of these diseases, which, if they were checked earlier, I asume might have been arrested or eliminated.

I think your idea is an excellent one.

I interrupted you. I want you to go on.

Dr. MAGNUSON. I just wanted to carry that to this stage. Suppose you started this thing for children. Suppose a hospital built a small building. They could use their own clinical laboratories. You could have these children's blood tested and their chest X-rayed and their spine X-rayed and what not, for a very small sum, if it were organized on a kind of a mass production basis, and set aside for certain hours and days. From that, I think you would find that real diagnostic clinics for your whole community might develop and weld this whole group of doctors into a clinic group which wouldn't interfere with their private practice at all but would make them a homogenous mass of medical talent, instead of spattering themselves in competition over a big field that they can't possibly cover as individuals.

Mr. HESELTON. Do you know whether this has ever been undertaken anywhere?

Dr. MAGNUSON. I don't think so. I would like to see a pile of programs set up. I offered to set one up in Chicago at one time, but I haven't gotten very far with it yet.

Mr. HESELTON. The American Medical Association appeared when we first opened the hearings and gave assurance that they were interested in the committee's study and would be interested in any concrete suggestions.

I think the suggestion made this afternoon is one that certainly ought to be included in the program. I hope they will consider it carefully.

Dr. MAGNUSON. Well, I think they will. As a matter of fact, I want to say this: that we got complete cooperation in our studies, on this Commission, from the American Medical Association, and every branch. They gave us all their statistics. There were 1 or 2 or 3 men at every conference that we had. They were compeltely informal. It wasn't testimony. It was just as you and I are sitting down here talking now. And there was no acrimony and no unpleasant discussion in anything except possibly the finance basis, when Dr. Falk and Dr. Dickinson sat across the table from each other, and I thought maybe there was a bit of acrimony that went back and forth there, but I didn't hear it.

Mr. HESELTON. I may be wrong, but I think they made some comments about the report.

Dr. MAGNUSON. Some of us have been shot at before, and our hides are kind of thick, and thank God everybody has a right to his opinion in this country. If we didn't, we wouldn't have an America any

more.

Mr. HESELTON. Do you have any further suggestions?

Dr. MAGNUSON. No, I would like to leave this outline with the committee to use for whatever they see fit. It is just a carbon copy of the plan that I put out, and the diagram of the thing is missing, but I think I can find one of those in my office, if you want it.

The CHAIRMAN. It will be made a part of the record.

(The material referred to is as follows:)

A PLAN FOR NATIONWIDE MEDICAL CARE

Based upon two major factors:

First: The weakest link in our chain of medical care results from the lack of diagnostic and public health facilities, particularly for people who are neither indigent nor wealthy.

Second: A positive solution to this problem is possible one that is compatible with our democratic enterprise system-a solution that is in accord with our Federal-State-local system of government-a solution that involves cooperation between public and private agencies-a solution that avoids the extreme alternatives of do-nothingism on the one hand and of bureaucratic futility on the other.

The key to the success of this plan lies in local control.

"Our health is far behind the progress of medical science. Proper medical care is so expensive that it is out of reach of the great majority of our citizens."-President Harry S. Truman (message on the state of the Union, Jan. 5, 1949).

FOREWORD

This proposal is the work of one individual-sustained by his interest as a citizen and by his lifelong devotion to the medical profession.

This report is the work of one individual—it carries no other sponsorship and has no other support.

As a professional medical man, I am distressed to hear the emotional arguments used by those on the one hand who favor compulsory health insurance and by those on the other who blindly oppose every proposal to meet the problem of national medical care. It seems to me that the proponents of both extremes miss the point-the heart of the problem is the lack of diagnostic and public health facilities.

The ultimate solution will be less glamorous to some people than compulsory health insurance and far more postive than the negative approach of donothingism.

The accompanying proposal is therefore offered in the sincere hope that it will contribute to the general understanding of a critical problem and that it may point the way toward a midle-ground solution acceptable to both the American people and to the medical profession.

THE OVERALL PROBLEM

PAUL B. MAGNUSON, M. D.

The deficiencies in our present system of medical care have been carefully documented and completely exposed in the voluminous reports of governmental and private agencies. Although men of good will may differ as to the interpretations of our conclusions drawn from these data, we cannot ignore these facts:

1. Forty million Americans reside in areas that lack the basic protection of full-time public-health departments.

2. Less than 10 percent of the public-health departments of the Nation are provided with physical facilities even approaching reasonable standards of decency.

3. There is a shortage of doctors, dentists, nurses, laboratory technicians, and specialists of every variety. In the public-health field alone, more than 30,000 vacancies exist throughout the United States.

4. In terms of population, our doctors and other medical personnel are unevenly distributed. In Mississippi there is but 1 physician for every 1,400 people; in California the proportion is twice as great. Rural areas suffer especially. 5. In the rural areas, also, there is no provision for medical men to maintain contacts with professional progress, to receive stimulation in the advances of medicine and education in modern methods.

