TRENDS
IN HEALTH LEGISLATION AND ADMINISTRATION
By JOHN P. HUBBARD, M.D., Contributing Editor
This and subsequent descriptions of events and trends are intended to be unbiased and factual,
presenting both sides of controversial matters so that conclusions may be formed from critical
appraisal of things as they are. These statements do not necessarily reflect the opinion of the
writer nor are they to be interpreted as official opinion of the Academy.
T
HE 81st Congress continues to receive an increasing number and variety of health bills. Among this growing list, we wish at this time to draw attention to the following:NATIONAL CHILD RESEARCH BILL
In February we published in this column a preliminary draft of “The National
Child Research Bill.” This bill, with few but significant changes, was introduced into
the Senate by Senator Douglas on February 10 as 5.904. In preliminary draft form
this bill provided for a National Child Research Institute to be established in the
Children’s Bureau. Thus it was intended that there should be created within the
Children’s Bureau a separate institute comparable to the National Institutes of Health of the U. S. Public Health Service. In 5.904 there is no mention of a separate institute;
it is proposed that the Children’s Bureau itself be “authorized to establish and carry
out a program of research in child life and development’ ‘ with such additional
quar-ters as may be necessary to enable the Bureau to discharge its functions provided for
in this bill. In other respects 5.904 is identical to the draft bill previously published.*
THE SCHOOL HEALTH SERVICES BILL
This bill, preliminary draft of which was also published in this column in February, became entangled in legislative strategy from which it has not emerged as of present
date (February 23, 1949) . In late January there arose within the Senate Committee on
Labor and Public Welfare a proposal to add school health services to 5.246, a bill
calling for $300,000,000 a year in Federal aid to elementary and secondary schools. An additional annual appropriation of $25,000,000 to be used for school health
services was suggested as an amendment to 5.246 with a formula to be worked out for the distribution of the funds through the state education agencies. (The School Health
Services Bill proposed by Senator Saltonstall in the 80th Congress, 5.1290, called for an appropriation of $10,000,000 for the first year and $15,000,000 for the second year.)
The Committee rejected the idea of combining the two programs in one bill. It
de-cided that a separate bill should be drafted on the subject of school health services and
that the two bills should then be considered together in the light of their interlocking
objectives. A subcommittee was named to draft the health measure “expeditiously.” Members of this subcommittee are Senators Hill, Douglas, Taft and Smith.
DEPARTMENT OF WELFARE
An Administration bill (H.R. 782) to carry out the President’s recommendation
* PEDIATRICS 3:243, 1949.
to convert the present Federal Security Agency into a Cabinet Department of Welfare
has now been approved by the House Committee to which it was referred. It is
note-worthy that this bill as approved by the Committee creates a “Department of Welfare” instead of a Department of Health, Education and Security. On February 1 5, the final day of hearings on this bill, Dr. John W. Green of California stated the AMA
opinion favoring the creation of a cabinet Department of Health with a physician as
secretary and opposing the creation of a department covering education and welfare
as well as health. The National Education Association is also opposed to a joint
de-partment and has urged a separate agency in the field of education.
It may be anticipated that the Department of Welfare bill will receive prompt
action. Federal Security Administrator Ewing has stated that he is wholeheartedly
in favor of the bill ; the Bureau of the Budget (on behalf of the President)
recom-mends its enactment ; former President Hoover testified that he thought “the general
consensus of view is that there should be a Department of Welfare.”
LOCAL PUBLIC HEALTH UNITS BILL
This bill (5.522), which received favorable attention a year ago in the 80th
Con-gress, was introduced on January 17 by Senator Hill with bipartisan support. It has
been sponsored by the National Congress of Parents and Teachers and appears to have high priority among the many health bills. It has been endorsed by the American
Medical Association, the State and Territorial Health Officers Association, the American
Public Health Association, the National Tuberculosis Association, the National Society
for Crippled Children and Adults and other organizations. When introducing this
bill, Senator Hill called attention to the great lack of full-time health departments
throughout the United States. “This bill” he stated “would take a long step toward
helping to get enough trained doctors, nurses and technicians into the local and county health departments to carry on the great fight of preventive medicine. . . . The bill
would help provide health examinations for our children at the all-important
pre-school age when so many physical defects can be discovered and corrected.”
In brief the bill would provide Federal grants to states to assist them in establishing
and maintaining local public health units in order to provide basic full-time public
health services in all areas of a state. Within certain standards to be established by
the Surgeon-General, each state would set up its own plan for carrying out the pur.
poses of the bill. The Federal aid thus provided would be in addition to existing
grants-in-aid programs such as tuberculosis control, venereal disease control, cancer
control, mental health and maternal and child health services. Grants are also provided
to enable public and other nonprofit institutions offering training in public health
work to train needed personnel for both state and local health work.
It is reasonably certain that this bill will be enacted essentially as it is or will be incorporated into a broader bill along with other measures, Since its enactment would
have a close relationship to state action for child health, it is quoted in full below.
S.522
To amend the Public Health Service Act to authorize assistance to States and political
subdivisions in the development and maintenance of local public health units, and for
other purposes.
