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the quality of medical care, the American Medical Association will oppose those efforts with all the means at its command.

[Reprinted from the editorial department of The Journal of the American Medical Association, February 23, 1946, vol. 130]

THE AMERICAN MEDICAL ASSOCIATION HEALTH PROGRAM AND PREPAYMENT SICKNESS INSURANCE PLANS

At the annual session of the American Medical Association in Chicago in December the house of delegates adopted a resolution instructing "the board of trustees and the council on medical service and public relations to proceed as promptly as possible with the development of a specific national health program, with emphasis on the Nation-wide organization of locally administered prepayment medical plans sponsored by medical societies."

At a series of meetings held in Chicago beginning February 13 the board of trustees and the council on medical service completed considerations which made possible a long step toward protecting the American people against the costs of sickness.

The fundamental step in the development of this plan was the establishment of standards of acceptance for medical care plans which have the approval of the council on medical service of the American Medical Association. Any plan which meets the standards of the council will be entitled to display the seal of acceptance of the American Medical Association on its policies and on all of its announcements and promotional material. In order to qualify for acceptance, the prepayment plan must have the approval of the State or county medical society in the area in which it operates. The medical profession in the area must assume responsibility for the medical services included in the benefits. Plans must provide free choice of a qualified doctor of medicine and maintain the personal, confidential relationship between patient and physician. The plans must be organized and operated to provide the greatest possible benefits in medical care to the subscriber.

Medical care plans may be in terms of either cash indemnity or service units, with the understanding that benefits paid in cash are to be used to assist in paying the costs incurred for medical service. The standards also include provisions relative to the actuarial data that are required, systems of accounting, supervision by appropriate State athorities and periodic checking and reporting of the progress of the plan to the council.

Coincidentally with the announcement of these standards of acceptance there was organized, as a voluntary federation, an organization known as Associated Medical Care Plans, Inc. This independent association will include as members all plans that meet the minimum standard of the council on medical service of the American Medical Association. The Associated Medical Care Plans will undertake to establish coordination and reciprocity among all of these plans to permit transference of subscribers from one plan to another and use of the benefits in any State in which a subscriber happens to be located. Under this method great industrial organizations with plants in various portions of the United States will be able to secure coverage for all their employees. Moreover, it will be possible for the Veterans' Administration, welfare and industrial groups and Government agencies to provide coverage for the people in any given area through a system of national enrollment. In addition the Associated Medical Care Plans, Inc., will undertake research and the compilation of statistics on medical care, provided consultation and information services based on the records of existing plans and engage in a great campaign of public education as to the medical-serviceplan movement under the auspices of State and county medical societies.

The board of trustees of the American Medical Association also announced establishment of a division of prepayment medical care plans with a director and a staff who will administer the activities related to the promotion and development of medical care plans in all the States.

In announcing these proposals for a Nation-wide provision of sickness insurance on a mutual nonprofit basis, the board also presented a complete health program with 10 points, which include the development of services in the field of preventive medicine, maternal and child health, voluntary prepayment plans for protection against the costs of sickness, compensation for loss of wages due to illness, the care of the veteran and the development of a high standard of housing, nutrition, clothing, and recreation.

The American Medical Association last June through its board of trustees and council on medical service announced a 14-point program to improve the health

and medical-care situation in the United States. In October 1945 the interpretation of these 14 points and methods of implementation were adopted by the council on medical service. In December 1945 the house of delegates approved the whole program, suggested its rearrangement and directed the board of trustees to keep the program constantly up to date so that it will stay at least even with and, if possible, a step ahead of the needs of the public.

With this in mind the board of trustees has adopted a restatement of the 14-point program, which clarifies still further the position of the American Medical Association on some of these points and brings into the program more definitely maternal and child welfare, medical research, the medical care of the veteran and the part to be played by the voluntary health agencies. This restatement follows:

NATIONAL HEALTH PROGRAM OF THE AMERICAN MEDICAL ASSOCIATION

1. The American Medical Association urges a minimum standard of nutrition, housing, clothing, and recreation as fundamental to good health and as an objective to be achieved in any suitable health program. The responsibility for attainment of this standard should be placed as far as possible on the individual, but the application of community efforts, compatible with the maintenance of free enterprise, should be encouraged with governmental aid where needed.

2. The provision of preventive medical services through professionally compe tent health departments with sufficient staff and equipment to meet community needs is recognized as essential in a health program. The principle of Federal aid through provision of funds or personnel is recognized with the understanding that local areas shall control their own agencies as has been established in the field of education. Health departments should not assume the care of the sick as a function, since administration of medical care under such auspices tends to a deterioration in the quality of the service rendered. Medical care to those unable to provide for themselves is best administered by local and private agencies with the aid of public funds when needed. This program for national health should include the administration of medical care, including hospitalization to all those needing it but unable to pay, such medical care to be provided preferably by a physician of the patient's choice with funds provided by local agencies with the assistance of Federal funds when necessary.

