I would like to present to your committee some of the reasons that prompted the board in taking its action.

1. This disability benefits program represents a plan that will inevitably be expanded far beyond its somewhat limited applicability as proposed in the bill. The majority report of the Advisory Council itself suggests that the recommended program is only a beginning when it stated, after discussing the administrative difficulties involved in carrying out the program (p. 2, S. Doc. No. 162, 80th Cong., 2d sess.):

In view of the admitted administrative difficulties in undertaking the payment of such benefits, however, the Council recommends a highly circumscribed program. More progress will be made in the long run if the persons responsible for operating the program have an opportunity to develop experience under relatively favorable conditions.

There is implicit in the foregoing statement, it seems to me, the expectation that as administrative experience accumulates-after what we may call a settling process-the program will be expanded.

To minimize the occurrence of malingering, the Council recommended, and the bill provides for, a waiting period of 6 months after the determination of disability before benefits will be available. After the administrative experience mentioned by the Council has accumulated, it is not difficult to anticipate that this waiting period will be shortened or perhaps done away with in its entirety.

There is no specific provision in section 107 to provide medical care to the recipients of disability benefits. I give emphasis to the word "specific" for the bill does provide that the Federal Security Administrator may direct a recipient of benefits to accept rehabilitation services available to him under a State plan approved under the Federal Vocational Rehabilitation Act. That act contemplates that a State plan will make available medical care to those needy individuals undergoing rehabilitation. The accent is on the needy, in that particular place. Whether or not a recipient of benefits under section 107 of the pending bill who is directed to undergo rehabilitation under a State plan will receive medical care only if he is needy or whether the Administrator, under the broad discretionary powers given him by section 107, may authorize the furnishing of such medical care without regard to need is a question that the bill does not clearly answer. Assuming, however, to stress a point, that there is nothing contained in section 107 of the pending bill that would authorize the supplying of medical care except perhaps to those financially in need, there is little assurance that the program will not be expanded to provide federally controlled medical and surgical care to the disabled. It seems to me that that eventuality is not remote. The providing of benefits to those who suffer disability, either temporary or total, has been suggested to the Congress on previous occasions and almost invariably such suggestions have been coupled with the supplying of medical care on the theory that if medical care will lessen or terminate the period of disability then the need for rendering federally financed aid to the disabled person will cease and Federal funds will thereby be conserved. That is a line of reasoning with which there is no argument, but the manner in which that medical care shall be provided and what shall be its standards and who shall be entitled to that care is quite another matter, which is left to a very broad discretion.

Time and again representatives of the Federal Security Agency have recommended disability benefits plus medical care. I do not believe that that statement will be seriously questioned but I wish to recall to the attention of the committee the viewpoint expressed by Mr. A. J. Altmeyer, then Chairman of the Social Security Board, who is now Commissioner for Social Security, presented on July 18, 1941, to the House Committee Investigating National Defense Migration, at which time he said:

In

Our eventual goal should be the establishment of a well-rounded system of social insurance to provide at least a minimum security to individuals and their families due to unemployment, sickness, disability, old age, and death. addition, we must provide a series of constructive social services to supplement the cash aids provided under social insurance. Medical care should be available to individuals and their families so that we may build a healthier, happier Nation. Such a system of medical care would be instrumental in reducing the costs of cash payments for sickness and disability.

That is the end of the quotation. It is a blueprint of the structure of which the provisions of H. R. 6000 relating to disability benefits must be considered as an important part. The provisions contained in the bill in section 107 should not therefore be appraised solely as an isolated, detached effort to provide some measure of aid to the disabled worker but as a part of a movement toward completing plans for a compulsory, federalized sickness insurance program such as is contemplated by another bill now pending before the Senate Committee on Labor and Public Welfare, S. 1679, which, among other things, proposes a compulsory national program of so-called health insurance which will result in the federalization of the practice of medicine.

Expansion of the pending proposal may be anticipated along other lines, too. With benefits provided for total and permanent disability, it will be only a short step to providing benefits for temporary disability, including sickness, and then benefits for the dependents of the disabled.

I urge the committee, therefore, to explore carefully and fully the potentialities of the pending proposal.

Senator KERR. May I ask a question?

