Eighth. We need to go slow, and accumulate further experience be fore venturing on the road to national health insurance.

I would like to outline our position with regard to these objections.

FREEDOM OF CHOICE OF DOCTORS

Far from limiting the freedom of choice of the doctor by the patient, the bill would greatly increase the freedom of choice of an overwhelming majority. There is far less freedom of choice today than many people seem to realize. Our rural and small town people have little choice. I was a member of a committee appointed in Illinois back in 1915 to look into the question of compulsory health insurance, and I was living at that time in Jane Addams Hull House, and was in very close contact with poor people. I knew what our committee investigation later proved, that the close relation and the power between physician and patient, the family physician relation, was not general among the poor. It varied in the cities. It was very seldom found, and the choice was certainly very limited for those people. Those privileges belong to the well-to-do. They do not belong to the poor. You are not taking away from the poor any beautiful relation between patient and physician by a health insurance system, I can assure you.

As for the country, the rural and small town people have little choice. In my home, the choice is determined largely by distance. You employ the physician who can reach you. We have not many doctors in rural Connecticut, and we take the physician nearest. One of our neighboring towns has had for years a very incompetent doctor who fortunately has gone to his rest now. He had a very large practice because he was there. Our choice is very limited.

They must take the local doctor or go without care. The bill would probably increase their freedom of choice by bringing more doctors to smaller communities, since they would be sure of the adequate income these areas now cannot provide. One quarter of our mothers today are unattended in childbirth by a physician. This is not by choice. The bill would give them a choice. Take the studies which indicate that of the more than 8,000,000 cases of illness, disabling for a week or more, over one-fourth of the patients receive no medical care whatever. The bill would make it possible for them to have i I hope this bill will supersede a bill for compulsory insurance. I saw it in a number of industries when I first went into industry because in the dangerous trades, the mining and smelting and the heavier trades, the medical care and surgical care was provided, but what happened was that a certain sum was deducted from the man's wages every week, and that supported the medical and surgical system.

Now, that was absolutely undemocratic. There was no choice there. The doctor was chosen, appointed, paid by the employer, and he was the employer's doctor, and the men all looked upon it as such.

The CHAIRMAN. Those systems have been in vogue in this country for many, many years.

Dr. HAMILTON. They are very much modified now. Most of the larger companies bear the expense themselves, but the doctor is stili the company doctor. However, the old system is still to be found. I know that it is in the coal-mining industry, for instance, with all

of its old objectionable features. I should hope that this bill would supersede that. That system is compulsory and yet has none of the safeguards provided by this bill.

The CHAIRMAN. Yet the medical profession have accepted that system in various parts of the country and gladly took employment under that system, did they not?

Dr. HAMILTON. Yes, I think there has been no dearth of doctors and surgeons in those industries. Organized medicine did look upon it with a good deal of distrust in the early years; industrial medicine had a very bad name, and I think partly for that reason. But of course now industrial medicine is a perfectly respected and accepted branch.

The CHAIRMAN. And in many of the sections of the country where that system was in vogue they did not have adequate hospitals or facilities for the treatment on a modern basis that we have now.

Dr. HAMILTON. Many of the company hospitals were very good. The CHAIRMAN. They have developed them in recent times.

Dr. HAMILTON. Oh, yes, greatly increased; the whole situation is very much improved, but the old system does still remain and some very bad spots are evident.

The CHAIRMAN. The leading members of the profession are rendering service under those systems in the various parts of the country. Dr. HAMILTON. Yes; that is true.

It means, of course, a great many instances that the worker pays twice for his medical care, because he mistrusts the company doctor and goes to his own doctor.

Our lower income families, as a group, have little freedom of choice. The bill would give many of them the first doctor-patient relationship they have ever enjoyed. I have already indicated how large a proportion of our people have incomes under $2,000. The Bureau of Labor Statistics studies indicate' that the average break-even point for urban families of two or more persons was about $1,950 after income taxes in 1944. It took that much income on the average to avoid going into debt. In other words, families at this income level have little or no savings. The report of families with $1,950 a year said:

Such families, averaging three persons in size, lived very modestly, spending an average of barely 22 cents per meal per person, and $30 per month for housing, fuel, light, and refrigeration.

