That would be a very simple way of dealing with the kind of question, to give them that kind of authorization.

Mr. PEPPER. Let me add one other thing that is relevant here, and perhaps of national interest.

We have here in our area, as you know, a large Latin population. They have a tradition of clinics which began in Cuba a long time ago. So, in Dade County, for example, we have one group that I know, that is supposed to have about 90,000 people in their clinical group. They pay so much a month per individual and so much per family, and then they are supposed to be provided complete, comprehensive medical care for those prepayments.

Another one has about 30,000 people. Now, the reason I interrupted here is because one of those providers came up with a novel plan, and I wanted to mention it to Senator Gordon. They came up with a novel plan that if their covered people would pay $15 a month more than they were paying, then there wouldn't be any deductibles; they would get comprehensive care and they wouldn't need any additional coverage and that would be it.

The reason I mentioned it is that that program has been approved by the State Insurance Office and also by HEW.

At the insistence of the carrier, I submitted the plan to HEW and they said it was all right, and they were willing to let them try it out, to see how it worked. That is another way of getting prepaid medical

care.

Mr. HEFTEL. Senator, in Hawaii we passed a law that requires every employer to provide a prepaid group health care plan for employees, and to pay at least 50 percent of the cost of the plan.

How do you feel about such a plan by States, and do you think there would be any merit in a Federal program which would require States to have a State law that required all employers to pay at least 50 percent of the cost of a health care plan for every employee in order to qualify for certain programs?

Mr. GORDON. Well, if the direction you are going to go is a subsidy of some sort to private insurance, if private insurance is going to be the primary direction of national health insurance, then I would say that that is a very fair way to do things. I suspect that probably two-thirds of the employers in the State of Florida who have over 100 people are in that position.

I don't think there are very many large employers that aren't pay ing at least half of the health insurance. I think what is important is the kind of health insurance that they are required to get and whether it has enough of an educational preventive component to actually be promoting health, rather than just looking upon insurance as a way to take care of unexpected sickness. That is a sort of fundamental difference, and you can bring those kinds of incentives into health care; but I would see nothing wrong with that.

Mr. HEFTEL. Do you think we can solve the problem with Federal legislation? Do you think a national plan administered by the Federal Government is the answer?

Mr. GORDON. I think a national plan is the answer. I think you could administer it in different ways, and you could administer nationally, and you could permit some States to administer, States who have more experience.

What I find in the total Federal situation is that there is never provision for alternatives. That is true in the whole range of social services and education; there are some States that can do some things as well or better than the Federal Government, and there are some States that can't do anywhere near as well.

We don't seem to have any mechanism to let States that can do it go ahead. Hawaii, which already has this legislation, has 85 percent of the people in the health care plan, is relatively homogenous and three-quarters of the population on one island about the size of this county, and its problems in health care are obviously tremendously different than the State of Texas, for example.

The Federal system needs to get some flexibility to deal with that, but I do think that we are not going to solve health problems in this country without a very strong Federal commitment and some Federal restructuring of the incentives in the health field, because we have essentially little control now, and a nonworking situation. So, I don't think leaving it the way it is will be any better.

Mr. HEFTEL. Do you think any Federal program has to build in a control and fee schedules from the medical professionals

Mr. GORDON. Well, yes.

Mr. HEFTEL [continuing]. As opposed to the "usual and customary" being used now?

Mr. GORDON. No. I think the "usual and customary"-75 percent customary is a very feasible way of dealing with it. I am sure that costs differ from place to place. Wherever you have a lot of doctors and a lot of money to pay for medical care, you have high fees. You have all of this Federal money for medicare that is present here in Miami with the elderly population and an exceptional number of doctors for the population. The more doctors, the higher the fees. Mr. HEFTEL. You mean the more competition, the higher the price? Mr. GORDON. Yes, but it is not competition. Very interesting studies have been made by medical economists. What happens in a town where there were 10 surgeons and now there are 20 surgeons, and the 10 surgeons were earning $100,000 and when you are looking at the 20 surgeons, they are earning $100,000, that is known as monopoly pricing, and it is not confined to the medical profession.

