which that would be interpreted is new nomenclature in this field of assistance.

Mr. KING. Dr. Larson, you speak of the phenomenal progress made by voluntary health insurance, but our committee has been told that even the aged who have health insurance find that only a small part of their total health bills are paid by that insurance because of the very small benefits, deductibles, cancellations, long waiting periods, exclusion of preexisting conditions, and low annual and lifetime ceilings. The spokesman for the Health Insurance Association told us that he had no figures showing how many of the old people covered are subject to these important limitations. Do you have any figures showing how many of the aged have really comprehensive protection against hospitalization costs or other forms of medical care without stringent limitations?

Dr. LARSON. No, we have no accurate figures on that, Mr. King. I would like to ask Dr. Annis to answer if you will.

Dr. ANNIS. I could only answer for the State of Florida where many of our elderly people have for several years been able to purchase Blue Cross and Blue Shield at any age group.

Also, in talking with the health insurance council in Florida I was informed that this has been such a rapidly developing field-it has all developed since I have lived in the State-and that policies are available today that were not available even a year ago, and they are being improved. They are being written to avoid some of the things that I believe I alluded to briefly in my direct testimony, to get away from paying the minor illnesses, but to cover at a lower rate the wider illnesses. Nationwide, I believe, and if it was not in Mr. Rietz' statement, it was in one similar to it, that the Health Insurance Association of America points out whereas in 1957 only about 5 of 10 people who reached 65 were able to continue their insurance in a group with their companies or convert it, today it is 7 out of 10 who may. These policies with big corporations are becoming increasingly comprehensive, much like the coverage you gentlemen passed for employees of the Federal Government. We find in our practice that more and more people are totally covered by their policies.

I cannot give you exact figures, but from a practical point of view in our own practice and the changes I have seen in Florida just in the past few years, there is increasing evidence that people are becoming a little more selective in picking the type of insurance coverage. They have learned they can get coverage of a broader type to take care of a major illness if they will eliminate some of the minor Coverages. There is an increasing number of people who are using basic coverage like Blue Cross and Blue Shield, or similar coverage, plus major medical. As I indicated the number covered with major medical by this industry in 1959 was 17 million, and yet, 1 year later that had jumped to a little over 30 million. I believe as more and more people can be educated toward major coverage because major coverage is not costly to buy. We can encourage people who buy the insurance and the companies that sell it, not to encourage first and last dollar coverage, because this is where there is tremendous cost. I cannot recall the specific figures, but in meeting with the Health Council of the State of Florida, I was amazed when members of the health insurance industry pointed out the percentage of their total payouts for bills under $20. It was a sizable proportion and if these

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could have been eliminated the cost of premiums could have been lowered, if I remember correctly, 20 or 25 percent. So again, I can say only from personal knowledge without giving you statistical data, but from a practical point of view learned in my own practice and from what I know in Florida, more and more people are getting broader and broader coverage so that they have to pay less and less of their own money in addition to their insurance coverage.

Dr. LARSON. Mr. King, may I make a comment ?

Mr. KING. Yes, Doctor.

Dr. LARSON. This subject of coverage for elderly people is, of course, a very important one. Dr. Annis has discussed the situation in Florida. In my State of North Dakota, which I agree is a small State from the standpoint of population, only about 600,000, the new Blue Cross and Blue Shield policies are available to practically any age group. We have an elderly lady who came to live with us. One day she said, "I noticed an advertisement in the local paper that I can get Blue Cross-Blue Shield. What should I do?"

I said, "I think if you can get it you should." She applied and she got it. I looked over her policy. I do not happen to carry Blue Shield because I depend upon my associates to take care of me for medical care, but I carry Blue Cross. I looked over the Blue Cross policy and it is just as good as mine. It is a $25 deductible policy and I have been assured that she can keep on carrying it as long as she pays the premium. She does not have very much, but I know she can pay it. She just issued a sigh of relief that she was able to purchase coverage. I think that is what is going on gradually in many parts of the country. We want to see it through not only Blue Cross but private insurance companies.

