This proposed legislation is not insurance in the real sense; it is a political approach to a health problem. A Government-sponsored program inevitably costs more than actuarial figures would indicate, because there is no one with real incentive to see that costs are kept within actuarial bounds. In addition, once such a program is started, the demand for services mushrooms and yet is politically irresistible.

The experience of other countries proves this statement to be true. For example, the Lougheed report on the Saskatchewan hospital insurance plan states: "After 1 year of operation it was discovered that original forecasts of costs were about 50 percent too low. Those costs have continued to grow and in 1957 accounted for 23 percent of the total net general expenditure of the Saskatchewan Provincial Government."

The original estimate of the gross cost of the English National Health Service for the year 1957-58 was over $490 million, while the actual cost for the period was over $2 billion, or over four times the original estimate. In addition, to our knowledge only one public hospital has been built since the arrival of the National Health Service-despite the obsolete hospital facilities which were cited as one of the main reasons for the establishment of the plan originally. This is dramatically significant when contrasted to the great progress in Minnesota cited above.

The present explosive growth of the general problems of the aged should not panic us into acceptance of Forand-type legislation. Many important steps have been made and will continue to be taken to meet these problems through private enterprise. While some 43 percent of this group now has some form of health insurance, no one even knows what the total insurance coverage of the over-65 population is. At the current rate of growth of existing plans, 70 percent will have health insurance coverage in 1965 and 90 percent in 1970.

Pooling, reinsurance and similar techniques are available to speed development of these plans and to broaden their benefits. Farm group health plans are underdeveloped, at the present time, and should be further encouraged. Blue Cross and Blue Shield plans are in the process of offering sound, nationwide coverage, and commercial insurers have already inaugurated national plans for the aged with intensive campaigns. We urge the use of these existing tools and their expansion by all means possible. We deplore the prospect of their rapid destruction by enactment of the Forand bill.

We also wish to point out that approximately 45 percent of the persons over 65 in Minnesota at this time are ineligible for the proposed Forand-type coverage, as they are not recipients of social security. In view of the fact that 23 States (including Minnesota, with others to follow rapidly) already have coverage available to all the population over 65, and in view of the fact that these plans offer more extensive and more desirable coverage than H.R. 4700, we believe it would be tragic to institute a permanent and practically irrevocable plan that would destroy such programs and the incentive for their further development. Given reasonable time and proper encouragement, we firmly believe that the temporary problems that seem to have exploded for the aged will be solved by the same private enterprise and initiative that has given this country the finest health care in the world. Since it is our belief that the adoption of H.R. 4700 would destroy voluntary efforts to provide health care for our aging citizens, it seems to us most unwise to assume these unnecessary and staggering costs.

Attached is a copy of a resolution adopted unanimously by the house of delegates of the Minnesota State Medical Association on Monday, May 25, 1959, which demonstrates our attention to this matter before hearings on H.R. 4700 were scheduled.

In summary, the physicians of Minnesota are aware of the problems involved in providing health and medical care for our senior citizens. We are pledged to meeting this challenge by implementing existing plans, and we wish to be permitted to carry out this pledge. We believe that H.R. 4700 is unnecessary and destructive. We urge that a concerted national effort be made to publicize and strengthen the existing health plans which are so near to a solution of the problem at the present time. We will support what we believe to be suitable legislation to stimulate and encourage individual enterprise and effort to provide health care for the aged, and we would endorse thorough studies of sound new methods to meet this challenge. But we are unalterably opposed to H.R. 4700. Respectfully submitted.

B. B. SOUSTER, M.D., President.

THIS RESOLUTION WAS ADOPTED BY THE HOUSE OF DELEGATES ON MONDAY, MAY 25, 1959, ON RECOMMENDATION OF THE RESOLUTIONS COMMITTEE

Whereas the problems of aging are recognized by the American Medical Association as major and serious; and

Whereas Minnesota physicians recognize the broad implications of these problems; and

Whereas we, as citizens, fully recognize our responsibilities and are actively participating in the ultimate solution of these problems, both sociological and medical, Therefore, be it

Resolved, That the Minnesota State Medical Association commend those groups, private citizens, and public officials who have taken an earnest interest and have provided leadership in the recognition and study of the problems associated with the ever-increasing number of senior citizens. We fully appreciate the value of specially organized groups, such as the Governor's Council on the Aging, established by Gov. Orville Freeman, and sincerely hope that members of the Minnesota State Medical Association will be freely called upon for their assistance in studying the general problems of the aged and the specific problem of medical care for senior citizens.

