The same would apply to farmers. Mr. HARRIS. I was going to ask about that next. How would it apply to farmers?

Mr. CRUIKSHANK. We are proposing now, and we agree thoroughly with the President's proposal yesterday to include farmers in old-age and survivors' insurance. We have done a good bit of thinking about how those insurance premiums and the public system could be paid. We have discussed it with representatives of the Treasury Department, the Health, Education, and Welfare Department, and all of them. We feel quite confident that there is no difficulty in the collection of premiums.

the

In the rural districts your problem would be there as it is now, provision of benefits, but a part of the whole integrated program is the development of a chain of facilities, health centers, clinics, and so forth.

Mr. HARRIS. Thank you very much.

Mr. O'HARA. Mr. Cruikshank, pursuing a bit further the questions which have been addressed to you by my colleague, Mr. Harris, I presume that it is true, as we have seat here listening to these different plans, that what may be a local plan which works in a locality very well might not necessarily be a good plan in some other locality; is that true?

Mr. CRUIKSHANK. Yes; I think that that is very true.

Mr. O'HARA. Because we would have this sort of a situation: A group of steelworkers at Gary, Ind., might have a plan which would be the type of plan that would be satisfactory to that group of workers. That same plan might not be as appealing to a group of candyworkers in a candy factory in Chicago, or a group of creameryworkers in Minnesota, for example.

Would not that be true, because you are dealing, the medical profession and the hospital, is dealing with completely different factors of health, as well as other elements of insurance received in the employment; is that not true?

Mr. CRUIKSHANK. Yes; I think that that is undoubtedly true, sir. I do believe so, that we can recognize certain essential elements of health needs that are a common denominator to all groups-farmers, professional people, industrial workers, and all. These are some that have attempted to outline.

For example, the basic element of preventive care is applicable to a steelworker in Gary, Ind., or a cottonpicker in Louisiana.

Mr. O'HARA. One thing that troubles me a bit is this situation, Mr. Cruikshank: Now, there have been many plans which are industrywide or unionwide, or in particular localities where agreements have been made on a bargaining basis or otherwise between the employer and the employee. Now, we have run into this in the committee to some extent where you have these various pension plans.

Here is what I am concerned about: We have people who are contributing either privately, or through groups, and making payments. for the type of medical protection and hospital protection that appeals to them. Now, if we go ahead and superimpose some governmental plan, deductions would have to be made or payments would have to be made either on a payroll basis or by some form of compulsory payment. Certainly the head of every family would have to make the payment.

Now, we add those all up and they amount to quite a little money, so that we do have a problem, Mr. Cruikshank, in considering any overall plan such as national health plans, as to what extent we can go without it becoming quite a burden on the individual; is not that true?

Mr. CRUIKSHANK. Yes; that is very true. Certainly we cannot avoid the realities of these costs. Our feeling is, however, that we do not escape the costs by not making it a matter of a payroll deduction. They are there, and in some aspects the overall costs can actually be reduced. The cost of medical care and service to the people of the country is here. It may not be as apparent if it is

paid in one way, as if it is paid in another.

But it is there, and we have to meet it. It is a burden on our whole economy.

Mr. O'HARA. We have naturally, Mr. Cruikshank, in our consideration of the problem, in which certainly this committee has a very deep and sympathetic concern, the situation in which we are involved, namely dealing with so many segments of our population.

Any sort of a health program must, as a foundation, have hospitals, clinics, doctors, nurses, and technicians to effectively operate. What may be a simple problem in St. Louis may be in a rural community much of a problem of furnishing the facilities. In any program that we have, it certainly has some very far-reaching thinking to be done. Mr. CRUIKSHANK. Yes, indeed, and I would be the last to deny the very complex nature of the problem with which you are struggling. We have felt that for a long time.

If I may recall to your memory the fact that the Hill-Burton hospital-construction bill was originally title II of a comprehensive health program which we had endorsed and sponsored. We have never sponsored a health-insurance program just as is, because we know that it would not meet the whole health problem. You must have personnel, more doctors and nurses, and those other technicians who support the medical profession, and you must have health centers and clinics and hospitals. They are inseparable. It is a complex interwoven problem.

