The CHAIRMAN. Thank you, Dr. Rosenbaum, for bringing to us the views of the Oregon State Medical Society. We appreciate your bringing along the president of the society.

Mr. Curtis.

Mr. CURTIS. I cannot fail to express my deep appreciation to you and the people in Oregon and the committee engaging you for having conducted this kind of survey. I just wish that you people had done this before in other areas. It still needs to be done in other areas just to be sure of this.

In a minor way I have tried to do the same thing as an individual Congressman. When people were claiming there were a lot of people in my area who were unable to get medical aid, I, as best I could, publicized it and said "Write to me on a confidential basis, I will follow through on any case," because I wanted to find out what was going wrong, or was there a gap here, Doctor, I have gotten only one reply out of some 400 people who originally wrote to me, including my labor leaders in the city saying they knew of someone. Only one person took the trouble to reply to give me a case I could go to work on. I have gone to work on a number of cases and each time I have found out that there were district facilities, there were misunderstandings sometimes, there were a couple of instances where there were administrative errors, but in all instances it was something that our present setup could take care of and I want to add one other thing. This isn't to say, and I am sure your testimony isn't saying it, that we haven't got a lot to do to continue to improve our health care and our quality and so forth, and we want to get on with that too. Dr. ROSENBAUM. Thank you.

Mr. CURTIS. Thank you very much.
Mr. ULLMAN. Mr. Chairman.

Mr. KING (presiding). Mr. Ullman.

Mr. ULLMAN. I again want to express my appreciation to my physician friend from Portland and would appreciate it if you would send a copy of your new insurance policy, the OPS.

Would you make that available to the committee just for the files so we could have it here in case we want to refer to it?

Dr. ROSENBAUM. We would be delighted to make a policy available to the committee and the reports of our continuing study. Mr. KING. That would be helpful.

Mr. ULLMAN. That would would be helpful to the committee; yes. Thank you.

Mr. KING. We appreciate your offer to do that. We appreciate your testimony.

Mr. CURTIS. May I ask one other question?

Did the Department of Health, Education, and Welfare express any interest in what you are doing? Do they know about it or have they shown any concern?

Dr. ROSENBAUM. Well, I don't know if they have expressed any interest. I really can't say if they know about it or not, but I think you have a good point and we will so inform them.

Mr. CURTIS. Yes; I wish you would. This is for the record, too, and they will read the record. I have just wondered why there hasn't been more concern in the Department of Health, Education, and Welfare as to what is being done in local communities and local States. When the Connecticut plan just recently went in for health insurance for the aged I did contact the Department and asked if they were going to make any comments or whether they had been following it, and it was a negative there, too. I hope you will send it to them, and I hope they develop the kind of procedures in the Department so they collect this data from all over the country and in that way become a clearinghouse so that you could get the benefit of other studies. We had a very interesting study prepared in the State of Delaware along these lines with some extremely interesting results.

Mr. KING. Are there any further questions?

If not, Dr. Rosenbaum, I just have one.

The committee is pleased with your statement that every effort is being made in Oregon to avoid the possibility of any one going without medical care, but in the event you find persons who, for whatever reason, have not had medical care, do not such persons, no matter who reports them or where they are reported to, finally end up on the public assistance medical program?

Dr. ROSENBAUM. Congressman, as I understand your question it is, Does every person who does not receive medical care end up in the public assistance program?

Mr. KING. Yes.

Dr. ROSENBAUM. Not necessarily. Some of them might. Some people do not receive medical care simply because they are afraid of going to the doctor. Some people do not because they do not have transportation. Two of the cases we uncovered did not want medical care because of their religious beliefs. Two youngsters, and this was the saddest thing and shows this couldn't be handled by the King bill, who were not being taken care of weren't being taken care of because their father refused to leave work during the day and drive them to the doctor and the mother did not want to spend the money for the taxi. This of course could not be directed by any legislation. This is a social problem.

Mr. KING. But generally those unable to pay who have become chronically ill, when they are reported are cared for, of course; but in most cases that type would end up on the public assistance rolls?

