ciation's methodology for providing substantially the same kind of health to older people that the medicare law actually provides. The basic difference were two in character. The eldercare proposal would have geared its support to need. We did not give a blanket coverage to the wealthy, the moderately well to do. This, too, was geared to individuals who had by some yardsticks demonstrated economic troubles. The second major difference is that the eldercare was not financed. through an extension of the social security system.

Now, eldercare differs substantially from our new program, well, in the obvious area of its applicability to beneficiaries. Eldercare talked about over 65. Our current program talks about under 65. Our current program, however, shares with eldercare the absence of the use of the social security financing system. There was no tax credit element in eldercare. I don't know whether that answers your question or not. There are those differences.

Mr. LANDRUM. Reasonably so.
Thank you, Mr. Chairman.
Thank you, Doctor.

Mr. BURKE. Mr. Byrnes?

Mr. BYRNES. Doctor, I appreciate very much your testimony. There is one aspect that I wondered if you grappled with and that relates to those cases where you have employers subsidized in health policies; for instance, you have it in a lot of union contracts. You have it here in the Federal Government as far as civil service employees. There is a subsidy for medical insurance. How would you gear that into your plan that seems to be entirely related to the individual taxpayer?

Dr. ROTH. Extremely important, Mr. Byrnes, and a great deal of thought has gone into gearing this to just precisely that problem. Actually, let me start by saying that the American Medical Association is in favor of group insurance coverage. It is the most economical kind of insurance and we favor this and we have tried to be very selective in our provisions in order not to interfere with this.

We have, for example, constructed our curve of the credits with particular attention to the avoidance of any point where the individual employee or his union or anyone else might get out a sharp pencil and figure it would be to his advantage to ask for a cash wage increase rather than to broaden medical insurance protection. We believe this is in the bill.

There is another, perhaps not apparent, point as you read my testimony to date, until you have a chance to look through the bill and analyze it in particular, but please remember we are talking about insurance coverage which is not first dollar coverage.

By and large, labor in this country has gone wholeheartedly for first dollar coverage. By and large, the voluntary Blue Shield-Blue Cross provide first dollar coverage. We have a $50 deductible on hospital and a 20 percent coinsurance up to $500 worth of medical expenses. This one feature would indeed in many instances militate against an enthusiasm for employees for our package as against what may be provided in collective bargaining and we do not make any effort to give the employer any tax break on this. It is only the employee's contribution in the case of contributory plans that is subject to the credit. So we have taken this point into consideration. If there are other points, we will welcome the advice of this committee, of the insurance industry, and the tax experts.

Mr. BYRNES. This seemed to me to be one of the complicating aspects. Let's take a Blue Cross-Blue Shield policy that has a first-day coverage. Your standard policy here would have a deductible?

Dr. ROTH. Yes, sir, for the hospital.

. Mr. BYRNES. For the hospital, all right.

Under that, then, the employee would not be able to get any credit for those premiums that he paid?

Dr. ROTH. Yes, he will, sir.

Mr. BYRNES. On a policy that didn't have a deductible? Maybe I am getting into minute details here, but it does seem to me it is a question of how you gear this into the insurance coverage that currently exists in the country.

Dr. ROTH. Policies in general which are equal to or more comprehensive than our basic policy, I think, would inevitably be approved policies and, therefore, the employee contribution, that part which he actually puts out from moneys due him, would be eligible for tax credit.

Mr. HARRISON. Mr. Byrnes, our suggested draft of the proposal does provide for supplemental benefits which may be added to the package. One of the benefits could be coverage with respect to the deductible or coinsurance. Just on the face of your example, it would appear to me that such a policy would be elegible for the tax credit. The employee's contribution, then, would be eligible for the same tax credit based upon the sliding scale we provide relating to his tax liability.

Mr. BYRNES. In other words, your sliding scale is the mechanism that you use to gear this program into the already existing industrial policies and group policies that exist and are subsidized by the employer?

Dr. ROTH. Yes, sir. If you take the trouble to plot out that scale of ours which runs over two pages in the bill, you will find that it is not either a straight line or a smooth curve. It is a skewed curve of which comes down rather abruptly, plateaus, and then goes back down. The explanation for this is our effort to take into effect the very problem you are talking about.

