A constructive health program, based upon the principle of prevention as well as cure, should encourage, prepay the costs of, and provide facilities for regular physical examinations and the earliest possible diagnosis and treatment of symptoms and ailments.

It should make the services and facilities of all the various specialties as well as of general practitioners, working together, readily and conveniently available to the individual.

It should provide for the continuing education and guidance of the individual in the use of the facilities available to him and in the proper care of his own health and that of his family.

It should provide those who suffer from chronic conditions ready access to the kind of attention and advice they need in order to prevent their condition from growing worse, and, if possible, to improve it. All of these services and facilities should be closely integrated with those which are provided for the hospitalization, care and treatment of more advanced cases of illness and disability.

It is in precisely this area of preventive service that the system, if it can be called a system, of medical enterprise which currently prevails is most glaringly deficient. I refer both to the solo-practice, fee-forservice method of offering medical services as such, and to that arrangement as it has been modified, or, rather, embodied in, the prepaid insurance plans which the medical societies and commercial insurance companies have placed on the market.

We believe that a large part of the health problems which now confront this Natoin can be traced directly to this deficiency. Because this fundamental need is neglected, individuals are discouraged, by costs, inconvenience and lack of knowledge, from seeking the care and attention they need, until their condition becomes so acute that they can no longer avoid recourse to medical services.

An adequate health-insurance program must be comprehensive in its scope, and must provide complete family coverage.

The health-insurance plans which are most prevalent today largely ignore the most important areas of cost. They do not cover the dayto-day health needs and conditions which are most common to every family, nor do they cover those conditions which, though relatively infrequent, are most burdensome and costly when they do occur. They are limited largely to partial coverage of an in-between area, short-term hospitalized disabilities.

In industry today, thousands of different arrangements exist, whose variations in scope of benefits are not justified by any criteria, despite the prevalence of the appeal to fit the insurance benefits to the needs of a given group or industry. The needs are always comprehensive health services and medical care.

This piecemeal approach means inequality of benefits for workers even in the same community or neighborhood.

Medical care without detriment to its quality cannot be fragmentized. Its component parts must be integrated into a comprehensive continuous whole. Diagnosis cannot be arbitrarily separated from treatment, surgery cannot be isolated from preoperative and postoperative care, care inside of the hospital cannot be provided as a thing entirely apart from care in the home, office or clinic. Anything short of a comprehensive, unified program is to that extent an inadequate program.

Full family coverage is likewise an essential criterion of adequacy. Many of the plans in existence today cover only the wage earner himself, and excludes his wife and children. The contribution which such plans make toward the solution of his health problems is very small, even if these plans were adequate in all other respects, which they are not, for the medical expenses of the worker himself are but a small part of the total family medical bill.

In fact in a comprehensive survey, which was made in the San Francisco area, we found that the family costs ran about 80 percent of the total medical costs.

That is the cost to the dependents as distinguished from those of the breadwinner himself.

A satisfactory health program should at the very least provide a means of making possible the full prepayment of the costs of the services offered. The application of the social insurance principle also requires that the rate of payment bear some direct relationship to the income of the persons covered.

The so-called voluntary plans offered by commercial insurance companies and medical societies fail on both counts. That is particularly true of cash indemnity plans.

In other words, here we have the ironic example of prepayment plans which in many cases do not prepay, and insurance plans which, though costly, do not insure.

The most obvious evidence of this may be found in the wide disparity between the large percentage of the populace which these plans claim to cover, and the very small percentage of the total medical costs of the Nation which they actually pay. While 56.6 percent of all families in the United States have some form of insurance protection, the record shows that only 15.2 percent of all medical costs were paid by such insurance.

The typical cash indemnity or reimbursement plan does not cover all the costs even of those services which it undertakes to cover. It does not even cover a predictable portion of those costs.

It places a ceiling on benefits, but there is usually no ceiling on the actual charges made for the services rendered. Unhappy experience has shown that those charges all too often tend to vary, depending upon whether or not the individual is "insured" against them.

