Committee on Economic Security (CES)

Volume VII. Health in Relation to Economic Security


Part 4- Wednesday Morning Session, January 30, 1935

Medical Advisory Board

Wednesday Morning, January 30, 1935

The meeting was called to order at 9:20 a.m. by Chairman Sydenstricker.

DR. LELAND: (Illustrating with charts) The black represents counties in which there are no general hospitals. The shaded areas are counties in which there are general hospitals not recognized or registered. The white represents counties in which there are general hospitals on the registered lists. In each county the number of physicians are given. In each county where there are hospitals the number of hospital beds are given.

We have uniformly used a fifty-mile radius here around the chief centers in which there are general hospitals. This does not include mental, nervous, tuberculosis, or other special hospitals-merely the showing of facilities that are available for general care.

The whole area of the United States is being compared in this way, and when this is done a large map putting them all together and giving a bird's-eye view of the whole United States will be prepared.

To show you the difference in these and why we thought it was necessary to use a uniform radius, you can see the difference in the California circles, which are also fifty-mile radii, and those in some of these other states.

DR. ROBERTS: Let's put Georgia up there just for fun. (Laughter)

DR. LELAND: If we put Georgia beside Arizona it is quite a contrast.

Now if we take Connecticut you can see where our circles are. This is a fifty-mile radius again using this as a center and also these two as centers. Here is the circle out here and here, so that the whole state is taken in.

Here is another one (map of Delaware) with Wilmington as the center.

There is Florida. There is Idaho. Illinois-of course, representing one of the states of quite a different situation. Here is one that Dr. Bierring will be interested in-Iowa and Kansas.

By looking at all those maps it will give you a little sample clear across the country. Each state is being prepared in this same way. At the end we will have a complete United States map altogether but without all of this detail on it. It will show all of this shaded, black and white area, with the circles.

DR. CRILE: I am not sure that I get the significance of the black and white.

DR. LELAND: The black represents counties in which there are no general hospitals. There may be in some of those counties (we haven't spotted them) some special hospitals which are not available for general care. The shaded represents counties in which there are general hospitals that are off the registered list. The white represents counties in which there are hospital facilities that are on registered lists.

DR. GREENOUGH: That has no reference to density of population?

DR. LELAND: This particular map does not have.

DR. GREENOUGH: You could, for instance, have a state that had, we will say, fifty-fifty black and white which would still have far less population than a more densely settled state and thereby perhaps more people go without hospital facilities in a densely populated state.

DR. LELAND: For example there is Arizona with not a black county, and there are one or more general hospitals in every county in Arizona.

DR. ROBERTS: I have been out there and lived in and studied that country. Those counties are 150 miles across. This county here (indicating) is larger than the State of Connecticut.

DR. BIERRING: The circles would indicate that?

DR. LELAND: A circle indicates that, but I should say also (and Dr. Davis can amplify this) that he and Mr. Mills are collaborating in a similar study, with just a little different method. In Mr. Mills' study he uses this same method of a circle to indicate an area, but he goes farther in outlining the counties which might be included in this area and then outlines other districts in the state. Then he finds the bed capacity of that county, or in other words the number of beds per population. He has gone into considerable more detail in another direction than we have in this study. Perhaps the two may need to be used in conjunction.

CHAIRMAN SYDENSTRICKER: This will be very useful when we have hearings or anything of that kind before the House and the Senate.

DR. LELAND: If I may offer just a little suggestion as to contrast, I believe that these maps more easily show at a glance the condition of hospital facilities than Mr. Mills' map, because this black and white area stands out much more clearly than an area outlined in red without any contrast.

CHAIRMAN SYDENSTRICKER: I should think, Doctor, we should use those before the Hospital Advisory Committee too.

DR. LELAND: I should like to have available for you at that time, if it is not too urgent, the whole set and that will be finished probably by next week. It ought to be.

CHAIRMAN SYDENSTRICKER: That will be fine. That is very interesting indeed.

DR. CRILE: May I ask a question while you are waiting, that is in your careful studies would you say there has been progress made in the health and longevity since 1900?

