So some of this is working out all right. But there are a lot of people that are not healing themselves.

We do have a problem in putting them within the reach of decent medical service.

Now we do not sit here, Doctor, and dream up plans in the night to stretch the gargantuan hand of the Government over all the world and all over the people. We are pushed and shoved into this by an angry constituency, all of us are suffering the anger of constituents who most of the time deplore the quality and availability of their medical services and that is what prompts us to action. We are not innovators here. Dr. ENGLAND. I know that.

Mr. VANIK. There are bulldozers behind use and there are thousands of people who want to replace us if we fail to do something to take care of their health problems.

I have been around here a long time and I can promise you that I have not seen any places that I know of on Capitol Hill where Members are sitting in quiet dark chambers trying to think of new ways to spread the heavy hand of Government over the people.

There is no sinister thing like that going on. We are just trying to deal with the problems that are thrust upon us and, believe me, we do not feel that we have created the problems entirely. We feel that the problems are or have been created in part by your profession, by the health services activities, and by the people. We all have a hand in creating that problem.

But I would like to have your—you suggest no action. Most of the doctors I talk to suggest no action.

It is difficult for me to stand by and see people that I love and whose friendship I cherish and whose votes we need-we need to keep them alive, you know-suffer needlessly.

[Laughter.]

Mr. VANIK. I just hate to see them perish for lack of decent medical service and hospital service.

I want to say this, that this evil thing called medicare was conceived right in this room, and do you know why it was conceived? At the time we brought medicare to life, most of us were only thinking about a hospital insurance program but the doctors say, "No." AMA says, "Oh, no; there should be full coverage." They did not believe that but they wanted to mess up our plans, so we just consolidated the two ideas and medicare, and part of medicare, was created by cooperation with the American Medical Association, which I assume you are a member of, are you not?

Well, you do not have to answer that.

Dr. ENGLAND. I am.

Mr. VANIK. That is how it came to being. Now, if it is an evil thing, I want you to know that the doctors of America, through the organized association, helped us to bring it about. They have a part in the conception.

Dr. ENGLAND. May I make a comment?

Mr. VANIK. Sure.

Dr. ENGLAND. You covered an awful lot of bases.

Mr. VANIK. Well, I do not have much time. Give me 15 more minutes and I will go.

Dr. ENGLAND. I have the feeling that what is interpreted as constituents' demands frequently finds its voice through an exercise such as we are participating in this morning, where parties who have various interests in this problem come to Washington and say thus and thus and thus is so, and the response of the legislator is, "Oh, the voice of the public."

Well I am not the voice of the public. I am Bob England, I am nothing more. I am a member of AMA. I cannot and did not support the tragic errors that they committed even back as far as KerrMills.

There were terrible misjudgments of what really was right and wrong.

That is no secret to you now nor to them then.

Now, the figures that Mr. Cathles was talking about, those people who do not have the type of insurance that is spoken of here today as ideal or comprehensive or whatever that might be by who ever's definition, it would seem to me it ought to be by definition of the guy paying for it, he should decide what he wants.

Now I will agree, there may be some people who are not able to afford what they really want. In my experience, this is not a great number. There are other people to whom paying their hospital bill and paying their doctor is a low priority item. That is freedom. They can do that if they want.

Then we take whatever is left over and say, here is the problem that we have to take care of. These people-well, the ones that decide not to spend the money for the type of insurance deemed proper are making a judgment that is wrong. Now, these are your constituents that are making these mistakes. To what other areas of decisionmaking might their stupidity extend?

That is the question that I think no Congressman really wants to answer, or ask even.

I do not believe that it is the function of the Federal Government to wet-nurse us all.

I cannot think of anything that is more stifling to the development of an individual than to keep him in a nursery school forever and ever. Now, we are approaching the area where an idea has become extant that the citizens of this country just do not know what is good for them and somebody here has to tell them.

Now, I do not believe that it is Congressmen. But unfortunately, you are the ones that have to take the rap.

