sultants, the provision of the more complex diagnostic and therapeutic facilities, and hospitalization. Medical machinery must be geared to carry to each patient the full benefits of the whole art and science of medicine. What is needed is a better coordination and organization of medical facilities. A health insurance scheme must be based on the principle of cooperative group practice. Group practice offers many advantages to doctors and patient. It cuts down overhead expenses-rent, secretarial and nursing help-it eliminates duplication of expensive laboratory equipment, and makes it possible to use such equipment to capacity. This saving can be passed on to the patient, who can thus obtain the best diagnostic and therapeutic services for at least 30 percent less than if he had to visit many individual doctor's offices, each one fully equipped but utilized only part of the day. But there is a much greater merit to the plan When a group of doctors work together, examine the same patients, and discuss the many problems that arise in the daily practice of medicine, they are constantly teaching and stimulating one another. Each physician is learning some thing daily from his colleagues, and is ever stimulated to his best performance. Group practice made available by means of a prepayment plan, whereby the patient is entitled to all of the facilities of the clinic that are needed in his particular case, without paying separately for each item, assures much better medicine. The bill permits the Surgeon General to make contracts with hospitals for complete medical services, and so enables the present excellent university and voluntary hospitals to serve the insured public. Funds designated to pay for physicians' services, however, are not earmarked. It is important that the amounts allocated for hospital care and for professional services be separated. else it might lead to exploitation of the physicians by the hospitals. Additional provisions are needed in the bill to safeguard the physicians' rights and privileges. There should be some specific provision assuring that the income of physicians will conform on the average to levels at present current in more prosperous communities of the United States, with due consideration to the fact that income levels should actually be somewhat higher than they are today. because the physician will be paid for much of the work he today does without compensation. There should be provisions enabling the physician to pursue postgraduate study, and to take appropriate vacations without loss of income. To bring good medical care to the country at large, to make group practice possible and to provide for the needed extension of public health and preventive services, fully equipped health centers, smaller general hospitals and large geleral hospitals must be established throughout the country. It would be impossible to make intelligent plans for a Nation-wide medical-care program, as provided for in this bill, without making provision for needed hospital facilities. Health centers will be the units in which the preventive medicine of the local commanity will be established. They should be large enough to include facilities for offices for physicians of that area, who with proper equipment and working as a group can take care of many of the local needs. These health centers should be inte grated with county or district hospitals, and these hospitals in turn should be related to larger hospitals in the urban centers where the most difficult cases and those requiring the most specialized treatment will be taken care of. Very many communities have not the financial resources to establish such institations, and Federal funds will have to be made available for their construction. With such a set-up doctors will be attracted to the smaller communities and will be able to practice good medicine. Many have cherished the hope that voluntary sickness insurance might fill the need. Even the conservative organized medical profession has accepted the principle of voluntary health insurance, provided the organization furnishing such protection is governed and controlled by physicians. During the past decade an increasing number of voluntary health insurance plans have been launched. Broadly speaking they may be divided into two great classes: one which operates on a fee-for-service basis; i. e. the doctor is paid out of the insurance fund for every individual visit or service rendered: a second which is a per capita prepayment or service plan where the physician receives a certain sum annually, for which he renders complete general practitioner service to the patient. Organized medicine has insisted on the fee-for-service method of paying doctors, and has supported a number of plans developed on this principle throughout the country. In most of these benefits are restricted to all or part of the doctor's fee for a surgical operation, or for obstetrical services. These plans are essentially medical expense indemnity insurance, much like accident and sickness insurance one can buy from a commercial insurance com pany. They are schemes to reimburse the patient for the costs of medical care provided through physicians. They give the patient a certain protection against the cost of catastrophic illnesses, but do not assure him adequate medical care. They guarantee the physician payment of certain of his bills, but do not make it much easier for him to provide the best medical service to his patients. The cash indemnity plans strike at only one of the several weaknesses in the current medico-economic set-up, the unpredictability of heavy medical expense. Experience has demonstrated that medical insurance, to be practical and to provide adequate medical service, must cover all elements of medical care, and must be of a service rather than of an indemnity character. It must