AVAILABLE SOLUTIONS

Referring to (X) above under health care expenses, you will note that it is this element of the older folks' problem to which an emotional appeal is made for legislation. (Note later that the proposed medicare would nonetheless include all of the older folks, even those who have proven their ability to provide for themselves.) So let's approach this problem from the standpoint of a person over 65 who actually has tried his best to save and care for himself, but due to unforeseen and uncontrollable events finds himself without funds and in need of medical care. This is the person to whom our sympathies are extended. Where can he go for help?

(1) Doctor's private office: According to figures on page 76 of the March 1965 issue of "Physician's Management" magazine, American private physicians forgive $760 million in fees annually. In addition, many free samples of medication are dispensed that have been made available by drug salesmen.

(2) Private insurance: If this person has insurance either through his own efforts or through his previous employer or union, this will help to defray medical expenses. National statistics show that about 60 percent of persons over 65 are covered by health and accident insurance. In addition, the "Western 65" plans are gaining wide acceptance, where lower rates are offered to older people, which is made possible by many large insurance companies pooling the risk.

(3) County hospitals: These are usually run as charity hospitals, or provide a a means test with an escalating percentage being paid by the patient, depending on his income. I am now going to speak in favor of a tax-supported county hospital, and later I will denounce any medical care supported by a compulsory Federal tax and run by the Federal Government. I'd like to show that this is not as contradictory as it would at first seem.

(a) In a federally controlled tax-supported medical care system, only the elderly recipients would benefit, whereas on a county hospital basis, the entire community benefits:

(i) County hospitals provide training for young doctors, and as such attract young doctors to the communities supporting the county hospital. (ii) Frequently the county hospitals. being large and being training centers, have equipment that is considered experimental, such as the heart-lung machine, the artificial kidney, etc., that are rare and lifesaving, and these otherwise might not be available to residents of the community who might suddenly need them.

(b) A federally controlled compulsory tax medical care expanded into socialized medicine throughout the country. on a county, or even a State, level.

system can be This is not so

(c) A county hospital can be closed down or at least revised by the county board of supervisors, if its funds are mismanaged. No such restrictions are possible in a compulsory Federal situation such as medicare. These are the basic means of caring for indigent and near indigent patients that have stood the test of time. Under the above systems, Federal intervention has been successfully restrained for over 30 years, because under this system not one individual in the entire United States could be found who was actually in need of medical care and could not get it. But the pressure for Federal "help" kept mounting until finally the Kerr-Mills bill was passed in 1960.

(4) County-State medical care system-Kerr-Mills: MAA (medical aid to the aged): This is a system of medical care supported by State, county, and Federal funds on a matching basis, and administered by the State and county, usually through the State welfare departments and the county hospital systems. Under this plan, a person may have up to $1,200 in cash ($2,400 per couple) and $5,000 real property, and an income which does not much exceed his cost of living to qualify for complete medical care. He must pay the first 30 days of hospital or nursing home care in California, but otherwise all diagnostic tests, medications, doctors' fees, hospital fees, and operations are covered completely at no further cost to the patient. Repeal of this 30-day limit is now under consideration by the California Legislature."

(5) Federal programs-Medicare: This bill has not yet been completely drawn up, but it is expected to follow the same general plan as the Gore amendment to the social security bill which was passed in the Senate in the fall of 1964. Almost every politically knowledgeable reporter predicts that passage of such a medicare bill is almost politically inevitable this year.

This is a system of medical care for the elderly supported by a compulsory Federal tax on all employees, either as an increase in social security taxes or as a separate payroll tax. This plan would provide : '

(a) Limited hospital care:

(i) Up to 45 days in hospital if patient pays nothing.

(ii) Up to 90 days in hospital if you pay $10 per day for first 9 days. (iii) Up to 180 days in hospital after a deduction of 21⁄2 times the average cost of 1 day's stay in the hospital

Specifically excluded are medical or surgical services provided by a physician, resident, or intern except in the fields of radiology, pathology, psychiatry, or anesthesia.

from a hospital and then is allowable only in a hospital-affiliated nursing (b) Limited nursing home care: A maximum of 60 days after discharge from a hospital and then is allowable only in a hospital-affiliated nursing home, of which there are only 1,500 in the entire country (out of 25,000 nursing homes).10

(c) Limited outpatient diagnostic tests: Tests will be covered during any 30-day period after an initial $20.

