quired to obtain more clerical help to fill out Government forms. Doctors were forced to divert time from the care of patients to supervise reporting and often had to make lengthy justifications to remotely involved utilization review committees and ordinary government clerks as to why they did what they thought was necessary at the time of decision. Expensive, cuumbersome, and inefficient Government administrative procedures for control of use and cost and for research in improving medical care, diverted doctors and other scarce medical personnel from patient care.

Dr. SACKETT. I am a doctor, Walter Sackett, a practicing physician in Miami for 30 years and a member of the Florida legislature for 4

years.

The Honorable J. Enoch Powell, Minister of Health in the United Kingdom for 3 years, says in his book "Medicine & Politics" (see Appendix I) that when the recipient pays no money for medical care, he has no sense of responsibility. Also, that:

The vulgar assumption is that there is a definable amount of medical care "needed" and if that "need" was met, no more would be demanded. This is absurd, as every advance in medical science creates new needs ..

The difference between a legislator's and doctor's viewpoint is important. For a doctor, the general law is relevant only as it helps or hurts the individual. For a politician, the individual case is relevant only insofar as it illuminates the general law. For a Government employee, the individual case must be subordinated to some general rule. Uniformity is demanded which causes quality of medical care to

suffer.

INDIVIDUAL VERSUS COMMUNAL RESPONSIBILITY

Mr. McNerney, national head of the Blue Cross Association, as agent for the National Government obtains large sums of taxpayers' money, and as a chairman of a task force on medicaid and related problems, recently reported that:

The country today is well into a transition from considering that health is largely an individual affair to understanding that health is necessarily a community affair.

This is basically wrong-it is patently evident the primary responsibility for a competent individual's health rests in that individual himself. Communal interest is no substitute for self interest and, therefore, cannot replace it.

THE TACTICS SAME TO PROMOTE SOCIAL SECURITY AS MEDICARE

Madam Perkins in 1962 reported to HEW employees how the Social Security Act was passed. This HEW publication gives the uninitiated a glimpse how power is manipulated.

We got advice. All these actions were for the purpose, not so much of advice as of propaganda. The constitutional problem was the greatest one. How could you get around this business of the State-Federal relationships? Justice Stone supplied the solution: "The taxing power, my dear, the taxing power. You can do anything under the taxing power."

This is the reason of course that we built so strongly on the taxing power and the whole system of taxation is the basis of the Social Security Act. We gave way on washing out universal insurance; that is, universal coverage. We let them take out one group after another; no objections, just so we got the basis of

the bill.

In establishing the principle of medicare the same tactic was used. Proponents said: "If we can only break through and get our foot inside the door, then we can expand the program after that."

The advocates of medicare got their foot inside the door, established the principle, and here in this legislation, are seeking to expand the program. Mr. McNerney's task force report on medicaid sheds light on what the Federal interventionists intend. For example: "The escalation from individual need to community crisis, to public decisionmaking, is the choreography of social action in a democratic society."

THE POOR ARE MERELY THE EXCUSE

"To infer from our recommendations that steps need to be taken only with respect to the provision of health care services for the poor and the medically indigent, would be to lose completely the significance of our criticisms as well as the opportunity for great progress." Bismarck's great discovery-long before McNerney-consisted in a device for making political capital out of poverty and human suffering.

MEDICREDIT

The dangers and defects of Government intervention cannot be avoided by calling it "voluntary medicredit." It is a trap because : Government is to pay; therefore, it will control; but, demand will exceed supply due to the absence of the restraining force of individual responsibility. Former Secretary Celebrezze said of the Bow billmedicredit principle-"It will require stringent Government controls on the insurance industry."

The scheme of subsidy and special privilege to closed panel, per capita prepayment group practice in the bill (H.M.O.) is another foot-in-the-door trick. (See app. V)

It is designed to expand it to people under 65: increase Government expenditures; is not new; is backed by Mr. Wilbur Cohen, the UAW, Mary Lasker and Mr. Rockefeller. HEW has propagandized for it for years; it did not grow in competition as its Government promoters hoped: State laws are to be attacked with HEW money.

Dr. Garfield, director if the Kaiser plan admits: extending Government health insurance to the entire population would compound demand; is folly; will result in serious deterioration in quality and availability of services for the sick; after years we learned that when fee-for-services is eliminated the regulator of flow into the system is gone, worried-will usurp doctor's time and interferes with care of the sick and freedom of choice of alternative systems is preferable for both the public and physician.

It is regrettable that time did not permit us to fairly show why the United States is so healthy and prosperous under freedom. We urge you to study the more complete material we have briefly submitted. Please send us questions which we will be happy to answer for the record. The best system in the world deserves to be defended without compromising principle.

