Mr. ELLISON. I think it exemplifies the thinking of Arkansas. Those people are no different than anybody else. They are just common, ordinary working people.

The CHAIRMAN. Good Arkansas folks?

Mr. ELLISON. That is right. The kind we like to have.

The CHAIRMAN. Mr. Curtis?

Mr. CURTIS. In your discussions, were there some at your union meetings that took a different point of view, as to why people thought that was not the proper approach to getting what we all want, protection for older people? Did you have someone there who had a different point of view?

Mr. ELLISON. Are you speaking of the local union meetings?

Mr. CURTIS. Yes. You said this has been a subject for discussion. I was wondering if you invited to your union meetings to discuss with the membership one who had a different point of view on it.

Mr. ELLISON. In most cases, no. To understand how we work, Arkansas has 75 counties. Our organization is very small. We only have two people who are on full time. We don't necessarily keep a schedule. We just have a calendar of local unions and we stop in when we go by.

In the schools, we have a member of the house or senate of the State legislature who is a guest speaker and is privileged to give any views he cares to before the group.

Mr. CURTIS. The reason I ask is that in my home community of St. Louis I have requested time after time the opportunity of discussing not only this issue but other issues before labor meetings. In a period of 12 years I think I have received two invitations.

I thought that a better way of discussing things was to give the membership, whether it was doctors or union members, an opportunity to listen to people who express opposite viewpoints rather than just presenting one side. That is the reason I asked.

The CHAIRMAN. Mr. Curtis, if you have never attended a union meeting in Arkansas, let me tell you that you cannot raise any subject in one of these union meetings without having both sides discussed, because there will be somebody at the meeting that will take an opposite view. Isn't that right, Mr. Ellison?

Mr. ELLISON. That is true.

Mr. Curtis, you will be surprised to know, of course, there is a minority, but there are some members who don't think I am the best man qualified for this position.

Mr. CURTIS. Someone told me the other day there was an awful lot of exchange of ignorance that goes on in America. I know I am guilty of some of that. That is the reason it is important sometimes to get before the group someone who is knowledgeable in the subject to express one viewpoint and another express the other, so they can get the benefit of both as this committee is trying to do, to get different points of view from witnesses like yourself who have something to contribute, as you have, which is of value to us in weighing these

matters.

The CHAIRMAN. We do appreciate, Mr. Ellison, your coming to the committee. Thank you very much.

Mr. ELLISON. Thank you, Mr. Chairman.

The CHAIRMAN. Our next witness is Dr. Ingram.

Dr. Ingram, you are a member of the medical profession in the city of Memphis. Your representation has extended beyond the borders of Tennessee over into the State of Arkansas. We are pleased to have you with us today, sir, and you are recognized.

STATEMENT OF ALVIN J. INGRAM, M.D., ON BEHALF OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS

Dr. INGRAM. Thank you.

Mr. Chairman and members of the committee, I am Alvin John Ingram of Memphis, Tenn., a doctor of medicine specializing in orthopedic surgery. I appear today to represent the American Academy of Orthopaedic Surgeons whose executive committee has approved my statement. This is the largest, the best known, and one of the most esteemed orthopedic associations in the world.

We are grateful for the opportunity to express our opposition to H.R. 4222 before this distinguished committee. It is based on the following points:

(1) In the first place, we are not convinced that the findings made in section (2) (A) of this bill have been conclusively and finally proved. We agree, however, that the costs of medical care pose a significant problem for the aged, as well as all other segments of our populaton, as do food, clothing, shelter, and other essentials of everyday living. More importantly, we believe that the aged need protection from the gradual shrinking of the purchasing power of the dollar which they have earned and saved in an attempt to meet these specific problems.

(2) Since the bill would provide benefits to some who have not paid for them, and for some who have demonstrated no need for such assistance, it would tend to undermine the basic responsibility of the individual to provide for himself and his family. This responsibility, in our opinion, has brought forth in our citizens the characteristics of thrift, self-reliance, and self-determination which we consider to be essential if people are to govern themselves freely and responsibly. Any policy which undermines these traits of character is in direct opposition to the welfare of our citizens.

(3) The fact that this bill would provide medical care by four medical specialty groups through a centrally controlled, compulsory arrangement, without regard to need, indicates that these areas of medicine would, in fact, be socialized. The inequities created by this situation and the unremitting pressures for expansion of this program would ultimately tend to lead to the socialization of all medicine.

(4) We believe that the enactment of this bill would interfere with the voluntary, personal, and confidential relationship which exists between a patient and his physician because it would be necessary for a governmental employee to study the patient's complete records in order to determine whether the charges made and the care rendered were justified and pertinent. We believe that patients would be reluctant to divulge intimate and personal information if it is to be available to scrutiny by a governmental agent, regardless of the desires of the patient.