Few experiences have been more frustrating to our members than that which many union groups have encountered in the fruitless effort to catch up with the will-of-the-wisp of rising medical and surgical charges by negotiating expensive increases in the benefit schedules of cash indemnity plans.

Increases in benefit schedules negotiated in the effort to approach full prepayment of costs have served only as an excuse for further increases in hospital charges, room rates, and medical and surgical fees, leaving the members confronted with the same extra charges, over and above their insurance benefits, that they had to pay before. Through this process, in some areas we have seen surgical benefit schedules in the plans negotiated by union groups rise steadily over a few short years from a maximum of $150 to maximums of $450 or $500, without actually improving the position of the membership in relation to their medical bills. In fact, in some cases, grounds exist for a very strong suspicion that individuals covered by such plans have been left no better off than they had been without it.

To the extent that this tendency exists, these plans may properly be described as "doctors' benefit" plans, rather than employee-benefit plans. For they enable doctors to receive higher fees for services to low-income workers than would otherwise be the case, without sacrificing their ability to charge what the traffic will bear to others, regardless of the schedule of maximum benefits contained in the plan.

I know that there have been many pious condemnations by spokesmen of the American Medical Association of this practice of hiking fees for insured patients. But it is difficult, if not impossible, to prove a deliberate hiking of fees.

And until the officials of the AMA and local medical societies throughout the country show a greater willingness to sit down and work out with consumer groups a reasonable schedule of fees which they will accept as a standard and as full payment for services rendered, their self-righteous disclaimers will remain singularly unconvincing.

Moreover, if you accept the traditional attitudes of the medical fraternity as expressed in the fee-for-service approach which the AMA defends so vigorously, it is hard to blame individual doctors for raising their fees. It is a reaction which is entirely consistent with their traditional sliding-fee scale based upon the patent's ability to pay, and what the market will bear.

On that basis, it is only natural for a doctor to look upon an indemnity insurance policy as an additional financial resource of the patient. If the patient could afford to pay $50 for a given operation before he had the insurance, and the insurance policy provides a benefit of $50 for that operation, surely he should still be able to afford $50 out of his own pocket. Therefore, by this kind of reasoning, he should be able to pay up to $100 now that he has the insurance policy. This attitude persists, despite the fact that the spread of insurance has gone far toward wiping out the theoretical rationale for the slidingscale system.

Organized medicine offers a sort of Robin Hood theory in justification of this system. According to their argument, they must soak those who are able to pay, in order to compensate themselves for the vast amount of free or reduced rate services they render, or alleged that they render, to the poor. The spread of insurance plans has undoubtedly served to reduce the amount of charity work that is done and to raise the fees that doctors are able to obtain for services to lower income groups.

Yet, this changing situation on one side of the scale has not been matched by a compensating change on the other. Organized medicine continues to insist upon the right to charge what the traffic will bear, even though the effect is to nullify the value of insurance plans, save as a source of guaranteed income and insurance against nonpayment of bills for the members of the medical profession.

The fact is that as long as insurance benefits are paid in cash with no guarantee of the medical services they will actually purchase, this constant upward pressure on fees can be expected to continue. That is one of the major reasons why the service, rather than the cash indemnity principle is so essential to a constructive, effective health

program.

But, regardless of whether a plan undertakes to offer services or cash benefits, there can be no adequate check upon costs in the absence

of effective consumer representation in the administration of the program. This applies particularly to medical society plans which play up their "nonprofit" character and yet are controlled exclusively by the very doctors who give the services at fees which they themselves establish. Under such circumstances, the use of the term "nonprofit" is surely a meaningless technicality, a mere antic of semantics. However honest, no one can be entrusted with spending another person's money economically when it is primarily a matter of paying himself. The inflationary effects of these plans upon costs to the consumers of medical care operate in a threefold manner:

1. By creating an upward pressure upon medical, hospital and surgical fees and charges, as noted above, which is reflected in extra charges and in steadily rising premium rates;

2. By increasing the demands upon available hospital and medical facilities and personnel with no compensating program for the increase and expansion of facilities needed to meet these demands; and 3. By tacking on top of purely medical costs a heavy structure of administrative, promotional, and other expenses.