be a prepayment plan for medical services. The patient pays a certain sum annually, and for this receives complete medical coverage, for general practitioner, specialist, laboratory, hospital and preventive services. A few such voluntary health insurance plans are in successful operation. They can exist only under special favored circumstances, among employees of one large industry, and as a rule with a subsidy from the employer. Usually they cover the worker, but not his family. They succeed in times of plenty, but with curtailment of employment, at a time when they need it most, many workers lose their insurance. In all such plans that are functioning efficiently-plans such as those of the Endicott-Johnson Shoe Co., of the Stanacola Co., of the Henry Kaiser Permanente Foundation, and of the Ross-Loos Clinic-the physicians are salaried. They do not operate on a fee-for-service system. Experience has shown that a certain small percentage of both patients and doctors take advantage of the insurance fund if payment is made for each service rendered, instead of by straight salary, and run up unnecessary bills. So in order to protect the insurance funds, plans employing the fee-for-service method of payment compel the patient to pay for the first few calls of any illness, and set up a complicated and expensive system of checks to detect cheating. Such safeguards discourage the patient from calling the doctor at the first signs of illness, and impede preventive services, but are essential to protecting the insurance fund from bankruptcy. A number of insurance plans initiated by medical societies suffered such financial losses, were compelled to give up complete medical coverage and now sell only indemnity insurance for surgical operation. Insurance guaranteeing complete medical coverage cannot be set up, except at a prohibitive cost, if the fee-forservice principle is retained. But even when doctors are paid by salary or by a capitation scheme, i. e., a certain sum annually for each patient on their panel, voluntary insurance against sickness is not cheap; the charges must be from $25 to $30 per person per year. For a family of four this amounts to $120 a year. For low income families, for those with incomes below $2,500, this is far too expensive. The other necessities of life at these income levels are too demanding; prepayment for illness is put off in the hope that illness will not strike. Skimping of charges to make the insurance plan available to persons with lesser incomes leads to poor medical service and to exploitation of the physicians. Many voluntary insurance plans have this defect, particularly those set up by labor or fraternal organizations. The reason lies in the simple fact that the clients have incomes too low to allow payment for complete satisfactory medical services. For all of these reasons the protection offered by voluntary sickness insurance in this country is minute in comparison to the need. A mere handful have complete medical coverage, and even if one adds thereto those with partial insurance of an indemnity nature, hardly 5 percent of the population of the country are covered. In this the experience of the United States reflects the experience of other countries more advanced in the organization for the distribution of medical care voluntary plans fall far short of meeting the needs of the country. The essence of the arguments presented by the opponents of this bill is that it would bring about a system of "State medicine" or "socialized medicine." What is this great bugaboo we have been taught to fear? The terms as used today have an emotional, not a factual, connotation; they are catchwords employed to arouse emotional resistance to plans to improve or change the methods of distributing medical care. As President Truman stated in his message to Congress recommending the enactment of national health legislation: "They (i. e. the American people) will not be frightened off from health insurance because some people have misnamed it 'socialized medicine.' “I repeat-what I am recommending is not socialized medicine. Socialized medicine means that all doctors work as employees of the Government. The American people want no such system. No such system is here proposed. "Under the plan I suggest, our people would continue to get medical and hospital services just as they do now-on the basis of their own voluntary decisions and choices. Our doctors and hospitals would continue to deal with disease with the same professional freedom as now. There would, however, be this all-impor tant difference: Whether or not patients get the services they need would not depend on how much they can afford to pay at the time." Yet we have a good deal of State medicine in the country. Those who cry that this bill destroys the private practice of medicine in the United States ignore completely that a large part of the expenditures for doctors and hospitals in 1942 were either tax-supported or otherwise without cost to the patient. We have public systems for the care of the mentally ill, the tuberculous, the merchant seamen, and the veteran. We have advisedly devoted most of our remarks to title II of this bill. It's the most important section and at the same time it bears the brunt of the attack by the opponents of the bill. Yet, title I is an important part of the program for a healthier nation and it receives the support of the physicians forum. We approve of the section which provides increased grants to States for public health services. The present system of grants-in-aid and cooperation between the United States Public Health Service and the States in the promotion of public health services has been very successful, but limited in scope. Under the provisions of the bill it will be possible to expand these programs rapidly, and in particular to help those States that are