Mr. KING. Doctor, in your statement you say that the proponents of the King bill have opposed medical assistance for the aged. First, I want to state that I do not recall the actual vote of this committee for that program, but I would venture to say it was almost unanimous. We do not dispute that proposition at all. I feel that it will dovetail very well with H.R. 4222, and this statement is contrary to what we were told by such proponents as President Meany of the AFLCIO, and spokesmen for the American Nurses Association, and also welfare groups. I notice, moreover, that the special weekly report of July 24 by the Department of Health, Education, and Welfare lists 16 State legislatures that adjourned without action on the Kerr-Mills proposal. With few exceptions, these States are rural rather than industrial. They include Florida, Kansas, Nebraska, Nevada, Wyoming, in addition Georgia, Iowa, and New Mexico are not expected to implement medical assistance for aged this year, because no funds are available. As a practical matter these States that have failed to act are not such that organized labor could probably be accused of having influenced such a block. They were a little sensitive that they, by implication at least, had been accused of an attempt to block the action by legislatures on the Kerr-Mils bill when they are on record as approving the proposal.

Have you any comment?

Dr. ANNIS. Mr. King, we heard this morning, on the Today show, the Secretary of Health, Education, and Welfare indicate that as of today active implementation of the Mills-Kerr bill has been carried out in, and I believe he stated, 23 States. However, I believe the

record will show that he is not referring to those States which carried out the basic intent in both OAA, old age assistance, and the medical assistance for the aged, which is a new program.

On the basis, however, of those who have incorporated a part of the provisions of Kerr-Mills all but around five or six States have taken specific action. My State of Florida, for example, would not be included in the Secretary's report, but in Florida for over 6 years, in a program which was set up under former Gov. Leroy Collins-and I had an active part in the establishment of this program-we established the basic principle of your Mills-Kerr bill for the acutely ill in the State, irrespective of residency, irrespective of age, to take care of anyone in the State of Florida who becomes ill or needs hospitalization, for medical or surgical care. This, to us, is the MillsKerr bill for the acutely ill.

I give you this in detail because Florida is not considered among those that the Department refers to as having implemented MillsKerr legislation. The reason is that we already have a program in Florida to carry out the intent of Mills-Kerr. At the last session of our legislature, we added outpatient care, the care of the acutely ill mentally, and also the diagnostic and therapeutic treatment for cancer which had not been included in our original hospitalization program. Whereas 4 years ago the legislature appropriated approximately $4 million for medical aid, the last session appropriated $20 million for the biennium.

Some of our legislators expressed the view-I want it clearly understood that the doctors of Florida did not agree with them-the legislators had the feeling and several made speeches to this effect, that if we implement Mills-Kerr with the nonresidency requirement what is to prevent people who become ill and need an operation for their gall bladder or their hernia or some other thing in Chicago and Detroit, or some of these other places in the north in January, December, November, and since it is much nicer in our section of the country-what is to prevent them from coming down here and having Florida take care of them?

As physicians we did not feel this way, and we expressed the view that we thought very few people would be motivated to leave their home State to come to Florida for such care. It was because of this our legislature voted not to go along with Mills-Kerr on the Federal matching basis, as long as there is a nonresidency requirement. But they provided, in law, that if the Congress were to change the law to provide that a person is a resident of one State until they have lived in a second State long enough to meet its residency requirements and that they would be the responsibility of the first State, then we could use this money to match further Federal funds.

Meanwhile, the Florida Legislature appropriated funds to carry out the purpose of Mills-Kerr so that on the record, when the Secetary states that 23 States have only implemented the Kerr-Mills program, his statement is true, but it is also true that several other States already have programs carrying out the old-age assistance part of Kerr-Mills. My State is one of those. It is also true that other States feel they can carry out the purposes of the legislation without using added Federal funds. So, the number of 23 is not truly reflective. There are some 45 or 46 who have introduced legislation, modified legislation, added to old-age assistance, some of them

medical assistance for the aged. As I tried to point out briefly before, the States are waiting to get experience and to be guided by the experience of other States, but the purpose, the intent, has been accepted and acted upon in most of our States.

Mr. KING. I know the members understand my position here as being a little different from my position on the other legislation since as the chief sponsor of the legislation, I want to cover the field thoroughly, but a this time, I would like to suspend, at least for a time sufficient for other members to question the witness.

The CHAIRMAN. We can return to you then later, Mr. King, if you desire.

Mr. Byrnes?

Mr. BYRNES. I do not have a question, Mr. Chairman, at this time, but I do have a statement that I would like to make.

