We support the President's proposal because we believe that the inclusion of hospitalization services is a logical extension of the social security program to insure the American population against need in their declining years. Medical need is as real and essential as the need for food and shelter. The same concern that prompted our Government to promulgate and to broaden the Social Security Act should also inspire us to include hospital and nursing-home care. Moreover, we are concerned with the dignity of the individual. A means test is ultimately a pauper's vow. Our older people do not want charity. They are entitled to the preservation of their selfrespect. We have always supported the social security program primarily because of our moral and religious concerns with the preservation of the dignity of the person.

A means test robs a man of this sacred possession. We thus view our public assistance categories as a residual program to take care of the needs of those who are not covered by an insurance program. As our social security program is broadened, the outlay from the national budget for public assistance and old-age assistance programs will be to that extent reduced.

It may be of interest to note that in 1950, 22 percent and more of our aged were receiving public assistance help in the form of old-age assistance. This past year this proportion of our aged receiving such help has been reduced to under 14 percent.

In conclusion, our old people frequently cry out with the psalmist "Do not cast me off in old age, when my strength faileth forsake me not."-Psalms 71: 9. I hope that we will heed this poignant cry of our aged and will not forsake them, in their declining years, when they suffer from the infirmities of old age for which they certainly bear no fault.

The CHAIRMAN. Are there any questions of Professor Lander?

If not, Professor, we thank you, sir, for bringing to the committee the views of the Synagogue Council of America.

Mr. Besdine.

STATEMENT OF DR. MATTHEW BESDINE, BROOKLYN, N.Y., ON BEHALF OF THE AMERICAN DENTAL ASSOCIATION

Dr. BESDINE. I am Dr. Matthew Besdine, of Brooklyn, N.Y., chairman of the American Dental Association's Council on Legislation. I am also president of the Dental Society of the State of New York. I am accompanied by Mr. Hal M. Christensen, the association's Washington counsel.

In accordance with the instructions contained in the press release issued by the chairman of this committee, dated July 11, 1961, we have attempted to keep this statement brief and free of repetition.

The members of the American Dental Association have an intense interest in H.R. 4222 and similar measures which would embark the Federal Government upon a massive health care program for a large segment of the American population. Many of this association's State and local constituent and component dental societies would have welcomed the opportunity to appear before this committee to present personally their views on this important legislation.

However, in keeping with the chairman's request, in the interest of conserving the valuable time of the members of this committee, the

following comments and recommendations will constitute the formal presentation representing the position of organized dentistry in the United States.

The American Dental Association has a membership of 95,000, and of this number, about 85,000 are engaged in the private practice of dentistry in large and small communities throughout the country.

The members of the dental profession are gravely concerned about the problem of extending the availability of dental health care to all segments of the population. This is reflected in official policy which establishes as one of the major missions of the American Dental Association the duty to assure to the greatest extent possible that dental care is available to all people of this Nation regardless of income, geographic location, or any other factor.

Thus, at the outset, in the interest of objectivity, it might be conceded that the American Dental Association and the sponsors of H.R. 422 have a common objective in that both are motivated by a desire to bring adequate health care to a segment of the population which includes some persons who may not be able to afford such care. The only point of difference that arises is how best this common objective can be accomplished. The American Dental Association does not believe that the means provided in H.R. 4222 and similar legislation constitutes a desirable or adequate approach.

H.R. 4222 adheres to the basic framework of legislation introduced in recent sessions of Congress by former Representative Forand of Rhode Island and would finance nursing home and other health-care benefits for persons meeting OASDI eligibility requirements. Such benefits would be provided without taking into consideration the economic needs of eligible recipients and no consideration would be given under the program to aged persons unable to qualify under OASDI rules.

While increasing numbers of dentists participate in hospital practice, it is recognized that dental care would be involved only to an incidental degree in the benefits proposed in H.R. 4222. At the same time, it is recognized that H.R. 4222 has far-reaching implications for members of all health professions as well as for others interested in the Nation's health. It would be naive, we believe, to ignore the real probability that once this type of program is initiated, it will be extended progressively to include comprehensive health care for the entire population. It is this potentiality within H.R. 4222 that gives pause and concern to health practitioners everywhere and is the reason for my appearance before this committee today.