Mr. BYRNES. Thank you very much.

Mr. BURKE, Mr. Fulton.

Mr. FULTON. Thank you, Mr. Chairman.

Dr. Roth, I want to compliment you on your testimony and presentation today. I think it is a very realistic and humanitarian approach to a problem that we are all aware of.

Also, on the question which was directed to you with reference to the high increase in the cost of medical services over the past several years, I happen to have with me this morning a copy of a recent publication which gives the cost of living increases in several areas from September of 1968 through September of 1969.

The cost of living has gone up 5.8 percent; food costs, 5.9 percent; housing, 6.8 percent; clothing, 5.3 percent; transportation, 3.4 percent; health and recreation combined, 5.6 percent; and services, 7.4 percent. I thought that should be made a part of the record.

However, I am aware that there are instances where there have been some rather gargantuan increases in the cost of medical services, but just as possibly you have stated, I thought these were the actions of only

a few. Congress has found it necessary also to have an Ethics Committee, which also has difficulty with some Members of Congress.

In the first day of this session of Congress it was my privilege to introduce a bill, H.R. 19, which is very similar to the bill that I understand that you have presented today.

Dr. ROTH. We are well aware of that.

Mr. FULTON. I later introduced a modified version as H.R. 9835.

I would like to think that this approach of tax credit is just following along the lines of the tax reform bill that we just recently passed in the House.

Dr. ROTH. You are completely entitled to take that viewpoint, sir. We have been delighted with the input of your bills.

Mr. FULTON. As to the estimated cost that you have, from $8 to $12 billion, based upon many of the contingencies, the elimination of the medicaid program of course, as you pointed out, is a saving of some $2 billion to the Federal Government, as well as some $2 billion to the State governments.

We are all aware that the State governments are looking more and more toward Washington for assistance in meeting the needs of the States. Even now being proposed is a tax-sharing plan with the States. Certainly the adoption of this program would give some additional relief to the States that do not have the additional money to meet these problems.

Have you taken into consideration what it would mean for local governments as well as State governments in the reduction of the care for the indigent that they presently are having to serve?

Dr. ROTH. The reduction of the costs of the care for the indigent? Mr. FULTON. Yes, sir.

Dr. ROTH. Yes, sir. We would hope that it would in no way decrease the volume of the care, but the cost would in large part be lifted from local government budgets, although we have included some participation, possibly, in respect to the deductibles in coinsurance.

But, you see, one of the reasons for the dampening of our original enthusiams back as far as the Kerr-Mills program and title XIX, which we espoused in principle, has been that to work, it requires adequate implementation, which has not been forthcoming through all 50 States and four other jurisdictions. It requires adequate funding, which has not been forthcoming.

So that when we talk about title XIX programs, we are talking about quite a motley collection of plans. There are still eight jurisdictions in which I believe there is no formal title XIX program. There are others where there is a program, but the benefits are very small and constricted compared to what we call comprehensive coverage, and, therefore, in the absence of implementation and funding, we have felt that it is necessary to do something. The problems in implementation and funding have largely been at the State and local levels, and therefore we attack this weakness in our proposal.

Mr. FULTON. I will not take but just a moment. Mr. Schneebeli has asked a number of questions that I was prepared to ask.

Just to summarize your approach, the intent or purpose is to bring about a financial mechanism for the medical care for all of our citizens, I believe.

Dr. ROTH. Yes, sir.

Mr. FULTON. That is, those who would not be covered under medicaid, and it would be contrary to some of the proposals of other organizations.

It would be on a volunteer rather than a compulsory basis, and the carriers of this medical insurance would be private carriers, rather than the Federal Government, and also, under your proposal, I believe it would be administered by a State insurance board, with Federal supervision.

Dr. ROTH. The Federal supervision would be limited to guidelines or requirements, standards, to which the States would have to conform for approval of policies and coverage. But basically we have the insurance industry still dealing with State insurance commissioners and commissions, as they have traditionally done their business, and which they are used to, and with which they are, I think, reasonably comfortable.

Mr. FULTON. Dr. Roth, I want to thank you again for your appearance before the committee, and the contribution that you have made to the deliberation on this most important matter.

