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The result was an almost immediate correcting of the situation. The demand for full service by these patients fell to a rate comparable to that of my full paying patients; and I might add with no discernible impact on their health.

Í very much believe that this same idea of coinsurance would help control the unnecessary demand for services under a national health insurance plan. In any event, the mechanism you decide upon should insure that the system is not overwhelmed and that quality care is available to those who really need it.

My second concern is one that I am sure you have heard before. This is the ever-increasing burden of paperwork and redtape. On the surface, it may seem trivial, but to the practicing physician, believe me it is not.

Currently, only 40 percent of ambulatory care is covered by insurance. In my practice, that percentage is considerably lower, but the amount of paperwork even this small percentage generates is extremely burdensome. It requires many hours of my own and my staff's time; time spent on paper rather than on people.

As a matter of fact, within our practice we have found it necessary to hire one full-time person to do nothing but fill out forms for thirdparty reimbursement. I do not look forward to the day when a claim form would be required for every patient visit. The amount of paperwork we would face could easily triple or quadruple.

All this paperwork means additional expense to the health care system. The hours spent on paperwork are part of overhead expenses which must be covered in my fees. The cost is a substantial one. Already, for example, the current fee paid for a patient visit under medicaid in Pennsylvania does not cover overhead. In other words, the cost of the visit is greater than the fee allowed for the visit.

If you multiply the present paperwork cost by the number of physicians in the country you already have a very substantial sum. The danger of a national health insurance paperwork explosion is a real

The problem would be worsened if on top of all this we added a Federal bureaucracy. Many existing Federal programs have already demonstrated their inefficiency. I would contrast this to the Blue Shield and Blue Cross plans in Pennsylvania with their low administrative costs; approximately 10 percent of the premium dollar. It would seem ill advised then to transfer the functions now provided efficiently by private carriers to a Federal bureaucracy.

My third concern, and perhaps the most serious of all, is the eventual impact any national health insurance plan will have on the physicianpatient relationship. This is a relationship of mutual trust entered into voluntarily by both parties. It must be this way. For medical care to be effective, it must be accetpable to both parties.

I cannot accept every patient who comes to me for treatment, just as some patients cannot accept me as their doctor. It is also human nature that at times two individuals may become incompatible. If this is the case, the patient and the physician must both be free to discontinue the relationship; otherwise the quality of care will suffer greatly.

It is therefore imperative that patients and physicians have the right to choose their own health insurance plan; to choose the delivery system in which they wish to participate and how they wish to pay for it.

one.

This freedom of choice is not just a nicety, it is a necessity for good care.

My final concern is about our expectation of what we will gain from a national health insurance plan. Will we increase life expectancy? Will we reduce illness? I doubt it very much.

National health insurance does not address the social factors which have the biggest impact on national health.

It is estimated that we have 600,000 alcoholics in Pennsylvania. The effects of alcohol abuse on an individual's health are considerable. Liver disease, kidney disease, and cancer are all related to alcohol abuse.

What will national health insurance do about smoking? There were more than 602 billion cigarettes sold in this country last year. The World Health Organization has said that the control of smoking could do more to improve health and prolong life than any other single action in the field of preventative medicine. A study done in Pennsylvania has shown that the difference in longevity between smokers and nonsmokers is ten years.

Traffic accidents remain the number one cause of death for persons under forty. Poverty, poor housing, and poor nutrition are all related to poor health. National health insurance can do nothing about these. Many of the medical conditions that I must treat every day can be traced back to one of these larger social problems.

To summarize, I believe that we need a national health insurance plan, but we must recognize that there are limitations in legislating good health and be realistic in setting our goals and expectations.

Thank you.
Mr. ROSTENKOWSKI. Thank you, Dr. Masland.
Dr. Masters?

STATEMENT OF BROOKER L. MASTERS, M.D.

