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to thank you very much for having come this distance to give us the benefit of your observations. I am certain that we will study your comments and your observations in great detail.

On behalf of the Subcommittee on Health and the staff I would like to thank you very much for your contributions.

If the next panel would prepare to take the witness table, we would proceed.

We have Dr. Burkhart, Dr. Hamilton, Dr. Lymberis, Dr. McGill, Dr. Masland, Dr. Masters, and Dr. Quinlan.

Good afternoon, gentlemen, and welcome to the Subcommittee on Health of the Ways and Means Committee.

You have seen the format that we use. I have noted some of the statements that have been prepared and presented to the committee are quite lengthy. If any one of you would like to summarize as opposed to reading your entire statement, that certainly would be in order. We will use the same format. I suggest you use no longer than 15 minutes in the presentation and if you want to cut that down, that is entirely up to you.

The opportunity will be afforded you for panel discussion and then opened up for questions.

A PANEL CONSISTING OF JOHN H. BURKHART, M.D., KNOXVILLE, TENN.; JOHN HAMILTON, M.D., ROCHESTER, N.Y.; MARVIN N. LYMBERIS, M.D., CHARLOTTE, N.C.; CLINTON S. MCGILL, M.D., PORTLAND, OREG.; DAVID S. MASLAND, M.D., CARLISLE, PA.; BROOKER L. MASTERS, M.D., FREMONT, MICH.; AND DONALD QUINLAN, M.D., NORTHFIELD, ILL.

Mr. ROSTENKOWSKI. Dr. Burkhart, I believe you are first. If you would like to begin, welcome.

STATEMENT OF JOHN H. BURKHART, M.D.

Dr. BURKHART. Thank you, Mr. Chairman.

Mr. Chairman and members of the committee, I am Dr. John H. Burkhart of Knoxville, Tenn., and I appreciate the opportunity to testify before you today. I assure you I will take no longer than the 15 minutes allotted to us.

You have been and will continue to be deluged with statistics, facts, and studies purported to demonstrate and prove either that there is a health care crisis in this country or that there is not, that some form of national health insurance is a necessity or that it is the worst thing that could happen to the American people, depending on who or what interest group utilizes various parameters to make their points.

I would prefer in the time allotted to me to offer an opinion based not so much on cold statistical numbers or surveys, but more on some 26 years of experience, knowledge, and attitudes acquired as a solo family physician engaged in administering medical care, advice, and treatment to a wide variety of individuals who have sought my services. I still consider myself a doctor, not just a provider, and those who come to me as patients, not just consumers.

To establish some basic precepts, let me first register what I presently believe. I believe that the vast majority, in fact virtually all

Americans, today have access to good, even excellent, medical care, and that through private insurance, careful personal planning, existing local, State, and Federal programs nearly all can afford this care.

I admit that some people have easier access to care than do others, and some in fact have some difficulty obtaining it. There is unquestionably some maldistribution of physicians and medical care facilities in our country, but more to the point there is also maldistribution of people themselves in the United States. Some live too tightly together, some too far apart, and the result is a maldistribution of other services and conveniences, schools, supermarkets, highways, public transportation, banks, theaters, attorneys, churches, utilities and most other things Americans enjoy and depend upon. Until there is a homogeneous distribution of the population there will not be a homogeneous distribution of the advantages that make living more enjoyable and secure, and this includes medical care.

I believe also that the problems and difficulties we presently may have in the adequate provision of medical care to our people will not be solved by larger and more expensive Federal programs which attempt to provide a utopian system in a nonutopian society.

Reminiscing is generally a useless pasttime, but it is sometimes pleasant. I recall that in the early days of my practice, before medicare, medicaid, or even Kerr-Mills, all of the doctors I knew, including me, took care of anyone who sought their services regardless of the ability to pay, and the hospital always had some little fund or arrangement with the city or county welfare department to pay the expenses of those who needed hospital care and had no money or insurance. I never saw anyone who asked for it deprived of needed care because of lack of ability to pay for it.

But somehow in the early or mid-1950's this rather disorganized but remarkably effective system of taking care of everyone, which had been traditional in medicine since it became an established profession, and which had prevailed in our country since the days of the first settlers, did not satisfy some who felt that it was too haphazard and that it depended too much on the generosity of the physician, the hospital, or the local welfare officer, and generosity to them was too intangible a factor to be depended upon.

