crease the membership throughout the country. Certain DepartmeÍ of Agriculture experiments were mentioned in these hearings, ar. were described as disappointing. It was stated that, among a gr. of low-income farmers, only 40 to 50 percent of the eligible famil too advantage of the privilege of voluntary prepayment for med and hospital benefits, even though the Federal Government parti... pated in the cost of the program. Initial participation in a voluntar plan by 50 percent of low-income farmers is encouraging. Farme`s are the most individualistic and independent-minded part of our ent population. Many have solved their problem of health service ș going without the necessary care. If such an experiment were ducted in an urban community, among a group of low-income workers in an industrial plant, probably 85 to 95 percent of the employerwould have enrolled. We are making strides in reaching the ru population, and we hope that we will make greater ones.

Thirteen. I will not elaborate on that unless you ask for it. Many of the Blue Cross plans have increased their benefits duri their period of operation without corresponding increase in subser. tion rates to the beneficiary. The increased benefits have been ms:possible through better selection among subscribers and decisionapply reserves to provision of immediate benefits. Blue Cross pla are, of course, concerned with providing protection for all costs hospitalized illness.

Fourteen. Voluntary plans have been accepted by many veterans a genuine opportunity for family protection.

Blue Cross has thrown down the bars of group enrollment as . patriotic gesture for the enrollment of the veteran and beginning month, in about 10 days, there will be a 1-month campaign by wh veterans will be completely exempted from the group requiremen for Blue Cross enrollment.

Some of the plans are already doing so. I have been surprised. the acceptance in Philadelphia, for example, and in Cleveland: ht ally thousands of veterans who are entitled to G. I. benefits are enro ing, and for two reasons. First, it gives them free choice of doe and hospital, and second, they recognize that care of the veteran h self is only one-fourth of the total cost, in hospitalization. The w: and children represent three-fourths of the total cost.

Fifteen. Blue Cross plans have been recognized by Govern agencies as administrative units for the provision of benefits. T Veterans' Administration has asked Blue Cross to serve as clear house for them in providing service-connected benefits, but not service benefits. That plan is just starting. We do not know b well it is going to work. The Veterans' Administration likes the r and we hope that it will be a genuine service to the public.

Of course that is not what the Blue Cross plans were created f but they can do it.

VOLUNTARY PLANS IN EUROPE

I hope you will bear with me if I say a word about Europe. M has been said about Europe, both as a matter of history, and othe wise. I have been there, and I have talked to the people who ha administered the health insurance plans.

It seems to me that there is very little affirmative suggestion s recommendation that can come from the experience there. The v

untary subscribers in America at the present time equal the total population of Holland, Belgium, Norway, Sweden, Denmark, and Finland. Blue Cross plans alone have more members than the entire population of all the Scandinavian countries, which are very civilized countries. I am a Scandinavian myself. But I do not think that experience in a small compact implies that it would be repeated in the United States. It might be.

But the real point I want to mention comes up in connection with voluntary health insurance generally. In England in 1911 there were, I think it is fair to say, literally thousands of smalf mutual benefit societies. They were scooped into the national health insurance act, and I understand that British officials are still living with the administrative complexities of those plans. Some were, for all practical purposes, private ventures.

In the United States the picture is different. The largest movement in the country is one with a small number of organizations, each operating unit with an average of more than 200,000 participants. There are only 86 in the entire country, and there ought to be less. I think 75 would be plenty. They are all coordinated, and are a network or foundation for a real public service.

Another angle about the European situation in health insurance is this. At the time when health insurance really began to expand, hospitalization was already tax-supported except in England. In European countries to mention Germany, Norway, and Denmark-the amounts which the health-insurance funds paid to the hospitals, for acute illnesses, were not intended to cover the cost of the operation of those hospitals. They were local government institutions with salaried doctors. We are considering a national program here at a time when the ordinary American thinks of health as a personal problem, to be handled in some sort of joint action. This is one of the few countries where a man still feels his health service is somewhat his own responsibility.

In England there is a voluntary program consisting of "contributory schemes." That was not set up to relieve the patient, but to relieve the taxpayer. The whole motive behind prepayment in the European countries was to give the taxpayer a break. That is an honorable motive also. But it is quite different here, where the first concern is to relieve the individual patient who might need care. In England, the only difference from the continental pattern was that most of the charity work was done in "voluntary" hospitals, supported by well-todo people who are not allowed to use these hospitals.

