It should be emphasized that the association's conclusions regarding H.R. 4700 were reached only after thorough deliberation and study of all the considerations involved including, specifically, the plight of aged persons who may not, at the present time, be able completely to bear the costs of adequate health care. In full recognition of the fact that deficiencies may exist in the availability of health care for some of our older citizens, the association is convinced that H.R. 4700 does not provide a practical or desirable solution to the problem; the association is equally convinced that there are other, more efficient, more economical programs which can and should be expanded to meet the problem. Dr. Friedrich will present the remainder of our statement, after which we will be glad to answer any questions.

APPENDIX-AMERICAN DENTAL ASSOCIATION POLICY ON FORAND PLAN

(H.R. 4700)

Resolved, That the plan for providing personal health care benefits to OASI beneficiaries within the Forand proposal (H.R. 4700) and similar bills is in conflict with the association's principles governing Federal support of personal health care programs; and be it further

Resolved, That the council on legislation apply the following restatement of principles to testimony on the Foralnd plan and similar proposals:

1. The American Dental Association has recognized that the Federal Government may justifiably provide health care, or financial support for health care, of persons within the following categories:

(a) Persons in military service for whom the Federal Government bears a direct responsibility.

(b) Veterans of military service to the extent that their dental disorders are directly attributable to their military service.

(c) Indigent persons through grants-in-aid in support of local and State welfare health programs.

The association is opposed to Federal financial support of personal health services for other segments of the population.

2. The association is opposed to the use of the OASI program as a device for financing personal health care for the following reasons:

(a) There is no evidence that OASI beneficiaries, as a class, are unable to finance their own personal health care.

(b) Those OASI beneficiaries who are unable to finance their personal health care can be provided for within the local and State welfare health programs supported by the existing Federal grants-in-aid contributions. (This is already being done, and to an increasing extent under the 1956 expansion of the Federal matching grant program for the health care of public assistance recipients.)

(c) With increasing pressures to have the Federal Government bear greater portions of the cost of personal health care from Federal taxes, there is a strong probability of an equal reaction against Federal expenditures for public health and research activities. The Federal Government has a long way to go in these fields.

3. The Forand plan and similar measures, in effect, require that participating practitioners subscribe to fixed maximum fee allowances. Experience in most Government programs of this type illustrates that the following takes place :

(a) The Government soon determines that it cannot afford the realistic cost of the services offered to beneficiaries of the Government plan.

(b) The cost of service is, therefore, held down, or even reduced, at the expense of those who provide the services; the Government also precsribes limitations on the types of services made available to beneficiaries.

(c) Because the plan is professionally unsound, many practitioners discontinue their participation in the program.

(d) Finally, the quality of care steadily diminishes to the detriment of the beneficiaries.

4. The growth of voluntary private health care plans should be encouraged by all groups. The program proposed within the Forand plan and similar measures would, in the association's opinion, seriously interfere with the development of private health plan coverage for the aged and other beneficiaries of the OASI program.

Adopted by the house of delegates, American Dental Association, November 1958.

Mr. CONWAY. Before calling on Dr. Rudolph Friedrich to present our statement, I should like to indicate for the record that the American Dental Assoication represents about 85 percent of the 120,000 practicing dentists in this country, that the association is opposed to H.R. 4700, the Forand bill, and that a copy of the policy statement adopted by our 1958 house of delegates is attached to Dr. Besdine's statement.

I ask that also be inserted in the record.

The CHAIRMAN. Without objection, it may be done.

Mr. CONWAY. Mr. Chairman, I would like to turn the presentation over to Dr. Friedrich.

The CHAIRMAN. Dr. Friedrich, you are recognized.

STATEMENT OF DR. RUDOLPH H. FRIEDRICH, SECRETARY, COUNCIL ON DENTAL HEALTH, AMERICAN DENTAL ASSOCIATION, CHICAGO, ILL.

Dr. FRIEDRICH. Mr. Chairman, and members of the committee, I am Dr. Rudolph H. Friedrich of Chicago, Ill., secretary of the Council on Dental Health of the American Dental Association.