STATEMENT OF OPPOSITION BY RALPH PERRY, M.D., PRESIDENT, MISSOURI STATE MEDICAL ASSOCIATION, ST. LOUIS, MO., RE H.R. 4700 (86TH CONG.) JULY 10, 1959

There are two basic reasons why Missouri physicians and the Missouri State Medical Association believe House Resolution 4700, the Forand bill, should not be passed.

First, we believe that any such legislation to provide hospital and medical care for social security recipients on a Federal governmental basis is unnecessary in the light of present-day progress in providing care on a private and voluntary basis.

Second, we believe that such legislation represents a threat to the quality of medical care in this country and can lead only to progressive socialization of medicine, with all the attendant disadvantages to the public that that would

mean.

The progress in the last year or so in providing protection for the older age groups both through the nonprofit community service Blue Cross and Blue Shield plans and the commercial insurance companies has been phenomenal. This progress will continue, if unhampered by government, and will become greater and better.

In Missouri, specifically, membership in the State's Blue Cross and Blue Shield plans is open to anyone without regard to age. Several commercial insurance companies are also providing coverage for those over 65. Protection is available and at reasonable costs.

We recognize that there will still be some who cannot afford such protection and who will not be able to afford to pay for their care. There are such people today. There is a great question, however, as to whether anyone has, or can, show substantial evidence that these people are not receiving full and adequate medical care. On the contrary, there is substantial evidence that there is no lack of care for them on a private, voluntary basis without Federal intervention. Physicians have traditionally accepted the responsibility to provide their services free of charge to those who could not pay. The local communities have taken this same responsibility in regard to hospitalization and are carrying it out excellently. No one in America today need suffer from a lack of medical care, no matter what his age. Care is being provided and without Federal Government control.

Physicians believe in the principle of care for the patient regardless of his ability to pay. The house of delegates of the Missouri State Medical Association voted unanimously to decline payment for physician's services under the FederalState matching program to provide medical care for welfare recipients. The physicians are willing to furnish care for these indigent patients on the traditional basis as they always have-they do not feel there is a need for Government payment for this traditional care or for Government intercession in the relationships between these patients and their doctors.

We believe the costs of the program outlined in H.R. 4700 have been seriously underestimated. The experience in Great Britain and other European countries and in the United States with Medicare and the Veterans' Administration bear out the contention that initial estimates of cost fall far short of actual expenses. As physicians we know the costs of providing care, and we believe the Forand bill would be a great deal more costly than published estimates indicate. This in turn would mean an even greater tax burden on the people.

Intervention of the Federal Government into the field of medical care inevitably affects the relationship between the patient and his physician. In any governmental program there must be control. These controls must in every case react in one way or another to interfere with the quality or quantity of the care of the patient, and the patient suffers. This is true now in programs already in existence in this country-the veterans home town care program, the Vendor programs, and certainly in the Medicare program. Whatever the good points of these programs, the fact of government payment and government control interposes an adverse element between the patient and his doctor that does not prevail when an independent patient freely seeks care from an independent physician.

The dangers of H.R. 4700 are not alone in its own provisions, although these are certainly great enough. It would be unrealistic to believe that, once put into effect, the principles underlying the Forand bill would not be extended until medicine was completely socialized. Extensions of the program can be foreseen in each succeeding session of Congress, until every American becomes a ward of the Federal Government for complete health care, while the cost of the program becomes impossible to support in addition to essential programs such as defense, and the quality of the medical care received by those who are ill deteriorates.

Because such legislation is unneeded in view of the progress in providing protection for those over 65 by priviate means, because such Federal programs are far more costly than provision of the same services on a voluntary and private basis, because intervention of the Federal Government into the health care field in this way will undoubtedly mean a lessening of the quality of medical care available to the public, the physicians of Missouri and the Missouri State Medical Association urge that the Forand bill, House bill 4700, not be passed.