Despite the higher-than-average earnings during the war years, the Bureau found after studying bond purchases in 1944 that—

total bond holdings at income levels below $3,000 do not comprise much of a backlog to be used for purchase of goods coming back on the civilian markets.

If a family with less than $3,000 does not have sufficient savings to buy a washing machine or a vacuum cleaner, it is obvious that it does not, by and large, have the reserves to meet the major emergency illness.

S. 1606 would not be necessary if we all needed a doctor once or twice a year. Most of our families can meet this cost. The bill is necessary because the majority of our families cannot budget for the sudden major illness. None of us can know which among us will be next. And when illness strikes, the burden falls unevenly. Onetenth of the people have to pay 40 percent of the total cost each year.

Even as you go up the income scale to $4,000 and $5,000 a year there can be little budgeting for the major illness. And when sickness strikes, it all too frequently even at this higher income range, it wipes out the family's entire savings and drives it to borrowing. It is estimated that 85 percent of our families have incomes under $5,000. All of these would find the insurance principle a godsend.

DOCTOR-PATIENT RELATIONSHIP

Those who are fortunate enough to have a personal family physician today would keep that relationship under the bill. The only change would be that the doctor would be assured of payment. Surely this could not destroy the doctor-patient relationship. The removal of the fear of the cost would bring many a person in for earlier diagnosis and quicker cure.

The opposition says, "Is not freedom curtailed if the doctor of your choice does not elect to come into the system?" Yes; it would be. But experience in the many countries which have adopted healt insurance indicates conclusively that all but a very small proportion of physicians elect to come under the plan. There is no reason to believe they would do otherwise in this country. I know that in my neighborhood our conscientious doctors sometimes do not pay as many visits to a patient as they would like to, because they know that the family is brooding over that bill, and is thinking he is running up a big bill. And that holds them back, which is perfectly natural. There is every evidence that the doctors of England and Canada would not, for one moment, turn back the wheels and return to preinsurance status.

Further another objection of the opposition:

Is not freedom curtailed if the surgeon general exercises his permissive power under the bill to limit the number of insured patients a doctor may serve? If the doctor of your choice has already accepted his quota, is not your freedom limite.

Yes, it is, but I would point out that a traffic light limits your freedom to go where you want to when you want to, but it gives you greater freedom to get there faster in the end. It is my view that it is wiser to leave this limitation in the bill. Without it, abuses may arise. Limitations of time today compel many doctors to refer patients t others, as we all well know.

SHOULD LOW INCOME GROUPS BE INSURED?

Let me turn to another point made by the opposition. Dr. Sensenich maintained last week that because lower income families experien more illness it is unfair to the higher income families to cover bo groups in a single plan, for, he said, this would impose dispropertionate costs on the more advantaged.

But let me point out, the higher incidence of illness of these lower income families results in very large measure from lack of care. Previde the care and incidence of illness in relation to income will ever out quickly.

I never went to a public school, and I had no children to send to s public school, but it has never occurred to me to resent the fact tha pay a school tax. And it must also be said that it is the rich wh

pay disproportionately for our schools. The largest families are in the poor group. Many of the rich send their children to private schools. Yet we consider it perfectly fair that universal compulsory education should be supported by all.

Surely when the National Physicians' Committee suggested last week that those to whom medical care is a hardship, the "indigent" as they were termed, should be given "free medicine," he recognized that this cost would have to be met by those with higher incomes. Either way the cost must be met. But surely there can be only one choice as between the democratic system proposed by S. 1606, which, like our school system, would be available to all alike, and the class system proposed by the National Physicians' Committee. Think of the implications of what that committee proposed. A voluntary insurance system for the upper middle income families; State medicine for those who find the payment of medical bills a hardship, based on the indignity of a means test.

