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Public Assistance: The Plan in Operation in the Commonwealth of Pennsylvania
DENTAL ECONOMICS PUBLIC ASSISTANCE: THE PLAN IN OPERATION IN THE COMMONWEALTH OF PENNSYLVANIA A S the result o f a study made by a commission set up by the governor o f Pennsylvania in December i 935j the entire question o f public relief in the state comes under the following plan. Seven recommendations proposing a sweeping reorganization and consolida tion o f all forms o f public assistance un der state supervision with local control were made. M ajor recommendations called for permanent relief, and the con solidation o f its supervision, together with that o f other assistance services (medical care), in a new state department to be known as the Department o f Assistance. O f equal importance from the view point o f the taxpayer was the recom mendation that the state’s 200 year old poor board system, supported by a direct tax on real estate, be abolished, and that all forms o f assistance in the home be financed by the state through budgeted appropriations. In the past, owing to the entrench ment o f the state’s 425 poor boards, rep resented by nearly 1,000 office holders, efforts have been directed toward reform rather than fundamental change. Prog ress that was made was in the form o f withdrawals o f responsibility, as in the case o f the Mother’s Assistance Fund, in 19 13 , and, more recently, the establish ment o f old age assistance and blind pen sions. The establishment o f the state emergency relief board in the summer o f 1932 , through which all state and federal funds for unemployment relief were Jour. A.D.A., Vol. 26, January 1939
spent until the adoption o f the present plan on January 1 , 1938, admitted fail ure o f the old system. T H E R EC OM M EN D ATIO N S
It was recommended that : 1 . A state-wide program o f public assistance and relief suitable to the pres ent need and adjustable to changing conditions in the future be maintained in Pennsylvania. 2 . Pennsylvania’s program o f public assistance o f needy persons at home in cluding general poor relief, unemploy ment relief, aid to dependent children in their own homes (known as Mother’s Assistance) and in foster homes, old age assistance and aid to the blind be unified and simplified and be administered through a single public organization in each county, subject to supervision by a single permanent department o f the state government. 3 . Locally administered public assist ance of individuals and families be super vised and standardized by the state government through a new department o f assistance. 4 . (a) Direct administration o f gen eral outdoor relief, unemployment relief, aid to dependent children in their own homes (Mother’ s Assistance) or in foster homes, old age assistance and aid to the blind be under the immediate direction o f a county board o f assistance in each county, composed o f representative citi zens o f the local community, serving without pay except for necessary ex152
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penses and charged with the responsibil ities to themselves, to their dependents ity for determining policies o f public and to the community. 6 . (a) The requirements for determin assistance to be applied in the county, subject to minimum standards estab ing the eligibility o f individuals or fam lished by the state department o f as ilies for aid among the various types of assistance be standardized as far as pos sistance. (b) The Mother’s Assistance Fund sible in administration. (b) The basis of eligibility for all boards, the Old Age Assistance Fund boards and the Emergency Relief boards, forms o f assistance to be administered where they existed, be abolished and their under the new county boards o f assist functions be taken over by County ance be as nearly alike as possible for all services; namely, the actual need o f as Boards o f Assistance. (c) The county, district, township sistance. (c ) The amount o f the grant avail and borough poor boards be abolished immediately and their powers, duties, able to any eligible dependent person be rights and privileges with respect to out the extent o f his need, established in ac door relief and the care o f dependent cordance with administrative regulations children be transferred to the County o f the state department o f assistance, al Board o f Assistance, and their powers, lowing for fluctuations in living costs. (d ) The present plan o f providing as duties, rights and privileges with respect to almshouses and other institutional care sistance or relief in cash be continued. be transferred to the county commission (e) A program for necessary medical ers o f the county, who shall be charged care be included among the services pro with ultimate residual responsibility, now vided to dependent persons. lodged with the poor districts, to provide 7 . All officers and employes in the assistance for such needy persons as may state department o f assistance, other than fail to receive aid from other sources. those in policy determining positions, and 5. (a) The financial cost o f public asall officers and employes under all county sistance in all the forms to be adminis boards o f assistance be placed under the tered by the county boards o f assistance Merit System. be assumed by the state. M E D IC A L CARE (b) Specific appropriations be made W hen the investigating committee to the state department of assistance for each form o f public assistance, and that undertook its projected study o f the gen an additional appropriation to a reserve eral relief problem, a systematic medical fund be made to the state department of relief program was in operation in one assistance, which can be allocated to any branch o f public assistance on ly ; namely, one o f these funds or to the payment of unemployment relief. This program en necessary additional services undertaken listed the advice and administrative co by county boards of assistance in accord operation o f professional groups in the principal fields o f the healing arts. ance with the law. W hen the medical relief program of (c) The state laws be amended to as sure assistance with federal aid for the the Pennsylvania Emergency Relief Mother’s Assistance Fund, the O ld Age Board was abandoned in September 1936 , a special advisory committee, consisting of Assistance Fund and the blind. (d) Public assistance be administered delegated representatives o f the profes in such a way as to afford every possible sional groups and associations concerned incentive to beneficiaries o f aid to strive with the healing arts, was created to dis to regain their power o f self-maintenance charge this responsibility. The plan and scope of the study un and to discharge their proper responsibil
