greater; at the maximum would be 2% to 10 times as great. What he would get for his money would be home nursing and dental care in limited and unknown volume, and he would pay a killing cost for it, even if he did not have also to pay indirectly his share of consumption costs more than equal to what he pays directly. I argue for the common man. Draw from his sustenance in this way, and you will destroy forever his chance to get voluntary coverage at a far lower cost. And, incidentally, you will detract from his independent character, as observed under the first head. For if you pass this title II, you will at once destroy the cooperatives that already protect about one-seventh of our popu lation and are in position to cover the rest at low cost. If the common man in the United States understood the implications of title II, there would be small demand for it. To state it bluntly, enactment would result, though that clearly is not the intention of the proponents of the bill, in a case of man's inhumanity to man. EDWIN L. PAGE The CHAIRMAN. We will now proceed with the statement of Dr. Goin. I noticed Dr. Sensenich arose as if he Senator DONNELL. Pardon wanted to be heard. me, Dr. SENSENICH. I was going to introduce the next speaker. He is Dr. Lowell S. Goin, of Los Angeles, Calif., who will represent the American Medical Association in his presentation, and I will let him qualify himself as to his medical connections. He is in the practice of medicine. The CHAIRMAN. Very well. Dr. Goin, you may proceed. STATEMENT OF DR. LOWELL S. GOIN, OF LOS ANGELES, CALIF. Dr. GOIN. I am Lowell S. Goin, of Los Angeles, Calif. I am a practicing physician, and I happen to be president of the California Physicians Service, which is a voluntary health-care plan of California, and I am also president of the College of Radiology and the Radiological Society of North America. I thank the committee for this opportunity to appear before them. I have a statement which I should like to present to the committee. VOLUNTARY PLANS CAN EXPAND TO MEET THE NEED I feel a great sympathy for the objectives which are hoped to be attained by the enactment of this bill, and I admire the humantarianism of those who work so hard for their attainment. There is not the slightest doubt that the sudden and unpredictable imposition of heavy costs for medical care is frequently catastrophic. The physicians of America are well aware of this and, individually and collectively, have devoted much time and energy to an attempt to solve the problem. They believe that a solution is becoming apparent, and that, given reasonable time, will be reached. They believe that the solution will be a better one than that currently proposed, and that more medical care, and much better medical care, will be available to the American people if voluntary plans are allowed to evolve than if compulsory health insurance becomes law. If it be argued that no voluntary plan completely meets the need, I reply that that is true, but that evolution is not a rapid process and that in a field in which there is little or no experience, haste must be made slowly. That this is likewise true in Government-controlled compulsory health-insurance plans is shown by German and British experience, Title II of S. 1606, for example, contains 17 sections, but the German insurance law had. before the war, grown to more than 3,300 sections-a certain indication of the complexity of the problem and of the impossibility of composing a neat and effective solution. The American Medical Association, speaking, I am confident, for the overwhelming majority of American physicians, opposes this legis lation on five grounds. 1. The existence of a need for it has been established more by emotional statements than by logic and documented facts. 2. Even if the need were soundly established there is no experience to indicate that compulsory health insurance would benefit the publ health, although there is some reason to believe that it would lower the health standards. 3. The costs are totally unpredictable, and no one has even a fair idea of what such a program would cost. 4. Medical care is not the sole factor involved in good health, and there are many things that could properly be done to benefit the public health before we embark on a program such as is proposed. 5. Voluntary health plans are more in keeping with the American tradition and will result in far better care being given to our people. I should like now to discuss each of these five points in turn: SELECTIVE SERVICE FIGURES NOT CONVINCING 1. The social planner maintains that the state of health of the American public is deplorable and that medical neglect is a commonplace occurrence. The reason, they say, is the interposition of a financial barrier between the sick man and the doctor, and argue that to remove this barrier will solve our health problem. Last fall the President of the United States in a message to Congress pointed with horror to the shocking figures of selective-service rejections as an indication of the dire need for the enactment of compulsory health insurance. Is it of no significance that our mortality and morbidity rates are among the lowest in the world? Is it an accident that the United States now leads the world in medical education? Is our constantly increasing expectancy of life a reflection of our deplorable state of health! Do you know that the American death rate for diphtheria is about onehalf that of Great Britain or prewar