There must, they decided, be developed a plan, followed in due course by sufficient appropriations, then regulations, then administration, and above all the sine qua non of all governmental programs, the inevitable forms, the paperwork. And so that no one would be made to feel ashamed or embarrassed by having to expose his neediness, the best arrangement would be to make everyone eligible for whatever benefits were provided.

This line of thinking eventually gave way to a dual system of determining eligibility, one based on financial insufficiency called medicaid, and one based arbitrarily on age alone called medicare. The first ignored the built-in incentives for abuse; the second ignored the elemental fact that one can be just as sick at age 64 as at age 65.

Mr. ROSTENKOWSKI. Would you suspend just one moment please? I would like to yield at this point to a Member of the Ways and Means Committee, one of the outstanding Members on the Republican side, my good friend, Mr. Vander Jagt, for purposes of personal introduction.

Mr. VANDER JAGT. I thank you very much for yielding and recognizing me. I apologize and thank all the members of your outstanding committee for permitting this intrusion into your very important deliberations so that I might introduce a very dear and personal friend of mine, Dr. Brooker Masters from Fremont, Mich., who will be appearing on your panel. Dr. Masters is a general practitioner so he can really give you insight from the firing line. From that general practice he rose to become the president of the Michigan Medical Association. He will be able to share that insight and benefit for you.

I am proud to have my friend appearing before this very distinguished subcommittee and I thank you for the kind words and for yielding to me, Mr. Chairman and members of the committee.

Dr. MASTERS. Thank you, Guy.

Mr. ROSTENKOWSKI. Dr. Burkhart, we thank you for yielding to our colleague. You man continue with your testimony.

Dr. BURKHARDT. But as I have said, reminiscing has no real value unless the experiences and mistakes of the past are utilized to improve the present and more carefully plan the future. The real question before us all today is what is the present situation and how can it be improved in the future?

În my opinion, which I know is shared by most of my professional colleagues, there is no health care crisis. But there can easily be one if those who proclaim there is one keep proclaiming it.

A recent poll found that a representative cross-section of Americans ranked health as 15th in a list of national problems, and almost every person polled stated that he or she had no difficulty with access to all the medical care he or she needed or wanted. But if enough publicity of whatever kind is fed to the public, insisting that a health care crisis exists and that medical care is in short supply, the public will eventually be convinced that this is true, and then the process so typical of human nature will take over. Anything thought to be in short supply becomes more desired than ever, the demand for it grows out of proportion, and sooner or later a true shortage will exist. How is that problem to be solved? Surely not by encouraging more demand on the supply.

The vicissitudes of life are real and are a part of everyday existence. It is not possible to insure or legislate against them and to thereby eliminate them from the hazards of daily living. Affliction with physical, emotional, or mental illness requiring care and treatment is just one of these hazards and must be met by individual initiative, courage, preparation, and foresight. It is not feasible for everyone to expect these virtues to be taken over by governmental adoption and the responsibility for them to be met by proxy. Our Constitution does not guarantee happiness, only the right to pursue it. I maintain, therefore, that we are our brother's keepers and that we should be concerned about his interests and his welfare, but-that the first obligation for this concern belongs to him, and then to his relatives, to his friends, neighbors, to various civic, church, and service organizations that are set up with this objective, and only finally to the Government.

There is one notable exception to this position and that is in the realm of catastrophic illness. I believe no one should be financially ruined by the cost of some long term expensive illness, and that here intervention by the Government as a last resort may be justified, but

even then only if other arrangements shore of total ruin have been exhausted.

But to be realistic and practical, if not idealistic, it would appear to me to be inevitable that sooner or later some form of national health insurance will be forthcoming in this country, needed or not. The whole idea simply has tremendous appeal because it envisions getting more of something for less. Free or nearly free medical care is a thrilling prospect. But so is living forever, and one is about as achievable as the other. Good, proper, appropriate medical care can never be free. It is too costly to provide. Someone must pay for it either directly or indirectly, and if one can accept that axiom, one can begin to look objectively at what a national program of health care might reasonably provide if starry-eyed dreams and promises are replaced by realistically worked-out provisions.

