was provided by the Government of the United States, but you paid for it.

Under the King-Anderson bill there is no free medicine. People are paying for it.

Mr. UTT. You can consider it, of course, any way you want to, but since I have the floor for a moment, I would like to say that your paper is simply a rebuttal to one of the more than 100 witnesses that will appear here. You are considering the AMA apparently as being the whipping boy or at least the individual that is on trial, because your entire paper is directed against their statement, and yet, nothing is said of the statement made by the gentleman who spoke for the Christian Science people who do not want involuntary medicine. A great segment of the American public is in that capacity; and you do not take into consideration the statements that were made by the doctor from Lithuania who practiced under socialized medicine and made a very fine case for private medicine, not for the doctors, but for the public, regardless of what country it is in. You say you believe possibly a majority of the doctors are opposed to the AMA. If that would be so, we would have more doctors appearing here in opposition to their position, and State after State medical association members have appeared here and I would say that probably 80 percent of the papers that will have been delivered by next Friday afternoon will be in opposition to this form of socialized medicine.

Yet, you just pick out one organization because it happens to be a popular whipping boy, so that I would have to say that your paper is directed solely at one witness out of more than a hundred that will have appeared here before next Friday afternoon, and I think that it is limited to that, and we must consider it as such.

You were here before and have testified. You have the general reputation of supporting socialized medicine and have supported it for many, many years; and your statement that there is compulsion in schools is absolutely incorrect, because I can go to a parochial school, if I want to. I do not have to go to a public school. I can go to a private school. I can go to a military school. The only compulsion is that I have to be educated, if I am in my younger years, but I certainly, all through my formative years, had a choice as to whether I wanted to go to a Lutheran school, a Catholic school, a Seventh-day Adventist school, or any private school in the State of California, so there is no compulsion in education.

Dr. BUTLER. Representative Utt, that last criticism you have made of what I said concerning public schools is a misapplied criticism. If you will read what I said, concerning public schools, I said nothing about compulsory attendance at public school.

I said compulsory education at the public school or its equivalent, thereby covering just the criticism you have made. I would like to also go ahead and take some other statements you have made. First, you referred to a doctor from Lithuania.

There is no relevance to what the doctor in Lithuania was talking about in terms of medicine in Lithuania and the King-Anderson bill, and I think it is grossly irrelevant to bring the subject up.

Next, you say what I have been saying about the AMA is not important in relation to current legislation. I claim it is important, and the AMA apparently thinks it is important, because I understand there is a special tax being levied against doctors, and I understand

that fund that is being built up to fight this kind of legislation by this kind of misstatement and misinformation that the AMA is putting out is probably over $5 million.

The AMA thinks this is important, and so do I, and the reason I singled out the AMA is that it is such an important organization. What it says may mislead the American public. I do not think it is going to mislead the Congress, because the Congress studies these things well, but it will give the Congress, perhaps a feeling that the American public is not supporting this type of legislation, and I am sure, except for the misinformation being given the American public by the AMA, the public wants this type of legislation.

Now, you say more doctors are not appearing and arguing from my point of view of favoring this bill. One of the reasons more doctors are not appearing is, doctors are afraid to stand up in public and expressing opinions different from the official opinions of American Medical Association, of their State and county medical societies. Mr. UTT. That is not so in the State of California.

Dr. BUTLER. That is so, and I can give you any amount of evidence showing it is so, and I will be glad to submit adequate factual evidence showing it.

Mr. ALGER. If you have additional information that is factual, you are entitled to submit it. If you can support your statement with facts, please do so. I take issue with you here and now that the doctors are not courageous and that they are afraid to speak up because of the action of the AMA.

Would you like to submit something else for the record, Doctor? Dr. BUTLER. I would like to very much. It is rather long. It is a discussion at Albion College this year, the title being-it was a very bad subject for the colleges to debate and I said "Should we have a national compulsory insurance plan?" I argued against it.

Mr. ALGER. Do you think it would help our hearings to have that

material?

