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and the people of our great rural districts would become supplied with their fair share of doctors and other health workers.

I should like now to turn to a more specific discussion of the provisions of Senate bill 1606 which relate to the establishment of a Nation-wide program cá medical care.

UNIVERSAL COVERAGE PROPOSED

As eligibility and coverage are now defined in S. 1606, it is estimated that from 75 to somewhat over 80 percent of the population would be covered, depending upon the economic condition of the country. The Public Health Service woul like to see this program assure medical services to 100 percent of the populatio We believe that this would be not only more equitable but also less complex administratively and, in the long run, more economical.

If coverage were made universal, there would be no need for special programs of personal health services for particular groups such as the "needy" at mothers and children, as now called for in parts B and C of title I of this bill. The character of medical benefits provided in S. 1606 has the heartiest en dorsement of the Public Health Service. The provision of medical benefits I the form of personal service, rather than as cash indemnification, is the bes assurance that beneficiaries will, in fact, get the medical care they need withou: financial handicaps.

NEED FOR COMPREHENSIVE SERVICES

Provision of comprehensive services-including the services of physicians and dentists, hospitalization, laboratory services of broad variety, and hone nursing is the only sound approach to health needs. To provide some types of service without others would be poor health practice; it would also be poor economics. To be protected against hospital costs alone, for example, while n enjoying the certainty of physicians care, is the very opposite of a preventive approach. When a person is ill, he should not have to wonder if his illness is serious enough to warrant the expense of a doctor's care. The financial as we as the human cost represented by a hospital case might often be avoided entirely by the early attention of a physician. The need for medical treatment of sy tematic disease might often be avoided entirely if dental care were provided Comprehensive services obviously makes the best sense.

At the same time it is well to recognize that certain controls over services and some limitations must be incorporated, even in a national program of cor prehensive medical care, if sound and economical use of funds is to be assures The bill realistically leaves considerable leeway, for example, with respect to dental care, home-nursing, and "laboratory benefits" (including clinical laboratory services, diagnostic and therapeutic X-ray, physiotherapy, refractions and eyeglasses, supplies and commodities). It recognizes the dependence of a full scope of such benefits on the sufficiency of funds and the adequacy of per sonnel and facilities. Services which are more or less optional, or for which facilities and personnel are limited in some respects, must await financial ex perience and provision of adequate personnel and facilities before their ultimate scope can be finally determined. An example is drugs, which might be provide. as a type of supply and commodity among the "laboratory benefits."

One fundamental question related to the matter of benefits probably requires clarification. The ultimate objective and responsibility of the National Gover ment must be to achieve a universally high quality of medical care in all parts of the Nation in the shortest possible time. This cannot, however, be done overnight with respect to all categories of service. It can be done in some places sooner than other. Any legislation should recognize that there will be sonLe delay before a uniform quantity and quality of medical care can be furnished to all eligible persons.

PROBLEMS OF ADMINISTRATION

One of the most important issues in the formulation of a national health pro gram is, of course, the method of administration. As a physician, I am acute aware of the personal nature of medical services. I am also aware of the prerog atives of the medical profession and of the importance of having its cooperation in any medical care program. No program could operate effectively which did not recognize these facts.

It would be medically undesirable and administratively impossible to operate a program of personal health services entirely out of Washington. Decentralization must be the rule. There must be flexibility to take account of different facilities, personnel, customs, and attitudes in different places throughout the Nation. For this reason, the Public Health Service is pleased to find the provision in S. 1606 that "the Surgeon General shall, insofar as practicable, give priority and preference to utilizing the facilities and services of State and local departments or agencies on the basis of mutual agreements with such departments or agencies." The Public Health Service has had a gratifying experience in just such relationships for many years, and there is every reason to believe they will continue.

At the same time, it is clear that the Nation-wide scope of this program and the Nation-wide origin of funds to finance it create the necessity for certain national standards. If adequate services are to be assured everywhere, the Public Health Service must obtain assurances that State and local agencies to which it delegates authority are, in fact, willing and able to bear responsibility commensurate with this authority. The Public Health Service would not be averse to the stipulation of standards for administration which the Surgeon General might apply in determining the desirability of delegating responsibilities to a State or local agency.

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Aside from providing for participation in the administration of this program by units of State and local government, S. 1606 calls for the negotiation of "cooperative working arrangements with private agencies or institutions, and with private persons or groups of persons, and with combinations thereof, to utilize their services and facilities and to pay fair, reasonable, and equitable compensation for such services or facilities." The Public Health Service interprets this to mean that the Surgeon General will be free to utilize the services of voluntary associations that have already accumulated experience in health service plans of different types in the administration of personal health services. All organizations engaged directly in the provision of medical care—such as group practice clinics or industrial health establishments-would obviously be looked to for the continued provision of integrated medical services. They would derive their main financial support for the care of insured persons from the national personal health services account rather than from private individuals themselves, as in the past.

