Senator AIKEN. I have a couple more questions. As I understand it, if a patient that is insured under this plan is in a hospital and desires better facilities and better care than would ordinarily be furnished under the plan of insurance, that he can get those better facilities and care by paying additional charge for the hospital; is that correct?

Mr. ALTMEYER. That is correct.

Senator AIKEN. Now, suppose that an insured person sends for the doctor, and ordinarily so many visits a day would be required, but he likes the doctor's company pretty well and he wants him to come more, then for those additional visits the doctor can charge whatever he sees fit?

Mr. ALTMEYER. No; I mean the doctor would have to decide what visits are reasonable and refuse to come just to hold his hand.

Senator AIKEN. Or tell him some new stories. We all know that a doctor's stories and conversation probably has more effect on more patients than medicine.

Mr. ALTMEYER. If the doctor felt that was so, it would be reasonable for him to call.

Senator AIKEN. If the patient wants a certain doctor and is willing to pay him more than the fee allowed by this, can he do so? Mr. ALTMEYER. NO.

Senator AIKEN. Not if he has to come under the plan?

Mr. ALTMEYER. If the doctor elects to come under this, and is serving the patient as an insured person he cannot charge an extra amount to the patient.

Senator AIKEN. But he could have him come an unnecessary number of visits if he wanted to pay the entire cost of those visits himself? Mr. ALTMEYER. You mean if the doctor had elected a fee for service? I do not think so, because the doctor would have to agree to submit. all of his bills to the insurance institution. That is a very important feature of any insurance system, that it does provide certain protection. If it does not provide certain protection, why then everybody is up in the air as to just how much he will have to pay if he gets sick. Senator AIKEN. He can pay for better hospital services?

Mr. ALTMEYER. Yes; because that is an objective thing that can be readily determined. He is guaranteed certain minimum hospital service, and if he wants luxury service, that is something very clear. Senator AIKEN. If the insurance guarantees him $7 a day, and he wants a room that costs $10 a day, he can take that other room and pay the $3 additional out of his own pocket?

Mr. ALTMEYER. Yes, sir.

Senator ELLENDER. As I understand it, Mr. Altmeyer, it is left entirely to the physician to determine whether or not an extra visit is necessary?

Mr. ALTMEYER. That is right.

Senator DONNELL. The term "Board" as used in section 201, namely in the language, "Every individual who is currently insured and has been determined by the Board to be eligible," is that the Social Security Board?

Mr. ALTMEYER. That is the Social Security Board. That eligibility refers not to whether he should have this doctor's service or not, but whether he is insured under the bill.

Senator DONNELL. To take the language of the bill, "Every individual who is currently insured and has been determined by the Board to be eligible for benefits under this title in the current benefit year," and that is the Social Security Board?

Mr. ALTMEYER. That is right.

Senator DONNELL. Now, let me ask you a question or two, but as I understand it, the Social Security Board, United States Public Health Service, which is administered by the Surgeon General, and the Office of Education are three branches, all under the Federa Security Agency; am I correct in that understanding?

Mr. ALTMEYER. Yes, sir; and the Food and Drug Administration, the Office of Vocational Rehabilitation, and some other agencies. Senator DONNELL. Is there a close coordination and cooperation between those various branches of the Federal Security Agency? Mr. ALTMEYER. That is right.

Senator DONNELL. Thank you.

Senator ELLENDER. There is one question that I would like to clear up. Under the plan to finance S. 1606, that you have discussed with Senator Donnell a moment ago, am I to understand that there is a limitation under which a person can become a member without paying the fee? If he is earning $150 a year, is he entitled to serv ices without pay?

Mr. ALTMEYER. If he earned $150 or more, he automatically be comes eligible, or if he had been employed half of the time in the last 3 years, earning $50 a calendar quarter in at least half of the quarters, he would be automatically eligible.

Senator ELLENDER. But the limitation is $150 per year?
Mr. ALTMEYER. In the one case.

Senator ELLENDER. And as to a person in that category, he woul automatically become a member without having to pay anything! Mr. ALTMEYER. It is assumed that there would be a pay-roll tax of 112 percent, that he would have to pay.

