TRENDS
IN
HEALTh
LEGISLATION
AND
ADMINISTRATION
JOHN P. HUBBARD, M.D., Coniributing Editor
Washington, D.C.
This and subsequent descriptions of events and trends are intended to be unbiased and faauai, presenting both sides of controversial matters so thas conclusions may be formed from critical 4’-praisai of tbin,gs 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.
S OF present writing (January 9, 1948) Congress has reconvened and President
Truman has come before a joint session of both houses with renewed and vigorous
support of a national health insurance program. But Congress is Republican and Senator Taft has dedared his determination to fight his Republican health program (5.545)
through Congress, despite what he has termed “increasing propaganda activity” in
behalf of the Wagner-Murray-Dingell Bill (5-1320) . And, it should be remembered, Senator Taft is chairman of the Committee on Labor and Public Welfare which will decide upon the health bills to be reported to the floor of the Senate during ensuing
months.
Last month when we reviewed the Wagner-Murray-Dingell Bills (S-1606 and S-i 320)
and the Taft Bill (5-545
)
, we stated that “it is unlikely that either a comprehensive Democratic or Republican health program will be acted upon in this session of Congress.”This prediction still looks good. It is a reasonably good guess that the Taft and the
Wagner-Murray-Dingell Bills will deadlock in Committee hearings early in the year. We
may then expect to see a less controversial measure reported out of Committee favorably
so that those seeking re-election in the fall can daim achievement in relation to the health of the people. The cause of child health is always popular. Therefore, the School
Health Services Bill (HR-1980 and 5-1290) may play the role of a compromise bill unless
it can be demonstrated that some other approach to health legislation is preferable.
This School Health Services Bill was first introduced about a year ago by
Representa-tive Howell. Shortly thereafter, Senator Saltonstall introduced a companion bill (S-1290). The purpose of this legislation is “to establish a national policy under which American children could not be permitted to grow up with physical or mental defects which could
be prevented or corrected in childhood.” One of its essential features would be to supple-ment routine physical examinations for school children with some provision for
follow-up medical care to correct defects and conditions likely to interfere with normal growth,
development, and educational progress.
The bill would establish a new grants-in-aid program administered by the Children’s Bureau “to cooperate with each State in providing and maintaining school health services for the prevention and diagnosis of physical and mental defects and conditions, and
(
especially in rural areas and in areas suffering from severe economic distress) the treat-ment of such defects and conditions.”In HR-1980 it is proposed to finance the program by an appropriation of $12,000,000 for the first year, $18,000,000 for the second year, and for each succeeding year, as much as might be necessary to carry out the purposes of this legislation. Senator Saltonstall’s
292 JOHN P. HUBBARD
$10,000,000 for the first year and $15,000,000 for the second year. Both bills
pro-pose that half of the State allotment should be unmatched and half matched with
con-sideration given to the population of school age children and high per capita grants for
the less wealthy States. Of the sum appropriated each year, $2,000,000 would be available to establish demonstrations, to train personnel for State and local school health services
through grants to schools of public health and other professional institutions, and to
administer the program.
Each State before receiving any funds would have to prepare a plan in accordance with
certain conditions specified in the bill. Included in these conditions is provision for
follow-up medical treatment of defects revealed by the routine physical examinations. Also the
State plan is to be administered by either the State health agency or the State education
agency according to State law, but the plan must be concurred in by both agencies. Thus
each State would determine how health and education authorities would cooperate in
making health services available to school children. Each State would draw up its own
plan according to its own needs.
State plans would be submitted for approval to the Chief of the Children’s Bureau,
acting with the advice of a board composed of the Chief of the Children’s Bureau as
chairman, the Commissioner of Education and the Surgeon General of the Public Health
Service. In addition to this Board, a National Advisory Committee on School Health
Services consisting of twelve members would be created to advise on the administration of this program.
Hearings on these bills have so far been very limited, In the House, hearings were
held on only one morning (July 16, 1947) by a special health sub-committee of the Interstate and Foreign Commerce Committee. In the Senate, hearings have not yet been
scheduled by the Committee on Labor and Public Welfare to which the bill has been referred. Although brief and limited mostly to statements presented by the principal
sponsors of this legislation, the testimony has been sufficient to bring out certain
im-portant controversial points, the two most important of which are: (1) the division
of responsibility between health and educational authorities and (2) the inclusion in
both bills of the two words “and treatment” which provide for medical service related
to the correction of defects discovered during the course of school examinations.
At the national level, the administration of the program is placed primarily in the hands of the Children’s Bureau, which is directed to utilize the services of the Office
of Education in matters involving State education agencies. These agencies-the
Chil-dren’s Bureau and the Office of Education-have not yet reached full agreement on the
division of administrative responsibility, but since both are in the Federal Security
Agency the way is dear for the development of a workable plan.
At the State level, the situation is not so easy. In many States school health services
are by State law under the administrative direction of the education agency, although
there is general agreement among educational agencies that medical care is the
responsi-bility of the health officials, When now it is proposed that health services should be
extended, we hear the voice of state health departments arguing that jurisdiction in
these matters should belong solely to them. The Association of State and Territorial
Health Officers and the American Public Health Association, both supporting the bill,
recommended to the House Committee that in due course-by 1950 or
recently, however, the School Health Section of the A. P. H.. A. has been attempting to
arrive at less uncompromising attitudes acceptable to education agencies.