CHAIRMAN SYDENSTRICKER: Oh, undoubtedly tremendous progress. I can't give you the figure exactly as to the expectation of life (I have it somewhere but I can't quote it exactly) but it has been advanced several years.

DR. CRILE: About twelve.

DR. FALK: All ages combined?

CHAIRMAN SYDENSTRICKER: All ages combined, but that expectation of life at forty, for example, has not increased at all. It is all in the early ages, the saving of infants' lives and children's lives.

DR. HORSLEY: There is a recent article in the Atlantic Monthly by Professor Miller (or some such name) in which he gives statistics showing that the average age expectancy of women is now 62.8 and of men it is 69.3.

DR. CRILE: Somebody gave me the figure that there are 50,000,000 people living now who would not be living in the United States except for what scientific medicines has been able to do.

CHAIRMAN SYDENSTRICKER: On the other hand we haven't done very much toward the prolongation of adult life.

DR. CRILE: But the child has more fun.

CHAIRMAN SYDENSTRICKER: But we are having fewer youngsters all the time. Our birth rate is declining rapidly. We are not reproducing ourselves except in the country districts, so that our health problems are bound to be shifted to adult society.

MR. SIMONS: Unfortunately I can't give you the exact name of the publication, but you probably know the article. It was in '32, and it was a publication of a study in New York primarily on heart disease to show that heart disease was not increasing, but I noticed they gave some life expectancy tables. It is the only one I have seen which did show an increase in the life expectancy for people over forty and fifty years of age.

CHAIRMAN SYDENSTRICKER: There seems to be no evidence from the official figures as to an increase in expectancy.

MR. SIMONS: I don't know enough about them.

CHAIRMAN SYDENSTRICKER: Of course, it depends somewhat on the locality.

MR. SIMONS: That was the first I had ever seen that tried to prove that point.

CHAIRMAN SYDENSTRICKER: It depends upon the locality. I think you will find in New York State some increase in life expectancy, but taking the country as a whole there is not only no increase but evidence of a decrease.

DR. HORSLEY: As to that article I spoke of, I remember now it was in the February number of Harper's Monthly.

DR. CRILE: We are always speaking of two plans, the Rich (?) Plan or this plan. It seems to me that the first thing that we could appropriately think about is what we now have, with it improved and its faults ironed out. I don't feel that we must all concede that we have been entirely wrong. The profession of medical science has apparently made the greatest progress of any of the sciences. I think the achievements have been very notable. The progress has been very rapid in so many directions, it seems to me that we should not think just of what is going to happen because medicine has failed. It doesn't seem to me that we are quite ready to say that it has failed.

CHAIRMAN SYDENSTRICKER: I don't think medicine has failed. I should say that our present methods are good, but they ought to be extended. This whole task that the Committee on Economic Security has passed on to us is really not an indictment of medicine or of public health or of any of those things. It is a question of extending what we are doing to the entire population and a recognition of new problems that will arise in the future. We are an aging population.

DR. CRILE: It may be just our professional pride-I mean the profession as a whole. I think we have the feeling that there has been a tremendous job in all directions, in public education and all those things, and it seems to me there are three things that we can do: Increase it, or modify it, or improve it, but not break its spirit. For instance, the last question that you asked me last night which I could not answer, namely, what should be the wage level. I am not an economist and I don't know, but I would say this, that after an egg is spoiled it doesn't matter what more you do to it. You may ruin medicine so far as I can see by taking out of it the greatest thing there is as an incentive to do work.

CHAIRMAN SYDENSTRICKER: I think, Doctor, that you expressed a very interesting idea. It is true nobody is indicting medicine, nobody is indicting public health, and nobody is indicting the efforts to improve the economic condition of the people. It is a question of extending the beneficial effects of all that to all the population so that all may benefit by it. I think there is plenty of evidence to indicate that not all of the people of the United States benefit from what we know about how to prevent and to cure disease. The real problem is the extension of that so that these benefits so far as we have them can be extended. We know perfectly well that we can't cure everything and we can't prevent everything, but some of these days we can prevent more and we can cure more and we ought to have the facilities, it seems to me, available in some way or other.