Senator DONNELL. You mentioned something about the number of plans, 86; you thought we might well get along with 75. I would like to know just as a matter of interest in my own State. By your table I see that there are two such plans in Missouri. Would you be kind enough, if you happen to recall, to tell us for the record and for our information, what parts of the State, or what proportion of the State of Missouri is covered by those two plans?

Mr. ROREM. St. Louis handles all localities except about 14 counties in northwest Missouri, which are handled out of Kansas City. Senator DONNELL. Is the entire State of Missouri covered by those two plans?

Mr. ROREM. Yes. That is in different degrees of intensity, of

course.

Senator DONNELL. Take a man in Hannibal, Mo.; take St. Louis; you are familiar with that. Suppose a man wants to join Blue Cross. He belongs to the bar association. Is that the same Blue Cross that the man who works for the Rice-Stix Dry Goods Co. joins in St. Louis! Mr. ROREM. The same one; the same organization.

Senator DONNELL. I see.

The CHAIRMAN. And the State of Missouri, I notice, has a population of 3,524,790, and your membership enrollment in your plan there is 795,819.

Mr. ROREM. Yes.

The CHAIRMAN. That is what percentage?

Mr. ROREM. 22.6 percent.

Senator DONNELL. Actually over this particular State, Mr. Korem. what proportion would you say, roughly, of the 795,819 are outside of the two larger cities, St. Louis and Kansas City?

Mr. ROREM. Not a very large proportion.

Senator DONNELL. Are you able to tell us how many hundred thousand in round figures belong in St. Louis and Kansas City?

Mr. ROREM. I would be surprised, if you find that more than onefourth of the Blue Cross people were outside of those two areas. Maybe as much as one-third.

Senator DONNELL. I do not understand that.

Mr. ROREM. Those 2 towns represent a million an a half out of the State population, that is, out of the 3,600,000. Those two tows would represent a third of the population. They probably have frou one-half to two-thirds of the total enrollment. There is greater co centration in the urban areas as a rule, because of administrative dif culties in reaching people outside those areas.

Senator DONNELL. How about the farmers in my State? Are they joining the Blue Cross in any considerable numbers?

Mr. ROREM. Not doing as well as they are in Iowa or in Kansas or in Minnesota, but in considerable numbers.

Senator DONNELL. How about the miners-the lead miners-for r stance?

Mr. ROREM. That I cannot answer. The miners are joining in western Pennsylvania and elsewhere. We hope they will be joining r Montana before long.

Incidentally, Senator; you will be interested, if you will look at a figures for Montana lately to know that of the 31,000 more than hal have been taken in within the last year through the revitalized ma agement of the organization there.

The CHAIRMAN. It is only in recent years that the question las taken hold.

Mr. ROREM. That is right. It is accelerating now. There used toe a statement-and I remember very well when it was made by a pers who was not really administering Blue Cross "the first 10,000,000 17the easiest." From now on it will be difficult. It has proved to be the other way around.

The CHAIRMAN. These bills that have been filed in the Congress for the purpose of bringing about a system of national-health insuranc stimulated interest in the country, a great deal of it, and have brong! about this effort to find some way to cure the condition without having to resort to national legislation. But the fear in my mind is that whi the Blue Cross plan is a laudable plan, and a plan that everyone show,

belong to at the present time, it does not go far enough to cure the problem which confronts the country. I do not think it ever will go far enough to cure the situation.

Mr. ROREM. That is, of course, the thing that we would like to test by experience. Our general plea, if we make one to the Congress, is essentially that we would like its sympathy, encouragement, and practical support.

One of the questions sometimes asked in a discussion like thisusually in good humor, but sometimes not-is, "Now, Mr. So and So, how long will it take for a voluntary plan to achieve this result." My answer is very simple and elementary. I do not know. But I am convinced it will not take so long if the Government helps us, instead of discouraging or disparaging our efforts.