This association does not believe there is a conscious desire on the part of the proponents of H.R. 4222 to introduce a system that may lead to a degeneration in the present high quality of the health services to which our people have become accustomed. Nor do we believe that the health practitioners of the country consciously would perform lower quality services because the Government, rather than private individuals or agencies, pays the bill.

It is believed, however, that the inescapable tendency would be for practitioners to perform their services in accordance with the rules, regulations, and directives promulgated by the Federal agency having sole control over their ability to provide a livelihood for themselves and their families.

With the Secretary of Health, Education, and Welfare or his delegate acting for the Federal Government as the sole purchaser of health services, it is feared that in the rendering of such services, regulation would be substituted for professional judgment and high quality would be replaced by mediocrity.

If the administration of the national health plan now under consideration by this committee follows the pattern of other Government health-care programs, mass production would become the watchword and individualized, personalized care would become the rarity.

Usually, the pattern is as follows: First the Government overcommits itself: it promises more than it can deliver. Second, costs are underestimated. Third, services and/or fees for services are cut, usually by laymen concerned with the budget rather than with the adequacy of care. Fourth, many practitioners withdraw from the program, freedom of choice evaporates, quality of care degenerates, and patient-beneficiaries become dissatisfied and disillusioned. This sequence of events occurred in connection with the so-called Veterans' Administration hometown dental program which was instituted after World War II and which finally, after much bitter experience, was revised by a law enacted in the early 1950's.

In some of the other ventures the Federal Government has made into the operation of dental care programs, quota systems have been established and treatment has been stereotyped and rendered according to the strict directions of a Government manual. In certain of the military programs, dentists were required to serve on what they nicknamed the "amalgam line"; their performance being rated and their promotions governed by the number-not the difficulty or quality of dental operations performed in a given period. Their performance, in many cases, was judged by nondentists having an eye on the budget and the timeclock rather than on the adequacy of the treatment. Certainly, the patients involved did not receive the best care under these circumstances.

It is believed inevitable that if a program such as is envisioned in H.R. 4222 is put in effect, the result will be constantly rising costs and lower quality care. The following excerpts from articles discussing the National Health Scheme in Great Britain illustrate our concern.

There is one thing certain: if the rate of costs increases in the next 10 years as it has in the first 10 then the great social experiment of a National Health Service could bring Great Britain to a state of penury. The first year's bill in 1948 was £360 million. After 10 years, 1948-58, it was £757 million.

An itemized scale of fees, linked to a restriction of clinical freedom, is based upon an average speed of work for operation of average difficulty; it takes into account average expense and average abilities; it provides automatically for the average sort of treatment required *** it stifles initiative, discourages more intricate forms of work which are advantageous to the patients' future dental health, rebuffs the individualist, and puts a brake upon progress.

We are in danger of becoming a piecework production industry.

The modern student has a high standard of operative work and skill taught in the schools today. *** When he leaves (school) and enters the National Health Service he is frustrated by the fact that the scheme cannot often afford elaborate and advanced technique to be carried out, and the patients are so grossly taxed they may not be able to afford the better and more costly work to be carried out privately.

Quite frankly, we are disturbed and we believe that many members of the American public are disturbed by the prospect of assembly-line health dispensaries in the grim atmosphere of conformity and regi

mentation with the Government's budgeteers in the saddle determining, after the fact, whether this service or that service was necessary to preserve the health of the patient. We do not believe such a system can maintain high-quality health care for the public. We do not believe such a system will serve the best interests of the public or the health professions.

We are further concerned that the system envisioned in H.R. 4222 would place undesirable limitations upon the availability of health personnel and facilities, both for persons over 65 and for all age groups. The administration has recognized the acute health manpower and facilities shortage and has recommended measures to help overcome the problem.