in greatest need. The section providing increased grants to States for maternal and child health services is admirable and the forum approves an expansion of these services. However, if we are to have a national health insurance program, as called for in title II of this bill, care should be taken to prevent any overlapping of services. As President Truman pointed out in his message to Congress: "Federal aid for community health services-for general public health and for mothers and children-should complement and not duplicate prepaid medical services for individuals." Maternal and child health services should be limited to communitywide services on the basis of filling any need not covered by national health insur ance, and the program should be carefully integrated with the over-all plans for health and medical services. Despite the Children's Bureau's enviable record of solid achievement in its present maternal and child health program, it would nevertheless seem desirable to coordinate this program with the general health services under the direction of the Federal Security Agency or of a Cabinet official. We endorse the provision for medical care of needy persons. At present States receive no grants for medical aid for general relief cases. Federal grants of percent of the State and local expenditures, up to a fixed maximum regardless of the financial capacity of the State and the locality, are at present provided in assistance for the needy aged, the needy blind and dependent children. More specifically, Federal grants are made only for amounts paid unconditionally to the relief recipient or his guardian. The requirement of a direct grant and # monthly maximum limit greatly the effective provision of medical service f indigent groups. The new bill removes these limitations. It permits Federal grants for all indigent groups, it removes the maximum, it makes larger grants to States with per capita income below the national average, it provides grants for medic care whether it is paid for by cash grants to the recipient or directly to those furnishing these services. In fact, it allows the States and localities to c tract with the insurance program to provide medical services to indigent In viduals who are not insured under the prepaid medical service plan-on the same basis as for the insured and their dependents. If the latter course is followed the inviduous distinction of charity patients will be abolished, physicians will give the same care to all and will receive like compensation for all groups patients from the insurance fund. The number of pay patients to be cared for by private physicians will thus be increased. The forum strongly disapproves of the use of Federal grant-in-aid for dind payments to patients for medical care-a method too easily abused, perhaps by inadequate payments, perhaps by failure of the patient to use the payment f medical purposes. The only sound method of supplying medical care to relief cases is by grants, the proceeds of which are used to insure such people undir the national health insurance fund. Chief among those opposed to national compulsory health insurance is the American Medical Association and its satellite, the National Committee of Physicians. The American Medical Association has always opposed public action in any field of medical care, except in the case of the indigent. It is common knowledge that it opposed the establishment of workmen's compensation insurance, of the Blue Cross hospital insurance plans, and until recently it relentlessly fought plans for voluntary medical-care insurance. It is instructive to review the minority report prepared by representatives of the American Medical Association who were on the Committee on the Costs of Medical Care. They wrote: "The minority recommends that Government competition in the practice of medicine be discontinued. The minority recommends that Government care of the indigent be expanded with the ultimate object of relieving the medical profession of this burden." They then go on to say: "Nothing has been made clearer than the fact that voluntary insurance schemes have everywhere failed. It seems clear, then, that if we must adopt in this country either of the methods tried out in Europe, the sensible and logical plan would be to adopt the method to which European countries have come through experience, that is, a compulsory plan under Government control." * * * * * In the light of these historic facts the present tactics of the American Medical Association in opposing national compulsory health insurance and in advocating voluntary plans under its own management seem somewhat disingenuous. It has already been shown that there is no basis for its chief claims that the practice of medicine will be regimented, that the personal relationships between doctor and patient will be destroyed, that there will be no free choice of physician, that the quality of medical care will deteriorate. The American Medical Association is in fact serving as a guild battling to retain the economic privileges of the medical profession. In this campaign it has allied itself with businesses that are purveyors of commercial aspects of medical care-with pharmaceutical houses, makers of surgical instruments and appliances, and certain insurance companies-and through the agency of the National Physicians Committee has obtained substantial funds from these sources to carry on its propaganda. While the American Medical Association accepts and encourages the business transformation that the modern industrial era has brought about in the practise of medicine, the physicians forum recognizes the evils that this change has entailed, their destructiveness to the medical profession, and their harm to the patients whom it serves. Through such a national health program as is proposed in S. 1606 most of the financial