all their medical costs incurred during the year, the drain on the assets of the aged is readily apparent.

Thus, Mr. Chairman, we can see how medical costs can shatter the economic well-being of many of the retired and can encumber their children with a tremendous load in paying such costs. Insurance plans do not offer adequate coverage. Three out of four aged persons can now, and would be able to in the future under the health insurance provisions, show need in relation to hospital costs. These medical costs average about one-third of the income of these people, and the insurance plans now in operation defray only one-sixth of the cost for those aged who do have insurance protection. These plans can pay no more than approximately 7 percent of the overall medical costs for the vast body of our elder citizens.

This, Mr. Chairman, is why I believe that enactment of H.R. 4222 is necessary. Whereas some 46 percent of the aged are reported to have some form of health insurance of varying benefits, the adoption of H.R. 4222 would enable some 80 percent of our aged population to receive specified protection against the heaviest of medical expenses, that is, hospitalization and nursing home care.

Is such a bill desired by the public, Mr. Chairman? Last spring I sent out to the voters in my district a questionnaire. Among the questions was one asking each voter if he or she favored amending the Social Security Act to provide hospital, nursing home, and surgical services to our senior citizens. The results of the poll indicate that 71 percent are in favor of amending the act in this fashion.

This is a resounding percentage. I am sure that favorable percentages have ben returned to similar questionnaires sent out by other Members.

I have also received numerous letters urging adoption of the bill. It is a subject that in various forms has been before Congress for more than 10 years and sponsors of proposals in the field, as we know, have included among others, such eminent Members of Congress as the late Senator Taft and the chairman of the Senate Labor and Public Welfare Committee, Senator Hill.

What would be the cost of the program? According to the HEW report, if the program were restricted to eligible aged persons, hospital service benefits would cost $1,015 million in 1960. To this would be added $25 million for limited skilled nursing home benefits (for the aged and disabled). The cost for home health services and outpatient diagnostic services together would be $20 million. The total cost of health care during its first year of operation (October 1962 to October 1963) would thus amount to $1,060 million.

These are estimates of experts. Others have ranged as high as $1,370 million. In general I believe that it would be safe to say that the total cost would run in the neighborhood of slightly over $1 billion in 1962. It may be trite to refer to such oft-quoted figures as national spending of $6,074 million in 1957 for cigarettes or $9,140 million for liquor, but few people could reasonably argue that 1 billion for the health of our senior citizens would not be a far more salutory expenditure.

These figures and facts, Mr. Chairman, convince me that the only effective and workable answer is the social security approach. That is why I urge your fullest consideration of H.R. 4222 and the added features of H.R. 4111.

To get back to H.R. 4111, may I again point out its similarity to H.R. 4222, and explain the area of difference.

My bill, like the King bill, provides hospital care up to 60 days, nursing home care up to 120 days, outpatient diagnostic service, and surgical treatment. There is a more liberal outpatient diagnostic service and nursing home care without the requirement of prior hospitalization, both of which are included in H.R. 4222, but are more restrictive than what is provided in this new bill. Furthermore, in my bill, surgical services are provided in a hospital, whereas there is no such provision for them in Ĥ.R. 4222.

Also, under my bill, H.R. 4111, men from age 65 and women from age 62 would be covered, either by the social security system, railroad retirement, Federal civil service, or a voluntary plan. The voluntary plan entitles men under 65 and women under 62 to contribute at the same rates as social security into a Federal health care trust fund which would be administered by the Social Security Administration to take care of their medical expenses when they reach retirement age. In order that individuals now at retirement age would not be left out, the new bill contains a provision to give them immediate coverage whether or not they have paid into the fund; such coverage without payment being an emergency step would be effective until January 1, 1964. To be eligible thereafter a person should have to have paid into the fund.

The bill also provides that where widows and orphans are receiving social security death benefits, they would also receive medical coverage. Further, the bill would allow States and municipal governments to enter and insure their employees against medical costs when retired.

The cost of the program remains at the rate of one-fourth of 1 percent of the incomes of the salaried, to $15 a year maximum; and three-eighths of 1 percent of the incomes of the self-employed to a maximum of $22.50 a year.