Dental Economics dertaken cooperatively by the Special Medical Advisory Committee and the Pennsylvania Committee on Public As sistance and Relief (the original com mission) were determined by two main objectives: 1. T o discover as quickly and fully as possible the extent o f the need for med ical relief in Pennsylvania and the avail able facilities and methods for meeting those needs. This necessarily included a study o f the incidence o f illness or of need o f health treatment among those receiving other forms o f public assistance and those on the borderline o f economic dependency whose own payment for nec essary health service might bring them into the relief group. It required also an analysis o f available information on med ical relief programs, both the recently discontinued Pennsylvania Emergency Medical Service for the unemployed and other experiments which had preceded or followed it. 2 . T o recommend the scope and basic conditions, as well as the approximate cost, of a suitable and adequate program of medical care for these groups of per sons in Pennsylvania. C O N CLU SIO N S A N D REC O M M E N D ATIO N S
1. Medical care (services o f the heal ing arts professions) is an integral and indispensable part o f any sound program for the public relief and assistance of persons unable to maintain themselves at a minimum level o f health and decency. The conservation o f public health and the promotion o f the general welfare justify provision o f adequate medical care o f those in need as an obligation of government. Governmental responsibility exists in the same measure for members o f families when they become ill as when they are well, and illness, which inaugu rates a more expensive and difficult con dition, does not alter or diminish this governmental responsibility. 2 . A state-wide service for this pur
*55 pose should be provided, designed to meet, as nearly as possible on an equal basis, the needs o f all such persons. Many o f the smaller divisions and sub divisions o f the state, if left to their own resources and initiative, not only would be financially unable to set up and main tain an adequate health service for those in need, but also would create a hodge podge o f services which would often be extravagant, overlapping and inefficient. The medical relief program should be supervised by the department o f the state government which will administer gen eral relief, but it should be so organized as to leave a wide latitude o f adminis trative freedom, under the supervision of the healing arts professions. 3. Such a program should, as far as possible, serve: (a) Those receiving other forms o f public assistance. (b) Other persons certified by the county assistance boards as unable to provide for themselves such necessary services as are included in the program. The right o f all these persons to receive public aid, by reason o f their economic status, has been established by investiga tion. As it has been proved that they are financially unable to provide themselves with other basic necessities o f life, such as food and shelter, it is obvious that they will be unable to pay for medical atten tion when sick. For estimating the prob lem o f this group, a great deal of factual information is available. They have been counted and studied by many agencies and organizations for years. In the economic group just above this level are many persons who are living on the lowest subsistence basis. These per sons are on the borderline o f independ ence. They are just able to maintain themselves without help at a level o f existence which the standards of public assistance organizations accept as toler able. Their position is a precarious one, however. Any misfortune upsets their
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balance and they quickly fall back into dependency. When illness strikes such a family, especially if it affects the bread winner, the members are unable to pro vide themselves with the necessary med ical attention, and unless some provision is made to supply it to them, they will soon increase the rolls of those on relief. These persons should not be classified as “ sick poor people,” but people who are “ poor when sick.” The number and extent o f the “ borderline” class of persons is unknown. It is a relatively uncharted field. In planning to include them in a health program designed for the indigent, it is realized that the problem of care and o f cost is largely increased. In spite o f these difficulties, it is, nevertheless, considered necessary, and de sirable to make provision for their care when sick, in order to enable them to maintain their economic independence. It is believed that these persons could apply and be certified for medical atten tion alone, after a routine social and economic investigation by a relief agency. This procedure would serve to prevent abuses and also to make it possible in time to obtain factual information on which more definite plans could be made hereafter for this group. At any rate, it seems foolish to require such a person to establish his inability to provide himself with some other necessity o f life, such as food, shelter and clothing, before being entitled to receive medical care. Such a policy provides an induce ment for joining the relief rolls and for sacrificing all economic independence. Furthermore, it is this borderline class of persons who are most neglected from a health point o f view. Provisions for sick ness have often been provided for the definitely indigent, and financially inde pendent persons will provide it for them selves. The person on the borderline is working and making an effort to keep off the relief rolls, and should be helped. 4 . This program should, as far as pos