DR. CRILE: I should like to return for a moment to your table. It is very interesting to me (I am not speaking of these rural counties, but I mean in the populous counties) that 10 to 15 per cent of the people who were sick and should have had attention didn't have attention. That figure is very close to that of the non-conformists. I mean the people who do not believe in scientific medicine and who are just naturally intellectually lazy, and beside that 90 per cent are self-curable or incurable. So sometimes a figure doesn't give you the picture. A difference between a fact and a truth is sometimes not very large.

DR. DAVIS: I should like to add a little to that point with a concrete example. In the Mulberry District of New York City, a densely populated district in the lower central part of Manhattan, a considerable portion of the population is Italian, but a good many of them are of a mixed group. In 1923 one of those sickness surveys was made by visits to the families by graduate nurses, getting the cases of sickness that had recently been in a family and the nature of the medical care, that is whether they had had a doctor, how many visits he had made, whether they had been to the hospital for the illness, and so on. In that study the percentage of those going through an incapacitating illness which kept them from work, or confined them to bed, or kept the child away from school was quite large-not 10 and 15 per cent, but running in the twenties, and in some sections of the district running up to 30 per cent. There you had a population in a city, with ample facilities, with plenty of physicians, close to large hospitals and close to medical schools. That was in the recovery period two years after the panic of 1921. It was a rather intimate study, the families were pretty thoroughly looked into, so that the elements of the socioeconomic condition of the family were known. The factor of poverty was the predominating factor rather than the factor of ignorance. Of that there can be no question because there was a desire expressed to have a doctor.

I am also thinking of the study that was made in Duchess County, New York, in 1915, in which in an area partly rural and partly urban, in a middle-sized town with hospitals and with plenty of doctors, the proportion was considerably larger, especially in the rural section, running over 30 per cent of the people who went through incapacitating illnesses without any medical attention.

The feeling of one who comes into personal contact with these studies has its significance because the feeling one has is this: You feel on the one side the point of view of the physician who is not aware for the reason Mr. Sydenstricker mentioned yesterday, because these people from the nature of the thing do not come to his attention-the lack of ability to get at that group of people because they must come to him; he cannot go to them-and on the other hand the people who come in direct contact with them in their homes have a feeling of pity for these people who are suffering and there is absolutely no question in the minds of the people who go into the homes and come back with reports that there is a desire for medical care.

DR. CRILE: Of course, I can't understand how that desire could be expressed by somebody and this negativity not be overcome by some system. Plato's state has not been realized, has it?

DR. DAVIS: That desire would express itself promptly if you removed the fear of expense in many more than half the cases.

DR. CRILE: Haven't they got hospital dispensaries, Doctor, and all that?

DR. DAVIS: In the Mulberry District within a quarter of a mile-at the maximum a half-mile walk-there are some of the largest and some of the best clinics on this continent.

DR. CRILE: And they would have served them?

DR. DAVIS: Would have served them, yes, but these are not poverty-stricken people in that district. They are earning their way and they are not looking for charity. They don't want charity. They don't want to go to a clinic and be investigated.

DR. CRILE: You can't arrest them and make them take medical care.

DR. DAVIS: They would go if they could pay a doctor. They pass right by the doors of doctors every day when they go to work and they don't go to them. I mean that is their point of view. I am quite sure of that.

MR. SIMONS: It seems to me that there are involved with this certain fundamental fallacies in reasoning. They are involved a good deal with what Dr. Falk said last night. (Excuse me for presenting what seems to be basic in what we are discussing.) I was somewhat surprised at the statement that most economists make that sort of classification of the payments of physicians. I have made as thorough a study of the writings of economists in relation to the medical profession as I could possibly make and I have had the aid of the heads of economic schools of large universities, and I have never found an economist who stated anything of that kind. However, that wouldn't necessarily follow. You can't prove a negative. But I think that bears, as I think I will show, on what I have to say here. That, however, indirectly involves a very old economic fallacy, and that is a sort of a recrudescence of the economic man: the supposition that every person in all of his economic relations always measures things by the principle of gain. Some of the economists of the middle of the last century would confine economics entirely to gain, and along with it was the idea that nothing else was used; that, therefore, the physician, in what is called this hedonistic calculus, sort of set to work and calculated that he would charge one man $100 and then, if necessary, he could work free all day and it would be the same.