Dr. BUTLER. You asked me to give information stating that action was taken against doctors who publicly expressed opinions differing from those of the American Medical Association. I made these comments at the request of the people who were running this intercollegiate debate. It was as factual a presentation in consideration of these young men as they ought to have in discussing this subject, which I did not think ought to be discussed, and I was arguing against such a program at the time, and Dr. Earnest Howard, the executive vice president of the AMA who also was on the platform with me, notified the Wayne County Medical Society that what I said should disqualify me from membership in the Wayne County Medical Society, and my membership in the Wayne County Medical Society was held up for 7 months because the executive vice president of the AMA had written that I, in expressing my opinions, differing from the AMA, should be disqualified from membership in the county medical society, and I would like to file my speech to show that what I said was a perfectly rational and fair discussion of the subject being debated by these young men.

Mr. ALGER. Mr. Chairman, subject to the decision of the Chair, as to the length of the article, which, neither of us knows, I ask unanimous consent that the doctor be permitted to file that and also that the record be left open for an appropriate rebuttal from those he men

tions of the AMA, if they choose to do so, so we can have both sides of the argument.

(Speech referred to follows:)

DRAFT OF TAPE RECORDING AT MEETING AT ALBION COLLEGE, NOVEMBER 18, 1960, WHERE SPEAKERS WERE REQUESTED TO PRESENT DIFFERENT POINTS OF VIEW CONCERNING THE QUESTION "SHOULD WE HAVE A NATIONAL COMPULSORY HEALTH INSURANCE PLAN?" TO STUDENTS WHO WERE TO DEBATE THIS SUBJECT

(The recording was garbled in places and gaps have been filled in and errors of transcription corrected as accurately as memory permitted. Also the redundancy and poor English of the spoken word have been edited)

Our next speaker is a very distinguished physician, is professor emeritus of the Harvard Medical School, president of the Physicians' Forum of the United States, presently director, clinical services, and chief of pediatrics, Metropolitan Hospital and clinics, Detroit, educated at Princeton and Harvard, he was an Edward Hickling and Bradford fellow in pediatrics and has in his long medical career served in a variety of positions such as senior surgeon, U.S. Public Health Service, chief medical officer for New England area Office of Civilian Defense, has been president of the American Pediatric Society, counselor of the Suffolk District Medical Society and the Massachusetts Medical Society, vice chairman, Committee for the Improvement of Medical Care, Inc.; member of the editorial board, Journal of Pediatrics; associate editor, New England Journal of Medicine; associate editor, Journal of Clinical Investigation; member, editorial board, Annual Review of Medicine and the Quarterly Review of Pediatrics. It is our pleasure to present at this time Dr. Allan Butler.

Dr. BUTLER. Chairman, members of the panel, and ladies and gentlemen, I, too, regret that the word "compulsion" has been introduced into the topic of tonight. It causes confusion and I would like to give a brief example of the confusion it causes. This winter the American Medical Association opposed the Forand bill, the Kennedy bill, the McNamara bill because they said these were compulsory medical care. And they opposed these bills because they said they were free medical care. Of course, they weren't free medical care. They were medical care paid for through increased payments into social security. But the AMA then turned around and supported the bill that was passed by Congress this summer and signed by the President. This bill is compulsory medical care. Under it we have to pay the taxes to finance the medical care of those who, being medically indigent, probably pay almost no taxes. So the bill the AMA endorsed is not only compulsory medical care but it is also free medical care, both of which the AMA have been denouncing all winter.