HEALTH LEGISLATION AND ADMINISTRATION 565
America in Congress assembled, That this Act may be cited as the “Local Public Health
Units Act of 1949.”
DECLARATION OF POLICY AND PURPOSE
SEC. 2. The Congress hereby finds and declares
that-(a) adequate protection of the Nation’s health is essential to the security and well-being of our country and cannot be achieved unless basic public health services are available in every locality through adequately staffed and properly equipped local public health units;
(b) at present more than forty million persons in the United States live in areas
not served by local public health units and less than ten million persons live in
areas served by units which meet basic minimum public health standards;
(c) many areas cannot support local public health units staffed and equipped to the extent necessary for the provision of the basic public health services essential to the well-being of the community;
(d) it is therefore the policy of the Congress, and the purpose of this Act, in the promotion of the general welfare and in the interest of national security, to assist
the States, through the measures provided for in this Act, in developing and
main-taming local public health units organized to provide basic full-time public health
services in all areas of the Nation and in the training of all types of personnel for local public health unit work.
LOCAL PUBLIC HEALTH UNITS
SEC. 3. (a) Section 315 of the Public Health Service Act, as amended, is amended by redesignating such section as section 304.
(b) Part B of title III of such Act is amended by adding at the end thereof the
following new section:
.‘GRANTS TO STATES FOR LOCAL PUBLIC HEALTH UNITS
“SEC. 315. (a) For the purposes of this
section-“ (1
)
the term ‘local public health unit’ means the governmental authority of alocal area authorized to provide in such area the basic public health services for which funds are made available under this section (including a unit of a State government specifically assigned responsibility for the provision of basic public health services
in a local area)
,
or a combination of the governmental authorities of two or more contiguous local areas authorized to provide such services in such combined area;‘, (2) the term ‘population’ (A)
,
as applied to a State, means the population thereof according to the latest estimates available from the Department ofCorn-merce on August 3 1 of the year preceding the fiscal year (or portion thereof) for
which a determination with respect to such population is made under this section,
and (B) , as applied to less than State-wide areas, means the population of such
areas according to the most recent decennial census figures certified by the Depart-ment of Commerce that are available on August 31 of the year preceding the fiscal year (or portion thereof) for which a determination with respect to such population
is made under this section, increased or decreased in proportion to the increase or
decrease since such census of the population of the State as estimated in accordance
with clause (A) hereof;
income of a State, as the case may be, means its average per capita income for the
three most recent consecutive years for which satisfactory data are available from the
Department of Commerce on August 3 1 of the year preceding the fiscal year for which the determination is made, except that the average per capita income of
Hawaii shall be deemed to be equal to that of the continental United States
(exclud-ing Alaska) and the average per capita income of Alaska, Puerto Rico, and the
Virgin Islands shall be deemed to be equal to one-half of that of the continental
United States (excluding Alaska).
“ (b) To enable the Surgeon General to assist the States and their subdivisions in
establishing and maintaining adequately staffed and equipped local public health units
for the provision of basic public health services, there are hereby authorized to be ap-propriated such sums as may be necessary to carry out the purposes of this section.
The sums appropriated pursuant to this section shall be used for making payments to
States which have submitted, and had approved by the Surgeon General, State plans
for carrying out the purposes of this section.
, ,(c) Within six months after the enactment of this section, the Surgeon General
shall by regulation
prescribe-‘ ,
(
1)
criteria for determining the minimum population and financial resources whichvarious types of areas must have, and the minimum number and types of full-time professional and other personnel which local public health units in various types of areas must employ per thousand population, in order to afford reasonable assurance of continued financial support for, and efficient and economical administration of,
basic public health services in such areas;
“ (2) criteria for determining whether methods for allocating, under State plans,
the funds made available under this section to local public health units are equitable and such as to assure the effective use of such funds in the provision of basic public health services;
‘, (3) subject to the limits set forth in subsection (d) (5)
,
general methods of administration necessary to assure efficient and economical provision of basic publichealth services under State plans, including the conditions under which compliance
with such methods may be postponed;
‘, (4) types of health services, including the training of personnel for local public
health work, which shall he considered basic public health services for which
funds may be expended under State plans, consideration being given in such regula-tions to the types of health services for which Federal aid is available under other
provisions of law.
“ (d) In order to be approved under this section, a State plan
shall-, ‘
(
I)
set forth a program for the extension of the State plan so as to assurecoverage under the plan of all areas in the State;
,‘ (2) contain satisfactory evidence that the State health authority and the local
public health units of the State whose populations are covered by the State plan will
have authority to carry out the plan in conformity with the provisions of this section
and regulations prescribed thereunder;
‘, (3) provide that each local public health unit providing basic public health
services under the plan service an area of sufficient population and financial resources
to assure continued financial support for, and efficient and economical administration
HEALTH LEGISLATION AND ADMINISTRATiON 567
such numbers as are required to render minimum basic public health services to the
population served by the local public health unit;
,, (4) provide for the allocation of all funds received by the State health authority
under this section to local public health units participating in the State plan in
ac-cordance with methods that will assure equitable distribution and the effective use of
such funds in the extension and expansion of basic public health services, and
pro-vide that all such funds shall be used by such units solely for the provision of such
services;
‘, (5) provide such methods of administration of the State plan, including methods
relating to the establishment and maintenance of personnel standards on a merit basis
(except that the Surgeon General shall exercise no authority with respect to the
selec-tion, tenure of office, or compensation of any individual employed in accordance with
such methods)
,
as may be necessary to assure the efficient and economical provisionof basic public health services under the plan;
,‘ (6) provide that the State health authority will make such reports, in such form
and containing such information, as the Surgeon General may from time to time
reasonably require, and give the Surgeon General upon demand access to the records
upon which such information is based. The Surgeon General shall approve any State
plan and any modification thereof which complies with the provisions of this
sub-section and regulations prescribed under subsection (c).