sible, supply a complete service includ-
ing:
(a) Preventive service, utilizing, in this connection, regular health agencies. (b) Corrective and curative service, including medical, dental, nursing, clin ical, hospital and pharmaceutic serv ices. A health program in order to be of real value either must itself take care of all phases o f illness and disability or must be correlated with other organizations supplying necessary services. It should be the aim o f a health program to recog nize and utilize all existing health activi ties, such as those o f the state and local departments o f health, the United States Public Health Service, public rehabilita tion services and others, only entering the field o f work covered by these de partments when it is absolutely necessary to fill a gap. The dental profession, represented by the Pennsylvania State Dental Society, desires the opportunity to work out with the state department o f assistance a plan that will provide: (a) Adequate service for children. (b) Emergency service for adults, with the provision for supplying restorative work when authorized by the county board o f assistance. The dental profession believes that there is no single program that can be applied with equal effectiveness to all parts o f the state. For this reason, the profession will offer for consideration to the state department o f assistance plans, made up in conjunction with the several county boards o f assistance, that will best meet the situation peculiar to each local area. In supplying dental service to children whose families are unable to purchase this aid, any program of public assistance in the health field should emphasize pre ventive measures and the early correction o f dental disease. Adults who may be returned to gain
Dental Economics ful employment should receive a mini mum o f dental care, and that only for the relief o f pain, the elimination o f in fection or such restorative dentistry as will aid in their return to gainful occu pations. The determination o f employ ability shall be made by the county board o f assistance. For those persons who are unemploy able and in the opinion o f the county board o f assistance cannot be returned to economic society, a more complete den tal service should be provided to insure comfort and safety to health. 5 . The organizational framework of this program should be based upon the county unit o f administration, with a liberal allowance o f local autonomy in administration and experimentation. 6 . The general scope, standards and forms o f operation should be determined by the state, through the appropriate de partment. 7 . The state office at Harrisburg should outline basic rules o f operation for the program and the local county com mittees should supply the detailed pro cedures o f operation which apply to their respective areas. The professional groups should be con sulted in deciding on the basic rules. Pro visions should be made for changing the rules in the future, if necessary, without involving too many tedious and compli cated procedures. Such a project as this complete medical program is still in an experimental state and it is impossible to be sure that any set o f rules accepted to day will meet the approval o f adminis trative officers and committees in the future. 8 . The program should provide, unless otherwise specified as the result of an agreement between the Department of Assistance and the professional group in volved, for the free selection o f licensed or registered physicians, dentists, nurses,
*57 hospitals, clinics, pharmacists or qualified organizations set up by, operated and controlled by the healing arts groups par ticipating in this work. 9 . Payment should be made on the fee-for-services principle, as far as prac ticable, and all necessary adjustments of bills should be made according to a pre determined plan. 10 . All participating professional per sons should be given the benefit o f a hearing before their own professional group before any official disciplinary measures are enforced. September 15 , 1938 , the medical care program was started after the necessary organization o f the healing arts group had been accomplished. This consists of an advisory committee to the state pub lic assistance board made up o f one rep resentative o f each o f the professional groups participating as well as similar committees in each county. Fee sched ules were established. The checking of all invoices is done by the subcommit tees and paid within two weeks by the state. The accompanying diagram demon strating the relationship between the component parts o f the set-up in Penn sylvania is published because it is working satisfactorily to all concerned, and al though at the present time medical care is being supplied only to those on relief, it can be expanded to include the socalled “ borderline group.” It is offered for study and consideration to all state groups where the need for such a pro gram is indicated and possibly impend ing. It requires the cooperation o f the other members o f the healing arts group as well as the lawmakers. A complete report o f the survey is filed with the Economics Committee o f the American Dental Association. R. M . W a l l s , Chairman, Economics Committee, A.D.A.