Senator ELLENDER. On whatever he earns, be it $150 or less?
Mr. ALTMEYER. That is right.

Senator ELLENDER. What is the limitation as to the maximum?
Mr. ALTMEYER. $3,600 a year.

Senator ELLENDER. So that any person receiving above $3,600 woul not pay anything on that amount but only on what he receives under $3.600?

Mr. ALTMEYER. Yes, sir.

Senator AIKEN. Mr. Altmeyer, I would like to ask this question Could a physician or surgeon participate in this plan 5 days a wee and reserve the rest of the week for his wealthy clientele?

Mr. ALTMEYER. Yes, sir; he could.

The CHAIRMAN. So that under those circumstances, he could reall increase his earnings?

Mr. ALTMEYER. Well, our cost estimates include higher average remuneration for physicians than they have ever earned in peacetime. so that even if he did not elect to serve patients outside of the system he would, under this, earn on the average more than he had been in th habit of earning.

Senator AIKEN. In those circumstances, with more people getting medical care, many more people getting medical care, he would not

have time to put in his additional visits which he might otherwise give to a wealthy patient.

Mr. ALTMEYER. He could limit himself, of course.

Senator AIKEN. Are there doctors enough in the country to meet the needs provided everybody had medical care?

Mr. ALTMEYER. If they are properly distributed, there are just about enough doctors to meet the need. The trouble is that they are not properly distributed.

Senator AIKEN. There must be some doctors then that are not making a living, because we know that they are not properly distributed. Mr. ALTMEYER. There are many doctors that are not making a decent living today.

The CHAIRMAN. Under this bill then, if it was put in operation, the income of the medical profession as a whole would be greatly increased?

Mr. ALTMEYER. Yes, sir.

The CHAIRMAN. That is because those who are now giving services are not being paid for them and would be able to collect?

Mr. ALTMEYER. There are two reasons. About one-quarter to onethird of the bills are not paid, and the other reason is that a great proportion of the doctors are not fully occupied, and under this bill they would be guaranteed payment and they would be fully occupied.

ATTITUDES OF MEDICAL ASSOCIATIONS

Senator DONNELL. How large an organization is the American Medical Association?

Mr. ALTMEYER. I think at least 100,000 members.

Senator DONNELL. Composed of physicians and surgeons?
Mr. ALTMEYER. Yes, sir.

Senator DONNELL. Do you know what proportion that is of the physicians and surgeons?

Mr. ALTMEYER. I think there are about 170,000 doctors licensed or somewhat more, and about 150,000 are active practitioners. Is that about right, Dr. Perrot?

Senator DONNELL. So that number of the members of the American Medical Association is about what percentage of the active practitioners or what proportion of the members of the American Medical Association are active practitioners?

Mr. ALTMEYER. That is just the reverse of your first question. Senator DONNELL. I withdrew the other question. I would like to know whether substantially all of the members of the American Medical Association are active practitioners?

Mr. ALTMEYER. I imagine practically all of them, about 100,000 or somewhat more, as I recall.

Senator DONNELL. Then there are approximately how many active practitioners altogether?

Mr. ALTMYER. Dr. Perrot said about 160,000.

Senator DONNELL. So that there is somewhere in the neighborhood of 60 percent of the actual active practitioners who are members of the American Medical Association?

Mr. ALTMEYER. Yes, sir.

Senator DONNELL. Now, doctor, if this bill is going to prove of financial benefit to the practitioners, what is the basis, if you know,

of the American Medical Association's opposition to compulsory health insurance?

Mr. ALTMEYER. I would rather that they speak for themselves. Senator.

Senator AIKEN. One other question. You said maybe 110,000,000 people would be insured under this plan. What groups comprise the other 30,000,000 people?

Mr. ALTMEYER. Mainly people not attached to pay rolls. I have a break-down here.

Senator AIKEN. You mean people living on fixed incomes, living on an annuity?

Mr. ALTMEYER. There are about 15,000,000 to 20,000,000 people who still would not be covered, even though this bill were amended to cover certain other groups that I mention later, and those consist of the following classes of persons: Marginal workers, unpaid family workers, and persons newly entering the labor market who just miss qualifying automatically; persons aged 18 and over and still in school; persons in institutions, of course; disabled individuals an their wives and children; next, widows not eligible under Federal Old Age and Survivors Insurance; and next, the aged persons who are not dependents of insured workers and who are not old-age beneficiaries; and finally single women not in paid employment.