Mr. O'HARA. Mr. Cruikshank, I wonder if you would care to comment on this: This committee, in 1949, made a trip to Europe in which we particularly made some investigation into the British health plan. We also went into the Swedish plan and others. It was quite amazing, as we talked with the man on the street in England, particularly, and my friend Mr. Biemiller, is I think smiling in retrospection on some of the things we learned by actually talking to them, of the fact that some of our British friends were not happy in the fact that they had to pay out of pocket in selecting the doctor who was not in the plan if he happened to be the doctor of their choice if they went to some doctor in whom they had little confidence, they had very little confidence in the whole system.

What I would like would be your comment on this: You spoke in answer to Mr. Dolliver about the St. Louis plan. I wonder how well that works out on a general basis? You and I know, as practical individuals, that about 90 percent of medicine is your confidence in the doctor that you go to. It is at least with me. I wonder what your experience is, the members of your own labor organizations that have

these setups, as to the feelings of individuals who want to have their own self-selection of their doctor.

Can you tell us how extensive that is?

Mr. CRUIKSHANK. Well, I can see why you ask the combined question about the British and the operation of some of our own programs. I think there is a parallel, although the parallel is limited. I do not think that the national health service of Britain would ever be a thing that we would want to undertake here in the United States. We do things quite differently here. I do feel this: When I was in England there was a continuing wider acceptance of the system, both among the patients and among the members of the medical profession, and I think that your chairman spoke of that observation on his recent trip here the other day.

I have asked that same question of some of our people who have been in these plans. You get varying degrees of the problem.

I asked a very sharp question, and you were very kind to me in your question, but I said, "How about the person who insists on going to a chiropractor?" Well, we let them go and, of course, we don't pay for it out of the system, and we do not put any pressure on them but I remember particularly talking to the head of a large retail clerks union in Los Angeles who had gone into the Permanente plan and we had spent a whole day together going over just these problems.

He said to me that an important part of this is that you can't go into this plan just by collective bargaining and buying into the Permanente plan. You have to have an educational program. We agreed with the doctors that they would have a period of 6 weeks when they would go around all over the areas of Los Angeles, in little groups of 15 or 20 where the covered worker and his wife would sit down and spend an evening talking to them about the advantages of this plan. We never put any pressure on them at all and if they wanted the services, they could have it.

At first, he reported to me that there was a question about it, the feeling that it was not satisfactory. But, it grows and grows rapidly until now there is complete acceptance of this method of doing it. Incidentally, in St. Louis, they ran more scientific inquiries on that subject than I was able to do myself. They had some professional opinion takers, who interviewed all of their members on a purely objective outside basis and made as nearly as they could an objective and scientific analysis of the attitudes of the covered people under the plan. They had them report that to the board of directors. They wanted to know what the people thought. They felt that honestly they could not get it either through the doctors, or the officers of the union going around, because they felt that would be a loaded answer. Instead, they got these opinion polsters who did a scientific analysis of what the attitudes of the covered people and the members of their family were.

I am sure that Mr. Gibbons would be glad to supply you with the records of those analyses that were made when he is here next week. Mr. BENNETT. Mr. Cruikshank, does your plan envision that upon the deduction of a payroll tax, the individual would be entitled to all medical and hospital services during the year, that either he or his family were in need of?

Mr. CRUIKSHANK. Just as comprehensive as it is at all practical to make it. First, you have some of the obvious limitations, if he is a mental-health patient and entitled to it or eligible to services of a State medical hospital, or tuberculosis or something of that kind. You do have to have some practical applications to what you can cover by the insurance program and prolonged chronic diseases.

Mr. BENNETT. I believe that you will agree that there is one of the most difficult provisions in such a proposal.

Mr. CRUIKSHANK. They are marginal and they are residual. They are something like the public-assistance cases that you will always have some of, no matter how good an old-age and survivors insurance program you have.

Mr. BENNETT. They are not covered, or they would not be covered under your proposal. The unemployed people or elderly people who have no employment income would not be subject to a payroll deduction and they would not come in under the self-employed provisions. You have many people that could not be included.

Mr. CRUIKSHANK. At the start, you have to make special provisions for those who are too old to be employed. That problem, over a period of years, would be washed out.