The bill offers no danger of Government regulation of medicine. In fact, the terms of the bill specifically forbid it. Its operation would not interfere with the practice of medicine, the manner in which medical services are provided, or the internal management of participating institutions. There would be complete freedom of choice of doctors and medical institutions and there would be no fixed fees; instead, local conditions would prevail.

Much has been said about the need for medical care for the elderly. Unfortunately, too little heed has been given to the forgotten 4 million who are not on the social security rolls. That is where my bill picks up where H.R. 4222 leaves off. It covers all older citizens, for it is an unhappy fact that those not covered by social security are afflicted to the same degree with the ills which beset those who are. And, with medical expenses 50 percent higher for the elderly, the forgotten 4 million not on social security are hit the hardest.

Let us have no more degrading pauper oaths, means tests or the like. Let us instead guarantee to all our aged, who have used their lives to enrich our land, an old age free from oppressive fears of sickness and the financial catastrophy it can mean.

Mr. Chairman, I believe that H.R. 4222 should be carefully considered by the committee. I believe that it proposes a reasonable method for meeting an obvious need; that it is supported by a great

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many Americans; that it offers a concept superior to suggested alternatives; and, that its cost, spread over an insurance program can be satisfactorily absorbed by the American economy.

Most important, this legislation will not put the Federal Government in competition with the commercial insurance companies. On the contrary, the Health Insurance Benefits Act of 1961 will instigate a new movement towards medical insurance just as the Social Security Act of 1934 stimulated interest in the life and retirement insurance plans of private companies.

I repeat, it certainly is not socialized medicine. Like the other great welfare programs which our Nation has undertaken, such as national distribution of Salk polio vaccine, it offers a pragmatic solution to an existing problem. This program is simply another application of the social security plan. A small sum provided by the employee, and a small sum provided by the employer, will amount to enough money to disperse those ominous clouds that now hover over the heads of our citizens in their otherwise peaceful retirement years.

I thank the committee for its courtesy and I respectfully urge, in its consideration of H.R. 4222, that it seriously study the additional provisions contained in my bill, H.R. 4111, and that it recommend effective and meaningful legislation in this vital area.

The CHAIRMAN. Dr. Durno? Dr. Durno is our colleague from the State of Oregon and we appreciate very much having him with us this morning. Dr. Durno, you are recognized.

STATEMENT OF HON. EDWIN R. DURNO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON

Dr. DURNO. Thank you, Mr. Chairman.

Mr. Chairman and members of the committee, thank you very much for permitting me to appear before this committee. I would appre ciate the privilege of revising and extending the remarks that are on my paper before the committee.

The CHAIRMAN. You have that permission already, Doctor.
Dr. DURNO. Thank you.

I have practiced private medicine for more than 30 years before becoming a Member of Congress.

As a physician I belonged to the local and State medical societies; to the AMA and the American College of Surgeons. I do want to preface my remarks today by saying that I have never engaged in any of the organizational activities of the AMA.

I have not attended a single meeting of the AMA, and I consider myself in no way a spokesman of the AMA. My primary interest has been in the development of better medical care in my country and in my State, and I have vigorously followed that precept.

I helped organize the first doctor-owned hospital association in Oregon which was the forerunner of the present Blue Shield and the Blue Cross plans, in the early thirties, and I was a member of the State board of medical examiners for 12 years.

In that capacity as a board member we acted as a quasi-judicial body between the public and the medical profession. We listened to complaints and grievances.

Politically, I was a member of the Ways and Means Committee of the State senate. We dealt with the problems of welfare, State institutions, and the problems of the aging in that committee. Acting in that capacity and having been a doctor for more than 30 years, I have grown older with these people. I think that we must first understand their problems, their sudden loss of jobs, their loss of loved ones, their empty time, their lack of hobbies, their lack of avocations. What these people need is social guidance. They need supervision. They need help in a social way. I am sure that if we can boost their morale in that way, we will reduce hospitalization by one-third.

I say that because as you approach the mystical age of 65, seemingly psychosomatic medicine develops to an alarming degree.

I think our second step in the problem of old age is the implementation of H.R. 4988.

I heartily endorse the increased appropriation for the Hill-Burton hospitals, regional hospitals. I endorse the increased facilities for the nursing homes, because I feel that that is undoubtedly the most crying need in America today, and I endorse the community health facilities and other things that go with that measure.