Senator AIKEN. How would they be cared for?

Mr. ALTMEYER. You remember I said that they could be brought into the system by the State paying in a premium on their behalf.

Senator AIKEN. What about 15,000,000 or 20,000,000 ex-service men and women that have the facilities of the veterans' hospitals at their command?

Mr. ALTMEYER. Well, there is no distinction made in this bill. Those who are in gainful employment would be covered, but they would be covered for everything provided under the bill. As yo know, the veterans' benefits apply to service-connected disability and to nonservice connected if there is place for them and if the perso can establish need, but they are not covered for out-patient care i nonservice connected cases, and their dependents are not taken car of under veterans' legislation.

Senator DONNELL. Is there any national organization of practicing physicians or surgeons which has expressed itself in favor of compulsory health insurance?

Mr. ALTMEYER. Yes, sir; there are several.

Senator DONNELL. Would you mind telling us which those are, if you recall?

Mr. ALTMEYER. There is one called the Physicians Forum, and the other one is the Committee for the Improvement of Medical Care. I presume they have asked to testify.

Senator DONNELL. Are those the only two that you know of that have so expressed themselves of the national organizations? Mr. ALTMEYER. That is all that I know of.

Senator DONNELL. I appreciate that they can testify themselves but I am asking you if you know as a fact approximately the men bership of the Physicians Forum?

Mr. ALTMEYER. It is very small compared with the A. M. A.
Senator DONNELL. Do you know about what it is?
Mr. ALTMEYER. No; I do not know.

Senator DONNELL. And this committee, what is the name of that? Mr. ALTMEYER. The Committee for the Improvement of Medical Care.

Senator DONNELL. How large an organization is that?

Mr. ALTMEYER. That is still smaller.

Senator DONNELL. Do you know what the actual membership is? Mr. ALTMEYER. I do not know.

Senator DONNELL. Smaller than the Physicians Forum?

Mr. ALTMEYER. Yes, sir.

Senator DONNELL. Those are the only two organizations of physicians that you know of that favor the compulsory health insurance? Mr. ALTMEYER. That is right.

Senator AIKEN. However, there are 50,000 or more that do not belong to any organization?

Mr. ALTMEYER. Yes.

Senator AIKEN. Are they peculiar to any particular region of the country?

Mr. ALTMEYER. No; I think that they are scattered.

Senator AIKEN. We have always been told that the A. M. A. was a closed-shop arrangement, and when you say 50,000 doctors in the country that do not belong, you naturally question the report that we have always had that the A. M. A. ruled every doctor, old and young, with an iron hand. But if there are 50,000 that do not belong, that makes me feel like asking more questions. I am wondering if we do have such a closed union as they are reported to have had.

Senator DONNELL. Are there any medical or surgical journals that you know of that have expressed themselves favorably to compulsory health insurance in this country?

Mr. ALTMEYER. Not that I know of.

Senator DONNELL. Have a number of them expressed themselves in opposition to it?

Mr. ALTMEYER. I think they have. There may be some that say a kind word.

Senator DONNELL. Do you mind telling us, Mr. Altmeyer, who is the actual author of S. 1606, I mean to say who actually prepared it, if you know?

Mr. ALTMEYER. I think it is a product of many minds that were put to work at the request of the authors of the bill.

Senator DONNELL. Was Mr. Falk, Isadore Falk, one of the gentlemen who participated in it?

Mr. ALTMEYER. Yes, sir; he is Director of our Bureau of Research and Statistics.

Senator DONNELL. Did he do the bulk of the work in the preparation of S. 1606?

Mr. ALTMEYER. I would not say he did the bulk of the work, he did a major or considerable part of it in cooperation with the United States Public Health Service and others.

The CHAIRMAN. Mr. Altmeyer, it has been a matter of evolution, has it not? It has been going on for a number of years. The bill was introduced by Senator Wagner some years back and hearings were held on that, and as a result of those hearings, additional ideas were developed and new provisions were suggested, and the thing has been growing over a period of years.