Mr. HEFTEL. Do you think it is practical to pursue your suggestion that pathologists and radiologists and the surgeons and probably also the anestheologists all be on a salary basis?

Mr. GORDON. Well, you take the major medical centers of the country, and there that is true; it is true in medical schools and true at the Cleveland Clinic and it is true at the Mayo Clinic and certainly it provides the proper kind of care.

There is a front-page story in the Miami Herald this morning, talking about the change of direction in the American Cancer Society on the question of chest X-rays, and saying they are of no particular value in early detection of lung cancer, and therefore ought not to be done because of the danger of radiation exposure.

I am sure there isn't a hospital in Dade County today that will admit a patient without taking a chest X-ray, because they charge $20 or $30 or $40 and whoever has the concession is going to take the money, and the taxpayers are going to pay for it.

You put them on a salary and they don't necessarily have to take that X-ray.

Mr. HEFTEL. Have you discussed with your local medical fraternity how they feel about the requirement that all of those fields be salaried at a hospital and about the hospital being in a government participation program?

Mr. GORDON. I had a serious heart attack a couple of years ago and I feel very good as to my own health, and so I don't get into those arguments directly with physicians, you know. Somebody made a speech, shortly after I had that heart attack, to the Florida Medical Association, and pointed out that they thought half of the doctors in the State wanted to treat me and the other half did not.

I have to maintain some relationships from a personal safety level; however, I do discuss it with them at a distance.

Mr. HEFTEL. Thank you very much.

Mr. RANGEL. I hope that you will continue to work with Senator Pepper and our committee, because it is clear to us that you have many other experiences to share. It is my understanding that some of the radiologists and pathologists who are solely on salary, that is those salaries are sometimes conditioned to the amount of money that they can bring into their departments-we have attempted to put a cap on that.

In addition to that, where we have assignments mandated in our bill, H.R. 3900-as a result of the work that your committee has done, Senator Pepper on H.R. 3990-where they don't receive 100 percent reimbursement unless they accept assignment. Hopefully, we will be able to get that bill passed in the House and the Senate.

I was concerned about so many areas that you have testified about that I may just send you some questions outside of the hearing.

One of the concerns that I had was your suggestion that all doctors be made to accept assigned cases. There is no question I support that. What is your answer to the hypothetical question that doctors may not accept any of the assignments if the agent is sick or poor?

Mr. GORDON. There are too many of them, and they couldn't survive in Senator Pepper's district and couldn't survive in my district if they said that. There are not enough of us young people to charge that money to, and the old people don't have it.

My other response, usually, to doctors is that when they tell me that, I tell them that I just don't believe they would violate their Hippocratic oath to that degree and just turn people down.

They always tell us they are not in it for the money, and so you have to accept that at their word.

Mr. HEFTEL. Up to that point, Mr. Chairman, you have been terribly persuasive. If we accept your argument, that a surgeon may be more apt to think in terms of medical needs if he is salaried, rather than getting a fee for that service, could you extend that to physicians generally?

Mr. GORDON. Well, no; I don't think so, because with your primary care physician, a person comes in and there is something the matter with him, and he is going to take care of it. He is generally not a high-fee person and he doesn't generally even have a different fee for different economic levels of his patients; he charges $10 or $15 for an office visit and people are used to doing that.

I don't think primary care physicians have the same kinds of conflicts over what to do.

You know somebody comes in and it is either someone they have taken care of in the family, and he is going to do something about it; it is where an option exists as to whether to do something or not. Usually the primary care physician does not have that kind of option, and there are levels of temptation.

If it is a difference of making $15 or $1,500, people's reactions tend to be different. They shouldn't, but that seems to be the way human beings are.

Mr. HEFTEL. There are problems in providing quality health care for older Americans. There are also problems related to the health care of a large number of non-American citizens. How do you take care of their health needs?

Mr. GORDON. I am glad you asked that. We are facing a veritable deluge of Haitian refugees for which the Federal Government has refused to accept any responsibility, and it has made a tremendously difficult burden on local services. The reason the Federal Government, while it did and it still does support services in this country for Cuban refugees, because they agreed that they were political refugees, they have not been willing to say that the Haitians are political refugees and therefore give them the same services.