‘‘(e) From the sums appropriated pursuant to this section, each State which has a
State plan approved in accordance with subsection (d) shall be entitled to receive for
each fiscal year an amount which bears the same ratio to one-third of the expenditures
for such year under the plan as the average per capita income of the continental United
States (excluding Alaska) bears to the average per capita income of such State, except that
(
1)
in no case may the amount paid to such State for a fiscal year exceed two-thirdsof the expenditures under the State plan for such year, and (2) there shall not be
counted as expenditures under the State plan for any fiscal year any sum in excess of
$1 .50 (or such higher amount as may be specified in the appropriation pursuant to
this section for such year) multiplied by the population of the local public health units
participating in the State plan. If, during the fiscal year, the areas covered by the State
plan are changed, appropriate adjustments, prorated in accordance with the time the
change becomes effective, shall be made in determining the maximum amount of the
expenditures.
.‘ (f) The Surgeon General shall, prior to the beginning of each period for which
a payment is to be made, estimate the amount to be paid to the State for such period
pursuant to subsection (e)
,
and shall then certify to the Secretary of the Treasury theamount so estimated, increased or decreased, as the case may be, by any sum by which
he finds that his estimate for any prior period was greater or less than the amount which
should have been paid to the State under subsection (e) for such period. The Secretary
of the Treasury shall thereupon, prior to audit or settlement by the General Accounting
Office, pay to the State, at the time or times fixed by the Surgeon General, the amount
so certified.
‘. (g) Whenever the Surgeon General, after reasonable notice and opportunity for
hearing to the health authority of the State
finds-.‘ (1
)
that the State plan has been changed so that it no longer complies with the,‘ (2) that in the administration of the plan there is a failure to comply
substan-tially with any provision required by subsection (d) to be included in the plan;
the Surgeon General shall notify such State health authority that further payments
will not be made to the State from appropriations pursuant to this section (or, in his
discretion, that further payments will not be made to the State from such
appropria-tion for activities or areas in which there is such failure) until he finds that the plan
again complies with such requirements or until he is satisfied that there will no
longer be any such failure. Until he so finds, or is so satisfied, the Surgeon General
shall make no further certification for payment to such State from appropriations
pursuant to this section, or shall limit payment to activities or areas in which there is no such failure.”
GRANTS TO STATES UNDER SECTION 314 OF THE PUBLIC
HEALTH SERVICE ACT
SEC. 4. (a) Subsection (c) of section 314 of the Public Health Service Act, as
amended, is amended to read as follows:
‘.(c) To enable the Surgeon General to assist, through grants and as otherwise
pro-vided in this section, States, counties, health districts, and other political subdivisions
of States in establishing and maintaining adequate public health services, including
grants for demonstrations, for the training of personnel for State and local health
work, and for the cost to the State health authority of administering the State plan
approved under section 3 1 5, but excluding grants for basic public health services for
which appropriations are authorized under such section, and to enable the Surgeon
General to provide demonstrations and to train personnel for State and local health
work (directly or through grants to public and other nonprofit institutions offering
training in public health work) and to meet the cost of pay, allowances, and traveling
expenses of commissioned officers and other personnel of the Service detailed to assist
States in carrying out the purposes of this subsection, there is hereby authorized to be
appropriated such sums as are necessary to carry out the purposes of this subsection.”
(b) The first sentence of subsection (d) of such section 314 is amended to read
as follows:
,‘ (d) For each fiscal year, the Surgeon General, with the approval of the
Administra-tor, shall determine the total sum from the appropriation under subsection (a)
,
theap-propriation under subsection (b), and the appropriation under subsection (c) which
shall be available for allotment among the several States.”
(c) Subsection (i) of such section 314 is amended to read as follows:
‘, (i) All regulations and amendments thereto with respect to grants to States under
this section or section 31 5 shall be made after consultation with a conference of State
health authorities and, in the case of regulations or amendments which relate to or in
any way affect grants under subsection (c) of this section for work in the field of
mental health, the State mental health authorities. Insofar as practicable, the Surgeon
General shall obtain the agreement, prior to the issuance of any such regulations or
amendments, of the State health authorities and, in the case of regulations or
amend-ments which relate to or in any way affect grants under subsection (c) of this section
for work in the field of mental health, the State mental health authorities.”
JOSEPH S. WALL, M.D., Chairman