Hon. WILBUR D. MILLS,

MONTANA MEDICAL ASSOCIATION,
Billings, Mont., July 20, 1959.

Chairman, Ways and Means Committee,
House of Representatives, Washington, D.C.

DEAR MR. MILLS: As a representative of the Montana Medical Association, I wish to record its opposition to H.R. 4700, hearings upon which were conducted by your committee during the week of July 13. We agree with the objections to this bill as set forth by the several representatives of the American Medical Association who presented testimony before your committee. I am aware of the objections that have been voiced by Leonard Larson, M.D., chairman of the board of trustees of the American Medical Association and of the other representatives of the American Medical Association whom you have heard. I was in Washington on July 14 and assisted in the preparation of their testimony.

We believe that here in Montana we are solving the problem of the care of the aged in a manner which is better than could be offered by a federally subsidized program. I would like to submit respectfully the following to your committee in support of this last statement:

(1) Since 1954, 266 additional nursing home beds, licensed under hospital laws, have become available and 116 more nursing home beds have become available and licensed under nursing home laws.

(2) Nursing homes under construction, which will be licensed under hospital laws, will provide another 68 beds.

(3) Chronic disease facilities presently under construction in Montana, which will also be licensed under hospital laws, will provide another 194 beds.

(4) In addition to the above there are in Montana as of June 30, 1959, 96 nursing and boarding home facilities with a total of 1,585 beds.

(5) There are 9 nursing homes affiliated with hospitals with a total of 128 beds and 10 other nursing homes with a total of 435 beds.

(6) This results in a total of 115 facilities with 2,148 beds actually in existence at the present time.

These figures may not seem impressive to members of your committee residing in large urban areas; nevertheless, they are impressive to us who reside in a State which has a population of scarcely more than one-half million, where the communities are smaller in size and where there exists a considerably greater tendency to care for our older age citizens in the homes of their children than may occur in the more crowded urban areas of this country where space is greatly limited.

In addition, through the State board of health, we are working in Montana to improve the quality of patient care in nursing homes. Using a pilot study in Bozeman, a working agreement has been established between the board of health and the nursing homes to organize assistance through local resources, including local health departments, welfare departments, the American Red Cross, civic groups, etc.; to develop an understanding and working relationship between local physicians and the nursing homes; to assist the nursing home facilities in developing and maintaining an adequate record system.

At the request of the House of Delegates of the Montana Medical Association, Montana Physicians' Service (Blue Shield) initiated on July 1, 1959, a series 65 coverage for individuals 65 years of age or older. This plan in Montana embodies both medical-surgical coverage and hospital coverage. More than one type of plan is being offered but, as an example, one plan provides complete paid-in-full benefits for medical-surgical services which include medical care, surgery, care of fractures, X-ray therapy, anesthesia, diagnostic X-ray and laboratory services up to $50 (after $10 deductible), and 120-day renewable benefits. Similarly, different types of hospital plans are being offered. One of the hospital plans, for example, pays $12 per day for 120 days of inpatient care during each period of disability and is renewable 90 days after discharge for another 120 days of care. In addition, it pays up to $150 toward the cost of listed extras. It should also be noted that the physicians in Montana are accepting lower fees from Montana Physicians' Service for care rendered under the series 65 plan.

The Montana Medical Association has, in addition, a very sincere committee on aging. This committee is studying actively the problems that exist in Montana and will have additional recommendations to submit to the house of delegates of the association at its next annual meeting in Butte during September. I believe that the physicians in Montana are accepting the responsibility not only for the organic diseases of their patients, but that they are working toward a solution of the social and economic results of such illnesses as they affect the individual and as they affect the community. It has been our feeling here in Montana that our citizens do not want charitable security, artificially created by taxation and legislation, but, rather, they desire an opportunity to maintain their productive usefulness to the community and thereby maintain their individual integrity and incentive.

We expect to actively participate in the White House Conference on Aging to be held during January 1961. We believe that to draft or to enact legislation such as H.R. 4700 before this conference will certainly be similar to treating a disease before its nature and its extent are fully known. Certainly, our representatives, who will attend the White House Conference on Aging, will be well aware of any problems that may exist in Montana. In addition, studies which are now being conducted will bring to light further solutions to the problems of the aging population and these solutions will become effective in Montana as soon as possible.

