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an expanding supply of qualified psychiatrists for the State in 1959. The society also sought legislative enactments establishing the State laboratory of hygiene and the Wisconsin Diagnostic Center, both of which are used extensively as training and research centers for physicians.

WYOMING

Wyoming is one of four States of the West not having medical school facilities available within the State. Representatives of these four States to the Western Interstate Commission on Higher Education requested their parent body (WICHE) to study this problem, and as a result of this request and a prior study in 1960, a research study is presently being conducted. Representatives of the State legislature, State medical society, and many other local and State groups have been involved in this very far reaching study. It is expected the study will be completed next summer and the results presented to representative bodies of the concerned States and then to the legislature. Considerable amount of research is being done at a local and State level to meet the medical manpower needs of the State.

Mrs. GRIFFITHS. I would like to make one more statement to you. As a matter of fact, I presume you are one of those people who opposes collection of dues from union members for the issuance of political propaganda. In a way I sort of agree with you on that, or anybody else who says it, but I would like you to know that I really dislike paying a medical fee where part of that fee is helping to put out political propaganda, too. I don't want that charged up to me.

Dr. ANNIS. Mr. Chairman, it would seem to me that politics is the business of everybody. If doctors in this country confine their activities to their offices and to the hospitals and never came out to tell the problems of medicine, they would be remiss in their responsibilities. When the American Medical Association was established, this country had twice as many medical schools as we have today. Not one of them was as good as any one of the 87 we have today. Every one we have now is a class A school, teaching the highest quality of medicine any place in the world. This didn't come about accidentally. This came over the years.

The progress of medicine has become more costly as a result of the increased cost of labor in our hospitals. Every time we get a new procedure, like a heart-lung machine for open-heart surgery, it requires not a doctor or two at a table; it requires 4 or 5 doctors, plus anesthesiologists, plus a half dozen nurses, plus the 15 or 20 technicians downstairs doing the blood matching. If any one of them makes a mistake-if he is not talented and trained-a person's life is at stake.

We need the industrial engineer and his knowledge to run our heartlung machine. It is costly. It is not medical costs that will go up. In the hospital that Mr. Pepper referred to this morning (it is one I know because I was on its advisory board for 22 years), $72.20 out of every $100 is the cost of labor, not doctors, not drugs, not equipment, just the men and women who work, the engineers, the plumbers, the electricians to keep these big institutions going.

It is natural when costs go up for people to get concerned. Those who are concerned for the social welfare of our people become concerned because some people can't meet these rising costs. But when their solutions to these problems move into the area where they affect the kind, the quality, and the amount of medical care that is available, then those of us in medicine who see the other point of view are duty bound to tell our story. If this is political propaganda, then I will

take it as it is. How many people would understand, unless we can tell the reasons for the cost of medical care? It is easy for someone to point a finger.

We will work with anyone, anyplace, and anytime to see that no one is denied medical care because of inability to pay. What we oppose is the imposition of a governmental structure, where nonmedical people will make medical decisions in our institutions. This is why I do feel that this is a proper place where some of our time, and our effort, and our money should be put forth.

If the record that we speak from cannot sustain and stand on its own merits, that is a different thing. But if it can, we will put forth every effort so that the American peope, who happen to be our patients, will have the benefit of all sides of this problem-before any long-range irrevocable decisions are made.

Mrs. GRIFFITHS. I would like to say to you, Doctor, I think one of your problems in your free medicine is that you are the sole judge of what the person should pay. That is one problem that you face.

The second thing that you face is that there is nobody to judge the type of care that is given, whether you gave them the absolute ultimate or you didn't.

This is one of the things that I think puts the doctor in a different light, for instance, from a lawyer. A lawyer faces his mistakes every single day. As for a doctor, you just don't. You alone are the judge. I think this is one of the things that makes it difficult for you and I think it one of the things that makes it difficult for the public. Thank you, Mr. Chairman.

Mr. ÅLGER. Mr. Chairman, I ask unanimous consent, in order to save time and no further questions on it, that Dr. Annis particularly and the AMA in the spirit of this exchange today give us a rebuttal of what Dr. Esselstyn has said because he has contradicted several things said in the last few minutes and your whole basic statement, even as you unwittingly or wittingly have contradicted what he said to this committee in your absence, and I ask unanimous consent that your views be placed in the record in answer to Dr. Esselstyn and Dr. Esselstyn be shown your answer so that he in turn can rebut that.