And so my final points are not an attempt to convince you that a national health insurance program is unnecessary, but to urge that if such a program is enacted by the Congress, certain essentials be contained within it. There are several that I think are absolutely basic, and I would like to list them for you.

First, it must be voluntary. It must be voluntary from the patient's standpoint, because compulsory acceptance of financial aid from any source is contrary to the American concept of freedom. And, further, if the resulting relationship is not completely voluntary on the part of the physician, then his interest is not wholly in what he is doing. The result in a situation in which these conditions are lost is that both patient and physician are unhappy and dissatisfied, and little if any good can emerge from this type of encounter.

Second, any national health insurance program must not limit the recipient's choice of when, how, and from whom he receives his services. He must have free selection of physician, hospital, extended care facility, pharmacy, and the other proffered services. And once the selection has been made, the services must be provided with the minimum amount of interference in a give-and-take relationship.

This does not mean to say that there should not be any degree of control or monitoring. As a tax-paying citizen of this country I would certainly hope that the Congress would never fail to keep some kind of eve on the money, my money, it so freely appropriates. But to extend a helping hand so crippled with regulatory strings, chains, and even handcuffs is to extend no hand at all. And to further require that hand to explain and justify its every ministration to some low-level clerk is to eventually thwart its efforts out of sheer fatigue and frustration.

The needs of the poor and the medically indigent should be paramount because they are the ones for whom the establishment of a national health insurance program might truly be justified. It would be wrong to have the program apply to everyone alike, for although we speak of equality in this Nation with patriotic pride and fervor, we the people are not equal in many ways, and one of these ways is our need for assistance in any realm. To be so arbitrary as to use age alone as a criterion for eligibility is to be completely blind to the real factors that determine need.

If private health insurance is utilized as a method by which benefits are provided, and I think it should be the preferable method, then such insurance must be available to all who qualify, regardless of

prior medical history. To make some ineligible because of existing or preexisting medical illness is to deprive the very ones who need the program the most.

There must be some co-insurance requirements, not only to keep costs down, but also as a deterrent to over-utilization. The allowance of a certain number of office visits or a certain number or hospital days in a given period is too rigid, and the illness will not always cooperate by conforming with this type of regulation. A better way is to provide that the recipient will pay at least a minimal amount from his own pocket for each service he will receive so that he will not be tempted to seek that service too often simply because it costs hims nothing.

And, finally, it must not promise what it cannot deliver, and then when it does not fulfill its promises place the blame where it does not belong. At the risk of singing the same song again, I maintain that it has not been the profession that has made medicare and, even more so, medicaid an expensively abused program. Doctors as a group have not abused the M. & M.'s, but many of the recipients have, and the regulations under which they operate encourage this abuse. All of us who practice under these rules and regulations can relate example after example where the regulations, far from reducing the cost, increase it and, far from providing good care, prevent it.

I expect that in the not too distant future Congress will establish a national health insurance program, although I believe the enthusiasm for it is much less than it was a few yearls ago. I would hope that the economic constraints would be a primary consideration, that some selectivity of recipients would be built in, that there would be some reasonable control and that the bane of the present programs would be at least reduced to permit the physician to go back to doing what he wanted to do when he chose his vocation, what those of us who have practiced before 1965 used to do, and that is to care for the sick, promote prevention, render advice and counsel, and extend hope full time and not half of the time while the remainder of it is consumed with paper shuffling.

I am not as vigorously opposed to a national health insurance program as I was a few years ago. In our present and changing society a limited program of this type might perhaps be beneficial. But I reiterate that it must be carefully planned, that it cannot be all-encompassing to provide everything for everybody, that there must be limitations and reasonable restrictions stipulated, and that as an absolute necessity it must not interfere with the traditional patientphysician relationship which includes such basic factors as trust, confidence, confidentiality, and availability.

The past 50 years have been called the "Golden Age of Medicine." More important advances in diagnosis, therapy, surgery, and rehabilitation have occurred in these five decades than in all of the previous history of man and medicine together. The result of all this is that now for the first time in the history of man his life expectancy has reached the three score and ten of Biblical promise.

The objectives of medicine are varied and complex. They can, however, be boiled down and concentrated to the fundamental principle of attempting to provide through research, clinical practice, and freedom from unwarranted and unjustified interference the best possible medical care and facilities for those who need these provisions and

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