I presume that identification with regard to Attila the Hun should be responded to somehow. For purposes of identification I wouldMr. VANIK. I did not apply that to you; I said I have heard other doctors that I knew who

Dr. ENGLAND. Well, I prefer not to get tarred by a lot of brushes. I am a registered Democrat, for whatever that does to that side of the table.

[Laughter.]

Dr. ENGLAND. And I am not a right wing extremist, but I am sure a lot of people think I am. But you know, what they think about me really does not matter a of a lot as long as I have my own head on straight in a manner that satisfies me. If I am free, I do not have

any other responsibility except not to impose my judgments on somebody else in the exercise of his liberties.

What I am saying is that while being a Democrat, perhaps even in spite of it, I still revere the Constitution and it disturbs me to see the general welfare clause pulled and stretched and pushed in every direction to promote social action on the part of the Federal Government that the framers of the Constitution had no idea they were setting up. It is personal opinion, probably way off base, but that is the way I feel. Increasingly there are more and more people that strangely are beginning to identify Government as somewhat of an enemy. Watergate sure did not help you in the public image. The things that have happened with gas and oil, and legislation with right to employment such as affirmative action, none of this is helping you or your image. The people are beginning to identify the cost of living with those really responsible for it. You talk about the price of medical care and the policies back in Massachusetts when you started out and compare them with now. Now what kind of comparison is that?

It is in fact completely illegitimate. What position would a housewife be in, following a recipe, if every day some son-of-a-gun came along and changed the volume that a cup of sugar contained? Cooking would be in the same situation that we are running into now and would be just as indigestible as what we are going to get.

I think all you have to do is take the 1930 dollar, where is it now? For that matter, take the 1967 dollar. Where is it now? Sixty-seven cents in 1973. I do not know what it is now. But I can tell you it sure ain't what it used to be. That is a problem.

Mr. ROSTENKOWSKI Your time has expired, Mr. Vanik.
Mr. Corman will inquire.

Mr. CORMAN. Thank you, Mr. Chairman.

Gentlemen, I have just been reflecting on my own history, which I realize is not any guide for a general situation. But I have lived 5 years of my life under a totally socialized medicine system, 15 years with a very good private insurance, and 35 years in an out-of-pocket situation, and in exercising my individual judgment as Dr. England has suggested we all do, I have decided never to become a patient in a hospital. I am glad of that because a great number of my peers who did decide to die, and I think that may illustrate really what the individual decision in this field really means.

We do not decide to be sick or not sick, and we really do not decide how much to spend for needed medical care at the time the problem arises because if we could do that we would never have had a private insurance system in the first place.

I would like if each of you would make a selection among these three general categories without defending them or getting into the intimacies of them because, depending on your answer, I may want to pursue other questions that relate to how the private system can fit in with all this.

If you had your choice of a public system, a compulsory private system or leaving things where they are now, which would you opt for, realizing that there are wide variations among them but philosophically those are three distinct approaches.

Professor Somers?

Mr. SOMERS. Yes, first, if I may, just as a way of getting into this, I would say I was under the impression when we came that we were being asked what role we would see for the private sector in some future national health insurance plan. In my opening remarks I tried to indicate I think it is very important that in any plan a role, a very significant role, be permitted for the private sector that could be constructive.

However, I found myself in a peculiar position with my colleagues on the panel, I gather the burden of the statements has been that there is nothing wrong with what is being done now in the private sector, and I do wish to completely disidentify myself from that, particularly the notion that 144 million people have adequate health insurance and defining a Blue Cross contract as that.

I happend to be a member of the board of directors and have been for 15 years of one of the largest Blue Cross plans in the United States, and the notion that what we are selling is an adequate program strikes me as absolutely absurd. If we doubled it we would not be adequate. My family spends over and above the

Mr. CORMAN. You are going to use my 5 minutes and I will not have a chance. Perhaps I did not make my question clear.

