In conclusion, may I reemphasize that from my contacts with machinists through the letters they write-and they have been many, I am convinced that we are confronted with an urgent social problem, and we must do something about it.

Whether the legislation we are discussing today will prove acceptable to Congress we do not know, but I assure you the members of the International Association of Machinists certainly hope so.

The CHAIRMAN. Mr. Hayes and Dr. Sawyer, we appreciate your bringing to use the views of those whom you represent.

Are there any questions of these gentlemen? Mr. Byrnes.

Mr. BYRNES. Dr. Sawyer, I gathered from your paper that you believe that the King bill should be extended to cover physicians' services. You spent quite a little time talking about the doctor and the doctor-patient relationship, and most of your time was spend talking about the AMA. I am interested in the bill.

Dr. SAWYER. No, I did not mean that it should include doctors' services. I just did not cover that.

Mr. BYRNES. Would you favor extending it to physicians' services? Dr. SAWYER. I think, Congressman, that one of the greatest needs, and in that particular, I would say that perhaps this bill is not as valuable as it might be, would be more outpatient type of service where early diagnosis and the treatment of early conditions could be taken care of before they become a major proportions and require hospitalization.

Mr. BYRNES. Did you support the Forand bill?

Dr. SAWYER. Yes, I did.

Mr. BYRNES. That covered the physicians' services.

Dr. SAWYER. Yes.

Mr. BYRNES. My question is rather simple. Do you favor extending this to cover physicians' services?

Dr. SAWYER. Yes, I do favor such a development, and I think inevitably it will come.

Mr. BYRNES. I think so, too. This is a start. There is no question about it.

Also, may I inquire as to whether you feel that this can be limited in the long run to people who are 65 years of age or over?

Dr. SAWYER. Of course, we can speculate upon that and I do not know. In this growing economy, and the importance of working people to our economy, there may be features of it which would have to be amended.

Mr. BYRNES. When government provides for the payment of the fees that are involved in connection with any given service, does that not entail the supervision and control over the fees and the type of service that is rendered?

Dr. SAWYER. No, I do not think so, necessarily.

Mr. BYRNES. Can you give me any example where, when government gets into it, that is not involved?

Dr. SAWYER. I think in the medicare bill arrangement, the doctors have had considerable privilege and right in maintaining their fee schedules. I know it has produced some debates and some difficulties, but I do not hear many of the doctors complaining today about their fees under that provision.

Mr. BYRNES. We do not have a situation today where we have a large segment of our population that is covered as would be contem

plated by the King bill or certainly was contemplated by the Forand bill. Certainly the King bill does, would you not grant, involve certain controls by the department over the fees to be charged for services in hospitals?

Dr. SAWYER. I must say there are some details about the operation of the King bill that I am not conversant with. I do not know what the administrators have in mind as to how that would work.

Mr. BYRNES. I thought you criticized the AMA on the basis that they did not know what they were talking about and had not studied the bill. I thought you practically said that in your statement. wonder whether you are on much firmer ground, if you cannot tell us what the bill would involve in that connection. It seems to me that is the heart of the problem, rather than this question of whether the doctor is going to get paid or not. He will be paid or the hospital will be paid on what some department decides is an appropriate fee for a certain function; the controls that go with that.

Dr. SAWYER. I haven't understood that fee schedules are going to be dealt with under this provision.

Mr. BYRNES. We are just going to pay whatever any hospital decides they want to charge for a particular service as long as they charge that to everybody?

Dr. SAWYER. I presume it will be something of that order.

Mr. BYRNES. Do you think you could have a program like that exist very long?

Dr. SAWYER. Well, as I repeated a moment ago, I think under the medicare arrangement that has gone on pretty satisfactorily.

Mr. BYRNES. You suggest in your statement, Doctor, that there has been no problem with respect to overuse as far as the impact on hospitals or quality of care given in those cases where physicians' services are covered. Does not the experience in England, for instance, and some of the experiences in Canada indicate the converse of that? Dr. SAWYER. I do not think so, sir.