spent until the adoption o f the present plan on January 1 , 1938, admitted fail ure o f the old system. T H E R EC OM M EN D ATIO N S
It was recommended that : 1 . A state-wide program o f public assistance and relief suitable to the pres ent need and adjustable to changing conditions in the future be maintained in Pennsylvania. 2 . Pennsylvania’s program o f public assistance o f needy persons at home in cluding general poor relief, unemploy ment relief, aid to dependent children in their own homes (known as Mother’s Assistance) and in foster homes, old age assistance and aid to the blind be unified and simplified and be administered through a single public organization in each county, subject to supervision by a single permanent department o f the state government. 3 . Locally administered public assist ance of individuals and families be super vised and standardized by the state government through a new department o f assistance. 4 . (a) Direct administration o f gen eral outdoor relief, unemployment relief, aid to dependent children in their own homes (Mother’ s Assistance) or in foster homes, old age assistance and aid to the blind be under the immediate direction o f a county board o f assistance in each county, composed o f representative citi zens o f the local community, serving without pay except for necessary ex152
Dental Economics
153
154
The Journal of the American Dental Association
penses and charged with the responsibil ities to themselves, to their dependents ity for determining policies o f public and to the community. 6 . (a) The requirements for determin assistance to be applied in the county, subject to minimum standards estab ing the eligibility o f individuals or fam lished by the state department o f as ilies for aid among the various types of assistance be standardized as far as pos sistance. (b) The Mother’s Assistance Fund sible in administration. (b) The basis of eligibility for all boards, the Old Age Assistance Fund boards and the Emergency Relief boards, forms o f assistance to be administered where they existed, be abolished and their under the new county boards o f assist functions be taken over by County ance be as nearly alike as possible for all services; namely, the actual need o f as Boards o f Assistance. (c) The county, district, township sistance. (c ) The amount o f the grant avail and borough poor boards be abolished immediately and their powers, duties, able to any eligible dependent person be rights and privileges with respect to out the extent o f his need, established in ac door relief and the care o f dependent cordance with administrative regulations children be transferred to the County o f the state department o f assistance, al Board o f Assistance, and their powers, lowing for fluctuations in living costs. (d ) The present plan o f providing as duties, rights and privileges with respect to almshouses and other institutional care sistance or relief in cash be continued. be transferred to the county commission (e) A program for necessary medical ers o f the county, who shall be charged care be included among the services pro with ultimate residual responsibility, now vided to dependent persons. lodged with the poor districts, to provide 7 . All officers and employes in the assistance for such needy persons as may state department o f assistance, other than fail to receive aid from other sources. those in policy determining positions, and 5. (a) The financial cost o f public asall officers and employes under all county sistance in all the forms to be adminis boards o f assistance be placed under the tered by the county boards o f assistance Merit System. be assumed by the state. M E D IC A L CARE (b) Specific appropriations be made W hen the investigating committee to the state department of assistance for each form o f public assistance, and that undertook its projected study o f the gen an additional appropriation to a reserve eral relief problem, a systematic medical fund be made to the state department of relief program was in operation in one assistance, which can be allocated to any branch o f public assistance on ly ; namely, one o f these funds or to the payment of unemployment relief. This program en necessary additional services undertaken listed the advice and administrative co by county boards of assistance in accord operation o f professional groups in the principal fields o f the healing arts. ance with the law. W hen the medical relief program of (c) The state laws be amended to as sure assistance with federal aid for the the Pennsylvania Emergency Relief Mother’s Assistance Fund, the O ld Age Board was abandoned in September 1936 , a special advisory committee, consisting of Assistance Fund and the blind. (d) Public assistance be administered delegated representatives o f the profes in such a way as to afford every possible sional groups and associations concerned incentive to beneficiaries o f aid to strive with the healing arts, was created to dis to regain their power o f self-maintenance charge this responsibility. The plan and scope of the study un and to discharge their proper responsibil