(5) Since it is within the power of the Secretary to determine the reasonable costs of services rendered and since he has the authority to

examine the "fiscal and other records" of cooperating facilities, it would seem that he would be in a very strong position to interfere with the independence of health care facilities through the power of the purse which he controls.

(6) If H.R. 4222 were enacted into law, we believe that there would be a marked increase in the utilization of the goods and services provided by this bill.

The granting of the provisions covered in this bill simply amounts to the satisfaction of rights which are due the patient and for which he believes that he has already paid. Thus, the status of the physician would be changed to that of an agent whose signature would be necessary for the provision of free pharmaceuticals, medical supplies, and appliances. Many people have some degree of need for many items such as wheelchairs, invalid walkers, hospital beds, hot water bottles, bedpans, and many other medical supplies. If these are to be furnished freely to the patients on our signatures, we do not relish the assumption of this responsibility, nor the paperwork it would entail. To illustrate the increased utilization of inpatient services, for example, fracture of the hip is a common disability in individuals over 65 years of age. In this condition, the average hospital stay varies rather widely, but in our particular area it is usually about 2 weeks and the patient is then transferred to his home or elsewhere for convalescence. The period of total and partial disability is usually between 4 and 6 months and frequently is longer and as far as the patient is concerned, he would have better medical care were he to remain in a hospital or skilled nursing home facility during this period.

If this individual felt that he had a paid-up, noncancelable right to such care, I believe that the physician would find it quite difficult and personally unpleasant to deny the patient and his family's request for such care. The result would be that the physician would further gradually change his concepts on the indications for hospitalization of individuals. Such a change would of necessity be in the direction of increased utilization of institutional facilities.

In our opinion, it is not free care in a nursing home which the aged of our country need or desire at this time. Rather, it is a reintegration into the family unit, the community and society, a desire to be consulted, listened to, wanted, and needed. In short, they want and need to feel that they are doing more than simply waiting to die. This is the overriding problem of the aged.

Unfortunately, H.R. 4222 would simply serve to increase the dimensions of this problem by giving the patient and his family a mechanism through which the aged could be institutionalized and thus withdrawn from his most important possession, his loved ones, for a prolonged period of time.

(7) We finally believe that since a superior law, the Kerr-Mills Act, has been enacted, there is no demonstrated urgent need for the establishment of a federally operated medical care program for all the aged covered by social security.

If the Kerr-Mills approach is given the opportunity, it could prove to be one of the noblest experiments ever conducted by a humanitarian government. A number of States have already begun to implement this act. Thereby, they are beginning to accumulate experience and information concerning the extent and magnitude of this problem.

The experiment is that the programs will be tailored to fit the needs peculiar to each State and since the administration of the act is at a lower governmental level, it should prove to be more sensitive to the needs of the people and, therefore, more easily changed to meet variations in local and individual circumstances. As experience accumulates, it will furnish us with more accurate and realistic observations on which to base our policies and plans in the future.

May I again respectfully express my appreciation for the patience and for the kind attention of the committee to the American Academy of Orthopaedic Surgeons and to myself. Thank you.

The CHAIRMAN. Dr. Ingram, we appreciate your coming before the committee today. We appreciate your statement of your views. Are there any questions of Dr. Ingram?

Thank you, sir.

Dr. INGRAM. Thank you, Mr. Chairman.

(The following extension of remarks was filed with the committee:)

STATEMENT OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS, RE H.R. 4222, 87TH CONGRESS, BY ALVIN J. INGRAM, M.D.

Mr. Chairman, and members of the committee, my name is Alvin John Ingram. I am 47 years of age, a resident of Memphis, Tenn., and a doctor of medicine specializing in orthopedic surgery.

I appear today to represent the American Academy of Orthopaedic Surgeons whose executive committee has approved of my statement. This is the largest, the best known, and one of the most esteemed orthopedic associations in the world.

The American Academy of Orthopaedic Surgeons has a distinguished record in the provision of care for physically handicapped citizens of all ages. The Crippled Children's Service Division of the Children's Bureau of the Department of Health, Education, and Welfare was, for many years, simply a coordination of the several community, regional, and State services for physically handicapped children which had been originated and professionally operated by members of our academy. The Office of Vocational Rehabilitation of the Department of Health, Education, and Welfare has also drawn heavily upon our membership not only in advisory capacities but for the actual provision of the professional services which they support for qualified individuals. Also, our membership has traditionally contributed greatly both in advice and services to all of the well-known and highly regarded, private and voluntary philanthropic organizations interested in the welfare of the physically handicapped members of our society. We have not only rendered our time, our services, and our advice to these organizations and agencies but we have publicly espoused them and have assisted them in every way possible to attain their goals and aims.