I would like to state in closing that I was very impressed with the way in which you conducted the hearings before your committee last week. The hearings were conducted with fairness, with impartiality, and with dignity. I left with the strong feeling of conviction that your committee plans to develop all of the facts relevant to this problem and that the solution as recommended by your committee will be the one which every member feels is a proper one for this country.

Sincerely yours,

JOHN A. LAYNE, M.D.

NEBRASKA STATE MEDICAL ASSOCIATION IN OPPOSITION TO H.R. 4700, 86TH CONGRESS, JULY 17, 1959, HOUSE WAYS AND MEANS COMMITTEE

Mr. Chairman and members of the committee, Nebraskans believe in free private enterprise. Since pioneer days, we think we have taken good care of our elder citizens. We think we are doing so now, and we feel that we can continue without Federal help and we hope without Federal Government interference. We still realize that the Federal Government has no money-only the power to tax and as more and more Federal programs are proposed to do things that we ourselves should, can, and want to do, we are hampered in our efforts and have less and less money with which to accomplish these ends.

In Nebraska we recognize two classes of the over age 65 group, which is quite apparently not done in H.R. 4700. This bill seems to conclude that all citizens over age 65 are indigent. There are many, many over age 65 people in Nebraska who are able to care for themselves, both physically and financially. Approximately 10 percent of our population are over age 65. The number of these people who are dependent on society for their food, clothing, housing, and medical care is unknown, and would require detailed survey to establish. It would seem fair to assume that the number is comparatively small. We arrive at this conclusion because of many factors. Blue Cross-Blue Shield reports that during 1958 they paid out approximately $700,000 to 12,000 to 14,000 people over age 65 on policies for medical and hospital care. This is only one company. We may reasonably assume that the total number handled by all of the insurance companies in Nebraska writing this type of insurance must cover and protect a considerable segment of this age group. It would appear ridiculous to set up a program of Government aid for this type of individual. State records indicate that there are approximately 15,700 individuals over age 65 on old-age assistance. This is the group that presents our problem, but it is in no way touched by the Forand influence.

What are we doing about these citizens? Certainly we are doing many things. We would like to point out some of these programs in Nebraska.

At the present time we have three units now in operaton for domiciliary care for the aged. These units are conversions of hospitals where new hospital facilities have been erected. Patients in these units have close proximity to medical care as well as hospitalization.

A law was passed in the last session of the Nebraska Legislature which makes it possible to permit the expenditure of inheritance tax funds for the relief of incapacitated or indigent persons through the construction of convalescent or geriatric units.

One of the more important facets of the care of the aged is, of course, the physician's care. What has Nebraska done about this problem? At the 1958 annual session meeting of the House of Delegates of the Nebraska State Medical Association, the Nebraska Blue Shield was directed to formulate a policy to cover the needs of the over age 65 group. This was to be done in cooperation with Blue Cross to provide hospitalization. Such a plan was to provide service at a reduced cost. The plan is now in operation. Each member may receive 60 days per year hospital care; 60 days per year in-hospital medical care, plus service benefits for surgical procedures. And the cost is only $7 per month. The hospitals in Nebraska are doing their part in this program. It is a wellrecognized part of the reason for existence for all hospitals that a portion of their budget should provide for care for the indigent. This is traditional, especially so of church-supported hospitals. A check of the three major hospitals in Lincoln, our capital city, and a reasonably prosperous community of 130,000 people, indicates that these hospitals provide as a part of their regular operating budget a sum of approximately $60,000 per year for care of the indigent. Passage of the Forand bill probably would not change nor take away this operational objective of these hospitals. A check of a number of Nebraska hospitals indicates that this same service rendered over the State is considerable.

Housing plans well distributed over the State are going into operation, part of which falls into the low-cost category for the benefit of our elderly citizens. The Committee on Aging of the Nebraska State Medical Association is cognizant of this problem and its many facets, and total effort is being expended toward resolving these difficulties into a smoothly operating program.

We may conclude that Nebraska is making a well-unified effort to give proper care to our citizens. H.R. 4700, known as the Forand bill, would add nothing to our efforts. In fact, it would interfere with our progress and eliminate a part of our present effort.