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The AMA physician directory does not have a breakdown of what percentage of rural physicians are AMA members and what percentage of metropolitan area physicians are AMA members.

I doubt that the witness' allegation is based upon fact. It is my observation that the highest percentage of AMA membership probably is in the cities. There are, of course, more specialists in the cities, and they generally belong to the local medical society. Also, it is more advantageous for a physician living in a city to join the local medical society, because he would be in a better position to take part in the scientific activities which larger, city-situated medical societies are better able to conduct.

Mr. Swire stated:

"Theoretically, the AMA is guided by its house of delegates, but there is slight representation for general practitioners, smalltown and rural doctors, salaried doctors, or doctors under 40 years of age. By and large, the AMA's House of Delegates is composed of specialists, city dwellers, private practitioners, and middle-aged or elderly doctors."

Comment

The house of delegates is composed of 216 members, most of whom are elected from each State association, on the basis of 1 delegate for each 1,000 active members of AMA or a portion thereof in each State. The house also includes 1 representative from each of the 20 sections of AMA's Scientific Assembly. This assures representation from every branch of medicine, since one section is devoted to general practice and the rest to the various specialties. The house includes, in addition, a delegate from the Army, Navy, Air Force, Veterans' Administration, and the Public Health Service. As a representative body of a profession in which most members do not begin active practice until they are about 30, it is only natural that the house of delegates is composed predominantly of middle-aged or older doctors. As for the allegation that the city doctors dominate the house, I don't believe this is true. For example, I am currently president of the AMA and my residence is Bismarck, N. Dak. The presidentelect is Dr. George Fister, of Ogden, Utah. Neither of our communities are considered to be large cities. The previous president, Dr. E. Vincent Askey, was from Los Angeles, but his predecessors were both from smaller communities Dr. Louis M. Orr, of Orlando, Fla., and Dr. Gunnar Gundersen, of La Crosse, Wis.

Mr. Swire stated:

"The AMA is run by a professional group of medical politicians who have been crying socialism ever since the end of World War I."

Comment

If to interest itself in the general and medical welfare of our people is to be termed "medical politicians," we gladly accept the name. The AMA practices representative democracy in its organizational structure and in development of its policies. Policies are adopted by the house of delegates and carried out by an elected board of trustees. The house is composed of physicians elected by members of State medical societies to represent them and their viewpoints in the formulation of policies. Membership in the house changes from year to year. In the past 3 years alone, the house has had a turnover of 78 members-about 36 percent. However, its policy of interest in the Government of America has never changed, for its right of concern over the medical welfare of Americans is inherent.

Mr. Swire stated:

"I charge the AMA with prime responsibility for the failure of our aged citizens to receive adequate medical care in their old age."

Comment

I am tempted to ignore this wholly unsupported and slanderous charge, rather than to dignify it by comment. However, I feel it is my duty to point out that American medicine and its allied professions have given to the citizens of this country-old and young, rich and poor-the best medical care anywhere on earth. The fact that our aged population now totals 16 million is proof of the quality of medical care in America. American physicians annually dispense more than $658 million of free medical care-much of it going to senior citizens. In addition, physicians-responding to the urging of the AMA-are adjusting their fees for those aged with low or moderate incomes in order that they may

purchase health insurance at reduced rates. AMA supported with vigor, and still does, the Kerr-Mills law for medical aid to the needy and near-needy elderly. Officials of the AMA and of medical societies across the country have stated and moved many times that no one in the United States need go without medical care because he is poor. Hundreds of county medical societies have purchased advertising in local newspapers stating that they will guarantee physicians' services to all, regardless of ability to pay. Lack of response to these ads have proven that medical needs are being met. AMA's work in behalf of the aged of this country ranks high among its many accomplishments. The AMA instituted its committee on aging to look into the problems of the aged, long before medical care of the aged became a political issue.

Mr. Swire stated:

"The last time the AMA had an original idea, outside the technical field of medicine, that merited praise, was in 1941. At that time, the house of delegates passed a resolution commending States which, 'adopted legislation to protect children under 16 years of age from the disastrous consequences of unsuitable work and bad industrial conditions.""