In my private professional life, I am a member of a medical partnership of 14 doctors of medicine who practice orthopedic surgery, rheumatology, and physiatry. In 1960 this partnership, in addition to many efforts in behalf of our citizens and our Nation, rendered free medical and surgical services to needy individuals under its care in the amount of $259,085. These charges are calculated on an estimated charge of $5 for each free visit to the doctor and $150 for each major operation performed without charge in 1960. As a group, we devote approximately 17 percent of our time to rendering free professional care to those unable to pay for such.

These statements are given not in an attempt to solicit your admiration or your pity but for simpler and deeper reasons.

First, they demonstrate that as doctors of medicine, we recognize it as our duty and responsibility to provide our services to those who need them, regardless of their ability to pay.

Secondly, they must indicate that I do not represent an organization with a negativistic attitude, automatically opposed to change, or which is completely selfish. Believing that we exist in a free society, the members of our organization are willing and eager to assume the responsibilities which are inseparable from their independence and their liberties. We further believe in the economic system of free enterprise based on the concepts of private property, a free

market, profit and wage incentives, competition, and the transference of goods and services by consent. We believe that, on the other hand, our Government has an obligation to all of its citizens, including ourselves, to serve as a referee and not as a participant, to regulate but not to control our activities, to protect us and our fellow citizens from violence, deception and fraud with fairness and impartiality to all.

Thirdly, it is our desire to demonstrate that we are and always have been vitally and directly interested in health care, not only for the aged, but for all citizens. Ours is not a theoretical, armchair-type of interest, but a personal one, since in the final analysis it is we who will prescribe or render the services which we are discussing here today. If there is to be a degrading change in the structure of the practice of medicine in our country, then it is we who will be the first to suffer; and, as certainly as night follows day, all of our citizens will ultimately suffer from such a change.

We deeply appreciate the opportunity to express to this distinguished committee our opposition to H.R. 4222, 87th Congress, 1st session, known as the King bill, for the following reasons:

(1) The bill is predicated upon unsound premises.

(2) The bill would be contrary to the welfare of the public.

(3) The bill would provide for the socialization of a portion of the practice of medicine and will ultimately provide for complete socialization of the practice of medicine.

(4) The bill would change the physician from his position of respect and esteem in the community to the status of an inferior civil servant.

(5) The bill would be a program of welfare assistance and would not be an insurance program as alleged.

(6) The bill would grant assistance to some who need it, to many who do not need it, and would not assist many of our citizens in need.

(7) The bill would bestow excessive powers upon the Secretary, and would interfere with the operation of hospitals, nursing homes, and other health facilities.

(8) The bill would be inflationary.

(9) The costs of the program are inestimable; they would steadily increase and would either destroy the social security system or would be a source of tremendous drain on the financial resources of the citizens of our country and their Federal Government.

(10) Since a superior bill has been enacted by the Congress (the Kerr-Mills bill, 86th Cong., 2d sess.), there is no need for H.R. 4222.

(11) Alternative suggestions are herewith made which would result in improvement of the health of the aged.

1. The bill is predicated upon unsound premises

The findings stated in section 2(A) and upon which this entire bill is predicated have not been conclusively demonstrated and, indeed, are not true in the opinion of many responsible citizens, including myself. It has not been proved that such costs are a "grave threat to the security of aged beneficiaries." It certainly has not been proved that "most of them are not able to qualify for and afford private insurance adequately protecting them against such costs.” Indeed, most recent studies reveal that the majority of aged citizens are covered by voluntary private insurance, and it is estimated that by 1970 fully 90 percent of this group who desire coverage will have obtained it. It would ap pear that the individual concerned would be better qualified to determine the adequacy of his protection, rather than a prejudiced governmental employee. 2. The bill would be contrary to the welfare of the public

If it were a fact, and I doubt that it is, that the aged beneficiaries are working a hardship on hospitals, private and public aid, and welfare sources, as alleged in section 2, it certainly has not been shown that costs of hospital and related health care are the prime cause of this hardship. These simply represent one facet of a many-faceted problem. Other important areas which compete for the financial resources of the aged citizens are food, clothing, shelter, transportation, entertainment, and, most importantly, the gradual shrinking of the purchasing power of the dollar which he has earned and saved in an attempt to meet these specific problems according to his needs, hopes, and desires. Why, then, should the hospital and related health centers be the object of such deep concentration and of such compassionate planning?