(d) Home health services by a visiting nurse for a maximum of 240 visits per calendar year.

Even though this program cannot compare with the advantages of Kerr-Mills, it is still being pushed hard in the Legislature this year. The only possible explanation is the desire of Federal bureaucrats to control the program and ultimately to expand it to engulf the entire Nation in socialized medicine. I can think of no advantages to this program, but many disadvantages are

evident:

(a) It is open to abuse. The system is being sold on the basis of the needy elderly. Why then should all persons over 65, even the wealthy, come under its provisions just because they are 65? This is unjust to the younger worker already heavily overburdened by taxes.

(b) It could easily be expanded by fiat to include other groups, such as widows, orphans, unwed mothers, underprivileged, etc., all with the same kind of logic (if some need it, give it to them all). Then, as the costs rise for each expansion, the wage earner being taxed $10, $15, or $20 per month would become impatient and want some benefits now, and eventually he and all of us will be included, and socialized medicine will have arrived.

(c) It is not insurance. No contract is given to the taxpayer, and the benefits are not guaranteed. Both the costs and the benefits may be changed by fiat. The fiscal solidarity is not governed by insurance laws. The money collected is redistributed, not invested as with an insurance company.

(d) Its costs have been grossly underestimated. Estimates of the cost for the first year alone range from $1.7 billion to $4 billion, and it would still provide less than 25 percent of the costs of medical care for the aged. Dr. Barkev Sanders, medical and welfare statistician for the Government for 30 years, reported in Nation's Business that the costs of the first year alone would be at least three and probably four times the presently estimated costs." Since a doctor must certify when hospitalization was necessary, it is entirely possible that "overutilization by the doctors" would be the explanation given for the high costs. U.S. News & World Report stated that if the United States instituted a program of medical care such as exists in Canada now, the cost would be $62 billion per year, or about twothirds of the present Federal budget.12

(e) It would subvert the existing voluntary health insurance plans. Over 60 percent of the elderly are now covered by some health insurance.13 (f) If this does lead to socialized medicine, the development of new drugs would be severely hampered. About 90 percent of all the drugs I prescribe today have been developed in the past 10-15 years, often at great expense to the companies. Pfizer spent $63 million develoying terramycin about 10-15 years ago, and this drug is continuing to save thousands of lives. All existing government-run programs (VA, MAA, county systems, and military service) have established a formulary of standard drugs. Instead of buying five or six tetracycline drugs, for instance, they would settle on one and buy it in carload quantity to save money, and this drug only would get into the formulary.

What drug company could possibly afford to spend such a large sum of money, if the Government has the only market, and might keep it off the formulary of approved drugs?

WHY ARE DOCTORS AGAINST MEDICARE?

Once Federal Government control of a compulsory tax-supported medical care program is established, it will unquestionably be expanded as explained above. The proponents of medicare have stated this openly. Since the Government cannot supply taxpayers with medical care only doctors can do that-the Government must control the doctors to fulfill its contract. This means that doctors will either be under the direct control of the Government or that doctors would be able to seek payment for their services from only one sourcethe Federal Government, and the Government could pay doctors whatever it wished. This has already occurred in all the other countries which have socialized medicine. What union leader or Government official would openly advocate that the Teamsters be paid only by the Government at a salary or wages determined by the Government? Yet this is what these same union leaders and Government officials demand of doctors when they call for legislation such as medicare. They are saying, in effect, that it is just and proper for semiskilled labor to bargain for their wages, but that the doctors who have a much more difficult, responsible, and exacting job, do not have the right to bargain for their wages on the open market. In April 1965, you will see probably 23,000 British doctors quit the British health plan and reenter private practice. Where does this leave the people who paid the taxes for this care that the Government now cannot deliver? The bigger question is, Why was the Government given this power in the first place?

