Senator DONNELL. Is the Doctor familiar with the investigation made several years ago by the New Jersey Medical Society in regard to the question as to whether or not there is any considerable proportion of the population not receiving adequate medical treatment?

Dr. SENSENICH. I heard about it at that time. I cannot quote from it at the moment but that was done and it was found that it was not due to medical neglect except on the part of the individual, at times, who chose to neglect it.

Senator SMITH. Doctor, I suggest that you proceed with your report. Dr. SENSENICH. Yes.

Senator MURRAY. Mr. Chairman, I regret very much that I am compelled to leave at this point.

Senator SMITH. I regret very much, Senator Murray, that you will not be here. I hope you will be here tomorrow morning.

Senator MURRAY. I wish to apologize to the Doctor, but I shall be very glad to read his testimony. I had very many meetings and conferences with him.

Dr. SENSENICH. I enjoyed the discussion and I hope if we can furnish anything to the committee that will be helpful that you will ask us, as we would be very happy to do it.

Senator SMITH. Thank you, Senator Murray.

You may proceed, Doctor.

Dr. SENSENICH. I will just go through this hurriedly.

No social or legal measure can cover this field by any process of compulsion without in the end destroying the very qualities we seek to stimulate and develop in the individual. No social legislation containing these compulsions can be enacted without infringing upon the very basic qualities of American freedom. The only social measure compatible with the freedom of our American way of life is that providing opportunity to all and assistance where there is need. Administrators in high position will admit that governmental measures at the top, too far removed from the local community and the individual are, even with the best intent, clumsy and inadequate or restrictive in their final application.

So much is dependent upon the education, the interest and the voluntary effort of the individual that elevation of standards and program must be accomplished by local stimulation of effort and cooperation of these individual units in the community. Legislation cannot accomplish those ends. No pattern can be established at the national level that can be practicably applied to the varying conditions in each local community; nor can national regulations deal adequately and fairly in the determination of local need or the application of proper local remedies.

It is, therefore, evident that effective approach to the problem will rest upon the voluntary efforts awakened by stimulation of interest, and development of methods and assistance where need is demonstrated. It would seem that any legislation directed to this field would be largely concerned with providing financial assistance where need can be demonstrated and the setting up of safeguards to determine equitable distribution of that assistance. Contributions from State or local levels should be required in proportion to financial ability. It will be necessary to leave to the local community the administration of local measures without introduction of bureaucratic controls or political interference.

Then, I go on with the matter of voluntary prepayment plans and I will leave very soon so that Dr. McCormick can take that up because it is of great interest.

I refer to the bill S. 545 introduced by Senator Taft, Senator Smith, Senator Ball, and Senator Donnell as more nearly approximating a legislative background for the development of a health program for the American people without destroying or restricting the objectives set forth in the broad national health program of the American Medical Association.

I pointed to that because the American Medical Association has frequently been said to be obstructive. We do not obstruct except in those instances in which we feel action would be harmful to the public or against its best interests, and we do have a broad program which we are endeavoring to develop as rapidly as can be done.

The house of delegates of the American Medical Association has repeatedly taken action recommending the consolidation of the health activities of the Federal Government, exclusive of the Armed Forces and the Veterans Bureau, under a department of health, the head of that department to be a cabinet officer.

Senator SMITH. Doctor, if I may interrupt, do you imply by that that there should be a department of health, not associated with a welfare department? It has been suggested we have a cabinet officer covering welfare generally which would include health and so forth. Dr. SENSENICH. We have opposed that for the reason that we feel that medicine would be in a subordinate position. I do not mean medicine, but health would be in a subordinate position.

And I follow through on that and I have with me here, if the committee cares, for your convenience, copies of the evidence that I gave before the other committee, the comittee on executive expenditures with reference to the Taft-Fulbright bill.

Senator SMITH. If that testimony is not too long, I think it might be inserted in the record.

Dr. SENSENICH. It is not very long.

Senator SMITH. Because this question will probably come up with this committee with regard to the separate health department or this other proposal.

I think we will just insert this statement from the American Medical Association at the hearing before the committee on the expenditures in the executive department. This is the testimony of Dr. Sensenich before that committee. That was in connection with S. 140 and it was a hearing of the committee on March 24, 1947. (The statement referred to is as follows:)

STATEMENT FROM THE MEDICAL ASSOCIATION SUBMITTED BY DR. R. L. SENSENICH, CHAIRMAN OF THE BOARD OF TRUSTEES

The American Medical Association includes more than 130,000 physicians who are members of the county and State medical societies. The policies of the association are determined by the house of delegates. The members of the house of delegates, numbering 175, are elected by the respective houses of delegates of the individual States, which in turn are elected by the members of the county medical societies. Thus the organization is democratic in its organization and in its functions.