Well, I know exactly what this means to my own town. What we call in the Middle West township a stretch of country with three tiny villages, farming country, and forest land. A long illness, a long sojourn in the hospital is a body blow to most of my neighbors. It eats up the savings and it drives them into debt.

CHARITY MEDICINE IS NOT THE ANSWER

It has got to be met in two ways, one or two ways, either assuming a burden of debt which will hang on the family for years, or going "on the town", as we call it. And to the New Englander that is the ultimate disgrace. He will not go on the town. Our town provides very well for our sick. We pay the hospital bills, and we pay the medical bills, but everybody knows it. Everybody knows that that case went on the town, and they do not do it. They do not get the medical care they need, and what medical care they get leaves them burdened with heavy debt.

It is obvious to all that voluntary insurance cannot and will not provide the full range of medical and hospital services for those with incomes under $3,000, the great majority of our people. Under the National Physicians' Committee plan, these people would have to claim indigence to receive care in their major illnesses, which indubitably impose financial hardship.

I have seen what great blessing the old-age pension bill has brought to our neighborhood. Instead of the poorhouse which is the ultimate disgrace, our old people collect their pensions with no sense of charity, no loss of self respect. They feel it is their due. The Government gives it. The Government is not charity. It means the difference between the poorhouse or being a heavy burden on your married daugh ters and being a self-respecting paying guest or living on in your own home.

I long to see something of the same sort come in the control of the burden of sickness.

QUALITY OF MEDICAL CARE

Said our friend of AMA: "National health insurance means inferior care." Surely they attack the integrity of our practitioners when they suggest that the quality of care would decline merely be

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cause the doctor is assured of payment. My experience leads me to believe that our doctors, more adequately compensated as they would be under this bill, and relieved of the unpleasant task of appraising capacity to pay, would be free to render better service.

COST OF HEALTH INSURANCE

The AM A tells us that national health insurance is too expensive, but I doubt if S. 1606 would increase our national medical bill. We pay between 4 and 5 percent of our national income now for medical care. The bill does not impose additional costs; it is merely a device to permit us as consumers of medicine to pool our small contributions and thus build a reserve large enough to meet, above all else, the crippling blow of major illness. This is primarily a problem of consumer organization.

PUBLIC DEMAND FOR HEALTH INSURANCE

The polls show us the people's view. The National Opinion Research Center, in a recent survey, found that a large majority wa an amendment to the social-security law for payment of doctor ar hospital care, even if this means an increase of 11/2 percent taken out of their pay checks. I do not believe the doctors themselves are far be hind. I cannot forget that back in 1938, before the National Phys cians' Committee began their scare campaign, the American Inst tute of Public Opinion found that 7 out of 10 doctors favored the insurance principle. As a doctor myself, I believe that the bill would bring a greater freedom and a greater opportunity to serve.

I found when I talked to the students in Harvard Medical Schoci that a great many of those young men were for such a system. They wanted to feel that at least their living expenses would be guaranteed to them during the first years of practice when under present conditions they did not see how they would even pay their office rent.

IS IT TOO SOON?

Finally it is claimed that we must not rush into national healt insurance precipitately. We must study the pros and cons. We m move cautiously. I ask "How do they define caution?" We hav studied this matter for over 50 years. During the years 1915-20, 1: State commissions were appointed to study the adequacy of our health provisions. The studies and investigations made since that time are legion. Twenty-five, thirty, forty years of study should be enough We have available a magnificent body of experience on the part of nearly 50 countries.

Since my work for over 35 years was in industry, and since I trav eled abroad a good deal, making industrial studies, I came to feel tha: the American worker in contrast to the worker in Britain and in mary industrial countries on the Continent passed his life under the shadow of three great fears. These were the fears of unemployment, of sickness, and of old age. Now we have dealt with two of those fears. We have removed them from his horizon. I hope fervently that we wi now remove the third fear, the fear of sickness.