Thus they exact a very high and, we believe, an unnecessarily high, price for the advantage of providing a means of budgeting an unpredictable and variable part of the costs of medical care.

Our concern is not limited to what is happening to the costs of medical care today. We are equally concerned with what is happening to the quality of medical care. In its propaganda against any governmental action in the health field and in favor of the status quo, the instruments of organized medicine have placed great emphasis rhetorically, at least, upon this important factor of quality. Yet the harsh and unfortunate fact is that the quality of medical care is suffering today under the impact of commercial insurance and medical society plans, and it is not likely to improve in the foreseeable future, insofar as most of the people of this country are concerned, without timely and appropriate action on the part of the Federal Government. One of the reasons why the hospitals of this country are overcrowded today lies in the fact that the most prevalent type of insurance plan pays benefits only for hospitalized illnesses and disabilities.

More authoritative persons than I have testified to the fact that a great many persons are being hospitalized unnecessarily, simply because that is the only place in which they can receive prepaid treatment, within the scope of their insurance plans. The resultant pressure upon hospital facilities and personnel can have only one result, deterioration in the quality of care.

Most of this unnecessary hospitalization could be avoided by the provision of adequate preventive care, and by the provision of facilities, within the scope of the insurance program, for diagnosis and treatment in outpatient clinics and health centers. This has been clearly demonstrated by the experience of those comprehensive service plans which do provide for this type of care, where the rate of hospitalization has been materially reduced below the level of plans which provide for hospitalized conditions only.

There is some evidence, including observations by prominent members of the medical profession, of the performance, for pecuniary purposes, of unnecessary or overly hasty operations, many of which may be detrimental to the welfare of the patient. We do not mean

to imply that such conduct is typical of the medical profession, but we do believe that it is much more widespread than the captains of organized medicine are prepared to admit.

While the responsibility for this must be placed directly at the door of the individual doctor who is guilty of such practices, its extent can be attributed largely to the growth of insurance plans which place a premium upon shady ethics and questionable practices. These plans guarantee the payment of liberal fees to doctors for the performance of such operations, while containing no protections to safeguard the interests of the patient.

In short, while those who oppose Federal action and point to commercial insurance and medical society plans as a substitute profess great concern over quality and the rights of the individual, the facts are that these plans do nothing to protect and promote either the quality of medical services or the interests of the patient in his relations with the members of the medical profession. In fact, there is much evidence which indicates that their end results may be detrimental to the quality of medical care.

This state of affairs is particularly serious in the light of the fact that the individual layman, when left to his own resources in his search for good medical care, is almost entirely at the mercy of the medical profession. He must take the word of the doctor for everything, including the professional merits of other physicians. The relunctance of doctors to speak to a patient of other doctors in terms that might be considered derogatory is notorious; it is generally viewed as a breach of ethics.

Medical ethics itself seems to have come a very long way from the day when it was designed and served primarily as a protection for the lay patient. Professional medical associations have come to direct more and more of their attention toward the economic and political self-interest of their leading members, a trend which perhaps reached its culmination with the era of Whitaker and Baxter.

With this shift in emphasis, there seems to have come a subtle change in the character of medical ethics, until today it is a debatable question whether the ethics of the profession as applied in some cases is a safeguard for the patient or an instrument for the mutual protection and benefit of the medical fraternity.

This is nowhere better illustrated than in the question of "free choice of doctors." On this point, I would first like to say that, contrary to the common allegation, the type of national health insurance program favored by the American Federation of Labor would not restrict the patient in his free choice of doctors. It would in fact enhance it, by offering him a much wider range of choice, as a practical matter.

It is, however, significant that this argument about "free choice," which is commonly and erroneously employed against both group practice plans referred to there as the closed panel and national health insurance, has its origin in and is most strongly championed by the spokesmen for organized medicine, rather than the actual consumers of medical care.

It is both ironic and indicative that those who most strongly insist that no one is competent to judge or to exercise discretion or authority over anything related to medicine except the members of the profes