Dr. GOIN. But not a member of the American Medical Association. Senator DONNELL. If I may interrupt, I call attention to page 151 of the volume from which the chairman is reading at which Dr. Schwitalla is described as "A. M. Schwitalla, PHD." I think the other gentlemen are mentioned as "MD", but he is referred to as "PHD."

The CHAIRMAN. After this meeting of the committee that was set up at that time, these medical men, who signed this report, opposed the voluntary system and advocated the compulsory system. Is that right?

Dr. GOIN. I could not answer. with it.

The CHAIRMAN. I will read it.

I do not know. I am not familiar

Dr. GOIN. I think it would be of little significance since it is nearly 16 years since the report was written. A great many things have happened.

Senator DONNELL. From what page are you reading?

The CHAIRMAN. I am reading from page 163.

Senator DONNELL. From the minority report?

The CHAIRMAN. Yes.

The Committee on the Costs of Medical Care has been in existence for 5 years and during that time has collected at considerable expense a great body of data. Among these data are extensive comments on insurance medicine as it has developed and is now working out in various countries in Europe, and also in this country. In 1931 Simons and Sinai conducted a study of health insurance for the American Dental Association which the majority report of the committee summarizes on page 99. One of the statements in their summary is as follows: "Every attempt to apply the principles of voluntary insurance on a large scale has proved to be only a longer or shorter bridge to a compulsory system. Every so-called 'voluntary' system is successful in just about the proportion that it contains compulsory features." Nothing has been made clearer than the fact that voluntary health insurance schemes have everywhere failed. In Europe they have been replaced by compulsory systems which are now under trial. Even in Denmark, where the system is nominally voluntary, there are indirect but very effective means of compulsion.

I understand that this report was submitted to the house of delegates of the American Medical Association, and that the house of delegates approved this in 1933.

Is that true?

Dr. GOIN. I could not say. I was not a member of the house of delegates at that time. But I repeat that I think it has but little significance since times have changed a great deal in the ensuing years. That report was probably written about 1930.

Senator DONNELL. 1931.

Dr. GOIN. 1931, perhaps. I think we are in a considerably different situation.

I would like to answer an objection that they raise, however, that the voluntary health insurance, all these plans, have always heretofore failed. I think that is true, too, but they must have been speaking of voluntary health insurance plans in Europe since we had none in this country at that time.

I might call your attention to the fact that attempts at democracy also did fail in Europe, and had we been guided by their failures we would not have had a republic in this country; that no country, until we did so, wrote a truly democratic constitution such as we live under; that voluntary health insurance plans might have well been

nourished by the rugged fertile democratic soil of America, whereas they would be like the wheat that was sown among the rocks in the parable, in Europe, where they have a working class they would almost consider indigent, where they have a social economic culture derived from the feudal period, where conditions are so much different that I do not think there is any valid comparison.

I would think if we could cover 71,000,000 people in America with life insurance on a voluntary basis, without any compulsion whatever, persuading these people to buy the insurance because they believe they need it, I see no reason to believe we could not cover 71,000,000 people with a voluntary insurance.

The CHAIRMAN. We have been trying for a long while to spread health insurance in this country, but we have not succeeded. Dr. GOIN. Not very long, Senator.

The CHAIRMAN. Do you think it would be possible in any length of time to get a complete coverage in the country under a voluntary system?

Dr. GOIN. I think the voluntary systems, if they were not handcapped by the fact that they are largely under the management of doctors and State medical societies having at their disposal extremely limited funds and having not much business experience, and berg totally unable to afford the publicity that they should have, and the sales campaign that they should have, if we were freed from the restrictions, I think we could sell an enormous amount of voluntary health insurance in a very short period of time.

The CHAIRMAN. But these voluntary health systems do not give the people joining them full medical coverage.

Dr. GOIN. No, nor does the compulsory health insurance, althougi. the bill says that it will.

But the fact is that it takes time to develop these things. Senator Murray, and one cannot just dash in and turn everything at first crack. The CHAIRMAN. What medical care or service do you mean to y that is not covered by the pending bill?

Dr. GOIN. It is all covered by the bill. But most of us have ser how it is actually applied and we are not too impressed.