Thank you, gentlemen.

(The prepared statement and appendixes follow. Hearing continues on p. 373.)

STATEMENT OF THE ASSOCIATION OF AMERICAN PHYSICIANS AND SURGEONS

The Association of American Physicians and Surgeons is a nationwide Association of doctors with membership in over 1,300 counties, in all of the 50 states, and Puerto Rico, and in the District of Columbia. The members seek through this Association to protect the responsibility, independence and freedom of doctors and patients.

We appreciate this opportunity to present our views on the legislation before you at this time.

We are deeply concerned about the trend of this legislation which extends Medicare and revises Medicaid. Our concern deepens as we study the report of your staff on Medicare and Medicaid problems in which the failures of these programs are admitted. We are not reassured by the admissions in a recent HEW Task Force report on Medicaid. Also, statements of the Administration advocating deeper and deeper government intervention into medicine disturbs us. Also, apparently well intentioned, but misguided, efforts to perpetuate these admitted failures-with doctors policing other doctors in an attempt to make an inherently unsound approach work needs careful examination in the light of fundamental principles.

Government intervention in medicine is fraught with profound moral, economic and political consequences which are presently only gradually being explored and understood. These consequences are widely misunderstood by the profession and public alike, as being accidental, transitory, easily remedied or due perhaps to the weakness of a particular approach, employee or administration. This is not so. The strains and stresses, the inadequacies and dissatisfactions which the profession and public experience are implicit in the nature of government intervention itself.

MEDICARE AND MEDICAID ARE IN TROUBLE

After five years of Medicare and Medicaid these "programs are in serious financial trouble." Costs have soared and waste is so apparent, that it is now admitted:

The two programs are also adversely affecting health care costs and financing for the general population.

As you will recognize, these are statements from your staff's report of February, 1970 exposing the situation. We thank you and your staff.

These programs are in such difficulty that about one year after Medicare and Medicaid started taxes were increased 25%. Now it is proposed to further increase taxes by many billions of dollars. Without these increased taxes HEW admits that funds will be exhausted in less than 12 years.

HEW SPENDING EXCEEDS ALL CORPORATE PROFITS; GNP OF CANADA, ETC. However, the situation is even more grave than government reports disclose. For example, the entire Department of HEW is now spending at an annual rate of over 59 billion dollars per year. This is more than all the profits after taxes of all the corporations of the United States (58 billions vs. 48.5 billions of profits after taxes). It is the most expensive non-war operation known-exceeding the 57 billion dollars gross national product of the entire 20 million people of Canada. Legislation which has passed the House would increase HEW spending another 42 billion, increasing the spending by HEW alone to over 63 billion dollars. This is over 50% of the gross national product of either West Germany, Japan, the United Kingdom, France or Italy. (Statistics for socialist countries such as the U.S.S.R., etc. are not published.)

Yet, H.R. 17550 proposes that HEW spend more.

Your staff states:

Unless the rapid and continuing escalation of the costs of health care are moderated, the Congress may reasonably anticipate increasing pressures upon it to extend the Medicare and Medicaid programs to encompass large segments of the population not now covered under these public health payment plans.

WRONG KEY

It is suggested that Medicare and Medicaid can be made to work more efficiently and economically by tightening government controls and administration. The report states:

The key to making the present system workable and acceptable is the physician and his medical society.

The suggestion is made that the profession needs to "police and discipline itself" and that

Prompt action is necessary by organized medicine (and other health care professions) to do what is required with respect to monitoring care pro vided and charges made for the care.

Your staff has sounded this warning:

We fear that virtually insurmountable pressures will develop for alter native control procedures which may be arbitrary, rigid and insensitive to the legitimate needs of both the patient and his physician.

WELFARE AND THE POLICE STATE

The fear expressed should not be surprising. In the book "Compulsory Medi cal Care and the Welfare State" Melchior Palyi clearly described the growt and extension "of governmentalized medical care systems on the Continent of Europe and in England."

The Key to making the present system workable and acceptable is "NOT th physician and his medical society" but rather for the elimination of the excessiv spending and interference generated by these programs.

POLITICIAN VS MEDICAL CONSIDERATIONS

The fact is that political medicine is bad medicine—not because politics is ba and medicine is good, but because the two do not mix. Wherever medicine ha been dominated by politics, it has been bad. These facts are well known:

1. Competition for votes results in promising more quantity and quality o medical benefits are available. (The hospitals, doctors, nursing homes, nurses etc. required to provide this care on the level promised, or the electorate think is promised, do not exist.)

The record speaks for itself. Political promises have been made that gover ment will give benefits with :

(1) Little or no cost to beneficiaries.