The CHAIRMAN. Yes, Senator Kerr.

Senator KERR. In the paragraph just before that, I take it that your objection is aimed solely at what you think to be the proposed method, and not at the objectives?

Dr. SENSENICH. As to providing that medical care should be available to every individual, regardless of whether he is disabled, whether he is ill, or what constitutes a need for medical service. With that we are in agreement.

Senator KERR. You are in agreement with that objective?

Dr. SENSENICH. But we are not in agreement, sir, upon the Federal Government or any government, for that matter, taking over the responsibility for the medical care of every individual who is ill. And that would seem to be, sir, the eventual development out of this program, of which this proposal as to the disabled is only one feature. Perhaps I didn't understand you, Senator.

Senator KERR. Well, you have answered enough questions, to where I would say you had answered any possible construction of what I asked you. The question I asked was whether or not you were finding

fault with the objectives in the paragraph, or with the methods by which you thought certain ones were trying to achieve the objective. Dr. SENSENICH. I am sorry I didn't understand you correctly.

2. The majority of the Advisory Council recommended a restrictive definition of a compensable disability in order to reduce the incidence of malingering. They defined "permanent and total disability" to mean any disability which is medically demonstrable by objective tests, which prevents the worker from performing any substantially gainful activity, and which is likely to be of long-continued and indefinite duration. That is quite a clear definition. That is the definition offered by the committee.

Senator KERR. How would you define it?

Dr. SENSENICH. I think that is a very good definition, sir. The definition contained in section 107 of H. R. 6000 departs from this recommendation by failing to require that the compensable disability be demonstrable by objective tests. By "objective tests" are meant the things that can be observed or proved in the findings of an examination of this man from a physical standpoint, Senator Kerr. Senator KERR. You think that anything a fellow feels inside of him, then, is determinable objectively by observation from others? Dr. SENSENICH. No; it is not. And if you were to ask me, Senator Kerr, as to whether I felt that that was all that was necessary in the diagnosis of a medical case or in its care, I should say that is not correct. There are many things that are not objective.

Senator KERR. It is easier to find fault with standards suggested than it is to suggest standards about which there is no fault.

Dr. SENSENICH. That is true, Senator Kerr. But if I may continue, I think you will find why I am presenting what I am at this place.

Senator KERR. I think I knew that before you started.

Dr. SENSENICH. I think I can make it clear, sir.

Senator MILLIKIN. Well, if you do not have standards based on objective tests, you open the whole field to malingering and phoney claims of all kinds.

Dr. SENSENICH. That is the reason I am continuing on. I think you have heard from those who have had to deal with the total disability claims to life insurance companies and the claims of others who allege disability, as a result of injury, and so on, the enormous amount of malingering and of complaint of disabling illness which cannot be proved by objective means and often is subject to great question.

The definition thus broadened in section 107 may bring into importance many simulated symptoms of conditions which cannot be demonstrated by objective tests and will make even more uncertain and indefinite a satisfactory application of the provisions of the bill. 3. Reference has been made to the discretionary powers proposed to be lodged with the Administrator of the Federal Security Agency in connection with the disability-benefits program. The Administrator will, for one thing, decide who will make the initial examination and the contemplated reexaminations to determine the existence of a disability of a kind to confer entitlement of benefits.

We meet up with that problem all the time. He may utilize physicians who are employees of the Government, such as salaried physicians of the Veterans' Administration or of the United States Public

Health Service, or other physicians who are on a salary specifically to function in connection with the disability benefits program. He may utilize private practitioners of medicine on a fee basis but there is no assurance that the family physician of the potential beneficiary will be permitted to have any voice in the determination of disability although he is the one presumably best qualified to make the determination.

Senator MILLIKIN. I think it should be said there, Doctor, that there also would be great pressure on the family physician to find the exist ence of a disability which might be questionable.

Dr. SENSENICH. That is very true, sir. As a matter of fact, in England, in the administration of their certification for certain benefits, it became so terribly difficult for the physicians that they asked to be released from that responsibility; the end result being that the illness, then, would be determined by a nonmedical individual, and the system. was very, very badly imposed upon.

