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and then when it looks like the individual is going to go down the drain because nothing else can be done, then there should be a Government provision to turn to.

Mr. MARTIX. It should provide that private insurance would get up to a certain point and other provisions would be made before the Government intervenes under the provisions of that law?

Dr. BURKILART. Yes.
Mr. MARTIN. Would others comment?

Dr. MCGILL. It has been pointed out around the table that catastrophic coverage is available now, and it is not terribly expensive. I think this is the advantage of using the tax credit approach. If you give the person the option of sending the money in as additional taxes, or buying catastrophic coverage, I think most of them would opt for the insurance coverage. In this way, the Government is not in a direct program, having to develop another medicare-medicaid program.

Mr. Martin. You are advocating an even simpler tax credit than the humble six-page document I was talking about, and that is a tax credit for the premiums, to encourage the people to buy the insurance which they are not now buying.

Dr. McGill. Some arrangement would have to be arranged that made catastrophic coverage logical. I think it could be arranged. In other words, this is a financing measure, rather than starting a whole new layer on the Government health care cake. We have too many layers now. Mr. Martin. Yes, sir. Dr. Masland ?

Dr. MASLAND. First of all, not many people use catastrophic coverage.

Ever since I have been in medicine. I have seen an individual ruined by their illness—financially. A home has been sold, a home mortgaged and so on. This has always disturbed me, and it is something I am talking about even prominent people. I know prominent people who have had this happen to them. I have always been concerned about it. I do like the tax credit type of approach, because I do think it must be made in the private system.

This is one thing that I want to say, because it goes back to your first comments, which is something that has always interested me, in what happened with the burgeoning patient loads that we had after medicare came in.

Before medicare came in, I bet my colleagues there wasn't going to be any increase, and the reason I didn't think there was going to be any increase, is that I knew we didn't deny anybody any medical care in my community, that we didn't have anyone who didn't have available medical care.

But we did have increased loads, and where did they come from?

Well, they really come from that group I talked about that we call the “worried well.” It is not an original term with me, but it is a significant thing that happens under these systems. The worried well are the group that work the system to death. I have worried well that I try to keep from coming back next week. They don't have a darned thing wrong with them.

I don't say they don't need a physician's assurance, but they take advantage of a free system. They take much more of your time than

the patient with acute appendicitis, or a patient with pneumonia. On a per patient visit, it is twice as long, and this is where the really significant load comes from under this system.

Mr. MARTIN. Dr. Hamilton?

Dr. Hamilton. We already have insurance, but it doesn't take effect until the individual is ruined. At the present time, someone has to use up all of their Blue Cross, Blue Shield coverage, or private insurance, they have to use up all their personal finances, and when they get down to the point where they still cannot pay their bills, then medicaid takes over. So basically, the Government is financing catastrophic illness at the present time, but not till a patient is essentially ruined financially.

I think your tax credit idea is very valuable, and should be utilized. Mr. MARTIN. Thank you. Mr. Chairman, I thank you for the time. Mr. VANIK. Mr. Duncan? Mr. DUNCAN. I don't have any further questions, but I want to thank Chairman Rostenkowski and the staff, both the majority and the minority for their work and cooperation in arranging the two panels we have had today. I think it contributes greatly to the record, and to the hearings, and also it indicates the fairness which is prevalent in this subcommittee.

Thank you, Mr. Chairman.

Dr. MASTERS. Mr. Chairman, if I might, and I know I will speak for all the doctors on the panel here, but I think we all are very appreciative of your efforts in having us here. All of us know right down in the depths of our souls that this program, if there is to be national health insurance-I don't know—but if there is, Government has got to take the practicing physician along in the development of such a program, and the closer that relationship or liaison is, the better will be the result at the end of the tunnel, and the idea that we get throttled with some kind of restrictive legislation will just simply cause the system to fall apart, and we will have too much conflict.

I think all of us are for improving the medical care for our patients at a financially feasible cost, and if organized medicine and the practicing medical community can go along with your legislative efforts, such as in this kind of a hearing, I know the people will be greatly benefited.

Dr. BURKILART. May I say one thing, Mr. Chairman?

I was struck by the similarity in the presentations of this group, and I want to tell you something that I hope you already know, and that is that none of us worked together on our presentations. This is an individual preparation by each physician. It just happens that we all think alike.

Mr. VANIK. Mr. Crane?
Mr. CRANE. Thank you, Mr. Chairman.

I would like to make a concluding observation in connection with Dr. Masters remarks.

I think, unfortunately, it is easier to find a reasonable dialog among those people who may be affected by the legislative proposals and the people who are the architects of those legislative proposals, than between, say, the Members of Congress and the Federal agencies that administer the programs that we draft. We had Secretary Weinberger

down here in connection with the suit filed by the AMA, and he finally conceded that he was working under what he interpreted as contradictory guidelines and then he finally made a discretionary judgment to pursue one versus the other.

Unfortunately, when Government gets involved in any kind of program, it feels compelled, perhaps not improperly, ultimately to be the final arbiter of all disputes.

This is to me the inherent danger in any relationship involving people in the private sector with their Government, because while the initial intent is not to dictate to the physician or to prescribe inferior quality health care for individuals, or even violate their rights to privacy, unfortunately, you get administration of programs and someone has to be held accountable, and that is the Federal regulator.

So I would only throw out a final caveat, that while I think we can have a reasonable exchange between us, that once we make legislative decisions you begin to feel the heavy hand of government through bureaucratic implementation, and as my grandmother used to say, “There is many a slip twixt the cup and the lip."

Thank you for coming here.

Mr. VANIK. I have a couple of things I would like to say. I read through all of the testimony. I would like to ask how many among you are supportive of the so-called AMA bill? Could I have a show of hands and get some guidance?