Dr. ROTH. Thank you, Mr. Fulton, for your contributions to this same effort.

Mr. BURKE. Mr. Conable.

Mr. CONABLE. Thank you, Mr. Chairman.

Doctor, I want to grasp the stinging end of the nettle, here, and talk about something which you have not mentioned, but on which I would like the view of your organization, and that is chiropractic.

I understand the history of the relationship of the medical and chiropractic groups, and I am wondering if there has been any evolution at all as a result of the licensing of chiropractic by most of the States.

I might tell you that my own position was that I voted against the licensing of chiropractic in New York State when this was up before the legislature some years ago and nobody could call me, historically, anyway, a friend of chiropractic.

But of course the purpose of licensing chiropractic was to upgrade it, and we find ourselves in a very strange and unstable position which has left Congress right squarely in the middle of a dispute between the two groups. Chiropractic is acknowledged and permitted to perform services under medicaid, but not under medicare. Frankly, it has not made a great deal of sense to have this situation. Those who, because of their circumstances, can claim health services under title XIX, who contribute nothing to the funding of the program, but because of their impoverished state are eligible, can elect to have chiropractic services, while those who contribute voluntarily under plan B of title XVIII cannot elect to have chiropractic services.

Now you see that this puts us in Congress in a rather strange position, where we are furnishing public funds for the treatment of people by chiropractors under title XIX, but not permitting those who contribute themselves to elect to have chiropractic.

I call this an unstable position, because it is illogical, and it is inevitable that we in Congress are going to be under great pressure from those who believe in chiropractic to include it also under title XVIII, as well as title XIX, as long as this condition exists.

I am a layman, and I am not knowledgeable about the various disputes between these two branches of the healing arts, but I am in

terested in whether or not there has been any revision of the relationship between the two groups as a result of the widespread licensing, most of which was directed at upgrading chiropractic as a healing art, and basing it on what at least from a medical viewpoint is a sounder basis than many people felt chiropractic had when it was unlicensed, when there was no public concern about the qualifications of those practicing chiropractic.

This is a complicated question, I realize, sir, and it puts you in a delicate position to answer it, I am sure, but I, as a layman, would be interested in your response. I do feel that we here in Congress are in the middle of a comparatively irreconcilable contradiction in our public health programs.

Dr. ROTH. I would hope it is not an irreconcilable contradiction, Mr. Conable, I have no hesitation in suggesting that the American Medical Association, and I would say overwhelmingly, perhaps every one of its members, would subscribe to the remedy which we would propose. We indeed feel that your program should be consistent, and consistency should be achieved by eliminating payment for chiropractic from all of it.

I would only point out to you that there has been a magnificent eclectic track record for the medical profession in this county, and elsewhere in the world.

I think that none of you gentlemen would harbor in your minds for one moment the thought that if the magnificent departments of medicine and surgery of our Army and our Navy and our Veterans' Administration felt that chiropractic had one thing to offer to the well being of our wounded servicemen and our sick and disabled servicemen, they long ago would have ignored any other considerations except the welfare of their patients. Yet they have never accepted chiropractic services.

I think there was an excellent study made by the Department of Health, Education, and Welfare on independent practitioners under medicare, which recommended a prefectly proper answer, which we of the American Medical Association would support 100 percent. May I read just one key paragraph from this:

"Chiropractic theory and practice are not based upon the body of basic knowledge related to health, diseases, and health care that has been widely accepted by the scientific community. Moreover, irrespective of its theory, the scope and quality of chiropractic education do not prepare the practitioner to make an adequate diagnosis and provide appropriate treatment. Therefore, it is recommended that chiropractic service not be covered in the medicare program."

I believe that we would wholeheartedly extend this to the point that it not be included in any other federally financed program. We believe this is an opportunity for two benefits: A savings of Federal dollars, and an improvement in the overall health care, since chiropractic is one of-I don't even want to use the word-the disciplines that I have grouped under nonscientific substitutes for scientific medical care.

Mr. CONABLE. How do we reconcile this with the licensing of chiropractic by the States?

Dr. ROTH. I come from the State of Pennsylvania, where this was Long and bitterly fought over a number of years, and all I can say is that the guys with the white hats lost.