HEALTH INQUIRY (VOLUNTARY HEALTH INSURANCE) FRIDAY, JANUARY 29, 1954 HOUSE OF REPRESENTATIVES, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washington, D. C. The committee met at 10:05 a. m., pursuant to adjournment, in room 1334, New House Office Building, Hon. Charles A. Wolverton (chairman) presiding. The CHAIRMAN. The committee will come to order. Dr. Martin, will you resume the stand. Mr. Williams, you may proceed with your questioning. STATEMENTS OF DR. WALTER B. MARTIN, PRESIDENT-ELECT, AMERICAN MEDICAL ASSOCIATION; DR. LOUIS H. BAUER, IMMEDIATE PAST PRESIDENT, AMERICAN MEDICAL ASSOCIATION, AND SECRETARY-GENERAL OF THE WORLD MEDICAL ASSOCIATION; DR. DAVID B. ALLMAN, BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION; AND GEORGE COOLEY, ASSOCIATE SECRETARY OF THE COUNCIL ON MEDICAL SERVICE, AMERICAN MEDICAL ASSOCIATION-Resumed Mr. WILLIAMS. Dr. Martin, like others yesterday, I want to congratulate you on the splendid statement you made to this committee and to thank you for the information you gave us. I think the American Medical Association probably is more intensely aware of the problem that faces the public than the public itself; that is, the availability and the high cost of medical care. In your statement-on page 4-you stated that we had a doctor, or practicing physician, for approximately every 1,000 people in the country. Can you tell me, Doctor, if you have the figures, how many of those practicing physicians are engaged in the general practice of medicine and what percentage of them are specialists? Dr. MARTIN. At the present time, there are around 48,000 to 50,000 board-certified specialists. Now, there are a number of others who have a selective practice. They like to work in one particular field, but that is the number of certified specialists. Mr. WILLIAMS. Doctor, the figure of 1 to 1,000, which would indicate that there is 1 doctor available for every 1,000 people would, in my opinion, be a little misleading, would you not think-in the sense that medical care is available on the ratio of 1 doctor for every 1,000 people? This is what I am leading up to: To what extent; if any, would you say that specialization decreases competition among practicing physicians? Dr. MARTIN. Among the general practitioners, or among doctors in general? Mr. WILLIAMS. Among doctors in general. Dr. MARTIN. I think the more good doctors you have in an area up to a certain limit the better medicine is practised and the greater the competition to do good work. Good men breed other good men. Mr. WILLIAMS. That is very true, but I think it has been shown by these hearings, that there is a shortage of doctors throughout the country; that the field of medicine or the practice of medicine has ceased to become a highly competitive field. I know of no doctors who are wanting for business. Are you familiar with the medical scholarship loan program of the State of Mississippi? Dr. MARTIN. Yes, sir. Mr. WILLIAMS. That program has been highly successful, hasn't it? Dr. MARTIN. It is my understanding it has been, and I think that Mississippi led in that field to a considerable extent and leads now in the number of scholarships they offer. There are a number of other States that have scholarship plans, and I have here-and I should introduce this in the record, if you wish it-a list of these States and the way the plans are set up. Mr. WILLIAMS. Doctor, I am not sure that insurance is going to meet the problem that we are facing, that is, Government insurance of any kind. I am not sure that we would be striking at the cause of the problem through insurance; rather, we would be striking at the effects. I am wondering what you might think about a program whereby the Federal Government would appropriate, jointly with the States, funds to be made available on a loan basis to medical students, in return for which the student contract with the State to practice in an area where there is a shortage of doctors. Generally, I think that you will find those areas to be small communities. The student would agree as a condition for obtaining the loan, to do general practice in such an area for a specified time after graduating. Dr. MARTIN. I believe that is the basis on which most of these plans are set up, the Mississippi plan or the plan in my State, where there are 25 scholarships, and part of them to white and part of them to colored. They contract to go into a certain community and that is decided by a board headed by the commissioner of health. There is a release clause in that which permits the faculty, if a man displays unusual talent in some particular field, to release him on return of the money that the State has granted him. I think that that is a desirable feature because you do not know, or a man may not know, his capabilities at the time he starts studying. Now, the amount of money involved is not very great per student, and whether it is desirable to have the Federal Government come into that picture I think would depend upon whether they would release funds unrestricted so that the determination of the contract between the State and the student would be entirely a State matter. If it is going to involve any degree of Federal participation in the administration of it, I would not be in favor of it. If it is just a straight gift and certain States need it and cannot afford to put up the funds for that particular purpose, we would probably have no objection. We have not felt in my State that we needed Federal funds for that particular purpose. Mr. WILLIAMS. Any such program, I agree, should be administered solely by the State. Dr. MARTIN. That is correct. Mr. WILLIAMS. Would you feel that such a program might be desirable if administered by the States under those circumstances? Dr. MARTIN. I think that program is very desirable because it furnishes a means not only of helping worthy students who are in need, and often they are rural boys who are well suited to go back to small towns and rural areas. It would help them but it would also provide a means of filling in some of the blank spots in the distribution of doctors in the rural and small-town areas. Mr. WILLIAMS. I think it is pretty generally agreed among members of the committee that the cost of medical care is entirely too high. Without attempting to put the blame for that on anybody or any profession if it is too high would you not say that, like everything else, it would be due to the fact that the supply of available medical care is not sufficient to meet the demand? Dr. MARTIN. That the supply is not sufficient? I do not think that that is the reason. Mr. WILLIAMS. In the final analysis, isn't it true that the problem could only be solved finally by training more and more doctors to make the field more and more competitive? Dr. MARTIN. No, I don't think that that is the answer to it, Mr. Congressman. Now, the big increase in the cost of medical care has been in the hospital field. The hospitals make no profit. Actually, the overall picture in the United States of the hospitals is a definite deficit at the present time. Now, they have gone up because of the increased cost of labor and the increased cost of food and the fact that they have had to purchase additional equipment with the development of medicine. There are more and more things