The American Dental Association has endorsed the legislation, H.R. 4999, S. 1072, to stimulate the establishment of additional dental and medical schools and to attract additional personnel to the health professions.

Existing health care demands cannot be met and with predictable population growth such demands will become increasingly acute. A Government program of health care for one age group in the population will only serve to create further imbalance and displace persons in other age groups.

The profession is especially fearful that adoption of a Government program which concentrates on adults will result in neglect of children's health needs. This has occurred under the British system and is completely contrary to all accepted professional standards of dental

care.

At the same time, we recognize that the existing system for providing health care is not perfect even though under it we have achieved the highest standards of health care in the world.

There are deficiencies in the availability of dental care which we would like to see corrected. We know there are aged and other institutionalized or homebound persons who are not receiving the care they should have. There are also children, some of them suffering from physical and mental debilities or other unfortunate circumstances, who need attention.

In short, there are people in all age groups who require some form of assistance in obtaining the care they need. As we have said, we favor programs to meet these needs but do not believe the total problem will be alleviated by singling out persons in one age group and permitting the Social Security Administration to pay their health

care bills.

We believe there are other more practical and desirable methods of meeting our health care problems. As indicated above, we favor legislation to help produce additional practitioners and facilities. We believe President Kennedy was correct in his appraisal of the serious shortages in this area. We believe the corrective legislation his administration has sponsored is sound. We believe the Community Health Services and Facilities Act recently passed by the House of Representatives is a forward step in assisting the aged and the chronically ill. We also favor increased emphasis on preventive

measures.

We have consistently supported expansion of the research programs administered by the National Institutes of Health, but it has only

been in recent years that Congress has appropriated funds on a realistic basis for these programs.

In addition, we are strongly supporting legislation to strengthen State and local dental public health programs. Enactment of this legislation, H.R. 4742 and S. 917, would assist States and communities in bringing dental health care to the chronically ill and the aged, handicapped children, and others in need. It would provide funds to purchase portable dental units and other specialized equipment necessary to provide treatment to the unfortunate.

In the opinion of this association, such programs administered at the State and local levels with a minimal stimulatory grants-in-aid from the Federal Government, offers a far superior means of meeting our health care problems than the drastic and irreversible departure proposed in H.R. 4222.

We believe further, in accordance with the same philosophy, that the Kerr-Mills program should be given a chance to work. Through refinement and expansion of efforts such as these, it is believed that high standards can be maintained and the availability of health care can be extended to all those who need it.

Finally, I wish to point out again that the American Dental Association has given support to five of the six major elements of the administration's health program laid before Congress on February 10, 1961. We believe firmly, however, that we must object to that part of the program represented by H.R. 4222.

It should be emphasized that this association is not concerned with slogans or labels manufactured to oppose or to support H.R. 4222. We believe it is our proper function and responsibility to evaluate health proposals on their merits, strictly from the professional viewpoint. Specifically, we believe it is our proper role to determine as best we can whether any such proposal can be expected to extend availability of health care without lowering its quality, thus serving the best interest of the public.

In our opinion, H.R. 4222 does not meet this test, and it is respectfully recommended that the bill be rejected by this committee. The CHAIRMAN. Are there any questions of Dr. Besdine?

Doctor, we think you very much for bringing to us the views of the American Dental Association. You have made a very fine statement in behalf of your association. We thank you, sir, very much. Dr. BESDINE. Thank you, Mr. Chairman.

The CHAIRMAN. Is the Reverend Vallaume in the room?

Mr. Colman?

Will you identify yourself for the record, please, sir, by giving your name, address, and capacity in which you appear?

STATEMENT OF J. DOUGLAS COLMAN, REPRESENTATIVE OF BLUE CROSS ASSOCIATION

Mr. COLMAN. For the record, Mr. Chairman, my name is J. Douglas Colman, 80 Lexington Avenue, New York City. I appear here as the representative of the Blue Cross Association.

The CHAIRMAN. You are recognized, sir.

Mr. COLMAN. Thank you.

The Blue Cross Association is the national coordinating agency of the Nation's 79 Blue Cross plans serving 56 million members, of