The American Medical Association is this year completing 100 years of its existence, devoted to improving the standards of quality of medical service and broadening the distribution of the best medical care to all the people.

64431-47-pt. 1————7

The American Medical Association has been in almost constant contact with most of the governmental agencies having to do with health activities, and has cooperated fully within the scope of policies agreed upon. The evident advantages of consolidation of widely scattered health activities prompted the board of trustees, in January 1937, to make the following recommendation: "The board of trustees of the American Medical Association would recommend that such health activities as now exist be so consolidated in a single department, which would not, however, be subservient to any charitable, conservatory, or other governmental interest.

"It has been repeatedly said that public health work is the first problem of the State. It is the opinion of the board of trustees that health activities of the Government, except those concerned with the military establishments, should not be subservient to any other departmental interests. This reorganization and consolidation of medical departments need not, under present circumstances, involve any expansion or extension of governmental health activities but should serve actually to consolidate and thus to eliminate such duplications as exist. It is also the view of the board of trustees that the supervision and direction of such medical or health department should be in the hands of a competently trained physician, experienced in executive administration." The house of delegates of the association approved the action of the board of trustees. The house of delegates in 1938 reiterated "its demand for a Federal executive department to be designated as the department of health, with a doctor of medicine at its head who shall have general supervision and direction of the affairs of the Federal Government pertaining to the health of the people."

In 1944, the house of delegates approved a resolution recommending that the functions of the Children's Bureau of the Department of Labor be transferred to the United States Public Health Service.

In the same session of the house of delegates, a resolution was adopted requesting "the Congress of the United States to create a Department of Public Health, the head of which department shall be a Cabinet officer, and to assign to such department all health activities of the Federal Government." These repeated actions of the house of delegates were conveyed to the Committee of the Senate on Expenditures in the Executive Departments in the Seventy-ninth Congress in the consideration of Reorganization Plan No. 2 of 1946.

It must be recognized that the American Medical Association throughout the years has maintained the closest contact and has directed continued study to the health activities of governmental agencies, Federal, State and local, educational and research institutions, voluntary groups, and philanthropic health agencies. It has also had the benefits of the experience and advice of unselfish investigators trained in the direction of health activities throughout the world. The reasons for the insistence upon the requirement that the health activities be under the supervision and direction of a "competently trained physician experienced in executive administration" and that the department be not "subservient to any charitable, conservatory or other governmental interest" is well founded.

The Federal Security Agency advances the following argument for the grouping of education, health, and security for the reason that the Federal Government has over a period of many years established agencies to deal with a variety of services to various groups of the population, referring particularly to the Department of Agriculture and those engaged in farming, the Department of Commerce with those in industry and management, the Department of Labor with workers in industry, Veterans' Administration for men with military service. The Security Agency then takes the position that "because each such agency was set up to serve a particular sphere of interest, no one of them is prepared to serve the citizen, and what is, after all, his fundamental character-as an individual human being. No one of them has a mandate to promote the basic concept of the general welfare-the welfare of people simply as people; their right to a firm base on which each can build his own assurances and pursue his own best interests."

The argument falls when it must be admitted by the Security Agency that the implication of effective broad general contact with the major portion of the population throughout the years is not well founded. It touches education only through the years in which compulsory attendance in school is required and that only through local autonomies over which it has little or no control. This is no doubt recognized by those who head the divisions of education.

Educational rehabilitation supported by Federal funds applies only to a relatively small special group, and its activities are carried on through State

agencies. The same applies to special institutions. There may be other isolated small groups who are by reason of Federal aid to some degree come under the direction of the division of education. Social security includes only special groups in covered occupations, and other voluntary agencies collectively exceed the number thus included. Welfare, likewise, has a field of usefulness, but applies only to special groups and does not have universal contacts. Under Federal Security are some other agencies not directly classified under any of these headings, but, again, their number is determined by special needs. It is not intended in these comments to in any way belittle the excellent work being done or to reflect upon the heads of the various activities. However, it is necessary to have a realistic appraisal of the situation in considering the provisions of this proposed legislation.