Finally, we must get to the care of these elderly people. I believe that that care should be provided through their own insurance plans, through the Blue Shield, the Blue Cross, the private insurance, H.R. 10, and, lastly and not least, those who cannot pay should be assisted through public welfare and through the Kerr-Mills approach.

I submit to you that this is the sequence to the solution of the total problem of the aged. It is only through this approach that we get the horse before the cart.

Now, I would like next to talk about the practice of medicine in foreign lands. In all countries with which I am familiar, Government invasion of private practice has ultimately resulted in nearly universal coverage by the Government. The quality of medical students has gone down. The quality of medical care has deteriorated. The ratio of patients to doctors has risen. The Government-subsidized medical schools in some areas are scarcely worth giving the term "medical school" to.

If you can visualize the University of Rome with 4,400 students with a ratio of 1 professor to 20 students, the University of Naples with 5,500 students, with a ratio of 1 to 40, the University of Lyons with 1,600 students, with the ratio of 1 to 59. Contrast those figures with Johns Hopkins with 1 to 1.3, and the University of California at Los Angeles with a ratio of 1 to 1.1, and the University of Oregon, my own school, with a ratio of 1 to 3.19. I do not think it is difficult to see why American medicine is better.

During my war years, I lived and worked in an English hospital. This was in 1943. We used to sit around a single bucket of coal and discuss what was going to happen to medicine in England. There was much conjecture and not a little apprehension on the part of the English students, and internes, and residents at that time.

In 1953 I returned to England. I met those same people. They had a program of 1 week's duration for me in two large English hospitals. I say to you that change between 1943 and 1953 was a very striking one. The hospitals were inadequate and they were overcrowded. The interns were not sharp in diagnosis and many of them were less than ambitious.

I am likewise familiar with New Zealand and its form of socialized medicine.

I know a young man who had flown as a fighter pilot in the RAF in World War II for 5 years. He came home to New Zealand. He graduated from Otaga University Medical School and was offered a Fulbright scholarship. After a year's study at the Massachusetts General Hospital in Boston, he went on to Edinburgh where he studied a second year and passed his Royal College of Surgeon's examination. He then returned to his native New Zealand. I visited in New Zealand in the winter of 1957 and 1958. I found that young man practicing medicine in his room. I found him seeing 60 to 100 patients each day for 50 cents a head. I found him finding it totally impossible to get a single surgical patient in a hospital in New Zealand.

Naturally, he was disappointed. He wanted to come back to America. I arranged for an additional 15 months' residency training program at the University of California in San Francisco for this young man. He is now handling my practice. He happens to be my son-in-law.

Within 2 months, this young man is going back to New Zealand and talk to the medical societies of New Zealand about his medical practice in the States.

I think, gentlemen, that we should learn a lesson from history. Now, I would like to turn to medicine in the United States. There are 12,000 foreign graduates in this country presently as internes or in residency training programs. Why do they come here? Undoubtedly because we have the best medical system in the world. I think categorically we can separate medical practice in this country into four large groups and I do so.

In the urban areas there are the medical centers, the medical schools, the outpatient departments, the community health programs, the home nursing, and in many instances contract practice.

In the suburban areas are the clinic practice, the private specialists and the general practitioners with the large hospitals.

In the rural areas, the vast areas of this country, there are the small hospitals, and the small groups, and the general practitioner. And in the institutional practice there are Government, State, and local divisions, the VA, the NIH, the public health department, the Army, the Navy, and the Air Force. May I continue on this?

American medicine is the best in the world because of the unselfish devotion of thousands of doctors who are giving free of their time in the medical schools. Countless thousands of doctors give their time to the great free clinics of the urban areas. Others are engaged in maintaining high hospital standards, in accreditation, in examination and licensing, as well as the disciplinary measures concerning their fellow practitioners. Still others devote their talents to the grassroots of hospital staffs, hospital committees, grievance committees of the county societies, and the integration of the county units into the State society.

Finally, there are that great group of researchers who probably would never be successful in private enterprise, who could never succeed as general practitioners, but who are precious and indispensable in their field. Their achievements have extended the average life span more than 20 years, and they have eliminated diseases that have