It appears in these hearings which have been underway for a week and a half now, that there has been a tendency by the proponents to put the American Medical Association on trial, rather than the bill. It seems to me that one of these days, we better get down to putting the bill on trial and not proponents or opponents as such. I could sug gest to Dr. Larson that when you write this article for the American Medical Association Journal about your not going to discipline anybody or anything like that, you might also disabuse the public feeling by an article that you are not beating your wives, too.

It seems to me some of the questions that are propounded are in the nature of when are you going to stop beating your wife, and that sore of thing. As a lawyer I learned long ago that when the merits are weak, what you start doing is trying the opposing counsel, rather than trying the merits of the case, and I think maybe that is what is being done here in some cases. I do think the American Medical Association of necessity has been placed in a position of defending itself. I think it is unfortunate that so much of your time has to be taken up, instead of getting into the meat and the merits of this particular proposal, trying to disabuse the public mind about some charges and countercharges that are constantly made.

I have not, frankly, had a chance to read your detailed statement as Mr. King has had. I was a little disturbed, however. Of course. he has a right to characterize it in any way he wants, but I thought that there might be some examples cited from the actual testimony as reasons for the statements that he made in characterizing your statement. I am going to be very interested in view of his comments, to read it in detail to see how farfetched that statements is and try to discover some of the ghosts that apparently Mr. King feels that you find under the bed.

To me one of the big issues here in this whole field is not so much whether we have medical care, but the question of the quality of medical care that we have. I would not want to have a situation where we all had prepaid medical care available to us but it was of the kind available in the 1920's and say, "Well, that made everybody fine. Everybody in the country had medical care." We would have medical care but we would not have the quality. I would rather have quality care than just a patch care or something where I could say, "Well, at least I saw a doctor."

Do we have any accurate measurements of the quality of medical care that we have in this country under the system we have? We are

one of the few remaining countries apparently that has basically the free enterprise system of medical care. Do we have any factors comparing quality between our system and what generally exists throughout the world?

I know it is true, or at least we have been told, that, whereas years ago many of our medical students and doctors would go abroad for special study and so forth-they would go to, I guess, Vienna and various other centers of medical learning-but now the trend seems to be reversed and you have them coming here, which would seem to indicate a shift to this country as the basic center in the world of medicine and new development. I suppose this is a factor to use to determine where quality is. Do we have anything else or any other factors that we could use to judge the quality that we have versus the quality of someplace else?

Mr. King was given question which I assume was intended to at least give the impression that we did not have such good medical care here because people over 60 were living longer in some other countries and, therefore, their methods of quality were probably better, but I think the point you made, Dr. Annis, was very well put with respect to how you can use those statistics. However, do you have any comments on this matter of quality, internationally, and where we sit in that picture in our present situation?

Dr. ANNIS. Again, Mr. Byrnes, I would have to answer as a clinician and my contacts with other physicians. I do know that in Milwaukee County where I went to medical school at Marquette, I worked in two of their hospitals, Misericordia and Milwaukee County Hospital, and a number of the other hospitals, and it was very high quality care for everyone, irrespective of their financial status, because they were taken care of by the same private physician. I do know that in my State of Florida, we have had visitors from a number of other countries who marvel at the equipment in our office, marvel at the type of things that we use. It is especially true of those from Sweden and England where I have had visitors from both of these countries. within the past 6 months. They marvel at the things which are available in our hospitals.

Interestingly, too, I have recently traveled a little and I have been to various places and doctors will say, "Well, we want you to come out to the hospital and see thus and so, such and such an operation,” and they are very proud of it. In one instance, I was in Baylor, Texas, where they wanted me to go out and see a replacement graft of the main blood vessel, the aorta, because they were proud in telling about this marvelous operation. It just happened I helped my partner to do one the day before I left Miami. They were talking about similar things in Columbus a week before. This is the way we compete with one another.

Doctors will work hard to be the first with a new idea, and new way of doing things, a new operation, and then the minute they get it, we put it in our medical journal. It comes out the following Monday morning and we share our knowledge.

As to foreign schools, what you say is true. Men in this country, when I was a youngster, used to go abroad to study. Today they come here. Today we have over 8,000 students, foreign graduates, that are over here for additional postgraduate study and training. Four of these were at the Mayo Clinic about 6 weeks ago, three from England