Purpose of the bill: H.R. 4700 would introduce a system of federally financed health care for all persons eligible for OASI benefits under the Social Security Act. The hospital, nursing home, and surgical benefits specified in the bill would be provided to eligible persons without regard to whether such persons were retired from gainful employment and without regard to their financial needs. The program would be administered by the Secretary of Health, Education, and Welfare, who would be responsible for, among other things, the negotiating and making of agreements for health care services with hospitals, nursing homes, physicians, and dentists throughout the entire Nation. Dental care would be limited to oral surgery performed in hospitals, and emergency oral surgery performed in a dentist's office.

Interest of the dental profession: Although it is recognized that dental care is a small part of the total health care benefits specified in H.R. 4700, the bill has far-reaching implications for members of the dental profession as well as others interested in the Nation's health. There is always the real possibility that once a program of this kind is enacted, it will be extended progressively to include comprehensive care for large and larger segments of the population.

Accordingly, the American Dental Association is concerned both with the dental aspects of the bill and, more importantly, with its broad implications regarding the future roles of voluntary groups and the Government in providing health care to the American public.

Traditionally, the Government has not and should not assume a major role in the provision of health care to the public-at-large. Up to now, its direct participation has been limited to those situations in which there has existed a responsibility for or special relationship between the Government and the beneficiaries. Such a responsibility or relationship exists, of course, between the Government and needy individuals covered under public assistance programs or between the Government and its military personnel or veterans who are debilitated as a result of military service.

H.R. 4700, however, represents a concept that is a marked departure from previous policy. That proposal would place the Government in the position of providing health services to a large segment of the population, including a substantial number of persons who have no special relationship to the Government and who are not in need of financial assistance.

It is believed that once the Government embarks upon a program of this kind-providing health care to a segment of the general public without regard to need-it is reasonable to expect that eventually the entire population will be included. The dental profession is concerned that such a consequence is inherent in H.R. 4700 and that it would be to the ultimate detriment of both the recipients and the providers of health services.

Simply, and frankly, the dental profession is greatly disturbed over the very real probability that programs of the type embodied in H.R. 4700 may be extended until the Government becomes the sole purchaser of all health services. The doctors of dentistry in this country, with good reason, are concerned that under the domination of one giant consumer there will be a loss of the independence and integrity that characterize and are essential to the acceptable practice of any profession.

As lawmakers, the members of this committee are well aware that in industrial life, when one business concern devotes its entire production to one big consumer, the former soon loses its independence and is placed under the complete dominance of the latter. Ultimately, the identity of the purveyor is merged indistinguishably with that of the purchaser.

In the case of practitioners of the healing arts, such a condition cannot help but result in an encroachment upon the professional judgments that must be made in the best interests of patient care; it cannot help but destroy the independence of professional judgment that has produced unequaled excellence in dental and medical treatment and care in this country.

The dental profession is confident that there are means of putting adequate health care within the reach of all those in need, including the needy aged, without resort to a system that we are sure will lead to a crippling of private professional practice and in turn to a lowering of general standards of health care.

Needs of the aging: The association recognizes that there may be a serious problem involving many of this country's older people. The association does not, however, agree with the assumption that the number of aged persons unable to meet the costs of their health care needs approximates the number who would be entitled to receive hospital and surgical care under the provisions of H.R. 4700.

Nor does the association agree that the primary need of all aged persons is for the kinds of health care specified in the bill. In this connection, there is much evidence that many of the problems of the aged stem from environmental and social factors rather than physical health factors.

There is a growing belief that it might be highly desirable to initiate a broad educational program to teach the aging how best to adjust to their longevity. Many believe that a prime need of the aged is for ordinary housing, or housing with a minimal amount of attendant

care, and that it would be foolhardy to fill the already overcrowded hospitals and nursing homes with persons who do not require intensive and costly hospital and nursing home care.

Effect of H.R. 4700 on existing facilities: Moreover, there has been no finding, to our knowledge, of the effects which inauguration of the pending proposal will have upon the availability of health services to segments of the population other than the aged. Experience with similar plans in other countries clearly shows that where health facilities and services are provided to persons entirely free of any cost, there is a normal tendency toward excessive utilization of those facilities and services.

