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people. While H. R. 6000 is primarily a social-welfare proposal, it does contain one provision having serious medical implications; namely, that section on compulsory contributory permanent- and total-disability insurance.

"The major benefits included in the present social-security system-old-age and unemployment-are adaptable to mass or objective administration from an office remote from the individual. This is not true of total- and permanent-disability benefits. Age is a condition over which the individual is unable to exercise any control, and unemployment is an occurrence over which the individual may have little or no control. Qualification for the benefits is categorical and not difficult to determine. In contrast, total and permanent disability is often a condition over which the individual who is disabled and his physician may exercise control.

“This subjective control which may be exercised by the individual multiplies the opportunity for malingering and actually takes the program out of the insurance category. We must always oppose any program which places a brake on the incentive of the sick and disabled to desire recovery.

“To initiate a Federal disability program would represent another step toward wholesale nationalization of medical care and the socialization of the practice of medicine. The program as now proposed would not accomplish the entire nationalization of medical care, but the inevitable expansion and liberalization of the program which would surely follow makes probable its eventual accomplishment. The steps in liberalization are not hard to visualize, such as payment of benefits to dependents of disabled covered persons, removal of the time lag of 6 months, and substitution of temporary-disability benefits, then eventually full cash sickness and disability provisions. We would then have nothing less than a total national compulsory sickness program.

“During the hearings on this bill persons fully qualified in the field of economics and insurance and students of political science warned against the high additional percentage of national income to be committed to social programs by the enactment of extensions as proposed by H. R. 6000. Of this danger, we are aware.

“The American Medical Association recognized the need for assistance to the disabled needy and feels that this aid should always be administered on a local level. Financial assistance to the locality should only be advanced from State or Federal sources when a need can be clearly shown.”

Section 107 of H. R. 6000, beginning with line 6, page 88 of the bill and dealing with disability-insurance benefits, was apparently included on the recommendation of the majority report of the Advisory Council on Social Security appointed by the Senate Committee on Finance pursuant to Senate Resolution 141, Eightieth Congress, and submitted to your committee under date of May 8, 1948.

As indicated in the statement of the board of trustees, the American Medical Association is opposed to this particular part of the bill, and 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. 162, 80th Cong. 2d sess.) :

“In view of the admitted administrative difficulties in undertaking the pay. ment 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 his 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 individuls undergoing rehabilitation. 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 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.

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 Secur. ity 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 :

"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. In additien, we must provide a series of constructive social services to supplement the cash aids provided under social insurance. Medical care should be available 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.

2. The majority of the advisory council recommended a restrictive definition of a compensabıe 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 perfurning any substantially gainful activity, and which is likely to be of long-continued and indefinite duration. The definition contained in section 107 of H. R. 60%*) departs from this recommendation by failing to require that the compensable disability be demonstrable by objective tests. The definition thus broadeneal may bring into importance many simulated symptoms of conditions which cantiot 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 lodgu 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 deter. mine the existence of a disability of a kind to confer entitlement of benefits He may utilize physicians who are employees of the Government, such as salaritd

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. 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 adyiser.

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. A dual relationship will obtain, one, a physician-patient relationship because the physician has been the attending physician, and the other, a physician-government-examinee 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.

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.

The majority report of the advisory Council perhaps realized that much discretionary power would be conferred on the Administrator if its recommendations were enacted into law, for the report suggested on page 2 as follows:

"We believe further that it would be desirable to establish a public advisory board to counsel with the Federal administration particularly during the early years of the operation of this new program. Such an advisory group could assure that a variety of viewpoints are considered in the formulation of policy. The advisory group might appropriately later review and make recommendations on the conduct of operations and the extent to which the program achieves its purpose.”

And again, the council recommended a decentralization of administrative procedure in order to prevent too much concentration of administrative action and decision in Washington. Here again, however, the provisions of section 107 depart from the recommendations of the majority report, for there is no reference to the creation of a public advisory board nor is there any indication that the administrative functions will be decentralized.

4. It is a fact well known to physicians that the mental attitude of a patient is a most important factor in his recovery. We may call it the will to get well. Disability benefits may well remove from many disabled workers the incentive to become a contributing member of society, the incentive, in other words, to recover from his disability.

5. As indicated in the statement on H. R. 6000 formulated by our board of trustees, no apt parallel can be drawn between the existing old-age and unemployment programs and the proposed disability-benefits program. A worker either is or is not aged and he has no control over the fact. A worker is either unemployed or he is not and, possibly with a few exceptions, he has little or no control over the fact. There are no border-line cases, generally speaking. Little if any exercise of discretion in awarding benefits, particularly on account of old age, is necessary. These two programs lend themselves somewhat readily to mass treatment. That is not true with respect to disability benefits. Highly personalized equations must be considered in individual cases and that necessity precludes the administration of the program on a mass basis. Too, total and permanent disability is often a condition over which the individual and his physician may exercise some control and that fact would seem to remove the program from the insurance category.