Dr. ROSENBAUM. I think some of these people would end up on the public assistance rolls. I think in the future some of them will end up under the Kerr-Mills bill. Those that I encounter personally in my practice I seldom put on public assistance. I donate my own services and the hospital that I am affiliated with happens to have a private resource fund, an endowment. I frequently use that. The other hospital I am affiliated with has a teaching bed. I frequently call up an intern and say "We have a good case." We cannot handle them all and some of them end up on public assistance of course.

Mr. KING. The only reason I ask the question is that I understood that quite well, Doctor, but I feel that repeatedly through our testi

mony, and it happens very often on certain days, it will be shown by the testimony that no one in this country goes without aid or care if he wishes it, or if it becomes known to the proper agency, whatever reason he is not having it, they see that he has it unless, as you state they have other reasons, and I didn't want the feeling, for persons unposted, to be created that there certainly couldn't be a need for further legislation in the matter because responsible witnesses one right after another have stated that their view was that no one was going without medical care if he needed it. Of course, as you know, one of the main objections of many persons in the country and one of the purposes of this bill is to avoid medically indigent treatment being given solely because people haven't the means to pay. That is the only reason I am inquiring.

Dr. ROSENBAUM. Do I understand the objection then is the means test?

Mr. KING. That is one of the principal objections.
Dr. ROSENBAUM. May I speak on this point, sir?

Mr. KING. You may.

Dr. ROSENBAUM. I think this concept of the means test depends on what one means by a means test. If by a means test one means that one stands on the street and is a beggar that begs for anything else and is refused, that is one thing, but may I point out that the means test in your society has now become perfectly acceptable. Take the people who are accepting public housing. If a man accepts public housing he has to show that he has the need for it, that his income does not go over a certain level, and he announces to the public every day that he walks through the door of that housing project that he has met a means test and he does not feel disgraced.

May I point out to you that those of our children who are able and who want to go to Ivy League schools can today apply for a scholarship, but this scholarship can only be given on the basis of a means test. They have to fill out a form that is more complicated than an income tax statement and then, when the father gets the scholarship for his son, he announces to everybody very proudly, "My son got a $2,000 Yale scholarship," but he met the means test. I don't think a means test is disgraceful if properly applied.

Mr. KING. I think that there is a great distinction between a means test that deals with persons seeking loans, housing, scholarship, or what not, as against one who finds the calamity of illness striking. I think there is some relevancy of course, but the individual is different and I think the cost of illness is altogether different from one's desire to inquire about building houses and all that sort of thing. I well know there are more cases than what you mentioned, Doctor, but many of us insist that when one who with limited means managed all their life to be independent suddenly finds the calamity of disease upon them or their husband or their wife, then it is forced on them. They have no alternative but to take it.

In the other cases that isn't so. It is a matter of choice. That is all.

Are there any further questions?
Thank you, Dr. Rosenbaum.

Dr. Emerson.

Mr. DEROUNIAN. Mr. Chairman.
Mr. KING. Mr. Derounian.

Mr. DEROUNIAN. I would like to introduce Dr. Ralph S. Emerson, who is an outstanding surgeon in Nassau County and has been for many years. He also happens to be a friend and close neighbor of mine, living in Roslyn. Maybe that latter fact will militate against him. He will try to present today the practical approach of the physician how this bill would affect the relationship with the patient.

Mr. KING. Dr. Emerson, you have been well recommended.

STATEMENT OF DR. RALPH S. EMERSON, PAST PRESIDENT, NASSAU COUNTY MEDICAL SOCIETY, ROSLYN, N.Y.

Dr. EMERSON. Mr. Chairman and members of the committee, first. may I express my appreciation for this invitation today and also my admiration for the members of the committee if this is an example of your day's work.

My name is Ralph S. Emerson. I am a physician engaged in the practice of general surgery in Nassau County, N.Y. I am also past president of the Nassau County Medical Society. I am here today to voice the vigorous and unalterable opposition of our organization, representing 1,700 practicing physicians in Nassau County, to the proposed law, H.R. 4222 and to substantiate the previous testimony given by the Medical Society of the State of New York.