Germany? Diphtheria, incidentally, is an excellent indicator, since it is one of the few diseases for which we have specific preventive and curative measures, and since. there being no secrets involved, the German and British physiciars know as well how to treat it as do Americans. So much has been made of the selective-service rejection figures-the 5,000,000 IV-F's-that they deserve a moment of special attention. Senator Pepper's interim report analyzes the 4,217,000 rejectees and breaks them down into groups. Four hundred and forty-four thousand eight hundred were rejected as "manifestly disqualified." These include the armless and the legless, the totally blind, the totally deaf. the deaf mutes, etc. What medical care could have made this whole? How shall the amputated leg be restored, and who knows how to cure optic disease. The modern concept is that mental disease is largely a constitutional inborn inability to cope with reality. What group has medical care to do with it? Five hundred eighty-two thousand one hundred were rejected for mental deficiency. That is to say, they simply lacked the intelligence to become soldiers or sailors, or, indeed, useful citizens of any sort. They are the idiots, the imbeciles, and the low-grade morons. Even a very slight knowledge of eugenics will persuade anyone that this group does not constitute a medical-care problem. Together, these three groups reach a total of 1,727,600, or more than one-third of the rejectees. If they are now excluded, there remain 2,426,500, a little less than one-half the famous 5,000,000. Three hundred twenty thousand of these were rejected for musculoskeletal defects. Senator DONNELL. Of the total number, you mean? Dr. GOIN. That is the congenitally short leg, the club foot, the withered arm, the congenitally dislocated hip, the absence of a half vertebra and the consequent crooked back. How, I ask, would medical care have restored these unfortunates to usefulness? Two hundred and eighty thousand were rejected for syphilis. Treatment for syphilis is offered freely everywhere. As a matter of fact our statute books are simply loaded about syphilis prevention. I doubt that there is a community in which a syphilitic may not receive treatment from a department of public health. One wonders how compulsory health insurance would have eliminated this group. Two hundred and twenty thousand were rejected for hernia, probably for hernias so severe that the Army was unwilling to attempt repair. I mean by that that likely these were bad hernias because I did think the Army repaired some. Hernia is the result of a congenital defect in the inguinal or femoral canal, presumably due to a defect in the germ plasm. If such a defect exists, its bearer is likely to have a hernia, and medical care has nothing whatever to do with the occurrence of hernia. One hundred and sixty thousand were rejected for eyes, by which I suppose is meant defective vision. Now, it is true, that some forms of blindness, ophthalmia neonatorum, for example, may be prevented by adequate medical care, and I think every State has a law requiring the installation of silver into the eyes of the newborn, and it is my belief that ophthalmia neonatorum is practically an extinct disease. But I think it fair to assume that this group of 160,000 did not include the blind, but those with visual errors too great to permit good or even fair vision. If one is born with an eyeball too long, or too short, or one that is not symmetrical, then one will have a refractive error and one will either wear glasses or not see very well, and medical care again has nothing at all to do with it. These groups total about 1,000,000, and the rejections which might be due to a lack of medical care are thus reduced to about 1,500,000, or about one-third of the shocking figure of 5,000,000. Although it is quite problematical whether any program of medical care would have altered substantially this figure, we may rest on it, confident that the figures fall a good bit short of establishing an urgent need for the enactment of compulsory health insurance. COMPULSORY HEALTH INSURANCE WILL NOT IMPROVE HEALTH 2. Even if we had thoroughly established the need for some better plan for medical care, it would be proper to inquire whether a proposed plan offered some reasonable probability of improving 85907-46-pt. 26 public health. Since compulsory health insurance has existed in various parts of the world for fairly long periods of time, it should: be possible to examine the experience in those areas and, by analogy. establish the probable effect of our plans upon our own health. I think it quite interesting to note that compulsory health insurance has been in effect in San Francisco for some years as regards the municipal employees. The insured are served by the same physicians and in the same hospitals as are noninsured persons. In spite of the fact that no financial barrier exists between an insured person and a physician, the incidence of ruptured appendix is higher among the insured than among the uninsured. In this instance, at least, the removal of the financial barrier, so abhorred of the social planner, did not seem to benefit the insured public. The morbidity and mortality rates are higher in nearly all insurance countries than in our own. May I quote to you from Dr. Nathan Sinai's book, The War of Health Insurance? Remember that he is a most able and ardent advocate of compulsory health insurance. He says, "Contrary to all predictions, the