The second reason doctors are against medicare is that the doctor is placed in a position of conflict-he is appointed unwillingly as guardian to the Treasury to ration's the scheme's benefits. On the one hand he must trust each patient to tell the truth about his ailments, but on the other hand must also mistrust and suspect each patient if he is to protect the solvency of the scheme.

(6) Federal programs-Eldercare: No Federal program is really necessary, but if a program must be passed let us pass one that will have as few disadvantages as possible. The eldercare program was promulgated by the AMA in response to the Federal medicare program, and is intended to replace it, not postpone it. Under this program, the existing State-Federal funds presently allowed under Kerr-Mills could be used to subsidize health insurance plans for low-income persons over 65 (Herlong-Curtis bill). The program would be administered by the State health departments, not by the welfare departments. Premiums would be subsidized on an ability to pay basis. Its relative advantages are these:

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(a) It would operate on an insurance principle, where money paid to the insurance companies is invested, and the products of this investment will help to defray the costs of the program;

(b) Recipients would get an insurance contract which would guarantee and spell out their benefits;

(c) Would be cheaper because:

(i) It would utilize existing personnel and equipment in the health insurance industry,

(ii) Taxes would be used only for the needy;

(d) Fiscal solvency would be assured, as this would be subject to insurance laws;

(e) It would not be compulsory; and

(f) It would probably be much more difficult to expand into a system of total socialized medicine than medicare, unless these taxes come from social security or payroll taxes or are especially denoted as being for medical care for the aged, thus enabling the taxpayer to see just how much he's paying for this. (See Disadvantages to medicare (b).)

PHILOSOPHIC CONCEPTS

Over the years various forms of medical assistance have arisen and others will unquestionably arise in the future. I would like to leave with you some basic philosophic concepts which may help to guide your thinking along clear logical lines, not only for the present, but also for the future.

CONCEPT OF CHARITY

Charity is held high as a Judeo-Christian virtue. For a man voluntarily to give $10 a month to his favorite needy organization is a laudable thing. For the Government to take $10 from him against his will and give it to the same organization is detestible. The philosophic point here is this: The right of charity resides with the givers of charity, not with the receivers. If the recipients of charity have the right to receive it, then those providing the charity are obligated to give it to them, and it is no longer charity. So if the older folks' need for charity or for medical care becomes a right to charity or medical care, how did they get that right? And why just the older folks, etc.? In our concern over being charitable to those that need it, let's not ignore the just concern of those providing the charity.

CONCEPT OF TAXING ALL FOR THE BENEFIT OF A FEW

That this really means is this:

(a) That the Government can take $5 from you and $5 from me, and out of that $10 keep $4 for operating expenses, and contribute more to the total economy with that $6 than we could have with our $10.

(b) That the $5 you were going to give to your old college, and the $5 I was going to give to my old medical school are not legitimate uses for that money, that the only legitimate need for that $10 is the health care for those over 65. Then, of course, the Government will point to our old colleges, and since the grads cannot support it any longer, the Government says it needs governmental support and the whole process starts all over again, each time with a different need in sight.

The philosophic considerations are:

(i) Whose need is really the more important?

(ii) Whose right is it to decide? And by what standards? Where does it all stop?

The process never stops until we are all entangled in a bureaucracy that does not allow us to spend our money the way we like because it has taken it all away on taxation. The only way we can let them get away with this is by looking at each program independently, and then agreeing to it without regard to the total picture. It is not the right of Government "to provide for those who cannot provide for themselves," nor does a need for this exist. Present-day charities would adequately take care of this provided the Government doesn't tax away all the dollars we would otherwise give for charity.

THE CONCEPT THAT EVERYONE HAS A RIGHT TO MEDICAL CARE

Let's examine what this means-does this mean that everyone or anyonehas the right to the products of another man's labor? This is exactly what it means. Who would have this right? To the products of whose labors? Why? By what standards? Compare the right to medical care to the right to go to a store and buy a can of peaches. If the Government made it economically unfeasible for all companies producing canned peaches to continue doing so, would you still have the right to buy a can of peaches. This is not a right, but a privilege. Ask any refugee from Castro's Cuba about that. I'm trying to say that to continue to have quality medical care you had best consider the source of the medical care; i.e., the doctor.