Dr. MASTERS. Thank you very much, Mr. Chairman, members of the committee, it is a privilege to appear before this subcommittee which is laboring over national health insurance. I am a family physician from Fremont, Mich.

Fremont is a small town of 4,000, and, therefore I believe I know well the problems of medical care in rural America. I am also the immediate past president of the Michigan State Medical Society, and we have been through the travails of medicaid, PSRO, and the malpractice problem, and believe that I also know the pulse of 8,000

Well, first of all, most of us are aware that there will be a national

What does a private practitioner think of an impending National Health Insurance Act?

Well, first of all, most of us are aware that there will be a National health insurance Act of some kind and probably soon. The political smoke of this philosophy has been around long enough that a final legislative effort will occur and I hope that it is not a "flame."

Consideration of what form and substance it will take seems to be the reason that you and I are here today.

Beyond this inevitability, a family doctor such as myself, thinks of many things. I should like my testimony to reflect the following major topics and from them draw a conclusion:

Öne, the tremendous cost of any national health insurance program.

Two, the ominous threat that lower quality will result in all branches of health care.

Three, the mountains of paperwork and regulations which will detract from time I could spend with patients.

Now as to the background:

It is a fact that today's high quality—and sometimes—miraculous medical care has been achieved by private enterpirse, by independent research, by a largely fee-for-service philosophy, and perhaps more importantly, by the psychology of an independent practitioner.

Gentlemen, you must not ignore the fact that the doctor you want to take care of yourself or your loved ones, in a time of medical need, must of necessity be an independent creature who has the courage to make decisions that are not just "right or wrong" but might well decide whether you live or die.

A doctor is a peculiar breed of animal, an enterpreneur of the first order, and for high quality care, he or she must always remain so.

When you talk of medical care under any other system, you are implying that the care delivered will be the quality care which our present system is capable of delivering. However, you must also believe history, which proves that National Health Services historically are rationed services. For there will never be a government or a country that has enough resources to meet all the demands any nation will make on a national health service. For years I have said this publicly: There is simply no limit to the public's demands for medical care; again, no country would finance everything that the consuming public might want.

The quantity of medical care provided would, of necessity, depend upon the volume of appropriations you gentlemen would be willing or able to make.

And why do we consider national health insurance? Obviously, to provide equality of care to all. Delivery of health services is admittedly inequitable, yet medicaid has proven that Government funding is not the whole answer. Shall we simply extend to the entire population those omissions of care so deplored for the welfare patients of today?

Other features of a national health service cross my mind : If it is “free," people will be irresponsible about their own health care. We may wish it were different, but people do abdicate their own responsibilities when the cost is not theirs directly.

Today's sophisticated medical care is very costly, not excessive by any means compared to the inflation throughout our entire economy; but the costs are high. Many of us think that it's rapidly reaching such a level that the average person cannot afford to be seriously sick. Something does need to be done.

There is no question that catastrophic coverage is needed as all the panelists today are saying. This requires careful evaluation. It is not just the $10,000 cost for open heart surgery, but a $1,000 cost for a ruptured appendix or complicated obstetrical delivery might be a "catastrophe" to a great percentage of the households in the United States.

Another thing, I worry that bureaucrats are not knowledgeable about good medical care. They really are interested in saving money

in health care, by promising the same quality and more quantity of care at lower cost.

Such an approach can only lower the standard of care, cutting back on immunizations, preventive care, et cetera. Gentlemen, quality care is going to cost money.

am convinced that we do not have the resources for national health care at this time, if it is to be simply an addition to our present delivery system by money or appropriations and without meaningful attention to innovative changes that will be necessary to accommodate the increased demand.

I envision that it might take 25 percent of our resources for health care under a national program. We simply do not have those kinds of resources. Can we involve that much money in health care when all segments of our society need monetary transfusions? What about the deterioration of our cities where much of our medical problems exist because of this very deterioration? And I understand that our entire industrial system is in urgent need of capitalization funds to make it competitive in future world markets—I worry.