(2) No governmental interference in, or control of the practice of privat medicine;

(a) Patients are promised freedom of choice of hospital and physician (b) Physicians are promised freedom to choose where to practice wit freedom to exercise independent, professional judgment in diagnosin prescribing, and caring for patients. Also, they are promised that the will be free to serve whom they choose at fees not fixed by governmen It is promised that government will pay usual and customary feesthat doctors may look to their patients for full reimbursement of charge Thus, the patient would be responsible for the difference between th doctor's bill and the amount allowed by government.

The publisher says "He makes clear how these services have been used in a countries to augment and strengthen control by politicians and bureaucrats. I addition, he has provided insight into the origin and development of Welfar State doctrine and deeds." In 1949 the publisher said:

During the past few years most Americans have begun to comprehen that vast revolutionary forces are in ferment in this country. It must understood that the establishment and extension of Welfare State concep and mechanisms lead to an inevitable end. If implemented here, they ult mately would mean for America, the frightening confusion that is Europ the tragic austerity that is England, and the Godless despair that is Russia

ACTION NEEDED

We agree that prompt action is necessary, but not by doctors. Prompt actio should be taken by government to stop this reckless spending and waste. Th actual crisis faced by the United States results from the lack of discipline, co trol and restraint by the central government. Excessive government spending ar interference in the name of the Welfare State is a major cause of our curre trouble. Doctors did not ask for these programs. In fact, we warned strong against them. They have failed.

2 Expectations of voters rise, they believe that everyone will be able to have all the medical care he wishes. All will be equal. All will get the best.

3. Voters believe that hard choices will no longer be the individual responsibility of the patient. He will no longer have to choose between using earnings for medical care needs as well as for housing, clothing, food, education, automobiles, colored TV, liquor, tobacco, vacation trips at home and abroad, recreation, etc. The Government will take care of almost anything. (Except a promised Small ($1.00) monthly payment for medical care.) Former President Johnson, when Vice-President, said: "Why anyone would want to deny a person the opportunity of putting in a $1.00 a month, along with his employer, to insure himself through Social Security against the staggering costs of hospitalization simply amazes me."

4. It is promised that utilization review committees are required-not to interfere with medical judgment or practice but to be sure that doctors do not put patients in hospitals unnecessarily or keep them there too long. Who judges is left vague in the law.

5. Executive Branch employees' estimates of costs to the public treasury, and for taxes are low. Such low estimates are accepted by some legislators who tell voters how much they are doing for them and skillfully avoid telling them what they are doing to them.

ALL OF THE FOREGOING ESTIMATES HAVE PROVEN TO BE UNREALISTIC AND THE REPORTS OF YOUR STAFF FOR THE MOST PART SO INDICATE. THE REASONS ARE CLEAR.

When the individual was relieved of responsibility of exchanging something of value for the medical services he sought, he felt no responsibility for restraining his wishes.

As a result, the demand for hospital care and doctor visits increased materially. This artificial demand for hospitals and doctors forced costs up to government and private seekers of services alike.

Taxes were increased. Government force was used to begin enroaching upon private practice.

Physician and hospital employment of more clerical help to fill out government forms was required. Doctors were forced to divert time from the care of patients to supervise reporting and often had to make lengthy justifications of why they did what they thought was necessary at the time of decision.

Expensive, cumbersome and inefficient government administrative procedures, for control of use and cost and for research in improving medical care, diverted doctors and other scarce medical personnel from patient care.

As the costs mounted, doctors and hospitals were blamed for higher utilization and costs without meeting demands. Now additional price-fixing and more red tape are being threatened. Poorer quality care will be the inevitable result. This key principle must be re-emphasized-it is necessary that the individual patient must be responsible to obligate himself in order to keep his wishes from being considered rights without duties thus causing demand to completely outrun supply. The individual patient and individual doctor must exercise independent, responsible judgment if we are to have good medicine. The doctor and patient are closest to the problem and are most competent at the time to make the best decisions for everyone concerned. If responsible individuals acting as such do not curtail irresponsible demand then government will ration demand on a political basis.

Not only are national government and state governments in trouble because of uncontrolled welfare spending, but Britain is in similar trouble.

The Honorable J. Enoch Powell, Minister of Health in the United Kingdom for three years, in a book: Medicine and Politics, points out that when the recipient pays no money at point of service for medical care, he has no sense of responsibility and from this many real problems are created. He says:

Common thought and parlance tend to conceal or deny the fact that demand for all practical purposes is unlimited. The vulgar assumption is that there is a definable amount of medical care 'needed' and if that 'need' was met, no more would be demanded. This absurd. Every advance in medical science creates new needs that did not exist until a means of meeting them came into existence, or at least into the realm of the possible.