Mr. BYRNES. It was my impression that there were examples of a very horrible situation with respect to the hospital situation, I believe in Saskatchewan, where they commenced a program similar to the King bill approach. They had practically chaos as far as people getting into the hospitals.

Dr. SAWYER. I think we must remember that in any change there are bound to be adjustments and some difficulties to bring about adjustment or to adjust to these new situations, and I am not denying that there are some situations that are not so good, but for every one of those situations, Congressman, I think we can cite similar situations in our present traditional form of practice.

Mr. BYRNES. I think that generally people are getting the highest quality of medical care of any people in the world under our current system. Recognizing that there are some examples that crop up that we are not proud of, it seems to me that the same rationale follows that you were just using, that you just do not throw out the baby with the wash water.

I think that part of our trouble here is that we are thinking in terms of a small percentage of cases and saying, "Well, we have to take care of those, but in doing so we encompass a great, great majority and a big percentage, and I am not too sure that the cure for the 5 percent might not kill the 95 percent.

That is all, Mr. Chairman.

The CHAIRMAN. Mr. King.

Mr. KING. First, Mr. Chairman, I want to compliment both Mr. Hayes and Dr. Sawyer. Because of Dr. Sawyer's long experience, which seems to fit the problems that are related to the legislation perhaps, he is, in my opinion, one of the most valuable witnesses we have had.

Would you explain just briefly your association with Eastman Kodak, Doctor?

Dr. SAWYER. Well, as medical director of their program, the chief point was my opportunity to see the benefits that came from a rather generous sick-benefit arrangement. Employees were paid rather generously when they were out sick. Visiting nurses called on them to be sure they were getting proper care. They paid their own medical bills. But it gave an opportunity to gage the kind of treatment and the neglect sometimes and the mistakes involved in late or neglected treatment, and out of it came this conviction which, after 30 years. I am pretty certain of: that again and again people will put off going to the doctor at the first symptoms because they fear the cost; they do not feel they have the money; there are so many other needs for their money; and many, many times we had to insist that they go to the doctor and even get them care that wouldn't cost them anything.

That is a very real problem and again I observed it many times under the mineworkers' situation where the lack of care was beyond description, and to be able to go to the doctor, to go to the hospital, to have the diagnosis made early is all the difference between prolonged disability and early recovery.

Mr. KING. In your experience, Doctor, do you not find it perfectly normal where people will put off going to a practitioner, whether it be for economic reasons or others? There is perhaps not a person in this room that has not neglected to go precisely at the time he or she knew he should go.

Dr. SAWYER. That is right.

Mr. KING. And it is not at all unusual to expect, as you stated, a backlog to encumber the hospitals in the event of the enactment of this proposal. It is perfectly natural, and you feel that it can be met?

Dr. SAWYER. I do. May I add one other thing?

I think that if we can rehabilitate many of these older people they can be made self-sustaining and some of them actually productive. That has been proven in the rehabilitation efforts in groups generally, and I feel that in our pressing needs for workers as we approach our world situation this is a tremendous opportunity to salvage many of the people that now are incapacitated.

Mr. KING. Many witnesses have also, Doctor, chosen to compare the systems in other countries with the systems here as to medical care and treatment. A witness yesterday dealt at some length with the difficulties experienced in England, and when he had completed his statement, I asked if it were fair to compare the provisions of this bill with the total socialized practice in England or enactment in England, and he admitted it was not fair, but it is being constantly compared. We had a doctor witness just last week who spelled out the terrible situation in the country of Lithuania after the Soviets took over. I cannot see the connection in laying out the terrible things

that happened or occurred to the medical profession in Lithuania after the takeover by the Soviet Union.

It is just ridiculous, in my opinion. There are other countries that have shabby, shoddy, nationalized programs, no doubt, but to compare them with what the provisions of this bill stipulate or provide, I do not think is pertinent. I think it is totally irrelevant. Two or three other witnesses, medical persons, have stated that if they knew what the regulations that will accompany the bill, if it is enacted, were, they might change their attitude. I do not think they would at all.