The CHAIRMAN. You mean to infer that it would never be carrie out?

Dr. GOIN. Well, it would be carried out in compliance with the letter of the law, but it would not be any good.

Twenty-five people walking through my office and saying they hav a cough, and having prescription 271 handed to them by me is not medical care in my mind.

The CHAIRMAN. How would it be better under a voluntary systen Dr. GOIN. You do not have any interference; any regulations. Tdoctor treats his patient as he sees fit. If the patient does not like h he goes somewhere else.

Under our voluntary health plan in California, any patient may select me if he likes, but if he does not like me, there is nothing to compel him to come to me. He can go to my neighbor. Hence, be:likely to find the medical care he wants. Nobody tells me what I mus do to these patients.

The CHAIRMAN. Under this bill nobody tells the doctor what bmust do.

Dr. GOIN. Oh, Senator, I could not quite agree with that.

The CHAIRMAN. That is what I consider your personal construction of the language. But it is not susceptible of that construction in my judgment. The bill properly construed does not interfere or attempt to supervise the doctor in any respect. In fact, it specifically undertakes to point out that it does not interfere with the doctor, or with the relations of the patient and doctor.

Dr. GOIN. Senator, if I could tell you a small personal experience that has not to do with compulsory health insurance, but is closely analogous to it, I will tell you that a very close friend of mine, a lieutenant colonel in the Army, had an ulcer of the duodenum: had an occurrence of it after 2 years in the Army; had it recognized and treated.

A year and a half later he had a second recurrence at which time the Army failed to find the ulcer. This is a matter of opinion. At this point he came to me as a private physician and friend and I again demonstrated that he had a penetrated ulcer of the duodenum. Being a lieutenant colonel, he was prepared to go to the colonel in command of the regional hospital and argue with him. If he had been an enlisted man, he would not have done very well. But he went to the colonel and said, "This is the fact." The colonel looked at it, and said, "There is no such thing as a vitaminic ulcer. It is not in the Army book." Maybe they do not have it in the Army, but civilians do, but that is the way regulations go.

The CHAIRMAN. I do not know about that.

Dr. GOIN. I am assured by my friend in the Navy that you cannot make a diagnosis that is not in the Navy book.

The CHAIRMAN. I do not know anything about the practice of medicine in the Army, or the Navy, but my understanding is that they made a great record in the war, and that the men, both in the Navy and in the Army, were very excellently taken care of, and there was absolutely no criticism whatever of the medical profession in the Army or the service that they rendered. It was extremely satisfactory and effective.

Dr. GOIN. Remember it was given by civilian doctors who only put on uniforms out of patriotism and are not making a lifetime job out of it. There is a big difference.

The CHAIRMAN. But you think they rendered a good service.

Dr. GOIN. I think they did a magnificent job in the call of patriotism.

The CHAIRMAN. Do you not think the doctors in this country and the various clinics and laboratories, operated under a group-practice system, also give excellent service to the American people?

Dr. GOIN. I think it varies a good deal between various clinics, but in general, I would think "yes."

The CHAIRMAN. The system of group practice in this country has, to a large extent, supplanted the former practice of individual doctors. Dr. GOIN. I would not say so. I think the individual doctors are by far in the majority.

The CHAIRMAN. But the group-practice system is growing in this country, and it is tending to

Dr. GOIN. Yes, sir.

The CHAIRMAN. It is the modern method of medical care now recognized as the most efficient. Is not that true?

Dr. GOIN. I would say it is an excellent way to practice.

The CHAIRMAN. Is it not much better than the old system of a single practitioner attempting to take care of a patient?

Dr. GOIN. I do not think a single practitioner does attempt to take care of a patient except in the most trifling incident. I do not think he has any hesitance to summon consultation. He does not secure the approval of the administrative officer of the district, either, but he does in this bill.

The CHAIRMAN. How does that affect the service that he would render, even if he did contact the administrative officer?

Dr. GOIN. Senator, I think the minute you interpose an administrative officer between the sick man and the consultant, you begin. to complicate the system.