Comment

The AMA has compiled a long, distinguished, and enduring history of achievements in advancing the science and art of medicine. It has, naturally, concentrated its efforts on improving the technical aspects of medicine. But it also has originated and endorsed programs of general health. Currently, the AMA is continuing its campaigns on the use of seat belts in all cars and safety in design of automobiles, proper labeling of household chemical products, drug safety, air pollution control, and inquiring into medical quackery and civil defense. The AMA was the first organization to recognize and warn of the danger of plastic bags to children. Its physician-members began reporting incidences of infants who covered their heads with the filmy material and suffocated. Nationwide warnings of this danger followed.

Mr. Swire stated:

"During the worst years of the depression when an attempt was made to secure health care through prepayment plans, an approach now approved by the AMA, the AMA openly opposed such activities."

Comment

In an attempt to support his position, Mr. Swire quoted from an editorial regarding the report of the Committee on the Costs of Medical Care, Journal of the American Medical Association (99:2035). In 1932, the AMA was not referring to ethical insurance companies or Blue Cross-Blue Shield as they exist today. It was referring to sporadic profit schemes for provision of medical care. As early as 1933-34, the association stated that it was not prepared to accept any plan in present existence, but proposed 10 principles to govern prepaid insurance plans. Thus, the principle of prepaid insurance was approved if certain ethical standards were met. This is a basic principle of democracy on which the United States was built. As far as possible, the individual is responsible for his own decisions and the direction of his life. He should have freedom of choice whenever possible, and, specifically in this instance, freedom to choose his own physician. It should be pointed out that the house of delegates, at a special session held in Chicago, September 16-17, 1938, approved a report of the reference committee on consideration of the national health program, which said in part:

"Your committee approves the principle of hospital service insurance which is being widely adopted throughout the country. It is susceptible of great expansion along sound lines, and your committee particularly recommends it as a community project."

Also:

"In addition to insurance for hospitalization your committee believes it is practicable to develop cash indemnity insurance plans to cover, in whole or in part, the costs of emergency or prolonged illness. Agencies set up to provide such insurance should comply with State statutes and regulations to insure their soundness and financial responsibility and have the approval of the county and State medical societies under which they operate."

Mr. Swire stated:

"In 1931, the Judicial Council of the AMA proclaimed that organizations offering medical and hospital services on a dues-paying basis, rather than directly to the doctor, are 'regarded as being economically unsound, unethical,

and inimical to the public interest.' This would apply to the present volunteer group practice."

Comment

The statement was no more made to apply to present voluntary group practice than economic policies of the same era were made to apply today. Subsidies to farmers and today's foreign aid program would have been considered highly irrational and radical in the context of 1931. Present voluntary group practice is organized on financially sound basis; have standards set up by hospital and medical professions; are reliable in protection of the public under terms laid down by contract. The statement was not made to apply to present voluntary group practice, but to unsupervised profit schemes for provision of medical care. This matter first came up in 1926 when the association reported "a number of communications have been received during the year concerning questions of ethics involved in the organization and operation of so-called health associations or hospital associations which, through paid solicitors or otherwise, solicit members. This matter was referred to the judicial council to consider the ethical problems involved. The council reported: (1) 'It has not been able to arrive at any definite conclusion with respect to the motives behind the organization of some of these groups'; (2) 'in some instances promises have been made that cannot be carried out because it is utterly impossible for adequate medical service, to say nothing of surgical hospital service, to be delivered for the sum realized through the collection of nominal membership dues.'' (3) "The Principles of Medical Ethics specifically condemn the solicitation of patients whether by individual physicians, by groups, by institutions, or by organizations of physicians."

In 1931 the judicial council reported "schemes have been put into operation in various places and have failed within a few weeks or months because of inadequate income or because of failure to render good service. The judicial council has regarded these schemes as being economically unsound, unethical, and inimical to the public interest."

(1) "Unethical" because these organizations solicit patients, are profitmaking companies, and cannot live up to promises of benefits.