Mr. BENNETT. Those people are being taken care of under our present system, anyway.

Mr. CRUIKSHANK. I don't mean adequately.

Mr. BENNETT. I agree that that is probably true, but it is recognized that they are an obligation of either the State or the Federal Government insofar as medical bills are concerned?

Mr. CRUIKSHANK. Yes; the principle has been recognized.

Mr. BENNETT. I am interested in your thinking, from a practical standpoint, as to how far you would go under your proposal. Suppose you made it a 1-percent or 2-percent deduction of payroll from both employer and employee. How much medical and hospital service would you give the individual for that tax?

Mr. CRUIKSHANK. Just as completely comprehensive as it is at all practicable to do. I am not begging the question. Maybe, your question is: What is practicable? All, except a few of the marginal things such as chronic illness and long-time hospitalization and so forth, is practicable. Over a period of time, you could cover the aged retired people but to start with you would have to take care of them through some special provisions.

Mr. BENNETT. Under the British system, as I understand it, a citizen is entitled to all of the medical and hospital services that he needs, either he or his family.

Mr. CRUIKSHANK. Yes, sir, and I think we could do that.

Mr. BENNETT. You would not go that far, I thought you said.

Mr. CRUIKSHANK. Oh, yes; we could provide such things as drugs, specialty services, and the X-ray services, physicians and surgeons, hospital beds, and care, where it was needed, and visits in the home and office of the doctor and complete medical care except with just the very rare exceptions. It would just be complete and comprehensive

service.

Mr. BENNETT. In effect, then, you are in favor of giving them all of the medical and hospital care that is needed?

Mr. CRUIKSHANK. Yes, sir.

Mr. BENNETT. If that is the case then, I can't see why you would suggest that there is any need for any other kind of a plan, a healthinsurance plan.

Mr. CRUIKSHANK. I did not think that I did. I thought, or meant to indicate, that these plans could be integrated as administrative units within such a health-insurance plan.

Mr. BENNETT. I thought that in answer to a question by Mr. Harris you said, upon the adoption of the plan that you are suggesting, that it would be integrated with the private plans that are now working. I cannot see how that would be feasible, or how it would be necessary. Mr. CRUIKSHANK. Our health-insurance plan is primarily a method of finance. It is not a method of administering health services. Where you have existing and operating and going concerns that are providing health services, you could use them as the agency for providing the benefits or the services paid for by insurance. In many places, you would have to develop such agencies and instruments.

Mr. BENNETT. What I mean is if I was employed and had a tax deduction for medical expenses, I do not think I would be willing to pay another premium for a health plan.

Mr. CRUIKSHANK. You would not have it. The participation in the national health-insurance plan would preclude the necessity of having a payroll deduction for the other plan. Your other plan would only be used as the administrative agency for benefits.

Mr. BENNETT. Well, do you envisage under your plan, that the operations of the program would be in the hands of private individuals or private groups, or do you envisage that you would have to have a Government administered setup, something like the British have to administer the program?

Mr. CRUIKSHANK. The agency of the Government that you would need would not be an agency that would provide medical care. Those agencies would be local and under the maximum of local control. The agencies of government that you would need would be largely fiscal and to make the allocations among the States and at the State levels to make the allocations to medical agencies at the local level. You would not have Government, the United States Government or even State government, actually engaged in medical practice. You would only have them certifying the eligibility of an agency or institution to participate in the plan.

Mr. BENNETT. You would have to have a Federal agency to collect the taxes.

Mr. CRUIKSHANK. And to make allocations as among the States, yes, you would.

Mr. BENNETT. What kind of a formula are you going to use? Mr. CRUIKSHANK. The Public Health Service could be the agency which would make the allocations among the States and to determine the eligibility of a participating plan. The Internal Revenue Service would be the only agency you would need for the collection, such as the Internal Revenue Service collects the social-security taxes.

Mr. BENNETT. If you are going to write this into the law, and I assume that your idea in appearing here is to convince this committee that some law should be written to carry out this plan, how, administratively, would the Government fit in and where would States and localities fit in? I just do not follow your procedure you have suggested.