3. The procedures established by modern medicine for advice to the prospective mother and for adequate care in childbirth should be made available to all at a price that they can afford to pay. When local funds are lacking for care of those unable to pay, Federal aid should be supplied with the funds administered through local or State agencies.

4. The child should have throughout infancy proper attention, including scientific nutrition, immunization against preventable disease and other services included in infant welfare. Such services are best supplied by personal contact between the mother and the individual physician but may be provided through child care and infant welfare stations administered under local auspices with support by tax funds whenever the need can be shown.

5. The provision of health and diagnostic centers and hospitals necessary to community needs is an essential of good medical care. Such facilities are preferably supplied by local agencies, including the community, church, and trade agencies which have been responsible for the fine development of facilities for medical care in most American communities up to this time. Where such facilities are unavailable and cannot be supplied through local or State agencies, the Federal Government may aid, preferably under a plan which requires that the need be shown and that the community prove its ability to maintain such institutions once they are established (Hill-Burton bill).

6. A program for medical care within the American system of individual' initiative and freedom of enterprise includes the establishment of voluntary nonprofit prepayment plans for the costs of hospitalization (such as the Blue Cross plans) and voluntary nonprofit prepayment plans for medical care (such as those developed by many State and county medical societies). The principles of such insurance contracts should be acceptable to the council on medical service of the American Medical Association and to the authoritative bodies of State medical associations. The evolution of voluntary prepayment insurance against the costs of sickness admits also the utilization of private sickness insurance plans which comply with State regulatory statutes and meet the standards of the council on medical service of the American Medical Association.

7. A program for national health should include the administration of Medical care, including hospitalization, to all veterans, such medical care to be provided

preferably by a physician of the veteran's choice, with payment by the Veterans' Administration through a plan mutually agreed on between the State medical association and the Veterans' Administration.

8. Research for the advancement of medical science is fundamental in any national health program. The inclusion of medical research in a National Science Foundation, such as proposed in pending Federal legislation, is endorsed.

9. The services rendered by volunteer philanthropic health agencies such as the American Cancer Society, the National Tuberculosis Association, the National Foundation for Infantile Paralysis, Inc., and by philanthropic agencies such as the Commonwealth Fund and the Rockefeller Foundation and similar bodies have been of vast benefit to the American people and are a natural outgrowth of the system of free enterprise and democracy that prevail in the United States. Their participation in a national health program should be encouraged, and the growth of such agencies when properly administered should be commended. 10. Fundamental to the promotion of the public health and alleviation of illness are widespread education in the field of health and the widest possible dissemination of information regarding the prevention of disease and its treatment by authoritative agencies. Health education should be considered a necessary function of all departments of public health, medical associations, and school authorities.

During the coming weeks the council on medical service will announce the activities that will be followed toward promoting the prepayment medical care plan and also the standards of acceptance that have been developed for such plans. The division of prepayment medical-care plans in the headquarters office will soon be active in aiding the development of plans in areas which do not now have them and in coordinating existing plans.

The policies of the association as expressed in the national health program may well suggest to legislators in the Senate and in the House the point of view of the medical profession as to the part that the Federal Government can play in extending necessary medical services to those who do not now have them.

We are not approving a regimented or socialized system of medical care, and we would oppose the creation of that kind of an agency within the Government. We do desire to cooperate with these agencies in providing the best possible medical care, and we have made this recommendation with that in mind, sir.

Mr. BENDER. Doctor, are you for this plan or against it? I cannot quite make out whether you are for or against it. I have read this very carefully and I have listened to you. Are you for plan No. 2 or against it?

Dr. SENSENICH. We are for the concentration of these medical groups under one head; therefore, we are for that.

Mr. BENDER. You are for this plan even though there is no competent medical man in charge; that is, the chairman has asked you if you knew that the division to which these services were to be transferred had no competent medical man in charge.

Dr. SENSENICH. I think that we have made the recommendation, sir, that they should all be under a medical head, and that that medical man should have Cabinet status, or if not, he should have direct access to the Cabinet level without going through any other agency.

Mr. BENDER. Are you for State control or Federal control, or Federal supervision or State supervision?

Dr. SENSENICH. It depends upon what particular feature you are concerned with. Throughout our entire program of health matters, we have insisted upon the greatest control at the local level, and in those areas in which that was not possible then to the State level, and the Federal Government be only in a supervisory or coordinating position, and that it be not interested in the local level any more than is absolutely necessary.

Mr. BENDER. In the last paragraph of your statement you say:

Should it be apparent that efforts are directed to the establishment of governmental regimentation or measures that would be harmful to the quality of medical care, the American Medical Association will oppose those efforts with all the means at its command.

Does that mean that you are carrying the banner for plan No. 2? Dr. SENSENICH. That is a fair question. We are for the concentration of the agencies as named in the President's plan No. 2.

Mr. BENDER. You are for that?