The rationing of medical services will be by Federal employees bureaucrats, if you will not by the ability to pay which has been traditional; not by doctors, not by patients, nor even by you lawmakers. And if we have medical care dictated by edicts in the Federal Registry then surely we shall have chaos.

And perhaps not lastly, I wonder about my own working habits and those of my fellow physicians. For many years now I have worked 60, 70, yes, even 80 hours per week. I have a daughter who is teaching medicine at the University of Illinois branch at Rockford, who estimates that she is working 100 hours per week, with her teaching responsibilities and patient care.

What will we do under NHI? Well, I plan to work 40 hours per week. How can you require me to work more hours than the national work ethic? It will take two and a half doctors to replace one of myself, or of the Dianes who I am describing. Coming from rural America I can tell you we are already short of doctors now.

Paperwork. In an office of three doctors, we have two full-time employees doing nothing but that, and it must occupy 10, 20 percent of my time. Any national health insurance plan will surely increase this burden, the costs, and take me further from my patient care.

These are some of the problems that come to mind when we discuss national health insurance. I feel you gentlemen have an awesome responsibility in this field. There is no question but that national health insurance will shape all medical care delivery in the future. I must tell you that if you plan to build upon the past, that if you plan to bring the system of today within the reach of everybody, that that concept simply is not possible. And I fear that all of our present concepts of national health insurance at this time are really just "patches," on a system already taxed to its capacity.

What to do? I believe it is your responsibility to determine what you want our health care system to do. What really are the priorities, since we cannot do everything? If your conclusions are that you can provide all the medical care everyone might want in today's system, then you are dealing with an impossibility. And, if you ask me, "Do

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you have an answer to this question ?” my answer is a loud, "No." But creative innovation is required, not just more money into the system.

There is no question but that the change must be evolutionary, not revolutionary, as has been the case in some other countries. An entire new program should not be installed full blown, upon an already overstrained medical system.

It seems to me that such an evolutionary concept of national health insurance needs to include only the following at this time:

1. Coverage of the catastrophic illness. 2. Preventive medicine.

3. Care of chronic illness, such as diabetes, hypertension and especially the drug bills for the aged.

4. Research—free and unfettered. One could wax at length on the pitfalls of federally funded research.

Just these are ambitious projects for the present. They, like any others, are going to cost money, much money. You must be prepared to pay for the program you select. I don't believe it is fair to promise programs which cannot be delivered because of cost, as has been so heartbreakingly true of the medicare program. Let us not allow “politics as usual” to be that callous again.

If I may be permitted a personal conclusion, I would state that I probably will not be accorded the opportunity to again appear before the House Ways and Means Committee when it considers such a momentous issue as national health insurance.

Therefore, I would like to challenge this committee to decide what kind of social changes you, the legislature, or society in general wants made through the health care system. Then fund national health insurance in such a way to insure that these things might happen. Anything less would be a betrayal of the American people.

Mr. ROSTENKOWSKI. Thank you, Dr. Masters.

Dr. Quinlan, I noted the length of your prepared testimony. I would like to point out that your entire statement could be put in the record if you care to summarize.

Dr. QUINLAN. Thank you very much.

Thank you.

STATEMENT OF DONALD QUINLAN, M.D.

Dr. QUINLAN. I thank the committee for allowing me to give my views on national health insurance, which of course, isn't insurance, but a governmental taxation and control scheme.

I am Donald Quinlan. I'm engaged in the practice of private medicine in Chicago, Ill. I was educated in Ireland, England, and Switzerland, and served from 1948 to 1953 in general practice under the British National Health Service.

I emigrated to the United States in 1958. Since then I have obtained additional resident training, and U.S. citizenship. I have been in private practice in Chicago since 1960 as a specialist in internal medicine and an clinical assistant professor of medicine at Stricth School of Medicine of Loyola University, Chicago.

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