It is natural that we should want to do all we can to make the declining years and health of our senior citizens brighter and more comfortable.

But we should beware in analyzing the Forand bill of any "pie-in-the-sky" political schemes that would not only threaten the national economy but at the same time would fail to do the job.

It should be the sincere hope of all those interested that in the hearings in Washington, all of the advantages and disadvantages of the Forand bill will be exposed to public and legislative scrutiny.

The fact is that close to 43 percent of our citizens over 65 years of age already are covered by health insurance, much of this during the last few years.

Also, the Health Insurance Association of America expects this trend to grow until 75 percent of the older people who need such protection can be covered by voluntary health insurance by 1965, and 90 percent by 1970.

If Federal aid is to be provided, it would seem that the better channels for distribution of such aid might be through the existing plans.

Mr. FORAND. The next witness is Dr. Braun.

Would you come forward, please, sir?

Doctor, I understand that you are substituting for Dr. Butler and Dr. Lavietes.

STATEMENT OF DR. EDMUND BRAUN, MEMBER, BOARD OF DIRECTORS, PHYSICIANS FORUM, NEW YORK, N.Y.

Dr. BRAUN. I regret exceedingly that Dr. Butler who, for over 30 years, has been interested in the improvement of medical care as a practioner, as a teacher, and interested in the social aspects of medical care was unable to come today because his plane was grounded in New England. I will take his place.

I am former chairman of the Physicians Forum, a national organization of physicians, and a member of the board of directors, and a member of the executive committee of the board of directors.

I am in private practice in New York.

Mr. FORAND. At this point, I would like to read for the record a telegram I received this morning from Dr. Butler. It says:

Regret that cancellation of airplanes from Marthas Vineyard this afternoon and evening because of fog prevents my being present at hearings 10 a.m. Tuesday as planned. Hence, I wish in this telegram to record endorsement of the Forand bill, H.R. 4700. Written statement has already been sent to the committee together with the policy statement of the board of directors of the Physicians Forum. We again, as specifically mentioned in our statement last year, feel some revision of the bill is needed to protect the quality of the medical services to be received by OASDI beneficiaries. The low standard of current welfare medical and nursing home care must be avoided. Fragmentation of services must be replaced by comprehensive medical services and standards must be defined for nursing homes if the proposed extension of benefits under the bill is to provide the desired quality of medical services. I would be very glad to discuss this aspect of the bill with members of your committee at any time. The form letter from Dr. Orr, president of the AMA, entitled "Legislative Alert,” and dated July 7, that urges doctors to contact their Congressmen immediately to ask them to register opposition to the Forand bill, indicates the usual reactionary attitude of AMA officials. I trust you know that such official opinion often is not that of the majority of physicians. For example, such official opinion is still opposed to including physicians under social security though the majority of physicians are now on record as favoring inclusion.

I have been unable to notify Dr. Braun, whom I was joining at your hearing in representing the physicians for us. Would you kindly tell him of this telegram and my inability to be present.

It is signed, "Dr. Allan M. Butler, President-Elect, Physicians Forum, Chief of the Children's Medical Service, Massachusetts General Hospital, and Professor of Pediatrics, Harvard University."

Dr. BRAUN. I would like to introduce the statement of our position in favor of the Forand bill into the record and then, in addition, I would like to make some comments of my own which have relevance to certain aspects of the problem of the Forand bill.

Mr. FORAND. Doctor, without objection, that will be included, and you are recognized for 10 minutes.

(The statement referred to follows:)

TESTIMONY OF THE PHYSICIANS FORUM ON H.R. 4700 PRESENTED BY DR. ALLAN M. BUTLER, PROFESSOR OF PEDIATRICS, HARVARD MEDICAL SCHOOL AND CHAIRMANELECT OF THE PHYSICIANS FORUM, INC.

I speak for the Physicians Forum, a national organization of physicians in existence for more than 20 years. Our members, who number over 1,000 and are mainly private practitioners, also belong to their county medical societies or other recognized professional associations.

The Physicians Forum appreciates this opportunity to present our views in favor of adding medical care benefits to the Federal social security system, a plan we have advocated for many years. The official position of the Forum on H.R. 4700 is contained in a policy statement which follows my introductory remarks.

The years of medical practice of our members and professional associates gives us extensive personal knowledge of the great medical needs of the aged and the frequently insurmountable obstacles they encounter in attempting to get good medical care. More often than we wish to recall, we have seen our patients, on reaching retirement, fail to receive necessary hospitalization, diagnostic procedures, and other medical services, and forced to give up their personal physicians.

From our experience we also know that currently available health insurance has not eliminated the financial obstacle to good medical care for the aged. Many do not have health insurance, particularly those needing it the most, while those covered still suffer considerable financial hardship because benefit payments are usually so inadequate.