Dr. SENSENICH. We are for that.

Mr. BENDER. Has your association acted?

Dr. SENSENICH. Yes; it has; not upon plan No. 2 but upon the concentration of these agencies.

Mr. BENDER. Why do I receive letters from physicians in my home State of Ohio opposing this plan? They are M. D.'s apparently in good standing. Apparently they have not consulted with your headquarters as to how you feel about this. They are terribly apprehensive about this plan and program.

Dr. SENSENICH. As a matter of fact, I could not state why they have written you because I have referred here to the various actions of the house of delegates of the American Medical Association, which is a very democratic and elected body. The delegates are elected for 2year terms, and I happen to know the personnel from Ohio are very outstanding men, so there is no question about the position of the American Medical Association throughout the years. The profession is at the moment very apprehensive as to the intent of certain governmental groups. That probably has its background in the message sometime ago suggesting a Government plan and almost immediately in timing the presentation of the Murray-Wagner-Dingell bill, many of the positions of which we have actively opposed and will continue to oppose. For that reason, and for the benefit of your friends in Ohio, we have stated in here that we are opposed to any kind of governmental regimentation.

On the other hand, the concentration of these activities under one agency, we are willing to assume, is with honest purpose and for improved efficiency in operation and not for other purposes.

Mr. BENDER. One witness offers this:

In brief, plan No. 2 reveals an elaborate set-up for the perpetuation of the Federal Government in the fields of sociology and welfare, although such matters originally were regarded as functions of the States and their political subdivisions, and although the Federal Government's part in them in recent years has heretofore been regarded as an emergency matter.

So, it seems, the Federal Government is to put further strain on the "welfare clause" of the Constitution, and is, according to the President's plan No. 2, continuously to invade State's rights and functions, as was so freely done in the name of relief and recovery.

Time was, in the days of the pre-Roosevelt Supreme Court, when the doctrine obtained that the people should support the Federal Government in the exercise of its legislative functions; but there is now about to be fastened upon the people the doctrine that the Federal Government must support the people and assure them good health, education, subsistence, and social security from the womb to the tomb.

Justifications submitted on requests for appropriations for the Social Security Board, Public Health Service, and related agencies and activities, make clear that the administration means to move ahead with its health and security programs on all fronts, without awaiting enabling legislation therefor by Congress. The instant reorganization plan lends strong support to that conclusion. In such

schemes a small opening in the flap of the tent is effected, and the administration carries on without so much as a "with your leave" to Congress.

That is one physician's point of view. How do you feel about that? Do you think that he is unduly apprehensive?

Dr. SENSENICH. Probably not well informed. As a matter of fact, in the reorganization bill, I see nothing indicating that these activities are to be expanded, but to the contrary, they are to be concentrated under one head. The grants-in-aid for particular things, and the things to which this man objected, are the things that are at the present time going on, only they are going on in various and scattered areas of government and probably are not quite as well controlled or directed as they would be if they were in one particular area.

Mr. BENDER. Are you in favor of economy?

Dr. SENSENICH. Yes.

Mr. BENDER. Are you aware that according to this plan No. 2, the Public Health Service will have an increase in '46-from '46 to '47— in man-years of 1,361; that is, man-years of '46 would be 19,008 and the man-years for '47 would be 20,369, or a net increase in cost of $7,635,842?

For the Social Security Board the net increase would be $862,000. Are you aware of that, or have you taken the time to check?

Dr. SENSENICH. That information, sir, was not available to us, and I am at a loss to know why any department under those circumstances should consume more money than they do at the present time collectively.

Mr. BENDER. Under the Food and Drug Administration this plan would provide an increase of $559,000. Have you studied that to determine whether that figure is correct, or have you made any analysis as to the relative costs of this new plan if it should become effective? Dr. SENSENICH. It was our understanding that it was in the interest of efficiency and economy rather than increased costs. The figures that you have referred to there have not been available to us.

The CHAIRMAN. Are those figures from the appropriation act for 1947?

Mr. BENDER. Those figures have been prepared for me by someone who is conversant with the facts and who knows what would actually happen in the event this plan becomes effective.

The CHAIRMAN. Have we not already passed the appropriation bill for the Federal Security Agency this year, and for other agencies? Mr. JUDD. That comes up this afternoon or tomorrow.

The CHAIRMAN. I assume those budget figures are in the present appropriation bill.

Mr. BENDER. There are any number of supplemental bills that come before us periodically, and these figures can all be revised, and are as a rule.

The CHAIRMAN. Is that not a matter up to the Congress? If we want to cut the figures in half that is up to us, or we can double them.

Mr. BENDER. If we pass something here that will make it necessary to increase the figures; if we fail to act on these Pittenger resolutions, we will be stuck with this plan and will have to proceed according to what the plan provides; is that correct?

The CHAIRMAN. I cannot see where the transfer of these agencies under one head would in any way-unless the Congress wanted to

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