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no assurance that Reorganization Plan No. 27 would not interfere with the creation of a separate Department of Health at some future time. The plan itself does nothing to facilitate such an independent department. If the plan becomes effective, I fear that separation of health functions of the Government into a single agency or department will be postponed for a long time, if not permanently. As previously indicated, Reorganization Plan No. 27 will, if permitted to become effective, elevate to the status of an executive department the existing Federal Security Agency. The Administrator of that agency, who it is reported will be recommended for confirmation as the Secretary of the new department, has widely publicized his advocacy of a Federal health program which would socialize or federalize the practice of medicine in the United States. To this date, the Congress has wisely refused to sanction such a program. To create such a department, however, as contemplated by Reorganization Plan No. 27, with an administrative head who advocates a program that will inevitably result in a poorer quality of medical care controlled and dominated by Federal bureaucracy, might suggest an implied approval by the Congress of that program. The present Administrator of the Federal Security Agency has no qualifications to conceive or direct a national health program.
Other health programs are before the Congress, such as Federal aid to medical education, which if adopted will be administered by the new department suggested by Reorganization Plan No. 27. If such a department is created, it is reasonable to assume that all health programs administered by it will reflect the present attitudes of the Federal Security Agency as evidenced by its Administrator. Additional programs may be suggested, such as the transfer of the medical department of the Veterans' Administration to the Department of Health, Education, and Security. The Congress must appreciate and understand the implications of the plan under consideration before permitting it to become effective.
There was published in the Journal of the American Medical Association for January 10, 1948, an article dealing with a Cabinet department of health, education, and security jointly prepared by Gerhard Hirschfield, director of research for the council for economic security, and E. M. Wood, research assistant. This article presented a detailed analysis of the proposal then embodied in S. 140, a bill to which I have made previous reference. I would like to submit for the record a copy of this article and to urge that its contents be given careful consideration by your committee in connection with the proposal now before you.
Mr. Chairman and members of the committee, I wish to express our appreciation for the opportunity again to present the views of the American Medical Association with respect to the proposal now being renewed in Plan No. 27.
Dr. BAUER. We feel that there is no important difference between. the proposals which are suggested by the legislation which was introduced in the Eightieth Congress, the contents of the President's Reorganization Plan No. 1 submitted to the Eighty-first Congress, and the current Reorganization Plan No. 27. They would all combine in the executive department functions relating to health, welfare, education, and social security. We feel it would not advance adequate and proper Federal programs to stimulate improvements in the health of the citizens of our country, but it would tend to subordinate health problems to those related to other aspects of our national welfare, and that would be quite unfortunate.
The American Medical Association has stood for a Federal Department of Health or, if Congress feels it is not timely to establish that at the moment, an independent health agency. At the recently concluded meeting of the American Medical Association which was held in San Francisco, our house of delegates expressed its firm conviction that Reorganization Plan No. 27 will not promote the health of the people and will not effectuate the recommendations of American medicine toward that end.
We feel that the so-called reorganization plan is a complete misnoIt does not reorganize anything; it merely elevates to an executive department status an existing agency of the Federal Government,
with all of its inadequacies. The plan does not suggest what economies it will effect. In fact, the President stated in submitting the plan to Congress that it is not practicable at this time to estimate the savings that will accrue from this plan, and I think the reason an estimate is not practicable is because it will not effect any savings.
We have a separate Department of Agriculture, and yet a comparatively small part of our population is actually engaged in agriculture. We have separate Departments of Commerce and Labor, and yet less than 35 percent of the population is engaged in those fields. On the other hand, 100 percent of the population is concerned with matters of health.
We feel that, if Reorganization Plan No. 27 were permitted to become effective,, it might well serve to bring about subservience of health to other matters.
The President stated in submitting the plan that the Surgeon General and the Commissioner of Education retain all of the statutory authority and duties now vested in them, and the Public Health Service and the Office of Education remain intact as statutory entities with statutory functions. I invite your attention to the fact that the plan provides for a Secretary of Health, Education, and Security. His top associates are an Under Secretary, an Assistant Secretary, and an Administrative Assistant Secretary. All of these will be over the Surgeon General, although the plan does provide that the Surgeon General may report directly to the Secretary.
The CHAIRMAN. May I ask you a question at that point? Are you undertaking to stress and place emphasis on the fact that there would be over the head of the health department, the Surgeon General, the Secretary of the Department, an Under Secretary of the Department, and an Assistant Secretary of the Department, and an Administrative Assistant Secretary of the Department?
Dr. BAUER. Yes; that is one point I wish to make.