Organizations not engaged directly in the provision of medical care, but serving currently as middlemen between a number of providers and a number of consumers of medical care, might also play a role in the program. It would be necessary, of course, for them to demonstrate that they can contribute to its operating efficiency and economy. Included among these organizations, on the one hand, might be those representing primarily the providers of medical service, such as medical society prepayment plans or group hospitalization plans and, on the other hand, organizations representing primarily consumers of medical care, like some fraternal lodges or farmers' cooperatives. Under a national health program, financed through social insurance and taxation, it is clear that one major task of these organizations-the collection of prepayment contribu tions from members-would cease to be necessary. But organizations primarily representing providers of service may continue to act as agents of professional personnel or institutions.

Certain other administrative problems should be given attention in considering legislation of this kind. I refer to such matters as the definition of "physician," standards for participation of hospitals, authority to apply "controls over abuses" on a local rather than a Nation-wide basis, and sanctions to make possible the discharge of Public Health Service responsibilities. Some consideration might also be given to providing specific inducements for the settlement of physicians and dentists in rural areas in order to assure equal opportunity for health services to our great farm and village population.

SAFEGUARDS TO FREEDOM

The ultimate test of this program, of course, is how it will operate for the individual patient and the individual doctor. I am sure we are all aware that a satisfactory personal relationship between doctor and patient is an essential feature of any national program of medical care. The Public Health Service is convinced that such a program will not in the least injure such relationships but will

actually enhance them by eliminating the cash barrier between the patient and the doctor.

As I read S. 1606, it seems to me to preserve the customary freedoms in Amer ican medicine. When an insured person gets sick or feels the need for medical care, he will, of course, have freedom to see a doctor or not. If he desires mediea! care, he will be able to go to a physician or dentist of his own choice. There will be no need for an official "authorization" for service of any kind; the patient will go directly to his doctor exactly as he does now. Only the problem of paying the bill out of his pocket at the time will be eliminated. He may have to present a simple eligibility card-something like a Social Security card-which would be issued to each covered person perhaps once a year. Even this simple step would be unnecessary if 100 percent of the population were covered.

All physicians, dentists, hospitals, nurses, and others will at the same time be free to participate or not to participate in the program. Even if a doctor chooses to participate, he will still be able to maintain an independent private practice, if he wishes. He may, for example, continue to serve privately persons who are not covered by the program. He will continue to have freedom to reject any particular patient entirely, just as he may do now.

Participating doctors and dentists in any area will have freedom to choose the method by which they will be paid. A majority vote in each area will determine the preference of the local general practitioners, whether they wish to be paid by a fee for each service-as they usually are now; by annual amount for each person choosing them as his family doctor (the capitation method); or by a fulltime or part-time salary. On the other hand, the minority of practitioners in any community may still be paid by the method of their particular choice, if this is administratively feasible. Specialists may work out their method of remuneration by agreement with the Surgeon General. Fees and salaries need not be nationally uniform, since the bill provides for variations to take account of many factors that govern doctors' incomes today.

Under the fee-for-service method of payment, the doctor will submit his bills for payment to a local area office, perhaps monthly. Confidential medical information acquired in the course of administration will not be divulged. Bills will be paid promptly, probably more promptly than is often the case in private relationships. The net payment for all services rendered will probably be better than it was in any normal year. If capitation or salary is the chosen method of remuneration, payments will be made regularly without the submission of bills for service.

The doctor's professional judgment will continue to govern his treatment of patients and the methods of diagnosis and treatment to be used. The quality of his work should, in fact, improve with the elimination of financial restrictions on the performance of thorough-going scientific medicine. When laboratory tests are indicated, he will be free to have them performed without having to ask the patient if he can afford the price. If X-ray examinations are necessary to establish a diagnosis or follow the course of a condition, they will be made. If the case calls for a consultation or the assistance of a specialist, suitable referrals may be made. If the patient requires hospitalization, it will be arranged for without delay. I know that the availability of many of these special services will depend to a large extent on the accessibility of personnel and facilities, but the very operation of this program should stimulate the development of these resources where they are lacking now.

In carrying the responsibility of administering a national health program, the Public Health Service would require the advice and consultation of professional groups and representatives of the public throughout the Nation. It is gratifying. therefore, to find that S. 1606 calls for well-balanced advisory bodies to guide and assist responsible public officials at all levels of administration, from Federal to local. Such bodies are the surest guarantee that the entire program will be administered judiciously and democratically, taking into account the best interests of all concerned.

ENDORSEMENT OF BILL

The Public Health Service strongly urges the enactment of legislation for the adoption of a comprehensive national health program. Although we are fully aware of the heavy responsibilities it would place upon the Service, we are confident that such a program can be effectively administered. Finally, we believe that, with appropriate modifications, S. 1606 provides the basic legislative framework for putting this program into effect.

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