Dental Economics dertaken cooperatively by the Special Medical Advisory Committee and the Pennsylvania Committee on Public As sistance and Relief (the original com mission) were determined by two main objectives: 1. T o discover as quickly and fully as possible the extent o f the need for med ical relief in Pennsylvania and the avail able facilities and methods for meeting those needs. This necessarily included a study o f the incidence o f illness or of need o f health treatment among those receiving other forms o f public assistance and those on the borderline o f economic dependency whose own payment for nec essary health service might bring them into the relief group. It required also an analysis o f available information on med ical relief programs, both the recently discontinued Pennsylvania Emergency Medical Service for the unemployed and other experiments which had preceded or followed it. 2 . T o recommend the scope and basic conditions, as well as the approximate cost, of a suitable and adequate program of medical care for these groups of per sons in Pennsylvania. C O N CLU SIO N S A N D REC O M M E N D ATIO N S
1. Medical care (services o f the heal ing arts professions) is an integral and indispensable part o f any sound program for the public relief and assistance of persons unable to maintain themselves at a minimum level o f health and decency. The conservation o f public health and the promotion o f the general welfare justify provision o f adequate medical care o f those in need as an obligation of government. Governmental responsibility exists in the same measure for members o f families when they become ill as when they are well, and illness, which inaugu rates a more expensive and difficult con dition, does not alter or diminish this governmental responsibility. 2 . A state-wide service for this pur
*55 pose should be provided, designed to meet, as nearly as possible on an equal basis, the needs o f all such persons. Many o f the smaller divisions and sub divisions o f the state, if left to their own resources and initiative, not only would be financially unable to set up and main tain an adequate health service for those in need, but also would create a hodge podge o f services which would often be extravagant, overlapping and inefficient. The medical relief program should be supervised by the department o f the state government which will administer gen eral relief, but it should be so organized as to leave a wide latitude o f adminis trative freedom, under the supervision of the healing arts professions. 3. Such a program should, as far as possible, serve: (a) Those receiving other forms o f public assistance. (b) Other persons certified by the county assistance boards as unable to provide for themselves such necessary services as are included in the program. The right o f all these persons to receive public aid, by reason o f their economic status, has been established by investiga tion. As it has been proved that they are financially unable to provide themselves with other basic necessities o f life, such as food and shelter, it is obvious that they will be unable to pay for medical atten tion when sick. For estimating the prob lem o f this group, a great deal of factual information is available. They have been counted and studied by many agencies and organizations for years. In the economic group just above this level are many persons who are living on the lowest subsistence basis. These per sons are on the borderline o f independ ence. They are just able to maintain themselves without help at a level o f existence which the standards of public assistance organizations accept as toler able. Their position is a precarious one, however. Any misfortune upsets their
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The Journal of the American Dental Association
balance and they quickly fall back into dependency. When illness strikes such a family, especially if it affects the bread winner, the members are unable to pro vide themselves with the necessary med ical attention, and unless some provision is made to supply it to them, they will soon increase the rolls of those on relief. These persons should not be classified as “ sick poor people,” but people who are “ poor when sick.” The number and extent o f the “ borderline” class of persons is unknown. It is a relatively uncharted field. In planning to include them in a health program designed for the indigent, it is realized that the problem of care and o f cost is largely increased. In spite o f these difficulties, it is, nevertheless, considered necessary, and de sirable to make provision for their care when sick, in order to enable them to maintain their economic independence. It is believed that these persons could apply and be certified for medical atten tion alone, after a routine social and economic investigation by a relief agency. This procedure would serve to prevent abuses and also to make it possible in time to obtain factual information on which more definite plans could be made hereafter for this group. At any rate, it seems foolish to require such a person to establish his inability to provide himself with some other necessity o f life, such as food, shelter and clothing, before being entitled to receive medical care. Such a policy provides an induce ment for joining the relief rolls and for sacrificing all economic independence. Furthermore, it is this borderline class of persons who are most neglected from a health point o f view. Provisions for sick ness have often been provided for the definitely indigent, and financially inde pendent persons will provide it for them selves. The person on the borderline is working and making an effort to keep off the relief rolls, and should be helped. 4 . This program should, as far as pos