The CHAIRMAN. In other words, there are four higher officers in the Department.
Dr. BAUER. That is correct.
The CHAIRMAN. They are higher in the Department than the Surgeon General who is the head of the Public Health Service.
Dr. BAUER. Yes, sir. And furthermore there is no provision that any of the positions should be filled by a physician. In fact, the plan goes so far as to provide that the Surgeon General need not be appointed from the regular corps of the United States Public Health Service, nor is there anything in the plan which would guarantee that he would even be a physician.
The CHAIRMAN. Let us look at the language of the plan at that point. I would like to ask you how you interpret this language with reference to training and experience.
Dr. BAUER. I think it says to have the necessary professional qualifications, or something like that.
The CHAIRMAN. Yes. How do you interpret this language in the plan with reference to the Surgeon General:
Have professional qualifications, experience, and training appropriate to the duties of his office.
Dr. BAUER. Well, the trouble, I think, Senator, is that it is subject to various interpretations. It is not specific enough.
The CHAIRMAN. To quote, "have professional qualifications" does not refer to and you interpret that to refer to qualifications with reference to health or treatment of disease as a doctor would have?
Dr. BAUER. Not necessarily, I do not think sir. I think it could be interpreted that that person might be a public-health engineer, for example, who would be familiar with some of the problems of public health but certainly not with all problems pertaining to medicine. He would have professional qualifications in the field of health.
The CHAIRMAN. Very frankly, now, personally I do not think one would be qualified to possess the qualifications here referred to unless he was a doctor. But what your contention is is that, while I might interpret it that way, it is susceptible of another interpretation that anyone with experience or professional standing in any field of health might qualify under that term.
Dr. BAUER. That is correct; yes, sir.
The CHAIRMAN. Very well; you may proceed.
Dr. BAUER. Now, the President said that the adoption of this plan would not in any way interfere with further adjustments in the functions of the new Department either by statute or reorganization plan. We have no assurance that Reorganization Plan 27 would not interfere with the creation of a separate Department of Health at some future time. The plan itself does nothing to facilitate such an independent department, and if this becomes effective I fear that the separation of health functions of the Government into a single agency or department will be postponed for a long time, if not permanently. The plan, if permitted to become effective, would elevate to the status of an executive department the existing Federal Security Agency. The Administrator of that Agency, who it is reported will be recommended for confirmation as Secretary of that Department, has widely publicized his advocacy of a Federal health program which would socialize or federalize the practice of medicine in the United States. Congress has wisely refused to sanction such a program up to date. But to create such a department as contemplated by this plan, with an administrative head who advocates a program that will inevitably result in a poorer quality of medical care, controlled and dominated by Federal bureaucracy, might suggest an implied approval by Congress of that program. We feel the present Administrator has no qualifications to conceive or direct a national health program.
The CHAIRMAN. May I ask you this. Of course you are referring there to the present head of the Federal Security Agency, who you are assuming and possibly that assumption is justified-would be immediately named Secretary of this new Department.
Dr. BAUER. Yes, sir.
The CHAIRMAN. And you already know his position with reference to projected compulsory health insurance program; and therefore you do not want at the head of medicine someone who advocates such a program; and it would be expected that, of course, he would continue as Secretary of the new Department to use his efforts, personal and possibly official power and influence to further promote and solicit support for the compulsory health insurance plan.
Now, would you not concede, and do you not think, that notwithstanding the attitude of the present head of the Federal Security Agency, notwithstanding his attitude, assuming that the President
would not appoint him as Secretary of this Department, is it not logical to assume that, whomever the President may appoint, it will be someone who shared the President's views with reference to that program, and it is not a question of Mr. Ewing, but you could not get away from it.
Dr. BAUER. That was the point I was going to make next. It is not a question of personalities; the position offers this opportunity to anyone, I do not care who he is.
The CHAIRMAN. Do you not assume that the President would not appoint anybody as Secretary of this Department except someone who was in accord with his views?
Dr. BAUER. I think that is true; yes, sir.
The CHAIRMEN. So it is not a case of personal or individual objections to the present Administrator.
Dr. BAUER. NO; it is not a case of individual personalities.
We have published in the Journal of the American Medical Association for January 10, 1948, an article dealing with a Cabinet Department of Health, Education, and Security; and I would like to leave a copy of that article with you for the record, Mr. Chairman. I think the rest of my statement which I have prepared here, if it just appears in the record, it is not necessary for me to take your time to read it.