I am bringing that in in connection with what you are saying for a moment to show the bearing of it when we make these studies. I wouldn't pretend to know vital statistics, Mr. Sydenstricker has forgotten more than I will ever know on that subject, but I do raise the question which you brought up as to some features and the means of correction. Nobody would deny that there are a certain number of people who are not receiving medical care and are not receiving it for economic reasons. I think that when you begin to make such an investigation that you take for granted the excuse which they give that they have no money in a great many cases. I think that is not rue of your nurses, but in some cases I think the diagnosis and the necessity of treatment is not there. The fallacy which I believe exists in that lies in this, that when you go to these people the remedy for the existence of the disease consists almost exclusively in the furnishing of medical service.

I think that in any one of those investigations you would have found if you had inquired (and I don't believe your facts are available to back it up) that there was poor housing which was responsible, you would have found that there was a lack of fresh vegetables and milk and the necessary diets that couldn't be obtained which were far more essential to the restoration of health than the visit of a physician, and especially the sort of a visit of a physician or care that is given, as I believe, in most of the insurance systems that we have.

If when you got back from this investigation you had gone to a renting office, you would have found the landlord sitting there or his agent. According to your economic theory he is charging the tenants all that he possibly can, but he is not sitting in his office an hour or two hours, or any number of hours a day, to furnish free houses to people who are unable to pay him. The same thing is true of the merchant and of all the others.

In other words, the defect in that whole thing is the assumption which some of the older economists had on the one side that there was this calculation. In the case of the physician if he follows the example of the landlord and the merchant that I have spoke of he becomes a quack and he becomes a member of a commercialized group that refuses to accept what the profession has always claimed to be the legitimate burden of caring for the poor and the sick.

You can carry it over into the field of law, which has a much more close analogy. We are told that justice should always be free and that a lawyer should defend anybody regardless of money, but we all know that there is not the professional pressure there and that the lawyer as a usual thing only defends without charge when assigned by a court. He does not sit there and charge a corporation all that he thinks he can for a day's work and then for the next two or three days give his services free.

I think there is a very big defect in the economic analysis there, and further, just to carry it a bit farther, in the proposals that you simply remove the economic difficulty to medical practice and leave the remainder of the economic pressure (I am fairly recognizing that the Committee on Economic Security has proposed to take a lot of that off) you are creating to a certain extent (I am on more dangerous ground now and all economists wouldn't agree with me) the same conditions that prevailed in the Elizabethan poor hall. The physician who gives free service helps to keep wages down and to maintain this condition, and you find, as a usual thing, that the pressure for this economic relief comes when the struggle for wages gets hard, forced at the same time by international competition and struggle, and I am just throwing out the idea that the effect of insurance has not been to so distribute the burden among the people less able to bear it that they can all be maintained at a lower wage than would be possible otherwise.

CHAIRMAN SYDENSTRICKER: That is an extremely interesting analysis Mr. Simons. The implications of it are disastrous from the point of view I would say of the medical profession which has a quite different ideal and a quite different point of view from that of the cold-blooded economist. There is a certain amount of sentiment I would gather, a certain amount of idealism in that profession which would prevent the doctor from not seeing a sick person for fear the economic order might be disturbed. I don't think the ordinary physician would refuse to see a patient because of being afraid the economic order would be disturbed.

MR. SIMONS: If I gave any such impression I want to correct it momentarily.