added to hospital service. So, the big increase in the cost of medical care has gone up in the hospital and there is no profit factor in that at all. As far as the doctors are concerned, the doctors share the medical dollar and their share has gone down from about 31 cents out of the dollar to something like 26 cents out of the dollar, and so I don't believe the competitive factor would necessarily effect on the cost of medical care. have any Actually, as I pointed out yesterday in our report, the cost of medical care has not gone up anything like the proportion of the general index of the cost of living. Mr. WILLIAMS. I think we have a twofold problem, and I am sure you will agree on that. When I refer to "medical care," I am including hospital costs and medicine, as well as fees. I think that we have a twofold problem: One, of course, the cost of medical care; and, two, the availability of doctors. Dr. MARTIN. Yes; that is right. Mr. WILLIAMS. Now, in Mississippi, we found that our greatest need was for more general practitioners in country areas. We realized most of the young fellows that would finish medical school would desire to specialize and move to the cities, where they can keep regular office hours, rather than to go out in the country where they would have to make house calls, and be awakened any number of times during 39087-54-pt. 7—20 the night. Naturally, the type of practice that a man has to do in the country, general practice, having to work in homes and without facilities and equipment and so forth, does not appeal to most of the students. They want to work in the city where they have all of the facilities. That is understandable. Therefore, I am inclined to think that these students should be encouraged to go into that kind of practice. That is where we need them most. Do you not think that the program I mentioned a few minutes ago might encourage young doctors to go out into the country? Dr. MARTIN. I think that is true, and I would like to say that I think your general statement is correct, that there is a need in the rural areas for doctors. We recognize that problem and we have our national program on placement service operated by the AMA and a number of State programs, as I pointed out yesterday, that I think there are about 32 or 33 States operating placement programs. There are particular rural States like Mississippi, Virginia, Kansas, and States that have the rural problem. It is not so much of a problem in industrial States like Connecticut and Rhode Island. Now, those placement services have two sides to the problem. The community has to do something about it, too, and I can speak with some knowledge of our own State program. They send men out to these communities and talk with the people in the communities and get them to do certain things themselves to make their community attractive for doctors. It is a two-way street and it has been very successful in getting more men into these areas. Now, that combined with your other suggestion about the scholarships is being done, also, in a good many States, as shown by this chart, and I think that is filling that need extremely well. That is particularly true with the development of facilities under the Hill-Burton Act, where these men have access to hospitals for their patients and access to X-ray and laboratory facilities. And with the development of good roads, the transportation problem either for the doctor or for the patient has been greatly decreased. So that the problem is improving. Now, there are some areas where a shortage still exists but I think that problem is being met to a very considerable extent through such efforts as in the program in Mississippi. Mr. WILLIAMS. I believe that is all. Dr. MARTIN. Then there is one other thing. This question has been agitated for some time. At the present time, there is a greater trend to a man going into general practice now than there was a few years back, so that the number of general practitioners will probably increase for a period of time. I think that the specialist field is getting a little saturated. Dr. BAUER. I think Mr. Williams would be interested in the fact that the house of delegates of the American Medical Association has recognized this problem and has appointed a committee to confer with the advisory board of medical specialists to see what can be done to increase the flow of general practitioners and decrease the flow of specialists. Mr. WILLIAMS. Then the American Medical Association is engaged in a campaign to discourage overspecialization, or rather to encourage general practitioners? Dr. BAUER. The problem has been recognized and studies are underway now to see what can be done. Dr. ALLMAN. If I may say a word to confirm what Mr. Bauer has said, and I happen to be on that committee, we have had several meetings and we are well along the road to seeing even if a man does want to specialize that he must devote a certain number of years to the general practice of medicine prior to that time. This will unquestionably change the ratio of specialists to general practitioners in favor of the general practitioner. Dr. MARTIN. I have here a statement of the numbers, if you care to have it, Mr. Congressman. Mr. WILLIAMS. I would like to have it; yes, will you put it in the record? (The document is as follows:) Physicians in the United States and dependencies Mr. WILLIAMS. I have one more question, Doctor. 202, 683 73, 724 55, 298 23, 331 6, 716 9, 732 29, 378 4, 504 You said that the American Medical Association is encouraging young fellows to go into general practice rather than to specialize. Is that an indication that the AMA recognizes that specialization might be one of the factors which has brought on all of the agitation for socialized medicine? Dr. MARTIN. No; I would not say that. I think that there ought to be a proper balance between the number of specialists. We need specialists just as much as we do general practitioners, if you are going to have good medicine. Mr. WILLIAMS. Do you not think there is presently an imbalance? Dr. MARTIN. There is, I think not only ourselves but men informed about medical matters, a feeling that there probably has become an imbalance at the present time and that is the reason that we feel it is desirable to increase the number of general practitioners, or at least make an adjustment of the ratio. Mr. WILLIAMS. I have noticed that I can call my family doctor down to my house, and it will cost only $3 or $4. I can go to a specialist in a city for the very same ailment and my visit to his office will cost me $8 or $10. I think that factor in itself is one thing that is causing quite a number of people to agitate for some type of Government medical insurance, even to the extent, in some parts of advocating socialized medicine. Dr. MARTIN. I would like to say this: I think a patient ought to go to his general practitioner and then only to the specialist if the general practitioner feels he has a problem that requires special attention. Now, a great many people make the mistake of shopping around among different specialists themselves without any good way of knowing whether they need a specialist or not. So, they bring a good deal of that on themselves just by using poor judgment. Mr. WILLIAMs. That is very true. |