The question before us regarding a national health insurance program is meaningful only in relation to provision of high quality health and medical care with dignity to the individual and at a price the public can pay. Experience with national health programs in Western Europe and with insurance plans here over the past 30 years, indicates that high quality at feasible prices usually is not obtained when laymen without professional advice seek medical care from solo practitioners who are paid fees for service. A desirable national health insurance plan, therefore, involves changing the dominant pattern of current medical practice in this country; that is solo fee for service practice. This is the major reason why the solo practitioner, like Dr. Manning this afternoon, and the AMA that represents him oppose a national health insurance plan. The book called "The Doctor Business," by Richard Carter, accurately tells the shocking story of the AMA's attempts to preserve the current fee for service practice and block changes that are essential to a compatibility of medical practice with advancing scientific knowledge, specialization and increasing costs. It is the blocking of desirable change by the AMA that now makes it impractical to discuss a national health program. This the AMA might take either as an insult or as a great compliment, because of course that is what they wish to do. But the fact remains that the misrepresentation of the pertinent problems by the AMA propaganda has so misled the American public that at the moment a national health insurance plan cannot be discussed with profit. Thus consideration of change in current medical practice is relevant and of prime important to the consideration of a national health insurance plan.

What are some of the things to consider? In this era of increasing complexity of scientific knowledge and techniques and inevitable specialization can 76123-61-pt. 2—36

a high quality of medical care be financed without resorting to prepayment or insurance? I think everybody agrees that it cannot and you have to resort to prepayment or insurance. Can voluntary prepayment or insurance finance a broad coverage of health and medical care of high quality? The answer is, "Yes," if there is effective control of the professional qualifications of physicians and the quality of service. The answer is "No," if there is no such control. One of the advantages of using the Government to finance insurance or prepayment medicine is that Government has the power to introduce controls that protect quality of medical care, that so far Blue Cross and Blue Shield or private practice have not had the power to introduce. Thus we should welcome Government controls to the extent that they introduce qualifications protecting the quality of our medical care. A high quality is served by having the professional services provided by selected groups of physicians: that is by so-called closedstaff groups of physicians paid by salary or on a per capita basis. And it is such closed-group practices providing medicine to those who have freely chosen to participate in such prepayment plan that the American Medical Association has opposed. Such prepayment plans with professional services provided by closed-group practices avoid the necessity of having the plan put under insurance laws. It also means that there are personal physicians in these groups who maintain intimate doctor-patient relationships and who without added cost to patients can call in consultants and specialists to provide the knowledge and care needed for a particular patient who has a requirement that his personal or family physician is not qualified to give. In these group practices the close association of the doctors and their intimate cooperation provides a check on quality, efficiency of care, and a continuing education of physicians that is practically impossible in current solo fee for service practice. The existence of such groups does not limit free choice. It extends the free choice of patients as to how they are going to pay and obtain their medical care and it extends the free choice of doctors as to how they are going to practice medicine. Finally, the system of closed-group practice permits the much-needed study and experimental testing of how to provide health and medical care in this rapidly changing environment of medical knowledge and techniques.

Why haven't we progressed more rapidly in adapting medicine to changing circumstances? I have mentioned the AMA's opposition. And what is it that makes the AMA's opposition so effective? It is the use of the misleading slogans that you are all so familiar with. "Free choice"-they say such plans deny free choice. Actually they extend free choice. "Third party"-no more third party than the third party that is introduced in Blue Cross, Blue Shield, and any commercial insurance plan. "Incentive"-they say the doctors lose incentive if the doctors are paid a salary or are paid per capita. That to me is an outrageous insult for a doctor's professional organization to make about doctors. And I would say without any hesitancy that far and away the largest segment of the highest quality of medical care in this country is provided by doctors who are paid salaries. "Independence"-you hear that. You lose your inde pendence. For 33 years I have practiced in closed-staff groups, and I am convinced that I have had more independence in practicing medicine than my friends who are practicing as solo practitioners on a fee-for-service basis. You hear the words "corporate practice of medicine"-nonsense. If the law that is on the books in some States about the corporate practice of medicine were put into effect today, the better and bigger hospitals practicing the highest quality of medical care would be declared to be participating in illegal practice.

Well, that perhaps gives you a picture of why I think that it is inopportune to debate this topic today, when you can't make much progress because of the type of opposition and the misleading orientation that is being given the public by the American Medical Association and State medical societies concerning the problems involved in providing a high quality of broadly distributed medical care at a price that is within the capacity of the public to pay.