CHAIRMAN SYDENSTRICKER: That is where your argument would obviously land on a thing of that kind. The very fact that we have economic disorder, which we hope the Committee on Economic Security will help to alleviate at least, it is there but does that prevent a physician from going and seeing the sick? Does that prevent any system from being developed whereby even these people who are the victims of economic maladjustment receive medical care? I think we have got an entirely different outlook here from the economic point of view.

MR. SIMONS: I evidently didn't make myself clear.

CHAIRMAN SYDENSTRICKER: Yes you did, but I think that is where it lands.

MR. SIMONS: Today as things are it does exist, but there is nothing else to do in the midst of this proposition as long as it exists.

CHAIRMAN SYDENSTRICKER: Than I don't see the point of the argument.

MR. SIMONS: Then the point of the argument is that merely taking away the economic obstacle to medical practice and not taking it away to other things may rather aggravate than help the thing.

CHAIRMAN SYDENSTRICKER: I still point to the fact that where you land in your argument is that we mustn't do anything about taking away the economic obstacle to medical care.

MR. SIMONS: I see where I have made my mistake.

CHAIRMAN SYDENSTRICKER: We have got to wait until everybody gets enough money to pay the doctor before we give medical care.

DR. ROBERTS: As I understand it we doctors are one-third philanthropists, one-third entrepreneurs, and certainly one-third philosophers. Now we have been philosophizing for nearly fifty minutes and we can philosophize here for a month. I enjoyed Mr. Simon's talk (I should like to get off in the corner with him and I just had to put the four-wheel brakes on me to keep from talking), but hadn't we better get down to the job in hand and minimize our philosophy? This question of health insurance and the job that this board has been given is just a tiny rivulet among many other rivulets that are flowing into the larger stream of economic security. It is just a tiny rivulet and hadn't we better follow the rivulet whose path we have been given to follow?

Furthermore in the light of all this demand for health insurance and medical service, philosophize as you may, is the crying need of the American people-we might just as well face that thing-and 90 per cent of the Negroes in my state do not get anything like adequate medical care. Sixty per cent of the farmers in my state (and 75 per cent of the state is farmers) do not get adequate medical care. They have lacerated pelvic floors from Rabun's Gap to Tybee Island, and they never get them repaired because they have no money for repairs, and they get practically no obstetrical care because they just haven't got the money.

I have a friend who has over 3,000 acres of land and he told me that he could, perhaps, make a little money off his cotton, and corn and potatoes if he didn't have any moral nature. I said, "How does that affect the farm?" He said, "I have to pay for the medical attention for those tenants on my place who are suffering with diseases. Come down there with me and I will show you." I went. Of course, if they had better food, Mr. Simons, they wouldn't have any pellagra, but they have pellagra, and our job is not to give them food but to do what we can to see that they get adequate medical service. We might just as well face the job. Philosophize or no, but we might just as well face the job, Mr. Chairman, and I move that we get down to the job and quit philosophizing. I like the philosophy better than I do the job.

CHAIRMAN SYDENSTRICKER: I quite agree with you. I think there is one thing that we should remember, of course. You talk about the economics of things, the standards of living, and all that sort of thing. There is one thing, though, we must remember, that even the poorest family if they have money they divide it up to buy food, to pay their rent and things of that sort, but they do not budget against the cost of medical care.

We will close the discussion on that.

DR. SINAI: This isn't a contribution to economic theory or economic history. It is talking to Dr. Crile's point. My contact has been quite intimate in the field with general practitioners and I think that some though ought to be given to the growing demand on the part of the men in the field, in the smaller communities and in the larger communities, that something must be done to provide more service, more adequate service, to the people with whom they have been in contact for years. Those men are constantly saying, "We are not getting our cases early enough." We have further evidence that when the bars are down there is a decrease in night calls. You can place whatever construction you wish on that decrease in night calls. From the acute conditions that are coming to the physicians in people whom they have had on their lists for years, the physicians know that they are not being called to these cases as early as they should, that the people are not coming to them because of their decreased incomes, not that they are on welfare, and it is those physicians who are demanding that something be done, probably much more than the physicians in the larger cities or the leaders in the profession. I am speaking of the demand, of the request of general practitioners in the field who are on the firing line and who know the conditions in their families.