(2) "Economically unsound" for the following reasons cited by the council: "Within the last year, some community hospitals have announced their intention to provide medical, surgical, and hospital service to families on a flat rate basis. In at least one instance, such service has been offered to families for $35 a year, irrespective of the number of members in such families. In most instances certain exceptions are made in that persons with chronic diseases are not entitled to receive the benefits of the plan and obstetric service is not supplied without additional compensation. The members of the judicial council doubt that it is wise to lead the people in any community to believe that all necessary medical and hospital service, even though chronic diseases and obstetric care be excepted, can be provided for the average family for $35 a year. In the cases presented to it, the judicial council has advised against the adoption of such plans by community hospitals because it is believed that they are not economically sound in that they may be unfavorably affected by conditions entirely beyond control under which contracts cannot be fulfilled. There are other aspects of the matter that readily present themselves for consideration involving the interests of physicians in the community who cannot participate in such plans."

Mr. Swire stated:

"In November 1939, the AMA, through the redoubtable Dr. Fishbein, even attacked the desperately needed social security program, surely one of the most humanitarian undertakings in our Government's history. Dr. Fishbein, speaking in Chicago at the Annual Conference of Secretaries of Constituent State Medical Societies, declared in part: "The introduction into this Nation of a Federal security plan whereby the Nation itself, as a Federal agency, will step ultimately into the security and life of every person in the country, will be the first step in the breakdown of American democracy.'

"Indeed, all forms of security, compulsory security, even against old age and unemployment, represent a beginning invasion by the state into the area of personal responsibility, a weakening of national caliber, a definite step toward either communism or utilitarianism. The people of this country today have begun to awaken to the insidious approach of such new forms of government."

Comment

Dr. Fishbein was directing his remarks to the Wagner health bill proposing compulsory health insurance, not to the Social Security Act. JAMA 113:2428 December 30, 1939. The American Medical Association House of Delegates has never opposed the Social Security Act as it was passed in 1935, e.g., cash benefits for those 65 years and older. In September 1938, the AMA house “unreservedly" endorsed the principle of "compensation of loss of wages during sickness." (Cash sickness benefits.) In the same year, the AMA acknowledged "the soundness of the principles of workmen's compensation laws and recommends the expansion of such legislation. * * *” (Unemployment insurance.) The association does not "oppose all forms of security," but is of the opinion that welfare is a responsibility of the individual, the community, as well as the Federal Government. In September 1938, the association stated, with regard to medical care for the medically needy, that "The role of the Federal Government should be principally that of giving financial and technical aid to the States in their development of sound programs through procedures largely of their own choice.

In concluding these remarks, let me state my opinion that neither this committee, nor the Congress of the United States, nor the people of our country are served by the irresponsible attacks made by some members of labor against the physicians and the American Medical Association. The purpose of the hearings conducted by this committee is to obtain all valid and useful information pertaining to the legislation under consideration. When Mr. Swire devoted most of his testimony to attacking the American Medical Association, he contributed nothing constructive for your deliberation. Instead, he followed a pattern which has been established by some groups. A pattern designed to discredit an organization which for more than 100 years has worked to improve and protect the health and welfare of our people.

An organization of which I am proud.

EXTENSION OF THE REMARKS OF EDWARD R. ANNIS, IN BEHALF OF THE
AMERICAN MEDICAL ASSOCIATION

On August 3, 1961, Mr. Walter Reuther, president, United Auto Workers, presented oral and written testimony on H.R. 4222. In his testimony, Mr. Reuther made numerous statements which were incorrect, or which were designed to leave a false impression.

Mr. Reuther's statements were made subsequent to my appearance before the House Ways and Means Committee hearings on H.R. 4222. In the interest of making the record complete, I would like to add the following comments regarding both the oral and written testimony presented by Mr. Reuther:

Mr. Reuther charged the American Medical Association, the insurance industry, and other organizations of business and industry including the chamber of commerce as having joined in a "coldly calculated" drive to dissuade Congress from meeting the medical needs of the aged.

Comment

Mr. Reuther's statement is the kind of slur on the insurance industry, the medical profession, and business groups, which has characterized his emotional arguments for the passage of H.R. 4222. Mr. Reuther would do better to bring forth facts, instead of attempting to fan the flames of mistrust and misunderstanding.