6. Facilities and equipment are likewise in short supply and unevenly distributed. This is particularly true of diagnostic facilities. Wealthy patients can afford the expense of thorough examinations; indigent patients get such examinations free even today in most of our hospitals in urban areas. The biggest problem concerns low and moderate-income families.

THE DIAGNOSTIC PROBLEM

Diagnosis and the maintenance of health are the two most important phases of medical care. The maintenance of health depends on routine or at least fairly regular health examinations. These health examinations do not consist of a few thumps on the chest and a stethescope over the heart and looking at the tongue; they mean examination of a patient from the roots of his hair to the ends of his toenails. They need electrocardiograms to check the condition of his heart, they need blood pressure readings to see the condition of his circulation, they need a basal metabolic rate to tell whether the metabolism of the body is working as it should; they need examination of the teeth to see whether there are any infections and examination of the throat to see whether the tonsils or nasal pharynx are infected.

The reason a patient comes to the doctor frequently is a pain. Maybe a pain which he has never had before. It is up to the doctor to find out why the pain is there. Also, there are many conditions which occur in human beings that do not cause pain but which are insidious in their onset. Cancer, for example, is one of the most insidious of all diseases. The cure of cancer is not so impossible when in can be found in its very early stages. One of the reasons why it is not found is because it gives no symptoms until it has progressed to a stage where it is incurable in a large percentage of cases. Cancer of the breast can be found early if there is proper examination, but cancer of the rectum and cancer of the stomach many times are insidious and far advanced before they do give symptoms. Therefore the ordinary diagnostic methods in a doctor's office are not satisfactory. Many times they are not satisfactory to the doctor or the patient. And so the general practitioner while he may be very skilful and may know the patient very well cannot always make a diagnosis without help. This help can be given by a group working together diasnostically and this help is what the doctor needs in order to make a diagnosis on early degenerative diseases and maligancies and other things that come on insidiously. There is no reason why this help cannot be given by even a traveling clinic if there are no facilities near. The proper kind of diagnostic service described herein is not available to many millions of Americans. A thorough diagnosis is expensive because it takes time, skill, matterials, housing, and the cooperative effort of specialists. Laboratory work for X-rays, blood chemistry, basal metabolism tests, etc., may run upward of $150 per case. In addition, we have a shortage of doctors and other professional personnel. We have a shortage of equipment. Any answer to the national health problem which glosses over these deficiencies cannot be an adequate

answer.

ALTERNATIVE SOLUTIONS

The scope, complexity and diversity of these problems generally stimulate two extreme alternative solutions: One group favors a do-nothing policy; the other jumps to the opposite extreme of national compulsory health insurance. I. The do-nothing policy is based upon these assumptions:

(1) The Nation is doing very well in a medical way, far better than any other major industrialized nation.

(2) Any action by Government is per se harmful and runs counter to our concepts of individual initiative.

(3) Government action would disturb the patient-doctor relationship. (4) Any Government action would increase taxes, would merely add to our overgrown bureaucracy, and would result in regimentation of our people. These assumptions, however, ignore these facts:

(1) Although America may lead the world, we can and should attain a higher level of medical care.

(2) Government action need not be incompatible with the private-enterprise system.

(3) Government should not be the master, but should be the servant of the people which means that local control is essential.

(4) Cooperation between Government and private agencies-plus local control may improve our system of medical care without resort to overgrown bureaucracy or regimentation.

II. The compulsory health-insurance advocates, reacting violently to the do-nothing philosophy, offer a solution that attempts through one sweeping

legislative act to convince the American people that they will be cared for from the cradle to the grave.

Such a scheme assumes:

(1) That illness can be legislated out of existence.

(2) That a bureaucratic organization directed from Washington will understand and meet the diversified medical needs of regions, States, and localities in the United States.

(3) That State and local governments and private agencies cannot do the job.

(4) That the mere selling of health insurance will automatically solve the great problems-the shortages of doctors and other medical personnel, the shortages of equipment, and the shortage of space.

(5) Finally, that another bureaucratic organization in Washington is compatible with our American system of individual initiative.

This proposal ignores these facts:

(1) That one law designed to eliminate illness will be as effective as one law designed to eliminate war; and that no matter how many billions of tax dollars are paid in, compulsory health insurance is a glittering promise that cannot be met so long as we have shortages of personnel and facilities.

(2) That the national health problem is complex and does not lend itself to one single solution; and that the health problem is most complex in the rural

areas.

(3) That the accumulation of bureaucracies in Washington will weaken our ideals of self-government, as well as individual self-reliance.

(4) That the tax burden necessitated by such a national scheme is unpredictable and especially burdensome in view of the current budgetary demands placed upon the Nation by the cold war with Russia.

(5) That wherever a compulsory scheme has been attempted the results have been poor in terms of the care given the individual and poor in terms of the progress made in medical research.