All but one.

Might I just ask how many members of the panel would be for a PSRO with changes that might meet some of the objections that have been raised?

One, which of the members of the panel would feel, notwithstanding all of your problems and disputes with the bureaucracy and government and politicians, that we ought to do something about catastrophic coverage?

I see that is all but one.

The next question would be how many of the panel would support a concept of catastrophic coverage that would probably be handled through the social security system?

No one.
Well, I just want to say, gentlemen-
Dr. LYMBERIS. I think it would be a catastrophe myself.

Mr. VANIK. I want to say to you that have given some of your time in preparing for this panel, I must take exception to Dr. Quinlan's position that we are sitting here under some sort of sinister influence trying to impose on the American people a great big bureaucratic problem that will invade their lives and take away some freedoms, some of the freedom of choice that they have.

As an observer of the political and government process for 21 years, I think it is unfair to say that we are bowing to the lowest denominator of political demand in our community, or that we are buying votes. I want to say that I have never received a contribution from the American Medical Association. I am trying to get elected to public office without contributions, and in order to try to achieve that kind of a support in my community-which I hope I might have for another round--I have to give them the satisfaction, or give them the

assurance that I am concerned in every way about the budget, the financial condition of the country, and the availability and the kind and quality of medical service that is available.

I would say that most people here are being pushed. I don't think they are being innovative in devising all of the programs that are necessary. They are being pushed by their constituencies, in a very proper way, who have alarmed the legislator to the point of very serious concern on the whole issue.

Now, very soon, we will be able to resolve these things when we count votes and decide which direction we are going to take. Whether the controversy ends with the product that we are able to write this year, or in this session of Congress, I don't know. But I would suspect it is going to be a long, long process.

I would also have to say that I think any program that we werk out is going to have to have the support of the medical profession. We can't do anything in health without doctors.

As a matter of fact, I can't even get certain vitamin pills without going to a doctor. Let me give you some of my problems—I just want to offer this as a problem of a citizen.

If I become ill in my community, I don't think I could get a doctor to come to my house. I had better call the Bailey's Crossroads emergency service and get carried over to a hospital. A lot of times, I can walk into a hospital.

It is awfully difficult to get service, even in a relatively aflluent community. I don't know what it is for the others, but it must be a lot worse.

My son is at college, he needs a prescription renewed, and I have to go through a tremendous process of spending hours of my time of calling doctors here and druggists there. It seems very complex sometimes. It is something we all agree he needs, but the procedure is all tangled up, and I suppose I should take all of his prescriptions immediately and have them transferred to his community where he resides.

I have also been concerned about getting coverage for members of my family, who are my dependents, but are beyond the age of coverage. My compensation stops at a certain point; if they are students, they are covered, but if they are not, they are no longer covered.

I can't find coverage. I am in the process of trying to get it, and I can document the companies and the procedures that I have tried to follow. And when I get these insurance people, they come back to me and say, “We have a policy,” but they exempt every possible illness that has occurred in the life of the patient.

So you get to a frustrating situation, where you try to protect your family, but you find yourself frustrated that the system does not give you that provision, that capability of doing it.

Then you are faced with the risk of jeopardizing all other family matters for what could be a tremendous health need for one individual of the family.

I want you to share my feeling as to my frustration. I am trying to figure out ways that I can protect the residue of my savings for essential family purposes against the risk and the great hazard of having to pay for the medical problem of a member of the family that could deplete the family resources.

It could forbid the continuance of education for other members of the family, deplete resources that other members might be planning for retirement or security in later years. These things are problems that I face as a professional person and I just don't feel anything covers those concerns.

We relate these things to our personal experience. That is our primary source of evidence. I feel a very severe sense of frustation in how to deal with the problems. I am speaking with you candidly, and honestly, and I am speaking to you in an effort to try to work out a program that is going to have your support, because without your support, nothing is going to work. I have pressure from my constituents, and I am at a stage in this business where I can be courageous. I don't necessarily have to do everything they want.

I think a great many of us here have a great freedom. It is surprising to find out how many people are really politically free. They could go either way on almost every issue. They are free. Their constituents have given them great latitude. Those are the best constituencies of all. We would all agree to that.

But what I am trying to suggest to you is that unless we can boil down programs that deal with the day-to-day problems that have to be solved in medical care, that we are not going to solve either our constituents' problems or satisfy you or the profession or anyone else.

I didn't mean to get any further response to you. I know your time has already been very generously given, but I would hope if you get further ideas on this whole subject, that you get them to us before we close our proceedings. I don't think we should enter this as antagonists. We have got to work it out together, and if there is some displeasure with the political part of the people that have to work here, that can always be changed.

You can change us. We can't change you. We have to do business with you, or our successors do. Please give us the benefit of your continued advice. I would like to feel free to write to members of this panel on an individual basis, and say, “What are you going to do about this problem here?” This is a problem. “What are you going to do about this?"

In my community, you can't get elderly people in to see doctors. I get the feeling that I want to let them see anybody, even those that are not doctors; I feel that doctors are restraints on the delivery of health services. Ninety-nine percent, I suppose, of the health efforts in the country is what we do individually for ourselves. It is that 1 percent that we have to buy and pay so much for.

Really, from where I sit, the average individual citizen has to do most of the health work that he receives. That is what he personally does. Either it is his life format or diet.

People go to the doctor as a last resort sometimes. When I have a person that I send to the hospital and they are there for 2 days, and I look at the bill, which my insurance pays, I am sickened; $35 for bringing a humidifier into the room. I can buy a good room humidifier for $20. I can buy one. Things like that appear on the bill.

Doctors' services get to be so complex that you go in with a sprain and you see three orthopodiatrists before you get through, and before you get through you have a $900 bill.

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