The CHAIRMAN. We have this system right here in the Senate of the United States. I go to an administrative officer, Dr. Calver, and he sends me out to the Naval Hospital. I go out there and I am checked up by doctors that I never saw before, and never heard of before. They tell me what is the matter, and recommend treatment.

Dr. GOIN. Would it be unfair for me to point out that you are a distinguished Senator from the United States, and not a fellow who works down at the docks.

The CHAIRMAN. If it is good enough for a distinguished Senator, it might be good enough for a person who works down on the docks. Dr. GOIN. That is true, but the reverse is not necessarily true. The CHAIRMAN. It seems to me that the system is good because it is effective, and because it is the modern way of handling the sick.

Dr. GOIN. Senator, I cannot believe that you would compare the service that a Senator gets in a Government hospital with the service that an ordinary plain day laborer might expect to get at the hands of panel doctors, subject to the adminstrative officer's directives. I cannot believe that.

The CHAIRMAN. You mean to infer then that an ordinary person walking into one of these voluntary systems would not get complete and excellent care?

Dr. GOIN. Voluntary system?

The CHAIRMAN. Yes.

Dr. GOIN. If he did not, he would go elsewhere.

The CHAIRMAN. You think it is only a United States Senator going through the Naval Hospital that can get the finest kind of care? Is that the idea?

Dr. GOIN. No, sir. What I say is that you probably get attention far surpassing that which might be expected to be received by an ordinary panel patient who is a laborer, who goes to the panel doctor. who is subject to the directive of the medical administrative officer of the district.

I think there is no comparison whatever between the two situstions, and I think you will admit it.

The CHAIRMAN. I do not understand the medical officer in the district having anything to do with the situation after the relationship of patient and doctor is established under this bill.

Dr. GOIN. Section 205, paragraph (a), Senator, establishes it. It says that the patient may have a specialist if his attending doctor requests it; if it is approved by the administrative medical officer of the district.

The CHAIRMAN. What is wrong with that?

Dr. GOIN. I think a good deal is wrong with it. I do not wish a medical administrative officer intervening between me and my desire to have a consultant if I am not satisfied with your medical attention.

The CHAIRMAN. Line 15, page 46 is as follows:

(d) The services of a specialist or consultant shall ordinarily be available only upon the advice of the general or family practitioner or of a specialist or consultant attending the individual. The services of specialists and consultants shall also be available when requested by an individual entitled to specialist and consultant services as benefits and approved by a medical administrative officer appointed by the Surgeon General.

Is not that a reasonable regulation?
Dr. GOIN. I would not think so, sir.

The CHAIRMAN. You would not?

Dr. GOIN. No. Under voluntary health care plans he could have the service of a specialist on his own demand. If he were sick and not satisfied with my doctor and wanted a specialist, I would feel I were entitled to get it on demand.

The CHAIRMAN. It says:

The services of a specialist, or consultant shall ordinarily be available only upon the general or family practitioner or of a specialist or consultant attending the individual.

Dr. GOIN. But if the family practitioner does not think you need a specialist, the patient cannot have one.

In line 21, "until the medical officer approved of it." That, I think, is unwarranted interference between the doctor and patient.

The CHAIRMAN. The various voluntary plans that have been called to my attention are all plans that do not give full medical care and hospital service. They all have some qualifications which prevent a person from getting the advantage of full modern medical care, and 9 times out of 10 they would be compelled to pay for the services that they would find themselves in need of.

Dr. GOIN. Senator, I can speak with authority only for the California physicians, which, as I told you, I am president of the board of trustees. But speaking authoritatively for that service I would say that is not the case.

The CHAIRMAN. That is not the case of California.

Dr. GOIN. No.

The CHAIRMAN. You have described your California system here in the course of your testimony.

Dr. GOIN. That is right.

The CHAIRMAN. We are glad to have it.

Dr. GOIN. Yes; I did describe it.

The CHAIRMAN. Have you any pamphlet, or any statement which comprises the system that we may have?

Dr. GOIN. No; I have not. I could easily send you one, and I have here a brief outline of the rural activities of March 28 of this year that you may have if you like.

The CHAIRMAN. We would be glad to have it.

Dr. GOIN. I would be glad to send the complete plan.

The CHAIRMAN. Thank you. We will put it in the record.