Our elderly patients with Blue Cross policies are also the hardest hit by the current wave of increases in Blue Cross rates; as a result, many find it difficult to pay the premiums and some have had to give up their policies. We are deeply worried about the unfortunate predicament these patients will face when they require hospitalization.

It is clear to us that currently available health insurance must be bolstered by the Federal social security system to assure universal coverage of the aged regardless of their limited and usually shrinking economic resources.

In the 23 years of the Federal social security system, we physicians have witnessed with gratitude the financial help it has provided to our patients. For many, this was sufficient to maintain their personal dignity without which mental and physical health rapidly deteriorates. For some, it made possible the continuation of important doctor-patient relationships or the purchase of necessary medical services. To the best of our knowledge, the benefits of the Federal social security system have been provided with a minimum of red tape and without political interference.

More recently, the Federal social security system has worked directly with the medical profession in administering the disability freeze and the disability benefits programs. Practicing physicians who have participated in this work have found the same rational approach that has characterized the entire system. In particular, there has been no interference with professional judgments, no loss of professional integrity, no lowering of the quality of care.

As physicians, we are distressed and ashamed that our principal professional organization should continue its anachronistic and unscientific opposition to the entire Federal social security system. The AMA has never presented specific evidence to support its sweeping indictment-there is none. Its dire predictions have never materialized-they were unwarranted. The AMA has and can only resort to political generalities, which were discarded officially by the American people 23 years ago and are now forgotten except by the AMA and a fringe element unresponsive to current American political thought and structures.

Most distressing and shameful to us physicians is that the AMA's policy is undemocratically maintained. We are convinced, from our personal acquaintance with the medical profession, that the overwhelming majority of physicians, like the American people in general, support the Federal social security system. In fact, it is so much an accepted part of our society that physicians never talk about it privately; it is only brought up in public speeches of medical politiciansrabble rousing bombast and platitudes based neither on the realities of America today nor on the actual views of physicians generally.

Supporting evidence for this last conviction of ours is the gross discrepancy between the official AMA policy and the objectively determined views of physicians towards inclusion of physicians in the Federal social security system. According to the most recent poll conducted by the independent magazine, Medical Economics, 56 percent of the Nations' self-employed physicians want social security coverage and 30 percent do not. This has been confirmed by the many polls conducted by State medical societies, distorted reports, and interpretations by organized medicine's leaders notwithstanding. It is difficult to believe that the majority of physicians favoring Federal social security coverage for themselves are opposed to the system in general.

Thus, as practicing physicians, we believe the medical profession should welcome the program set forth in the Forand bill as a first and essential element in the current nationwide effort to improve the health of the aged.

One principle in the Forand bill deserves special endorsement by responsible physicians the provision of medical benefits in the form of service rather than

cash. Unfortunately, too many patients with cash payment insurance are charged higher fees so that the value of their insurance is minimized.

On the other hand, the medical profession would legitimately benefit in an economic way by a Forand bill program. Judging from the effects of voluntary health insurance, extension of coverage to a large new group of people with modest or low incomes, means full payment to physicians for many services previously provided on a charity or semicharity basis.

It is important for physicians to realize that the Forand bill would not significantly alter the present pattern of providing medical service. Rather, it is primarily a mechanism for improving the method of financing medical care for the aged.

Some organizations and individuals are suggesting that the surgical benefit provision of the Forand bill be deleted. Again, experience with voluntary health insurance proves that hospitalization without physician services and diagnostic procedures is costly medically as well as financially. Rather than restricting the proposed benefits, we strongly recommend their expansion to a more complete curative and preventive medical service.

Last December, the AMA launched a major counteroffensive against the Forand bill. The principal new weapon is a proposal that physicians lower their fees for care to the low-income aged, on the premise that this would permit health insurance plans to reduce their premiums correspondingly. This proposal partakes fully of the AMA's penchant regarding social policy to be unbelievably oldfashioned, irrelevant, and even indifferent to the economic well-being of most physicians.

This proposal is nothing more than a public relations stunt to divert the public and the profession from the basic attitude of the AMA: "For those who do not have sufficient resources of their own, indigent medical care programs should be supported with adequate State and local appropriations." (Point 3 of “A SixPoint Health Program for Older Citizens" developed by the AMA committee on aging.)

We are deeply disturbed that it is some of our fellow physicians who are so callous as to promote the charity medicine approach. We are confident that most physicians have a higher regard for their elderly patients and a sounder understanding or what is good for the health of the aged. If the choice were presented to physicians fairly, they would reject the AMA position and enthusiastically endorse, as we do, the Forand bill which would give all our elderly patients the financial possibility for personal, continuous, and high quality medical care.