The insurance industry and the medical profession have been outstanding in providing our aged population with the well-being and financial security which can give so much meaning to the golden years. The insurance industry has done an outstanding job of providing various types of policies tailored to meet the particular health insurance needs of the aged. The tremendous growth in the health insurance coverage of the aged population in the past 5 years is proof that many senior citizens can, and want to, purchase their own health insurance. As for the medical profession, there are 16 million aged persons in the Nation today. Had it not been for the advances in medical science, many of these aged people would not be alive today. Medicine is aware and proud of the role it has played in increasing the longevity of our citizens. At the same time, it recognizes that the growth of the aged population has brought about

new social problems. In 1947, the AMA joined with other health organizations in forming the Commission on Chronic Illness, which made a study of the aged as part of its task. In 1955, the commission made its final report and was discharged. That same year, the AMA formed its committee on aging which has been stressing the positive approach to health care of the aged. The committee has urged help for the needy and near needy aged, the construction of better facilities for the aged, health insurance plans tailored to meet the needs of the aged, establishment of home care services, a basic change in the attitude toward the aged, need for health education among the aged, and moves to maintain the purchasing power of the dollar. Annually, the medical profession provides at least $658 million of free medical care-much of it to the aged population.

Mr. Reuther referred to an article in Medical World News and alleged same to have been written by Dr. Morris Fishbein. Mr. Reuther stated that the article referred to "secret"" AMA meeting where strategy against H.R. 4222 was planned.

Comment

The charges of a secret meeting are ridiculous. This again is a part of the emotional approach that Mr. Reuther is so fond of taking. The meeting Mr. Reuther apparently refers to was conducted March 18-19, 1961, at a prominent Chicago hotel. The meeting was attended by some 400 State and county medical society executives. Can a meeting be secret when it is attended by some 400 persons, most of whom are strangers to each other, and when the meeting is in a prominent hotel in the heart of a large city? The answer is obvious. As for the reporting of the AMA meeting in Medical World News, it should be pointed out that Dr. Morris Fishbein, whom Mr. Reuther cites as the authoritative source of his information, was not at the meeting. As for a reporter covering the meeting, there is no record of a writer from Medical World News being present. There were many statements made by many persons at the meeting. The story, as reported by Medical World News, is mere hearsay. Finally, there were no special police guards at the meeting as alleged. There were, however, ushers present, and they were there because the meeting room was not large enough to accommodate any more than those who registered for the meeting. I am sure that those acquainted with the business of holding large meetings would find this practice to be wise and customary.

Although Mr. Reuther insists upon calling it a secret conclave, the facts are that the AMA Press Relations Department answered numerous inquiries from local newspapers and from the wire services before and during the meeting. A news release was prepared for distribution at the meetings and it accurately described the conference as part of a continuing educational program to keep physicians abreast of national legislative matters of interest to the medical profession. Of course, the proof is in the pudding. It is obvious from Mr. Reuther's testimony that the AMA meeting certainly was not secret.

The American Medical Association believes that H.R. 4222 is not the best approach in meeting the health care needs of the aged. It also believes that H.R. 4222 will be socialized medicine for a segment of the population, and that it opens the way to eventual socialization of medicine in America. The AMA has conducted its educational campaign against H.R. 4222 along these very lines.

Mr. Reuther places special emphasis on an editorial which appeared in the San Francisco Chronicle, April 23, 1961. The editorial opposed AMA's legislative position on health care of the aged and criticized the association's efforts to bring the facts before the public. The editorial stated that the writer could find nothing in H.R. 4222 which explicitly or implicitly impairs the patient-doctor relationship, or restricts the free practice of medicine.

Comment

It is extremely doubtful that the editorial writer who composed the piece in the San Francisco Chronicle had sufficient legal or medical training to study H.R. 4222 and determine whether the Federal Government would control medical care in the examination room or in diagnosis or treatment. Following are eight specific ways in which H.R. 4222 may affect the practice of medicine and result in control of medical personnel and services: (1) The patient's free choice is limited if, to avail himself of the benefits, he must choose a facility which has contracted with the Federal Government. The patient also must choose a physician whose hospital has reached agreement with the Secretary of HEW. The direct effect is to control the patient's choice of physician; (2) It

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