The CHAIRMAN. The Government has never interfered with the development of these plans, and has sought to protect plans that were developing in the country with a view of serving the people. They brought an indictment against the American Medical Association because of its efforts to prevent just such voluntary groups as this to develop in this country, so that it cannot be said that the United States Government has ever interfered in any way.

Mr. ROREM. We would like to make a specific type of suggestion, because I think it is illustrative of the type of help we deserve. I refer to the matter of pay-roll deduction for Federal employees. It sounds small only at first, only 3,000,000 people. But the example would be tremendous.

The CHAIRMAN. I would be in favor of it if it could be established that through that system we would develop a program which would really bring medical care to every home in the country. I would be in favor of that. I am sure you do not criticize me or others in the Congress who have advocated some system of national health insurance, because every apportunity was available to the American medical profession to start a study of this situation, and to propose plans for overcoming it, but they failed to do it and somebody had to do it. Those of us who did come to the front and undertake it should not be condemned as Socialists or Communists.

Mr. ROREM. I think you rendered a genuine public service in this way. We are trying to do the same thing, perhaps not as well as possible. But we always are up against the problem of administration, as I mentioned earlier, and there is something about experience that makes a person cautious. We might be more lighthearted in our pronouncements and in our claims if we had not been in the field so long. We know what is involved in arousing the public, as opposed to driving the public. It is hard to drive the public. We try to pull them, try to shepherd them-using that in the best and not patronizing sense of trying to arouse an interest in their self-respect and to make it easy to implement that.

The CHAIRMAN. I am sure that you are helping us.

Senator DONNELL. I rather get the inference from this table, exhibit No. 1, that the Blue Cross has thus far had its maximum growth in the urban areas. That is true, is it not?

Mr. ROREM. That is true. I was going to say in Michigan and in Kansas, as illustrations, the percentage of enrollment is uniform throughout the State. But in Missouri that is not so.

Senator DONNELL. I notice in Missouri it ranks pretty well up here, 22.58. We drop down here to Kansas and only about half of that percentage, 11.32, and then go right across the State line into Oklahoma, and find only 6.74.

Mr. ROREM. That is true.

Senator DONNELL. Is it a fact that the city of St. Louis and Kansas City are largely responsible for the larger percentage!

Mr. ROREM. The explanation is that Missouri has been going twice as long. Kansas doubled its membership last year.

Senator DONNELL. And do you regard it as practicable to extend the Blue Cross operations in rural areas?

Mr. ROREM. Definitely.

Senator DONNELL. As in urban areas?

Mr. ROREM. Definitely. I once asked a man if he believed in total immersion. He replied: "Believe in it? I have seen it done." We do not only believe in it, but are doing it amazingly well. Groups of farmers will come to a meeting at 8:30 in the evening and take cars with them and go out and do the work themselves.

Senator DONNELL. So you do not regard it as an insuperable diculty to overcome, the fact that a given community is rural. You think that can be overcome by work.

Mr. ROREM. That is right. We need the economic equivalent of a place of employment or a group, and this is very difficult to find where we have one-family farms. But these units-the Farm Bureau, the special associations, cooperatives, the Grange in the East, particalarly-have been very helpful.

The CHAIRMAN. You have been working in the rural areas in recent times, have you not?

Mr. ROREM. Yes; and particularly the last 12 months.

The CHAIRMAN. And you are finding it very promising?
Mr. ROREM. Surprisingly so.

The CHAIRMAN. You expect, then, within the next year or two, you would be able to make much better showing?

Mr. ROREM. In the rural areas, yes; and there has never been a time when the prospects for immediate enrollment were as bright

as now.

These four points, can I mention them? This is what we would like to see: (1) complete medical care and hospitalization supported by taxation for all public assistance beneficiaries or indigent members of the population. That is in the bill now.

Senator DONNELL. That is grants-in-aid, as I see it.

Mr. ROREM. Blue Cross would not go into that.

Senator DONNELL. That which is set forth in title I, part C, you are in favor of that?

Mr. ROREM. Yes. Here is some discussion of that.

(2) Government aid in the construction of hospitals and clin facilities in the areas which require such assistance because of generally low income, sparse population, or sudden shift in size of or the com position of the public. This is in Senate bill 191.

The last two are new. Both would require legislation.

(3) Grants-in-aid to State approved voluntary health programs which are also supported by regular contributions from the bene