THE FORAND BILL-A STATEMENT OF THE BOARD OF DIRECTORS OF THE PHYSICIANS FORUM

PART I. GENERAL COMMENTS

The Physicians Forum enthusiastically endorses H.R. 4700, Representative Aime Forand's Social Security Amendments of 1959. This bill would correct, to a significant degree, one of the major deficiencies of American health insurance inadequate coverage of the aged. What is most important, it does this in a way which meets most of the Physicians Forum's long-standing criteria for satisfactory health-insurance plans.

Summary of the medical care section of the Forand bill

H.R. 4700 adds to the benefits now available to persons eligible for retirement and survivors benefits under the Federal social security system, the following medical care benefits:

(1) Semiprivate hospital care for a maximum of 60 days in a 12-month period; (2) Care in a nursing home when transferred from hospital for a maximum of 120 days in a 12-month period less the number of days of hospital care received in that same 12-month period; and

(3) Fully paid surgery in a hospital (including oral surgery) and in a hospital outpatient department or a doctor's office.

These medical care benefits are limited to services which are medically necessary. Free choice of surgeon is stipulated, provided the surgeon is certified by one of the American surgical specialty boards, is a fellow of the American College of Surgeons, or is on the attending surgical staff of an accredited hospital except in cases of emergency, in cases where such qualifications are not practicable, and in cases requiring oral surgery when a dentist is acceptable.

A National Advisory Health Council would be available for consultation by the Secretary of Health, Education, and Welfare who is given the primary responsibility for administering the program at the national level. Nonprofit voluntary insurance plans or organizations representing the hospitals, nursing homes, or doctors may be utilized to the extent that their use contributes to the effective and economical administration of the program.

The bill contains the usual clauses guaranteeing the confidential nature of medical information about individuals and prohibiting Federal control of or interference with the participating institutions or the practice of medicine.

Basis of forum endorsement

There is universal agreement that most retired aged persons have great difficulty in financing their medical care. Many who have been covered by health insurance while employed are not able to continue such coverage on retirement, for then, when their income is reduced, the cost of the health insurance is almost always at least doubled because of the termination of the employer's contribution and the increase in rates that frequently occurs for those over 65.

The best solution to the problem is the use of the Federal social security system as proposed in the Forand bill. This solution has been advocated by the Physicians Forum for many years. It is also endorsed by the AFL-CIO and major consumer organizations. This solution was also one of the unanimous recommendations of the last Presidential Commission on the Health Needs of the Nation, and was recognized as desirable by the Commission on Financing of Hospital Care.

The use of the Federal social security system provides a sound financial base coupled with a scale of contributions proportionate to the individual's ability to pay. It also surmounts the geographical and nongroup enrollment problems commonly associated with other health insurance programs.

The possible alternatives are admirably analyzed in the recent report of the Department of Health, Education, and Welfare "Hospitalization Insurance for OASDI Beneficiaries" issued by the Committee on Ways and Means of the House of Representatives. In our opinion, the inescapable conclusion of this analysis is that the only other practical alternative is public assistance medicine. The only organization seriously advocating this solution is the American Medical Association.

This solution, which is often inadequate, is distasteful to the American people and, in addition, is unacceptable to the Physicians Forum as not conducive to high-quality medical care and not compatible with good doctor-patient relationships.

The AMA more recently has embarked on a program to lower the fees physicians charge to those over 65 with modest or low incomes with the hope that this would permit the development of effective insurance plans at reduced rates. Even if these efforts were successful, they would have little relevance to the overall problem. Physicians' fees for the general population account for only 25 percent of medical care costs. The reduced-fee program obviously could not lower the costs of hospitalization, diagnostic procedures, nursing service, drugs and rehabilitation-all required to a much greater extent among older people. Even with respect to physician services, voluntary health insurance plans take care of only 20 percent of the fees charged to those covered.

In view of the fact that a Nation as wealthy as ours can afford the fair cost of the medical care required by its people and that it has established an effective mechanism by which the people finance the basic needs of the older age group, the Physicians Forum seriously questions whether the medical profession should be asked to subsidize the cost of medical care for the aged. Moreover, physicians with upper-income clientele will make no real contribution to the reduced-fee program, while those with lower-income clientele, insured or noninsured, will have to make a substantial financial sacrifice.

Outstanding features of the Forand bill

We particularly commend the requirement that the medical care benefits be in the form of services rather than cash indemnities. The Physicians Forum strongly believes cash benefits in any type of health insurance are so inadequate and so vulnerable to serious abuse that they often defeat the purpose of insuring the patient's medical bills.

Another most desirable and significant requirement is the restriction of participating surgeons to those properly qualified. The Physicians Forum believes that in the absence of standards for promoting a high quality of care self-im