations and others interested in the problems connected with maternal and child health services and medical care for mothers and children.

5. Voluntary prepayment plan. It is the opinion of the association that the bill should contain specific recommendations permitting State health agencies to enter into agreements for the provision of medica and hospital services with voluntary nonprofit organizations such as the Blue Shield and the Blue Cross.

6. Deficiency appropriations: The Federal agency should guarantee to the States sufficient funds to operate the plan, as approved. under the following conditions: (a) An emergency such as an epsdemic; (b) the distribution of unusual amounts of unforseen care: (c) Other unpredictable factors requiring the State to exceed its allotment for the adminisration of the program.

7. The administrative agency to be a Federal department of health: (a) The Association of State and Territorial Health Officers has, on numerous occasions, expressed the need for a coordinated Federal health program. It has been the experience of the various State health officers that a great deal of duplication exists. Duplicate reports, audits, and other inefficient operative procedures could be eliminated by the unification of the Children's Bureau of the Department of Labor, the United States Public Health Service of the Federal Security Agency, and other agencies of the Federal Government dealing with public health, into a single department of public health or of public health and welfare under the direction of a cabinet secretary: (b) it is, therefore, the recommendation of the association that until such time as a Federal department of health is established this bill be entitled "Maternal and Child Health and Welfare Act of 1945": that title I be administered by the United States Public Health Serv ice; that title II be administered by the Department of Labor; and that adequate changes be made throughout the bill, particularly in title III, to bring about this change.

8. Other changes: Since time does not permit detailed discussion of the numerous changes which the association recommends in Senate 1318, we have prepared the attached amendment (appendix II) and submit it on behalf of the association.

Would it be proper to insert that in the record?

The CHAIRMAN. Yes.

(Appendix II is as follows:)

APPENDIX II

SUGGESTED AMENDMENT OF S. 1318 SUBMITTED ON BEHALF OF THE ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICERS BY VLADO A. GETTING, M. D., DR. P. H., MASSACHUSETTS COMMISSIONER OF PUBLIC HEALTH, AND SECRETARY-TREASURER OF THE ASSOCIATION.

(79th Cong., December 7, 1945)

A BILL To provide for the general welfare by enabling the several States to make more adequate provision for the health and welfare of mothers and children and for services to crippled children, and for other purposes

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That this may be cited as the "Maternal and Child Health and Welfare Act of 1945."

TITLE I-MATERNAL AND CHILD HEALTH SERVICES

APPROPRIATION

SEC. 101. For the purpose of enabling each State to provide and maintain services and facilities to promote [the physical and mental health of mothers during the maternity period, and of children, including medical, nursing, dental, hospital, and related services and facilities required for maternity-care, preventive health work and diagnostic services for children, school health services, care of sick children, and correction of defects and conditions likely to interfere with the normal growth and development and the educational progress of children, and to develop】 general public health programs for mothers and children according to the following schedule: (a) medical, nursing, dental, hospital and related services and facilities required for the physical and mental health of all mothers, who qualify in accordance with section 103, during the prenatal, confinement, and postnatal period. (b) medical, nursing, dental, hospital, and related services and facilities required for physical and mental health, care for sick children, correction of defects and conditions likely to interfere with normal growth and development for all children, who qualify in accordance with section 103, under 1 year of age during the first year of operation of the program, to be extended in such manner as to include all children up to the age of 18 years by the tenth year of operation of the program. (c) preventive, diagnostic, school health, and related services and facilities for all children under 18 years of age, and the development of more effective measures for carrying out the purposes of this title, including demonstrations and the training of personnel for State and local maternal and child health services, there is hereby authorized to be appropriated for the fiscal year ending June 30, 1946, the sum of $50,000,000 and for each year thereafter a sum sufficinet to carry out the purposes of this title. The sums authorized under this section shall be used for making payments to States which have submitted to and had approved by the [Chief of the Children's Bureau] Surgeon General, State plans for developing such programs and providing such care and services.

ALLOTMENTS TO STATES

SEC. 102. (a) For the fiscal year ending June 30, 1946, and for each year thereafter, the [Secretary of Labor] Administrator of the Federal Security Agency shall allot to each State, out of the sums appropriated pursuant to section 101, such part of $5,000,000 as he finds that the number of children under [twentyone] eighteen years of age in such State bore to the total number of children under twenty-one] eighteen years of age in the United States, in the latest calendar year for which the Bureau of the Census has available statistics.

(b) For the fiscal year ending June 30, 1946, and for each year thereafter, in addition to the allotments made under subsection (a), the [Secretary of Labor] Administrator of the Federal Security Agency shall allot to the States, out of the sums appropriated pursuant to section 101, the amount remaining after the amount allotted under subsection (a) has been deducted, taking into consideration for each State such factors as (1) the number of mothers, and of children under [twenty-one] eighteen years of age in the State for whom the services and care as provided for in section 101 are to be made available, and the cost of furnishing such services and care to them, (2) the special problems of

maternal and child health, and (3) the financial need of the State for assistance in carrying out the State plan.

(c) The federal agency shall annually establish a stipulated remuneration schedule for each type of medical care rendered by physicians, dentists, other professional persons or organizations thereof and shall match, dollar for dollar, additional funds appropriated by the State for such professional services rendered provided that such federal matching funds shall in no instance exceed 50% of the original federal set remuneration. Such remuneration schedules shall be established only after conference with the State and territorial health officers and with representatives of the professions rendering such services in order that such remuneration furnishes adequate payment of physicians and others in those States where additional funds are not available to increase the fees paid for professional services.

APPROVAL OF STATE PLANS

SEC. 103. (a) A State plan for maternal and child health services under this title must

(1) provide for financial participation by the State;

(2) provide for a State-wide program or for extension of the program each year so that a State plan_adequate to carry out the purposes specified in section 101 will be [in effect] available in all political subdivisions of the State, not later than [July 1, 1955] ten years after the approval of the State plan;

(3) provide that as services and facilities are furnished under the plan they shall be available to all mothers and children domiciled in the State or locality who are determined by the State health agency to be eligible and 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 requirements;]

(4) provide for the administration of the plan by the State health agency or for the supervision of the administration of the plan by the State health agency, and for appropriate coordination of the plan with the general publie 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;

[(5) 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;1

(6) provide such methods of administration as are necessary for the proper and efficient operation of the plan, including methods relating to the establishment and maintenance of (A) personnel standards on a merit basis, except that the Chief of the Children's Bureau shall exercise no authority with respect to the selection, tenure of office, and compensation of any individual employed in accordance with such methods,] (B) standards for professional personnel rendering medical, dental, nursing, and related types of care or service and standards for hospital and other institutional care and services, such standards to be established by the State health agency after consultation with professional advisory committees, [appointed by the State health agency,] which shall include representatives of medical, dental, hospital, nursing and public health associations, who shall be recommended by said associations and others; all of whom shall be appointed by the State health agency with the understanding that the professional advisory com mittees reserve the right and are provided the facilities to make public their recommendations, and (C) such methods of administration of medical care as will insure (1) the right of mothers and children, or persons acting in their behalf, to select, from among those meeting standards prescribed by the State health agency in accordance with methods set forth in the State plan, the physician, hospital, clinic, or health service agency of their cho (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; (2) a high quality of care by providing for adequate remuneration, to be deter mined by the State health agency after consultation with the professional advisory committees, for the persons and institutions providing medical care and related services; opportunities for postgraduate training of professional