sible, supply a complete service includ-
ing:
(a) Preventive service, utilizing, in this connection, regular health agencies. (b) Corrective and curative service, including medical, dental, nursing, clin ical, hospital and pharmaceutic serv ices. A health program in order to be of real value either must itself take care of all phases o f illness and disability or must be correlated with other organizations supplying necessary services. It should be the aim o f a health program to recog nize and utilize all existing health activi ties, such as those o f the state and local departments o f health, the United States Public Health Service, public rehabilita tion services and others, only entering the field o f work covered by these de partments when it is absolutely necessary to fill a gap. The dental profession, represented by the Pennsylvania State Dental Society, desires the opportunity to work out with the state department o f assistance a plan that will provide: (a) Adequate service for children. (b) Emergency service for adults, with the provision for supplying restorative work when authorized by the county board o f assistance. The dental profession believes that there is no single program that can be applied with equal effectiveness to all parts o f the state. For this reason, the profession will offer for consideration to the state department o f assistance plans, made up in conjunction with the several county boards o f assistance, that will best meet the situation peculiar to each local area. In supplying dental service to children whose families are unable to purchase this aid, any program of public assistance in the health field should emphasize pre ventive measures and the early correction o f dental disease. Adults who may be returned to gain
Dental Economics ful employment should receive a mini mum o f dental care, and that only for the relief o f pain, the elimination o f in fection or such restorative dentistry as will aid in their return to gainful occu pations. The determination o f employ ability shall be made by the county board o f assistance. For those persons who are unemploy able and in the opinion o f the county board o f assistance cannot be returned to economic society, a more complete den tal service should be provided to insure comfort and safety to health. 5 . The organizational framework of this program should be based upon the county unit o f administration, with a liberal allowance o f local autonomy in administration and experimentation. 6 . The general scope, standards and forms o f operation should be determined by the state, through the appropriate de partment. 7 . The state office at Harrisburg should outline basic rules o f operation for the program and the local county com mittees should supply the detailed pro cedures o f operation which apply to their respective areas. The professional groups should be con sulted in deciding on the basic rules. Pro visions should be made for changing the rules in the future, if necessary, without involving too many tedious and compli cated procedures. Such a project as this complete medical program is still in an experimental state and it is impossible to be sure that any set o f rules accepted to day will meet the approval o f adminis trative officers and committees in the future. 8 . The program should provide, unless otherwise specified as the result of an agreement between the Department of Assistance and the professional group in volved, for the free selection o f licensed or registered physicians, dentists, nurses,
*57 hospitals, clinics, pharmacists or qualified organizations set up by, operated and controlled by the healing arts groups par ticipating in this work. 9 . Payment should be made on the fee-for-services principle, as far as prac ticable, and all necessary adjustments of bills should be made according to a pre determined plan. 10 . All participating professional per sons should be given the benefit o f a hearing before their own professional group before any official disciplinary measures are enforced. September 15 , 1938 , the medical care program was started after the necessary organization o f the healing arts group had been accomplished. This consists of an advisory committee to the state pub lic assistance board made up o f one rep resentative o f each o f the professional groups participating as well as similar committees in each county. Fee sched ules were established. The checking of all invoices is done by the subcommit tees and paid within two weeks by the state. The accompanying diagram demon strating the relationship between the component parts o f the set-up in Penn sylvania is published because it is working satisfactorily to all concerned, and al though at the present time medical care is being supplied only to those on relief, it can be expanded to include the socalled “ borderline group.” It is offered for study and consideration to all state groups where the need for such a pro gram is indicated and possibly impend ing. It requires the cooperation o f the other members o f the healing arts group as well as the lawmakers. A complete report o f the survey is filed with the Economics Committee o f the American Dental Association. R. M . W a l l s , Chairman, Economics Committee, A.D.A.