The proponents of H.R. 4222 state the bill will not:

exercise any supervision or control over the practice of medicine or the manner in which medical services are provided.

The above statement in our opinion is not true. The following examples are presented to show how the bill will interfere with the practice of medicine.

1. The bill does restrict the right of free choice for the patient and the physician.

(a) The patient would be restricted, because the bill specifically states the individual may receive services:

from any provider of services with which an agreement is in effect under this title and which undertakes to provide him such services.

In other words, the provider of services means those hospitals, nursing homes, or outpatient hospital diagnostic services who have signed a contractual agreement with the Government and who promise to adhere to yet unknown fee schedules and all other regulations the Government may impose. The patient could choose only those hospitals, et cetera, who would accept such an agreement.

This is the point, I believe, that Mr. Curtis was bringing out about an hour ago. The patient loses his right to select the hospital of his choice.

(b) The physician's right to treat his patient would be disrupted as the physician's hospital may not have a contractural agreement with the Government. Therefore, the patient would have to select a physician who is not only on the staff of a participating hospital but one who would also agree to act as a clinical clerk in rendering the myriad of forms the Government requires.

2. The bill interferes with the practice of medicine in a hospital. The bill stipulates the hospital may charge only "reasonable," but as yet undetermined, charges. In other words, there is regulation of the hospital charges of the pathologist, radiologist, psychiatrist, and an

esthesiologist, and yet no fee schedule has been forthcoming. Furthermore, it regulates the hospital charges of some of the specialists who would normally render service through the outpatient depart

ments.

In the event a fee is charged above the Government fee schedule, the Secretary of Health, Education, and Welfare may cancel the contract with the hospital and will not reinstate the contract with the hospital, or other providers, until the Secretary has been assured the violations have been corrected and will not recur. Is this not regulation of hospital and outpatient services by Government nonmedical personnel? If the program were expanded to include medical and surgical services in the hospital, all of the physicians would come under the control and regulation of the Government, merely by adding a simple amendment to H.R. 4222, as the blueprint is very broad in interpretation.

3. The bill discriminates against physicians in certain specialties who have offices outside of the hospital.

4. The bill may disrupt the normal relationship of the board of directors of the hospital and the attending staff.

If a violation occurred, in lieu of a physician not submitting a report, making a charge above the nebulous fee schedule, or not fulfilling sundry Government regulations, the board of directors would be in a dilemma. The hospital board of directors would have to make a decision to forfeit their contractual agreement with the Government, thereby denying citizens in their community the utilization of the community hospital, or to censure or discharge the physician. Since Government grants to hospitals will assume a greater proportion in the next decade, the old adage is appropriate of "who controls the purse strings, calls the tune." No hospital can assume its rightful role and render the best service unless there is complete coordination and cooperation between the board of directors of a hospital and the attending staff physicians. This bill in our opinion attempts to police the doctor through the hospital.

5. The bill places an undue hardship on the physicians in completing the records.

Anyone who has had experience with Government health services is familiar with the redtape, confusion, and delay in processing forms. Duplicate and triplicate forms of ordinary bookkeeping methods are simple compared with the voluminous paperwork of Government agencies. This additional burden of hospital records would fall on the shoulders of the already overworked physician. The paperwork involved in a nationwide Government project would be fantastic.

6. The bill is the blueprint for expanded medical services beyond the present plan of hospital, outpatient, and nursing services. On pages 66 and 67, section 402, H.R. 4222:

The Secretary of Health, Education, and Welfare shall carry on studies and develop recommendations to be submitted from time to time to the Congress relating to (1) the adequacy of existing facilities for health care for purposes of the program established by this Act; (2) methods for encouraging the further development of efficient and economical forms of health care which are a constructive alternative to inpatient hospital care: (3) the feasibility of providing additional types of health insurance benefits within the financial resources provided within this Act; and (4) the effect of the deductibles upon beneficiaries, hospitals, and the financing of the program.