If I could have the floor back just a moment, I think I did not make my question particularly clear. I am talking about the financing end of health care, not that we draft all doctors or that we burn down all insurance buildings. I am talking about the financing end.

Mr. SOMERS. If you are talking about financing only, of the three alternatives you mentioned, it seems to me there really is no option. It has to be publicly financed. It cannot be done any other way.

Mr. CORMAN. Thank you.

Mr. SOMERS. But I would add one remark. I would not think that implies it has to be administered by the Government.

Mr. CORMAN. We will get back to that.

Mr. Stark?

Mr. STARK. Yes, I would say we have all been born into this world and I do not believe that we should be forced to save all of our lives for a future illness. I do not think that we are ever going to be able to do this entirely in the private sector. I think it is going to need a good deal of support from the public sector.

Mr. CORMAN. Thank you.

Dr. England?

Dr. ENGLAND. Well, I think it is pretty well understood where I stand. I think that is a Hobson's choice, frankly.

Mr. CORMAN. At least at the moment you would not move us from where we are to the direction we are apt to go?

Dr. ENGLAND. Let's not make any more errors, no.

Mr. CATHLES. I do not believe you can solve the problem completely by going any one of these routes. I think there has to be a mixture. I do not think you can leave things the way they are and solve the problem. I think you have to have some public financing. I think if you mandate private you will have something less of a problem, but still a problem. You have to have some public financing, but I do not think public financing by itself is the right mechanism by any means.

Mr. CORMAN. We are not going to undo the $40 billion of the public sector we have now. I am not suggesting that. But I assume the next

step you would foresee would be a compulsory or mandated private misurance system minig in the gaps where needed with Federal funds. is that pretty much your feeling? Are you familiar with the former Nixon proposal?

Mr. CATHLES. Yes, I am, generally.

Mr. CORMAN. Well, as between that and the old Kennedy-Griffiths bill, Kennedy-Corman I hope now, which of those two directions do you think we ought to go?

Mr. CATHLES. Closer to the old Nixon approach.

Mr. THOMPSON. Congressman, I would reject the status quo and I would expend public and private funds for this support.

Mr. CORMAN. All right. If we go to the compulsory private, would you anticipate that there will be a significant part of the population that has the ability to pay premiums and should not be the subject of public assistance. Therefore, who would be eligible for this kind of group standard if they want to buy it, but who might just opt not to do it when they look at the cost?

To put it another way, will that not take a significant selling job on a case-by-case basis which will have to be added to the cost of health care?

I would ask you gentlemen to speak to that, perhaps Mr. Thompson and Mr. Cathles.

This is where I get hung up on, you can compel an employer to buy insurance for his employees, but what do you do with those who do not opt for it and their income is such that the public would not accept them as charity cases?

Mr. THOMPSON. Obviously in the category of the employer-employee group or the group so stated, the concept of a voluntary participation at least I find distinctly unattractive. I do not think it makes sense.

We are talking about a mandated period and a voluntary participation. I do not see a point to that, no.

You mandate the nongroup level, to a certain degree substantial economies should be inherent in that. The fact that everybody would be participating would go to that.

Mr. CORMAN. How do you get them to participate?

Mr. THOMPSON. In the nongroup category you wind up you do not have a representative sampling of the society at large. That is why the nongroup is difficult.

Mr. CORMAN. What do we do with those folks or should we not do anything with them?

Mr. THOMPSON. Of course you should do something with them. There should be a mandated minimum level of benefits in that category and there should be a mechanism to the extent that people's income prohibit or inhibit their participation that they are able to participate through financial assistance.

Mr. CORMAN. Then you would require every citizen to buy a private health insurance policy?

Mr. THOMPSON. I would provide every citizen a minimum level of insurance which he would either buy or be made available through some governmental mechanism.

Mr. CORMAN. I guess we have to suspend again. I hope to get another 5 minutes because I want to get through this one barrier with respect