THE CONCEPT OF A MEANS TEST, AND QUALMS ABOUT IT

If a person is destitute and needs care, he will accept charity and be grateful. He will also accept a means test graciously as a matter of justice. If someone is trying to get something for nothing, he will fear a means test discovering this fact. So to whom is a means test degrading?

THE CONCEPT THAT "I CAN'T AFFORD IT, BUT I DON'T WANT CHARITY” There are only two ways in which a man can receive money either he earns it or he doesn't. (Please note that insurance and inheritance can properly be classified under earnings-insurance, because the man by his own effort has provided for the eventuality which the insurance covers, and inheritance be

cause it was earned by his parents or ancestors and there is no one else to whom that money more rightfully belongs.) If he earns the money, it is his by right (in justice); if he does not earn it, only two ways of obtaining it are possible either by charity or by force-from someone else who has earned it. There are no other alternatives. Those who would say that they want to receive money, or benefits, or services which they have not earned but say they do not want charity, are actually saying that they want to receive these things from someone else by force (usually by governmental force; i.e., taxation of those who have earned their money). By what right can anyone hold this view?

CONCLUSION

Private medicine in the United States has created the best system of medical care in the world. It has built doctors of courage and vision who by their individual efforts have advanced medicine and led the way to better care for all the people. This has occurred because doctors are free to pursue their careers as they know best, not dictated by Federal bureaucrats.

Over the past 30 years the Government has expanded more and more into control over our individual decisions, and has taxed us heavily to support its control. Many of these programs are not authorized by the Constitution and hence are unconstitutional, including medicare in any form. The ultimate solution is for the people to find and elect to the Congress and to the Presidency men who understand and respect the Constitution and will therefore eliminate all Federal activity in the field of private medicine.

However, for the present we can hold off socialized medicine if each of you would write to your Congressman expressing your opposition to medicare and support for the eldercare program. Do it today. It's your health that's at stake, and your money, and perhaps your life.

BIBLIOGRAPHY

1 Reader's Digest, February 1965, "Medicare or Medical Care," by Walter Judd, M.D. 2 U.S. Census Bureau.

3 Wall Street Journal, Dec. 30, 1964.

1963 President's Council on Aging (a survey of 14 States).

5 Reader's Digest, February 1965, "Medicare or Medical Care," by Walter Judd, M.D. University of Michigan Survey Research Center.

7 Refer to department of social welfare, State of California.

8 Assembly bill 760, 1965, by Assemblyman Jack Casey, of Bakersfield.

14 H.R. 3727, "The Eldercare Act of 1965," introduced by Herlong and Curtis.

NOTE. The philosophic concepts are basically libertarian and reflect my personal convictions.

STATEMENT OF THE CATHOLIC HOSPITAL ASSOCIATION CONCERNING AMENDMENT OF H.R. 6675

The Catholic Hospital Association of the United States and Canada strongly supports the position of the American Hospital Association in recommending that H.R. 6675 be amended appropriately wherever necessary to provide that the cost of the hospital services of radiologists, pathologists, anesthesiologists, and physiatrists are reimbursable under the basic hospitalization plan.

The exclusion of the services provided in the field of radiology, pathology, anesthesiology and physiatry from the benefits of the hospitalization will penalize the very group which this legislation is designed to benefit, and will furthermore eventually affect existing patterns of payment for patient care for all who require hospital care since it will be impractical for hospitals to provide diagnostic and treatment facilities to be reimbursed under two systems of accounting.

The 860 general hospitals and some 300 nursing homes in the Catholic system of health care will be most grateful and appreciative for any efforts that can be made to include the above-mentioned specialty services in the proposed legislation.

Respectfully submitted for the Catholic Hospital Association of the United States and Canada.

VERY REV. MSGR. JAMES H. FITZPATRICK,

President.

REV. JOHN J. FLANAGAN, S.J.,

Executive Director.