Mr. KEOGH. I reserve the right to object, but I think that I can recall no precedent where a subsequent witness has been given an opportunity to rebut anything put in by a prior witness. The testimony of all previous witnesses has been made available to those who appear before us now.

Reference to their testimony was incorporated in the statements we have listened to, and I think that if you are going to insist upon this request, then fairness should require that we submit that rebuttal to Dr. Esselstyn and let him reply in any way he wants to that. Mr. ALGER. I made that a part of that request.

Mr. KEOGH. Where do you finish? Then you are going to let these people rejoin to that? I think you are just extending the record unduly. They have made their case.

Mr. ALGER. I renew my request.

The CHAIRMAN. Is there objection?
Mr. KEOGH. I am going to object.

Mr. CURTIS. Reserving the right to object.

The CHAIRMAN. Mr. Keogh objects.

Mr. ALGER. If that is the way we conduct these hearings then I too will necessarily make objections later on.

Mr. KEOGH. Act according to your own decision.

Mr. ALGER. I am very surprised, Mr. Chairman, that the public will be forestalled from knowing these facts and I am glad the record shows that the gentleman from New York does not want the AMA to answer Dr. Esselstyn who has said on the record that we don't have the best medical care in the world in the United States, and you have said we do, Doctor.

Somebody ought to resolve that for us and I know nobody better than the physicians.

Mr. KEOGH. Mr. Chairman, I think the gentleman is out of order when he assumes to interpret what my feelings are.

The CHAIRMAN. The matter has been objected to. It can be revised later on by stipulation if the gentleman from New York changes his opinion.

We appreciate very much, Dr. Annis, Dr. Welch, and the other gentlemen with you, the testimony that you brought us today on behalf of the American Medical Association.

We appreciate the responses you have given to our questions. I am sure your bringing all these facts to the committee will prove most helpful to us.

Thank you gentlemen for coming to the committee.

Dr. ANNIS. Thank you very much.

The CHAIRMAN. Without objection the committee will recess until 3 o'clock this afternoon.

(Whereupon, the committee recessed to reconvene at 3 p.m., the same day.)

AFTERNOON SESSION

The committee reconvened at 3 p.m., pursuant to recess, Hon. Wilbur D. Mills (chairman) presiding.

The CHAIRMAN. The committee will please be in order.

Dr. Mott?

Dr. Mott, we welcome you to the committee. Will you identify yourself for the record by giving us your name, address, and capacity in which you appear?

Mrs. GRIFFITHS. May I say, Mr. Chairman, Dr. Mott is director of the Community Health Association of Detroit. He has had more than 25 years' experience in medical care administration. He served in the rural medical care program of the U.S. Farm Security Administration, as Chief Medical Officer on detail from the U.S. Public Health Service; also as Chief of Health Services Branch, Office of Labor, War Food Administration; as Chairman of the Health Services Planning Commission, Government of Saskatchewan; medical administrator of the Miners Memorial Hospital Association.

I think he is fully qualified to speak on the subject at hand.
The CHAIRMAN. Thank you, Mrs. Griffiths.

Dr. MOTT. Thank you, Mrs. Griffiths.

Mr. Chairman, my statement is before you. I hope it will be placed in the record. If I may, I will summarize and give the highlights within the 10 minutes' objective.

The CHAIRMAN. Fine. Your entire statement will appear in the

record.

STATEMENT OF FREDERICK D. MOTT, M.D., PRESIDENT, GROUP HEALTH ASSOCIATION OF AMERICA

Dr. MOTT. Thank you.

My name is Frederick D. Mott, and I am a physician engaged in medical care administration. I am here as president of the Group Health Association of America, which has its headquarters here in Washington, D.C. My home is in the Detroit area, where I serve as executive director of the Community Health Association, a community organization providing comprehensive medical and hospital care services to a growing membership in the Greater Detroit area.