Senator MILLIKIN. We had some testimony earlier, as I recall it, to the effect that under some State plan-I may have this a little twisted, but I think the idea is correct-they have picked panels from another community to make these decisions, just to avoid the pressure that comes on the family physician and local physicians who know the

case.

Dr. SENSENICH. That is quite understandable, Senator.
Senator KERR. May I ask a question, Mr. Chairman?

The CHAIRMAN. Yes, Senator Kerr.

Senator KERR. Do I understand that you take the position that those to whom you have just referred should not be permitted to help determine the disability?

Dr. SENSENICH. No, Senator Kerr. What I am developing here, when I will have finished another paragraph or two, is rather to show the difficulties in the administration of this bill.

Senator KERR. You will pardon me if I seem to be unable to anticipate your conclusion, but I have found this out, that oftentimes when I did not know where I was going, when I was on a journey, I was unable to recognize the destination when I got there.

Dr. SENSENICH. I think that would be a fair observation but I am quite sure, Senator Kerr, that I know my destination.

Senator MILLIKIN. It would be advisable to know where you are going before you start.

Senator KERR. I am interested in your remark that he may utilize physicians who are employees of the Government, such as salaried physicians of the Veterans' Administration. Are we proceeding to the conclusion that they are not qualified to make these examinations! Dr. SENSENICH. No, this is just enumerating the means or what kind of medical proof might be submitted as to the total disability of this individual. We are not complaining of that.

Senator KERR. Now, on the basis of what would be adequate? Or what would not be adequate? I mean, you have some reason for putting that in.

Dr. SENSENICH. Yes, and I conclude that in the next paragraph, Senator Kerr.

Senator KERR. I am looking forward to that next paragraph with great anticipation.

Dr. SENSENICH. All right, sir. We will have then the probability of the disabled worker being forced to rely on a governmental employee

for the establishing of his rights, with no assurance of an opportunity to present evidence on his own behalf. This seems important in view of the fact that the bill grants no right of appeal from any adverse decision reached by the Administrator nor, as a matter of fact, is that official even required to act in accordance with the advice given him by his medical adviser.

Senator KERR. Do you think he should be?

Dr. SENSENICH. If we will drop that detail, I think that the individual should have the same right of appeal as he has in your and my life insurance policies, if we are not satisfied that we are being fairly treated as to disability.

This individual has no appeal. He has no appeal, and even the physician, who is not of his selection, who does not represent him but is appointed by someone else or provided by another agency, may do exactly as he wishes, and without anything from the individual physician, who probably is best acquainted with the facts. I wanted to make that clear in connection with your question, Senator Kerr.

Even though a family or attending physician is designated or permitted to make the required examinations and determinations, that physician will be placed in a most difficult position. This, I think, will answer your other question, Senator Kerr. A dual relationship will obtain; one, a physician-patient relationship, because the physician has been the attending physician, and the other, a physician-Governmentexaminee relationship, because the physician, compensated by the Government, will be examining the worker, not for the purpose of treatment but for the purpose of determining the eligibility of the worker to receive the specified cash sums. That situation has arisen many times.

If in a border-line case, and certainly many such cases will arise, the physician resolves a doubt in favor of the worker, who is also his patient, he may be accused of conniving to defraud the Government. If he resolves that doubt in favor of the Government, he will most assuredly invite the animosity of his patient and thereby will make it impossible for him to function efficiently thereafter in the treatment of his patient's condition.

It has been actually known, and I am sure, Senator Kerr, that you have heard of instances in connection with disabilities following industrial injuries, where the boards, the State agencies, must determine whether the individual is disabled, first of all, and the extent of that disability, and the probable outlook. Where it is found that the individual goes to a physician other than his regular attending physician, there is no argument about that. But there are cases where some physicians seem to be rather favorably selected by those who feel that their case should be presented to their interests.

Now, that is a bit unfortunate, but nevertheless it is a situation. which obtains, and which makes it difficult, in the administration of such an act. We are now in the border-line cases, and we have departed from those in which there is actual objective evidence. Obviously, a case in which a man who has lost a leg or an arm is one which is apparent to anyone.

Senator KERR. You would not even have to have a physician to determine that.

Dr. SENSENICH. No, Senator Kerr, I would be willing to ease up the restrictions on the determining of that disability.