A DEMOCRATIC SOLUTION

Between these extremes lies a democratic solution-a positive middle-way program that is compatible with our social structure and with our Federal system of government. This proposal avoids the false optimism of the do-nothing policy and the potential disillusionment of the other extreme. Furthermore, this proposal reflects the practical experience of World War II. During that conflict the American people learned something about the term "logistics.” We learned the importance of men and materials; we discovered that we could not pursue an all-out offensive on every front at one and the same time. The medical problem requires an overall strategy, carefully planned tactics, and a system of logistics that will provide men and materials where they are most needed. If the diagnostic facility is the weakest link in our medical chain, we should attack that point with all our resources. We should put our faith in a day-to-day battle against illness rather than in any mere Government insurance scheme. In order to win battles, the generals had to have their troops in the right place at the right time-even though the distribution of personnel was thin in some spots. We know the distribution of medical personnel is limited. Therefore, it must be used to the greatest possible advantage in order to combat disease.

It is suggested that in the following pages a plan is presented that is evolutionary rather than revolutionary in character, a plan that means progress without sacrificing those values that are of central importance to our way of life, a plan that realistically concentrates our resources in an attack at the weakest point of the enemy-sickness and disease.

This plan is something that we can afford. Equally important, it is something that should prove effective. And third, it can be started with the least possible delay. We will not have to wait 3 or 4 years to "tool up," because we will establish control locally rather than at one central point.

THE PLAN IN BRIEF

In essence, this plan calls for the establishment in communities throughout every State of diagnostic clinics accessible to all of the population, equipped with the most modern facilities for complete health examinations, and staffed with the highest type medical and professional personnel available.

Financial support for the plan would come from the Federal Government, the States, local governments, and private contributions.

The clinics would provide free, part-pay, or full-rate medical examinations and health advice to all members of the community who seek the service. But the clinics would not provide free treatment. The family physician, local hospital and specialist would provide treatment at their regular rates, suppplemented by deficit payments from funds provided by local, State and Federal sources, entitlement to be decided by a local board of control.

The cost of the diagnostic service would vary with the economic status of the patient-free, part-rate, or full-rate-to be judged by a local representative board.

The task of staffing the diagnostic clinic would be handled on a cooperative basis involving medical schools, State and local public health agencies, the Veterans' Administration, and the proposed National Science Foundation.

THE PLAN IN DETAIL

1. Supervision of the plan and standards of service would be under the medical schools and universities, locally or regionally. (In those States which have no medical schools, the universities could supervise the plan or work out arrangements for staffing with medical schools in neighboring States. In those States with several medical schools, a committee of deans, in cooperation with the State director of medical services, could supervise the plan, just as the deans' committee so successfully supervises the Veterans' Administration medical program.) The medical schools or universities would recommend a full-time supervising officer for each State for appointment by the governor. Such recommendations would serve to keep politics out of the plan.

2. Under this supervising officer, diagnostic clinics would be set up in the communities throughout the State which would be accessible to all the population. These diagnostic clinics would be established wherever possible in existing facilities (health centers, hospitals, etc.). New buildings for the diagnostic clinics would be built only where existing buildings are unavailable or impractical. The diagnostic clinics could be built as sections of the new Hill-Burton hospitals. Where necessary, traveling clinics could be instituted.

3. The diagnostic clinics would be set up with the most modern equipment for complete health examination, and staffed with the highest type medical and professional personnel available. It would be the direct responsibility of the Director of Medical Services to find and provide necessary personnel through the various sources, medical schools, science foundations, Veterans' Administration medical program, Government services (doctors, nurses, social workers, laboratory technicians, dentists, etc.).

4. The diagnostic clinic would provide free, part-pay or full-pay medical examinations and health advice to all members of the community who seek the service. But the clinic would not provide treatment. The family physician, local hospital and specialist would provide the treatment at their regular rates graded to the patient's economic status and with full consideration for the role played by medical and hospital insurance.

5. The diagnostic clinic would pay the family physician, the local hospital, the specialist for services rendered to those members of the community who cannot afford to pay for medical treatment. The locally controlled clinic would make up the deficit for those patients who can afford to pay part of the costs for both hospital and diagnostic service. Hospitals will benefit by being able to adjust their charges without fear of deficit. The clinic-aided by local philanthropies-will pay for all indigents and thereby provide relief to deficit-plagued hospitals and thereby prevent the destruction of one of the greatest public services to the country provided by its citizens.

6. The subsidized medical examinations would substantially reduce medical costs for the moderate-income families and make it possible for any income group to get the service now open only to the wealthy. The patient would be able to obtain a thorough and complete diagnosis, so necessary to really adequate medical and disease prevention, but a course which most patients shy away from because of the expense involved.

7. While reducing costs, the free medical examinations would also raise community health standards by making available diagnostic facilities not readily accessible to the general practitioner; by providing high type consultation for the general practitioner; by making it possible for the average patient to get proper diagnoses, and therefore, proper treatment; and by providing the family physicians opportunity for close contact with the most up-to-date medicine.