Now I would like to turn for a few minutes to some points that have been made by others here this afternoon and evening. Reference has been made to "contract practice." What's the ethical difference in the contract between physicians of a group practice and a prepayment plan and a contract that is made by Blue Shield with the individual private solo practitioner? I can see nothing that leads one to criticize the contract made with the group to a greater extent than the contract made with the individual practitioner. If it is doctors' earnings, I can give you quite an insight into what doctors are earning because I have been in the last several months in the market for doctors. At the Metropolitan Hospital we are paying young men who pust leave their residences

from $14,000 to $16,000 a year absolutely net: plus retirement allowances, medical care for themselves and their family, travel expenses to medical meetings to continue their education and, of course, being on salary they are eligible for social security benefits. Yet young doctors coming from hospital resident training don't think this is too good. We then increase the salaries $1.000 a year for the next 6 years and after that decide whether the salaries should be increased to twenty-four, twenty-five, twenty-six, twenty-seven, or thirty thousand dollars a year. And we are said to be underpaying doctors.

Then the Forand bill has been criticized because you are going to pay for the care of some millionaire. Well, we have a compulsory public school system in which millionaires can go to the public schools and we don't object, for we are concerned with the need of the many. And so it should be with the medical care of the aging, particularly as the aged who can afford to pay for their medical care are a very small percent of the total. And there is more compulsion in our education, as everyone must be taught; whereas no one will be compelled to receive medical care under any bill unless he wants it. Also, of course, in this democracy no one will be compelled to pay for it, unless the majority of the people freely vote to do so.

Dr. Howard has raised the issue of the Federal Government taking over control of medical care. There are some people in this country who so misunderstand the democracy we practice that they forget that the Federal Government is our Government and that our Constitution and form of government are such as to prevent undesirable central power. We have, for instance, the Sherman antitrust law and it is perhaps relevant to remember that the Supreme Court has found the American Medical Association and county medical societies guilty under that law of inhibiting the development of different types of medical practice.

Then mention has been made of the desirability of State plans rather than a Federal one. Yet in this society where people move so frequently from State to State a Federal plan is almost essential. For if each State sets up its own system of providing health and medical care people in moving to change jobs, etc., will not know what provisions will be available in their old age.

If you ask, if I am now for a national health insurance program, my answer is "No." Why not? Because the propaganda of the AMA would make it almost impossible at the moment to introduce the changes in our current medical practice that should be introduced as we enter into any such extensive insurance program as would be involved in a national health program. I do think, however, that when we have overcome this miseducation of the American public and can progress with prepayment or insurance medicine where the professional services are given by well organized groups of doctors, these groups of doctors in healthy competition with each other, then we should have a national health insurance program.

The CHAIRMAN. We'll have some questions from the audience.

Dr. Butler, would you give us some examples of the inadequate medical prac tices that you claim to be existent under solo practice and fee systems? If you do, would you support your comments with the sources of your findings? Dr. BUTLER. No; I won't for the simple reason that I am not going to tell stories on my fellow doctors in public. I can make general statements, and I am sure you all know, just as has been said here tonight, the best of our medical care is very good, the average of our medical care, in terms of the statistics available from other countries, is just fairly good. It is not as good as on the statistical basis of morbidity and mortality as about six other countries in the world. But we have in this country a lot of outrageous medical care. As I have been stating for some time we cannot expand medical insurance, when laymen freely choose doctors practicing solo fee for service medicine, because in almost every community 10 to 15 percent of the doctors will gyp the scheme. They will take out tonsils that don't need to be taken out. They will take out appendixes that don't need to be taken out. They will make calls that don't need to be made. They will admit patients to hospitals who do not need to be hospitalized, etc. And when I say this to groups of doctors, the commonest response I get is not one of "Oh, Dr. Butler, how unfair you are," but the commonest response is "Dr. Butler, you are far too generous to doctors." The CHAIRMAN. Do we have any questions from the panel?

Dr. Butler, I would like to refer to a documentary film of the British Broadcasting Co. which was done on socialized medicine in England. Mr. Sullivan, of the British consulate, this afternoon stressed the wonderful care they are getting in England, but this film which was not produced by