The second major controversial issue, arising from the words “and treatment,” is
fundamental to the purpose of the bill. It is now a widespread practice to require physical
examination of school children. Most States already have laws permitting or requiring
physical examination of children in school, Where current practice fails to meet existing need is in providing for the necessary medical care to correct defects revealed by the examinations, It is at this point that the proposed legislation intends to fill the gap ; and
it is also at this point that government impinges upon the private practice of medicine.
It must be admitted that striking out the provision for follow-up care or treatment
would result in an emasculated bill which would accomplish nothing. For example,
dental caries is undoubtedly the most prevalent defect among school children today.
The solution of this problem does not lie in more physical examinations to reveal more cavities, but rather in more and better remedial service so that children can have their
cavities properly filled.
Seeking to limit too broad an application of the words “and treatment” without
killing the bill, Dr. Wall, acting as chairman of the Legislative Committee of the Academy, was responsible for writing into the bill a significant clause emphasizing
treat-ment “especially in rural areas and in areas suffering from severe economic distress.”
This clause seeks to assure that the available funds will be used where needed most and
at the same time avoids specific mention of a means test. Since the bill is silent in respect to a means test, it is left up to the individual State to determine how this clause is to be
interpreted. A State is free to introduce a means test into its plan or to leave it out. The
question of a means test will undoubtedly be the cause of lively discussion in the
forth-coming hearings. On the one hand, we will hear the argument that health services should not be withheld from a child because his parents are more wealthy than those of a child sitting at the next desk. On the other hand, it will be pointed out that an appropriation of $12,000,000 to $15,000,000 is woefully inadequate to meet the need of medical care for children of school age, that safeguards are necessary in order to assure that the
avail-able funds will be used where needed most, and that if the appropriation should be
increased in subsequent years, as allowed in the bill, sufficiently to meet the entire need,
the government would then become seriously involved in the practice of medicine in
corn-petition with private practice.
One safeguard now in the bill and generally agreed upon, results from adherence to
the principle that each State should be responsible for working out its own plan. The application of this principle is stated very well by Senator Saltonstall in his testimony
before the House Committee: “This does not provide just an examination of the child,
it provides some follow-up. The question, of course, of how far to follow up is a serious problem, but it seems to me that we have got to leave that up to the local administrator.
My main feeling as a former State official, and now as a Government official, is that the Federal Government must in these days give financial assistance to local and State
gov-ernments on certain social problems to use the word in its broadest sense ; but I hope and
trust that when we pass these laws, we will not try to tell the local administrator just
how he shall do it, but we shall give him advice. If he lives up to certain standards, then
he gets our help. From there on, he goes it alone and he goes it in a way that he thinks
294 JOHN P. HUBBARD
A Department of Health, Education, and Security of Cabinet status as proposed in S-140 is increasingly likely to receive early action, It has already been favorably reported
out of committee but has not yet reached the floor of the Senate for consideration. Mr. Oscar Ewing, Federal Security Administrator, has come out strongly for elevating his
agency to cabinet rank and has let it be known that he would not object to a cabinet
post himself. The AMA has opposed this move on the grounds that the health activities of the nation should not be thrown in with welfare and security activities under a
non-medical cabinet officer. The AMA favors an independent national health agency without
cabinet rank as provided for in the Taft bill (-545).
Federal funds for medical education are being proposed with increasing vigor. Dr. Parran has recommended that the Public Health Service, and other medical services as
well, should consider a system of scholarships given to a sufficient number of medical
stu-dents to insure that the future federal need for doctors will be met, He states that : “So
far as the Public Health Service is concerned, I am convinced that some such system is
essential. I suggest that such scholarships be awarded on a wide geographical basis. The
candidate might be nominated by the Senators and Congressmen. . . . A plan such as this might be broadened so that the student if not required for active duty in the Service,
woul1 fulfill his obligation to the gov’ernment by employment in a state or local health
service, or even as a final choice, by practicing in an area of his state designated as a deficient area by the appropriate state authorities,” In agreement with Dr. Parran’s pro-posal, the Association of State and Territorial Health Officers has gone on record officially
recommending that the U. S. Public Health Service and the U. S. Children’s Bureau
study the problem of training and make plans to subsidize medical schools, schools of
public health, and training centers, as well as for scholarships to a reasonable number of
students for. the purpose of increasing the number of personnel in all fields of medicine
and public health,
Federal support of scientific research, inseparable from medical education, has also gained considerable momentum during recent months. The report to the President on the
Nation’s Medical Research submitted by Steelman’s Committee points to the financial
crises existing today in medical schools resulting from rising costs and decreasing income from endowments, grants, and gifts. “New money,” the Committee states, “in addition
to expanding public support of medical research, must be forthcoming to support the teaching function in graduate schools. . . . As quickly as possible, national expenditures
for medical research should reach $300,000,000 annually-nearly three times the present
rate. Most of this expansion must come from public funds.” Those with further
interest should read with careful attention Volume V of the Steelman Report. This