6. These Mr. Chairman, are some of the reasons that prompted the board of trustees to express opposition to the program outlined by section 107 of H. R. 6000. The board is convinced that that program is the forerunner of a completely federalized system of compulsory sickness insurance, such as has frequently been advocated by the Commissioner of Social Security, Mr. Altmeyer. It believes that any such nationally directed and controlled program will in. evitably result in the socialization of the practice of medicine and in a marked deterioration in the quality of the medical care that the American people have been accustomed to receive. While American medicine is interested in the rehabilitation of the disabled, it believes that the rehabilitation can best be accomplished on a local level without direction and interference from a Federal administrative agency remote from the problem. Furthermore, the proposed Federal disability program will call for a certification of a edical condition which, as defined in the bill, will invite abuse and fraud and the ultimate cost of the program cannot be predicted with any degree of assurance.

Several States have initiated programs in aid of the disabled worker but the period of duration of these programs has been too short to justify a final appraisal at this time. More experience in this field is necessary and should be gained before attempting even the somewhat restricted program contemplated by section 107.

I appreciate very much, Mr. Chairman, the opportunity to discuss this matter with your committee.

Senator Johnson. Mr. Chairman, I hope Dr. Murphey can be put on next, because I have to leave to go to another committee. I would like to hear Dr. Murphey's testimony, if it would not conflict with the procedure.

Dr. Paullin. We had a little different program arranged, but I think that is all right. Dr. Murphey is a representative of the Colorado State Medical Society.

The CHAIRMAN. Doctor, you may be seated, and we will be very glad to hear you at this time.

Senator MILLIKIN. Dr. Murphey, I may say, Mr. Chairman, is an outstanding and highly reputed physician of the Rocky Mountain area.

The CHAIRMAN. Doctor, would you like to put your entire statement in the record and deal with it, as the previous witness, Dr. Sensenich, did? Or would you like to confine yourself to your manuscript?



Dr. MURPHEY. Mr. Chairman, I would like to introduce the entire statement into the record, but in the interests of conserving the time and energies of this committee, I would like to single out certain portions of my statement for emphasis.

The CHAIRMAN. Yes, sir. Your statement will be set out in the record in full and you may proceed in your own way, Doctor.

Dr. MURPHEY. Well, let me begin, Senator, by saying that my name is Bradford Murphey, and I am a practicing physician in Denver, Colo.

I am here to speak in behalf of the officers and trustees of the Colorado State Medical Society, who are, as a group, opposed to H. R. 6000.

I am here to offer testimony against the bill as a whole, but more particularly I wish to emphasize the reasons why our group feels that the section dealing with permanent and total disability is an unwise procedure.

In the first place, I think that there is every reason to believe that the disability benefits proposed in H. R. 6000 would be continuously expanded and constantly liberalized, through political pressure.

The provision of benefits to the permanently disabled would surely lead to the extension of such benefits to the dependents of disabled persons; and also to those who are temporarily or partially disabled; and finally, perhaps, to everyone who is incapacitated, in whole or in part, either permanently or temporarily. This would all add up in the end to a compulsory sickness program of national dimensions.

In the second place, I am convinced that the permanent and total disability provisions of H. R. 6000 would lead to at least partial duplication with workmen's compensation programs in all those cases where the disability is occupational in nature.

In the third place, since total and permanent disability is frequently a condition over which both the individual, who is disabled, and his attending physician, may and can exercise some control, either consciously or unconsciously, qualifications for benefits will be very difficult to determine, the issue will be highly controversial in each case or certainly at least in border-line cases, and certainly for this reason it will be very expensive.

In the fourth place, since the definition of permanent and total disability as formulated in section 107 of H. R. 6000 does not require that disability be proven by objective tests, the proposed program, if adopted, would be wide open to abuse by dishonest claimants, through malingering, and to even greater abuse by unscrupulous doctors and lawyers working with such malingerers.

A disability program of this type would also be open to exploitation by another and far larger group of individuals, who are neurotic rather than dishonest, and who are for this reason bent on deceiving themselves rather than on defrauding the Government.

This program would make the flight of the neurotically ill individual away from self-responsibility and health and into illness profitable for himself and for his lawyer, and, by rewarding illness, it would make his return to health and self-responsibility very difficult and, probably in some instances, quite impossible.

In the fifth place, the failure of H. R. 6000 to require proof of disability by objective tests would, if the bill were enacted into law, involve the social-security program in enough controversy and litigation to keep all of the psychiatrists and lawyers in the country busy and for this reason would probably bankrupt our economy.

In the sixth place, H. R. 6000, like most of the legislative proposals favored by the Social Security Administration, gives the Social Security Administrator discretionary powers so great as to make him a threat to our democratic pattern of government, and further to make him a menace to the private practice of medicine.

Under the provisions of this act, the Administrator would be permitted to decide what physician or group of physicians could be used to determine disability and benefit rights. He would have the power to entirely exclude private practitioners from participation in such a program, notwithstanding the fact that the family physician surely would be the one best qualified to make such determinations of disability.

Under the provisions of this bill the Social Security Administrator could employ physicians on a full-time basis, to carry out this function of the disability-benefits program.

He could, as the previous witness has testified, have this work done entirely by full-time employees of Government.

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