handicaps that have prevented the extension of good medical care to all citizens will be lifted, and physicians will be free to rededicate themselves fully to the prevention of disease and the treatment of the sick. We urge favorable action of this bill. America now has its greatest opportunity before it-the opportunity to safeguard and improve the national health. As a nation we have learned the importance of good health of all our citizens, and are realizing that we cannot afford to leave the health of our people to the chance that they may have sufficient income to command modern medical care; or to expose them to the disadvantages that their race, their color, their occupation or their residence in a less favored economic community may bring about. Doctors must be given the opportunity to employ the complete resources of modern scientific medicine for the benefit of all our people. Senator ELLENDER. At this point, Mr. Chairman, I would like to insert into the record a statement from the Louisiana State Medical Society on this matter. The CHAIRMAN. That may be done. (The document referred to is as follows:) COMMITTEE ON EDUCATION AND LABOR, LOUISIANA STATE MEDICAL SOCIETY, United States Senate, Washington, D. C. GENTLEMEN: The Louisiana State Medical Society, through a special committee, on directive of the executive committee, offers the attached brief in reference to Senate bill 1606 and House bill 4730. This represents the objections of the medical profession of the State of Louisiana to the various provisions of these bills. It is our understanding that oral testimony by the individual State medical societies will not be permitted. We therefore respectfully ask that this brief be accepted and printed as a part of the hearings of the committee just as though an appearance had been made by our group. Yours very respectfully, P. T. TALBOT M. D.. VIEWS OF THE LOUISIANA STATE MEDICAL SOCIETY IN REFERENCE TO SENATE BILL 1606 AND HOUSE BILL 4730 We realize that there is some attempt made by these bills to expand and pro vide for needed medical services; a feature which is universally approved by the entire medical profession and something which we have been constantly improv ing for many years. The best medical minds in the world have been and are busy working on a continuation of this effort. Even through the most destructive war we have ever had and with the small number of men remaining at home, there has been no let-up in this activity during this period of time. The revolutionary plans as provided for in the bills, which should be regarded as socialization of medicine, are typical of postwar periods and such plans after being tried usually revert back to the methods of the past. Following is a review of S. 1606. The bill is basically in error in presuming that with the increase in medica! care there will be a reduction in the incidence of disability and illness in childhood. because, for such a reduction all students of health realize the basic needs are improvement of environments, especially of rural families, essential clothing food, personal and community hygiene, housing, sanitation, and raising the standards of literacy. The bills will not supply more adequate medical care as claimed by the proponents, which is the motivating influence claimed for such legislation. The results to the contrary, will produce inferior and politicalized medicine and this delude the American people in this erroneous impression. The implications in these bills are un-American and alien to ideologies, typical of totalitarianism and communism which weer the dominating rule in Germany Italy, and Russia. This is socialized medicine more sweeping and even more far reaching than any ever attempted in any country, with the posssible excep tion of Russia. It should be conceded by well supported data that the medical profession of this great country, on past performance and their potentialities, would be the right and proper group to turn to and depend upon for any remedial changes, if needed, in order to render adequate medical care, therapeutic medicine, and research. Any form of compulsion, implied or stated, is contrary to our democratic est cepts and robs our country of the stability and strength so strongly manifested by free enterprise, so elemental to our social economy. This freedom of medes. opportunities has contributed more to the strength, health, and happiness of thes great Nation than any other factor, which has resulted in making our Nation the greatest and strongest in the world. The United States Public Health Service should never be restricted or ham pered in the functions assigned to them of preventive medicine by added burdens of therapeutic medicine for which they are not prepared by practice to perform. comparable to our regular physicians. Their fields of preventive medicine offer many opportunities which have been so ignominiously neglected to their dis credit and reaction on the health of the Nation. In regard to title I, section A, we would refer to our statement above. Concerning title I, section B, we object to the Federal Government encroaching on the practice of medicine in any of its branches. We feel that the care of pres nancy and the care of infants and crippled children are specialized branches of medicine and should be left to the medical profession to provide for medien care in the same manner as they do for all other diseases of the human body In regard to treatment of crippled children, we feel that this field of medieite is very thoroughly taken care of in our State by the organized profession and allied groups and that the provisions for taking care of these children are ade quately provided for on a State basis. We do not understand why provisions for the above services should be included in this bill as all are provided for now by the Federal Governnicat. |