Health activities must be directed to everyone throughout all of life and it must be noted that the years of major exposure, resultant illness, and greatest economic loss are the years in which the divisions of welfare and education have no effective contact. To discuss the individual as an individual apart from his environment is, to say the least, impractical and ineffective. Medicine extends its activities in the maintenance of health into all the areas of human activity, each one of which carries its own particular problem. Medicine must have the closest contact with all the other agencies of Government-the armed forces, veterans' agency, and other major bodies with which education and welfare have no important contact. If better health is to be attained, preventive health measures must be emphasized, and this will be accomplished on a basis voluntary to the individual who will not necessarily have any health contact with education, security, or welfare. Voluntary agencies are of the greatest importance. All of the departments of Federal Security carry on through State agencies. Health activities have the most effective contact with the individual through State and local levels, and would receive relatively little benefit from combination with other Federal agencies. Health, welfare, and education operate individually at the State and local levels and there would be the greatest opposition to any effort to extend the control of the Federal agencies into the State level. Very large and important groups would prevent any extension of Federal bureaucracy and infringement upon the individuality and dignity of the citizen.

Medical research is likewise important to health progress. Productive research cannot be controlled by governmental agencies. Sufficient funds alone do not attract the brilliant research mind or insure effective research. There must be the closest professional contact, understanding, and cooperation between the voluntary agencies and professional individuals in order to accomplish desired results. It is not evident that welfare, education, and security, as established within the Federal Security Agency, would contribute to progress in medical research.

Medical achievements in the improvement of health, increase in the length of life, and betterment of the quality of living compare favorably with progress in any other scientific field, and the value of the contribution to cultural progress is beyond estimation. This field of activity, however, is highly specialized and cannot be confined within the area of welfare or economic security without loss of important factors in its continuing progress.

The American Medical Association has directed much study to the health needs of the Nation and has prepared a national program of 10 points covering the field of living conditions, fundamentals of good health, preventive medicine service and hospitalization, adequate care of mothers and children, facilities for diagnostic examinations, prepayment insurance plans, care of veterans, research, cooperation with voluntary health agencies, and health education. Senate bill No. 545, introduced by Senators Taft, Smith, Ball, and Donnell, which provides for a separate health agency, would seem to more nearly approximate the standards of this national health program.

All health activities of the Federal Government should be concentrated in one division. That division should be "under the supervision and direction of a competently trained physician experienced in executive administration." Cabinet status would be desirable, but would be attained at too great cost of diminished effectiveness if the health activity were subordinate to another agency. The American Medical Association will continue its efforts to attain the highest levels of health for all of the people.

Senator SMITH. You may continue. Doctor.

Dr. SENSENICH. The Department of Health should not be subservient to any charitable, conservatory, or any other governmental agency.

The American Medical Association opposes the inclusion of the health activities of the Nation in a Department of Health, Education, and Security, for the reason that an adequate national health program such as is now in process of development by the American Medical Association could not attain the high objectives sought, if it were combined in a Department of Welfare and Security. Evidence to this effect was presented in hearings before the Committee on Expenditures in the Executive Departments, United States Senate, Eightieth Congress.

You have copies of that testimony.

There is sufficient reason to maintain that the importance of the health activities is comparable to the importance of other departments and justifies the creation of a Department of Health of Cabinet rank. However, there is equal reason to believe that a national health agency without Cabinet rank could better serve the interest of the health of the Nation than the inclusion of the health activities with welfare or security, headed by a nonmedical Cabinet officer.

Senator DONNELL. May I ask the doctor if he has studied the provisions of S. 545 creating a national health agency?

Dr. SENSENICH. I have.

Senator DONNELL. And, generally speaking, are you favorable to the general terms of that section?

Dr. SENSENICH. The general terms; yes, sir.

Senator DONNELL. Yes?

Dr. SENSENICH. Yes.

In this brief statement, it is impossible to discuss very completely the various features of Senate bill No. 545. However, certain provisions of the bill should be particularly pointed out, notably, the bringing together of all scattered health activities into a national health agency headed by an outstanding physician; the determination of actual medical needs by requiring State surveys financed in part from Federal funds-this is a highly desirable feature provisions of grants-in-aid to States also making some contribution for the extension of medical care to people unable to pay for it; the encouragement of voluntary prepayment plans; the provision for voluntary pay-roll deductions of Federal employees; periodic examinations of school children; and the provision for encouragement and grants-inaid to certain types of research, properly directed.

These provisions of the bill should receive the approval of all those who are interested in a sensible approach to developing methods of extending aid rather than endeavoring to force upon the public a preconceived political pattern. It is noteworthy that no effort is made to establish criteria at the national level by which eligibility to a lowincome classification shall be determined in each local community. Obviously, the section of the country and living costs in proportion to income will have material bearing on that matter.

That is the point I have objected to in the way of general statistics. The appropriation of funds for the support of research in the prevention and control of cancer should be dependent as to the needs for continuation upon such cancer research as has been formerly under the direction of the Public Health Service. In other words, the situation might change if we have a committee appointed to deal with the over-all situation in research. I say here that if that com