On behalf of the Group Health Association of America, I voice our strong support for H.R. 3920, the proposed Hospital Insurance Act of 1963, as well as for its companion bill introduced in the Senate, S. 880. We earnestly hope that these proposals may be enacted into law at a very early date, and we urge this committee to take favorable action on H.R. 3920.

In the course of these hearings we feel certain that other witnesses who support the bill will have placed in the record a large mass of statistical data and supporting evidence pointing to the desirability of favorable congressional action on the hospital insurance bill. Rather than duplicate these data and observations in our testimony except in part, we in the Group Health Association of America would prefer to explain to the committee why our own particular experience in the growing field of nonprofit group medical care has led us to support the bill which is now under your consideration.

Group Health Association of America is an organization dedicated to improving the availability, efficiency, and quality of medical care. To accomplish these objectives, the association works for the creation and expansion of group health prepayment plans. These are organizations of doctors and consumers which provide comprehensive health care on a nonprofit basis directly to the individual through group medical practice, with financing on a prepayment basis.

In recent years there has been a marked trend toward this kind of organization of medical care. New group health plans are steadily being formed: membership in older plans is growing, often at dramatic rates. The GHAA membership now comprises 25 active organizational members and a considerably larger number of supporting organizations. We estimate that over 4 million enrollees are now participating in direct service plans in the United States. Typical of these kinds of group health organizations are the Health Insurance Plan of Greater New York, the Group Health Association here in Washington, D.C., the Kaiser-Permanente programs on the west coast and in Hawaii, Group Health Cooperative of Puget Sound in Seattle, the Labor Health Institute in St. Louis, the Community Health Association in Detroit, and the new AFL-CIO Hospital Association in Philadelphia. These plans are either members of GHAA or work closely with us.

The overwhelming majority of the subscribers of these nonprofit, prepaid health plans are active wage earners, and predominantly in the middle and lower middle income range. These people, whose medical needs we serve and whose views about health care we seek to reflect, are clearly and precisely at the center of that vast mass of

American citizens who are seriously concerned with the problem of health care for older citizens.

My own professional experience has involved me almost continuously in the work of organizing and financing health services for people of average or lower-than-average income. My work with the U.S. Farm Security Administration from 1937 to 1946 involved the development of health and medical care programs for farmers and agricultural migrant workers.

Subsequently I was concerned with efforts to develop effective medical and hospital care on an insured basis in Canada; I then served in the health program of the United Mine Workers Welfare & Retirement Fund in the Appalachian region. Since 1957 I have been executive director of the Community Health Association of Detroit, a prepaid group practice plan sponsored originally by the United Automobile Workers, which has an expanding membership now exceeding 55,000 persons.

Working in the development of this relatively new but rapidly advancing field of prepaid group medical care, my colleagues both doctors and laymen-have inevitably moved, on the basis of our observations and experience, to a common position concerning how this country must reach some fundamental answers to the challenging question of adequate health care for our rapidly increasing number of older citizens.

Those conclusions have been expressed in a series of resolutions adopted with overwhelming support at the annual meetings of the Group Health Association of America. Thus, in 1960, the GHAA voiced its support for

immediate action to provide health benefits for the aged, financed through the old-age and survivors disability insurance system.

In 1961, we reaffirmed the earlier statement, and noted that the social security system "provides a practical and workable means of financing health benefits for the aged ***. In May 1962 we suggested that health benefits for the aged can be "most logically financed" through social security. Similar views were expressed at our 1963 meeting.

Furthermore, we continue to support the detailed statement on this issue which was placed in the record and discussed at hearings of the Committee on Ways and Means in the summer of 1961 by Dr. Caldwell B. Esselstyn, then president of the Group Health Association of America, now the chairman of our board. The views expressed by Dr. Esselstyn in that testimony about the desirability of financing health care for the aged through social security, and his analysis of other legislation, are still highly relevant and coincide with our current thinking.

The facts of life concerning adequate health care for the aged are clear, and they are harsh. We in the field of nonprofit group health plans know these facts, and we know they cannot be dismissed, nor much longer evaded, without serious trouble for the people of the Nation.

It seems to me that some of these facts, and the conclusion we must inevitably draw from them, should properly be set forth here:

1. The steady increase in the number of older citizens-brought about in substantial part by the great advances in medical science is causing a far greater demand than ever before for adequate health

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