There is a grave question as to whether existing health care facilities and manpower can deliver the services envisioned in H.R. 4700 and continue, at the same time, adequately to serve the millions of people who are in need of hospital and surgical treatment but who do not meet OASI requirements. Are there enough hospital beds, physicians, dentists, and nurses to accommodate the aged in hospitals to the extent and in the manner contemplated in the bill, without displacing others equally in need of care? These questions should be answered before rushing headlong into the proposed program.

Effects on other age groups: In Britain, the national health plan dental program was instituted despite the fact that there was a shortage of dentists; the result has been overemphasis upon treatment of adults at the expense of the young.

The first element of a sound dental program is to take care of the young age groups where dental diseases can best be prevented and controlled.

Primary interest of the dental profession in the consideration of dental care programs for any group is dental care for children. In the early and regular care of the deciduous teeth and the first 8 years of the permanent dentition, dentistry can make its maximum preventive contribution to the oral and general health of the individual. Dental care during this period involves a relatively simple and limited scope of procedures which require much less operating time than is involved in adult care. The cost of providing essential dental service for children is, according to present estimates, less than one-half of the cost of providing essential dental service for adults.

Children's programs properly administered permit the correction of dental defects as they occur and prevent an accumulation of dental need. A generation of children who have had good dental care will reach adulthood with an appreciation of good dental health and an interest in maintaining their dental health.

It follows, too, that their adult dental care will not be a financial burden to them.

With the existing shortage of practitioners, it would seem unwise to introduce a program which, by concentrating care on the aged, might cause serious imbalance in the availability of care as between age groups and result, as it has in England, in a lowering of general dental health standards.

Productive Government programs: It would seem much more prudent for the Government to make its contribution toward programs which eventually would benefit all segments of society. These would include, among others, grants-in-aid for construction of dental and

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medical schools; support for fellowships, training programs, scholarship programs, and of utmost importance, dental and medical research projects.

In the long run the most effective solution to the dental health problem lies in the area of preventive dentistry. The association has consistently urged the Congress to provide increased funds for dental research. It has only been in the last 3 years, however, that realistic appropriations have been made by the Federal Government for this important purpose. As a result, there is now the beginning of a flourishing and productive program of dental research being conducted in schools and other institutions throughout the country, as well as at the National Institute of Dental Research. The contributions which these programs are making toward improvement of the dental health of all the people are unparalleled in importance.

One danger inherent in the advancement of proposals such as H.R. 4700 is that the Federal Government will be under such heavy pressure to finance treatment programs that progress in other fields such as research will suffer not only from lack of funds but from the diversion of manpower from research activities to professional practice. This backsliding has occurred in England and could occur here.

Experience with government programs: It is helpful but not necessary to look to foreign countries for examples of what usually happens when the government engages directly in the provision of health care. There are domestic examples close at hand. Ordinarily, there is a pattern in these things. First, the Goverment overcommits itself; it promises more than it can deliver. Second, costs are underestimated. Third, government fiscal authorities become unhappy. Fourth, appropriations are curtailed. Fifth, services and/or fees for services are cut-usually by laymen having an eye on the budget rather than on adequacy of care. Sixth, many practitioners withdraw from the program. Seventh, freedom of choice evaporates. Eighth, quality of care degenerates and patient-beneficiaries become dissatisfied and disillusioned.

The Veterans' Administration program provides a case in point. Shortly after World War II, the Veterans' Administration outpatient dental care program was providing treatment to thousands of veterans. Almost 85 percent of the care was rendered by dentists in private practice under the so-called hometown program. During the period between 1947 and 1952, the Congress appropriated, on the average, about $35 million each year for the hometown dental program. During this period, nevertheless, there was a progressively expanding backlog of applications for treatment caused solely by inadequate funds.

Despite the fact that many veterans entitled to dental care could not obtain that care under the hometown program, Congress reduced the fiscal 1953 appropriation for hometown outpatient dental care substantially, the House Appropriations Committee indicating in its report that "medical and dental fees are too high" (H. Rept. No. 1517, 82d Cong.). Actually the fee schedule for the Veterans' Administration program was significantly lower than fees charged generally by dentists.

For fiscal 1952, the Congress not only retained the appropriation for the veterans' outpatient program at the 1953 level but inserted a rider in the appropriation act limiting the veterans' entitlement.