The CHAIRMAN. Very well; it may be printed in the record. (The article referred to follows:)
A CABINET DEPARTMENT OF HEALTH, EDUCATION, AND SECURITY (Gerhard Hirschfeld, director of the Research Council for Economic Security and E. M. Wood, research assistant, Chicago)
[This article has been approved by the Bureau of Legal Medicine and Legislation of the American Medical Association]
Overshadowed by more spectacular legislation, the proposal to create a Cabinet department to administer the health, education, public welfare, and socialsecurity functions of the Federal Government has received little attention. A bill for this purpose, S. 140, was introduced early in the Eightieth Congress by Senators Fulbright and Taft. The proposal is in line with the steady increase in Federal participation in fields which have in the past been largely the concern of State and local agencies. The bill in itself adds no new Federal functions and grants no new authority, but it would add prestige to existing functions by giving them status in the highest level of Government, the President's Cabinet. In this connection it may have great potential significance.
STATE AND FEDERAL RELATIONSHIPS IN HEALTH, EDUCATION, AND SECURITY The Constitution gives Congress and the Federal Government the power "to promote the general welfare," but it has been generally understood that helath, education, and security functions are left for the most part to State and local authorities. Under the general welfare clause the Federal Government has gradually increased its activities in social fields in a rather haphazard, largely unplanned fashion. Legislation for this purpose tends to take two major forms, (1) expanding services performed by Federal agencies and (2) increasing Federal participation by grants-in-aid to the States for designated uses. Usually the promise of Federal funds has been conditionad on requirements for matching State and/or local expenditures. Indeed, Federal legislation has often had the deliberate purpose of stimulating State expenditures which probably would not have been made without this incentive. As a result, both State and Federal governments have steadily increased their functions in health, education, and security fields, and there is no evidence of any change in this trend.
The result of a succession of piecemeal legislation is that the relationship between Federal and State-local responsibility has become hazy. It is not clear where local responsibility leaves off and Federal responsibility begins. While the States
tend to be jealous of Federal encroachment, at the same time they are glad to receive Federal funds. It may be worth while to consider briefly the present status of Federal-State relationships in these activities.
WHAT IS THE PRESENT ROLE OF THE FEDERAL GOVERNMENT?
In the field of education State and local jurisdictions still carry the major share of responsibility. The Federal role, although increasing, is still relatively minor. It is possible that Federal participation in education may increase further, particularly in the poorer States which have yet to provide adequate educational facilities for their students. So far, however, Federal activities in education are confined largely to compilation of school statistics, research and advisory services, and to grants-in-aid to States and private institutions for limited special purposes, such as vocational education, training of handicapped persons and scientific research (chart 1).
The Federal role is greater in the field of health, There is, of course, an extensive Federal medical program for the military services and veterans, but the United States Public Health Service is the major agency providing health services for the general public. While this agency is primarily concerned with research and disease prevention, successive legislation has increased its scope of activities for specific health problems: Venereal disease, cancer and tuberculosis control, mental illness, hospital construction, etc. In addition, the Children's Bureau has health functions relating to problems of children, notably the administration of Federal grants for maternal and child health, child welfare, and services to crippled children. While the States have expanded their health services, they have come to be increasingly dependent on grants from the Public Health Service and the Children's Bureau (chart 2).
CHART 1.-Governmental expenditures for education by source of funds and fiscal years. The proportion of expenditures for educational purposes coming from Federal funds has been increasing, but the Federal role is still a minor one. Source: U. S. Office of Education, Sratistical Summaries of Education for 19351936, 1939-1940 and 1943-1944.
However, it is in the field of public assistance and social security that the Federal Government looms largest in the picture. Under the Social Security Act of 1935 the States were induced by the promise of Federal matching grants to adopt or extend "categorical" programs of public assistance: Old age assistance, aid to the blind, and aid to dependent children. Total costs for these programs have mounted steadily, and the proportion of Federal to State and local funds has risen from about 44 percent in 1939 to 53.5 percent in fiscal 194647. The absolute and relative rise in Federal funds has occurred even though in recent years the States have been strong financially, while the Federal Government has incurred a tremendous public debt. Federal control over funds expended through State public welfare agencies is concerned with standards of assistance and administration. While the States have sometimes chafed under these controls, they nevertheless have demanded and obtained continuing increase in Federal funds (chart 3).
In the case of other social-security programs the picture is confusing. Old age and survivors insurance is completely federalized; the States have no part in it. On the other hand, the States administer unemployment compensation, although the original inducement to adopt this program came from the Federal Social Security Act. Unemployment benefits are paid from State trust funds,