However, we cannot have regulations tailored along with the legislation as it goes through the Congress. They are set up to be applied later, but all of it hinges on what the Secretary of Health, Education, and Welfare might deem proper to incorporate in the regulations, to wit, the principal one, setting a fixed fee. There will be no need, in your opinion, for setting fixed fees by nonmedical persons in the Government?

Dr. SAWYER. None, whatever.

Mr. KING. Other plans are operating all right with an understanding among the practitioners in the communities as to what reasonable fees would be. Is not that sort of practice followed in existing plans?

Dr. SAWYER. Yes, sir.

Mr. KING. Doctor, I feel principally, because of your experience, that you are one of the most valuable witnesses we have had before the committee.

That is all, Mr. Chairman.

The CHAIRMAN. Mr. Curtis?

Mr. CURTIS. Mr. Chairman, I first want to make an observation that most of the witnesses, including, you, doctor, who have appeared before us in behalf of this program seem to spend most of their time attacking the American Medical Association. The AMA is not on trial here and as one person I am concerned with what arguments they might advance and others might advance, and I have been disturbed at the lack of understanding, part of which Mr. King has just expressed here, of some of the arguments that are advanced, and misstatements of what their arguments are, and I find a similar thread running through your testimony.

The issue of compulsion is a serious issue and we have had a lot of testimony, doctor, from people-we have not even had the AMA on the stand yet and including myself, who see that compulsion makes quite a bit of difference in a system. There have been a lot of comparisons between this and Blue Cross, for example, and the private plans that do set fees or enter into arrangements with hospitals. I try to point out that the difference is the fact that the other is a compulsory plan which includes all people over 65. I think it does make a difference.

I am interested in your arguments with reference to compulsion, but I do not believe you really grappled with the problems that the witnesses have raised in that area. Likewise, the issue of being more expensive, which you point out, has been before us and we have had

considerable detailed testimony, both ways I might say, but you do not direct your attention to that particular thing. You say:

There is no better insurance buy in the United States today than social security.

Well, it is not a buy and it is not insurance. That is the tragedy of the thing; and there are many people, myself among them, who are deeply concerned about the future of the program and not in a way that we are trying to alarm people. In fact, at least, I am trying to alert them so that we can do something, so there is another area where I think we need information, rather than opinion.

The third argument that you mention the AMA has advanced and I have heard others advance it, is the alleged deterioration in the quality of medical services. It was not because it was alleged that doctors would become callous as you seem to interpret that argument. It was because of somewhat the way the young medical student who testified yesterday afternoon approached it. Who will go into the field of medicine? What quality of person if it is not free medicine? So there have been, I think, some very valid arguments advanced and I think we need to discuss what the AMA and other people have been saying and not take, I think, an unfortunate approach of just calling them names.

That is about what I interpret most of your testimony to be, that they are backward looking in opposing constructive policies and so on. That may be.

Mr. Byrnes has pointed out the fourth argument, as to whether or not we would have the elderly flow into the hospital and crowd them all beyond reason. That is the point that the gentleman who looked into the British system was alerting us to. He did say that there was a comparison between that and the King bill, but in the broad aspect of the whole problem he said, yes, that you could not compare the two because they were not the same, but in certain details, and that is the reason he brought it to our attention, because of the situation in Saskatchewan. In fact, the King bill, in my judgment, made some advancements in this area to prevent this from occurring in the deductible feature, and the coinsurance features that are included here. This is a serious problem and it is not one I think that can be just passed aside and say it is just another argument that is being dreamed up by somebody.

Then, with respect to the point of forerunner of socialized medicine, doctor, this is the only country in the world, really, that is left that has what we call a free system of medicine. It has the highest quality, I think most people agree, of any society in the world. Medical students from all over the world come here to learn because this is where quality exists.

It used to be during years ago, our students went abroad, and for very good reasons, I would think. We should be concerned whether a program such as the King bill would lead to this kind of a switch from our basic system. There may be other arguments suggesting we do so, but I do not think you can dismiss the argument of socialized medicine by just saying that that is an epithet. Witnesses have presented us with some pretty interesting details and arguments to support their contention, and I myself am very much concerned along

this line.