most startling thing about the vital statistics of insurance countries is the steady and fairly rapid rate of increase in the number of days the average person is sick annually, and the continuously increasing duration of such sickness. Various studies in the United States [he says] seem to show that the average recorded sickness per individual is from 7 to 9 days per year. It is nearly twice that amount among the insured population of Great Britain and Germany and has practically doubled in both countries since the installation of insurance." Senator DONNELL. Might I ask a question, what is the approximate date of Dr. Sinai's book, if you know? Dr. GOIN. I would say roughly 1943 or 1944, maybe it is 1942. The seems to me a rather sound argument against compulsory health in-urance, although Dr. Sinai probably did not intend it thus. To clinch the matter he adds: "It seems to be a safe conclusion that insurance has certainly not reduced the amount of sickness." This puzzles me s little, since I have naively assumed that the intent was to reduce the amount of sickness and to improve health. I believe that the evidence in hand warrants the flat statement that compulsory health insurance will not benefit the public health. THE COSTS ARE UNPREDICTABLE 3. When compulsory health insurance was proposed in California. a year ago last January, no one appeared with any sound idea as to its cost. The guesses varied between $20 per person per year and S per person per year. Most thought that $40 was a fair figure. I think it significant that costs are nowhere discussed in the present bill, the Surgeon General of the Public Health Service being given a black check. At $40 per person per year, the program would cost $1,000, 000,000, and no one really knows whether this amount would suffice Experience elsewhere indicates that there is needed at least one employee (not including those actually delivering medical service) for each 100 insured persons (Crownhard, J. G., Sickness Insurance it Europe, 1938, p. 25). On this basis we would need to increase the Government pay roll by about 1,500,000 employees. And yet, to pay this vast army, to pay the doctors, to pay for hospitalization, and for sums are named, no appropriations are This is a rich country, but no wealth is the other benefits offered, no made and no limits are set. unlimited. OTHER STEPS SHOULD BE TAKEN FIRST 4. A sort of current custom is to use the term "medical care" and "health" as if they were interchangeable-as though one were a synonym of the other. As a matter of fact, medical care is only a small part of the health problem-not even the most important part. Health consists largely in not being sick; medical care consists largely in an attempt to cure or alleviate disease. Nearly all-perhaps allof the health legislation which has been proposed from time to time has been written by social planners, seldom, if ever, in consultation with physicians. Consequently nearly all of it contains much wishful thinking and not too much reality. Too much confidence is placed in preventive medicine; too much earnest belief that periodic health examinations will prevent disease, and all the legislation evidences a complete failure to understand that preventive medicine simply has not yet attained the goals wished for. To cite a very few of the problems: How shall heart disease (except that due to rheumatic fever) be prevented? What sort of health examination will be efficient in its control? How shall we prevent, or even recognize, early brain tumors? Shall every one with a headache have encephalographic or ventriculographic studies? Shall we do gastrointestinal X-ray studies on every one with indigestion and, if so, where shall we obtain the skilled personnel? How are bone tumors prevented, and what periodic examination makes one aware of the pneumonia of next week? Medical care is, and will for a long time continue to be the care of the sick, and this, I repeat, is only a fraction of the health problem. Some other fractions to which Government might well turn its attention are sanitation, hygiene, health education, adequate diet, good housing, adequate clothing, working conditions, patent-medicine control, and many others. If Government is sincerely interested in the health of the citizen, why should it not suppress patent-medicine advertising? Why should it not regulate the cults, and require that all who wish to practice the healing arts pass the same tests? Why should it not control radio publicity of nostrums, vitamins, and the like? This current legislation is attacking only a small segment of the health problem, and even if it were to accomplish all that its proponents claim, it still would not solve our health problems. VOLUNTARY PLANS ARE PREFERABLE 5. Voluntary health plans will, if given the opportunity, do the job, and do it better than Government-controlled plans can do. These plans, which already include a very large number of persons, are in accord with our traditional emphasis on personal responsibility, prudence, foresight, and thrift. They have an American dignity which is lacking in the regimentation of compulsory health insurance. They can be and are more economically administered, they can and do give better medical care, and they will be and are supported by thousands of physicians who are bitterly and unalterably opposed to Government-controlled medicine. In California we have made a good start. Our California Physicians Service offers medical care |