We feel that because we happen to be geographically nearest, we ought not to accept a national burden any more than I suppose California ought to accept the total burden of Southeast Asian refugees. That has been a significant problems.

As far as the Cuban refugees are concerned, we have been compensated because we took the position-and I was on the county school board at the time, from 1960 to 1968, and I was involved in some negotiations for the education money-we took the position that bringing the refugees here was a matter of national policy and therefore ought not to be a burden on local government.

I think as a result of policy or unwillingness to get involved in a close examination, I guess it would be a diplomatic way of saying it, of the Haitian Government, all of a sudden it is not a national matter and the burden is on us.

The Federal Government has not at all been forthcoming, except for a very minor amount of money. I read the paper two mornings ago saying that there was a 26-foot sailboat that came ashore on 15th Street in Miami Beach, right in the middle of the city, with 99 refugees on it. Stories like that appear very frequently.

Mr. RANGEL. What happens to the health care? In that instance you are talking about, what happens to those people that need medical care?

Mr. GORDON. A lot of them are thrown on the county and I think Mr. Hampton would be better able to tell us what is done. The State is not furnishing any funds for that. Primarily, State funds are matching funds to Federal programs or matching funds to local programs; but I know from most of these people, eventually they wind up living in my district, and I know that they are a tremendous burden, particularly on Catholic charities, which have been outstanding in their willingness to deal with these programs and with these people. I think Monsignor Walsh is on your list of witnesses.

Mr. RANGEL. That is good.

Mr. PEPPER. I would like to add that recently the Government has made available, I believe, $200,000—it is very limited funds and we have set up some reception centers for the Haitians and others who come in illegally. We found out that some of the Haitians carry contagious diseases. We have an amendment to the last refugee bill that provides that up to November 1, what had been spent in the care of these people who came in illegally, by the county for health and other care, would be reimbursed to them. It stops there.

As the Senator said, they are coming in every day. We have now estimated that from 12,000 to 25,000 Haitians have come in here without legal authority and Congress has not yet decided, or the Government has not yet decided, just what we are going to do with them. Black people here feel very strongly that that we took care of the Cubans who came in, and we ought to take care of the Haitians.

The only thing is, how many can we take care of? If you open the door, the Caribbean alone has a large number of people; we cannot with respect for human values ignore these people. They need decent care and housing and other things; they have been staying in churches and we have a very deplorable situation now with respect to illegal aliens who come in. As soon as this $20,000 is used, unless we provide more money, it will drop right back on the local authorities, when, as the Senator said, it is not their responsibility.

Mr. GORDON. I think there is one other small amount of assistance that the U.S. Public Health Service has given. There is a high influx of tuberculosis; they see more cases in the last few months among the Haitians than they probably have seen here in the total population in a number of years. So they have sent in a couple of people, but tuberculosis is a societal kind of situation and unless significant things are done in terms of housing and nutrition and so on, of course, the people are also, since they are illegal aliens, only able to take fringe jobs and hidden jobs and jobs that are the very lowest kind of jobs in the country, so they don't have too much opportunity to move forward. That is just an extra item.

I am glad you added the question.

Mr. HEFTEL. I have just one question, Senator. What happened to the 80 Haitians who were in a local church who were turned out? Mr. GORDON. Well, I only know the newspaper stories, Mr. Heftel. The people were simply scattered into other places, and probably other missions took them in.

If you ride over here just about 2 miles from here, and happen to drive up Northeast Second Avenue, you will see a number of stores with signs in French and Creole and so on. I suppose they are just absorbed in the community.

The church had been taking care of these people and other people for at least a year, and the Immigration Service very heartlessly would always take the people and dump them at this church, knowing that this church was going to take care of them because the Immigration people would not accept any responsibility for the people.

I guess in some other places they got absorbed. Monsignor Walsh might have a different answer to that.

Mr. RANGEL. Thank you, and we will stay in touch with you. Thank you very much.

Bill Hampton is the next witness, Dade County Department of Human Resources.