CHAIRMAN SYDENSTRICKER: I think that we had better get along.

I must say that I am utterly astounded that anybody in the field of medicine should ever question the fact that there is a considerable part of our population that does not receive adequate medical care, it is a fact so well established, so well known by every physician who deals with that class of people. I am not talking about the physician who deals with persons who drive up to the doctor's door in limousines but with the ordinary run-of-the-mine people. I cannot understand why anybody should question that fact at all. We may rationalize it as Mr. Simons has attempted to do. We may say, "Well, we can't do anything about this. The people haven't got money enough to pay."

MR. SIMONS: I want to correct that although I wonder why philosophy on this side is stopped and the others are not.

CHAIRMAN SYDENSTRICKER: That is where your philosophy lands I am sorry to say.

MR. SIMONS: The attempt to analyze arguments that are presented is stopped, but I don't want the impression to go out for a moment that I am not in favor of doing everything possible to remove this economic obstacle. I do say that I think it has been exaggerated considerably and that it is not being attacked in the right way. I do want to register a question, although we are almost barred from saying it, as to whether or not the proposals that we have in any case have removed that obstacle and furnished a medical service such as is desirable.

CHAIRMAN SYDENSTRICKER: I shall be very glad to hear from you some time, Mr. Simons. After we get through with these detailed things I want to throw the discussion open and you can say anything you want, and if you think that the proposals that we are talking about, and perhaps of some of the other countries, and that the things that we find developed in our country do not meet the situation, by all means say so. Even if you want to change the economic order, go ahead. It is fine. I don't mind.

I think we had better go over this first because I think that it will help us to understand how Dr. Parran's proposals will fit in with what we are considering. Last night we were considering the question of population. Dr. Falk, will you summarize that briefly for us and bring it right straight to a head -- the point on the scope of the population included in the health insurance system?

DR. FALK: I think that most of the specific statements from A to I inclusive which were presented here have already received about as much attention perhaps as they need, except possibly the first one, on page 15 of the short memorandum, the statement that the insured population should be as broad as is practical in respect to the income groups which are included. It may have received no attention because its implications are clear to you, or perhaps because attention was diverted to other subjects, but I think perhaps a word might be said there to make sure that you appreciate the reasons which underlie it. I won't take the time to go into any considerable detail. It is discussed at some length in the appendix to which reference is made on this subject, but I think that perhaps one or two points should be mentioned.

That it is desirable from the point of view of the public to be served that the insured population should be as broad as is practical I think is obvious. If a system is devised whereby the direct economic features in the purchasing or the securing of medical care are to be eliminated (and let us hope effectively) then obviously it is desirable that it should apply to as broad a fraction of the population as is practical. I won't go into any detail on that point.

There is, however, another reason upon which this statement is based, and that is the consideration from the point of view of the professional aspects of the intention here and that perhaps deserves just as much attention. At the foot of page 15 of the shorter memorandum, the point is that apart from the desirability of making the insured population as broad as possible from the public's point of view, there is an equally strong argument from the professional point of view. If the insurance system is limited to a narrow band, or a narrow fraction of the population, and they the low income classes, or the lowest income classes among the self-sustaining, the inevitable consequence is that except where there are large contributions from employers and the state, or one or the other, the amount of money which can be furnished to the system to pay for medical service is of necessity small. If the income of an insurance system is geared to what can be contributed by the lowest income classes, or by them aided by the employers and in a measure by the state, the inevitable consequence is that there is very little money with which to pay the doctors, or the hospital, or any other agent or agency which furnishes care. A consequence of that in turn so far as the practitioner is concerned is that if he practices principally among the insured population he must serve a large number of people in order to earn an income which will sustain him, and a consequence of that is hurried, or crowded, or unsatisfactory service.

Consider the matter conversely. The cure I think for such a condition where and when it obtains is evident. If the actuarial basis or the financial basis of the insurance system and of the remuneration of the practitioner is to be sound in respect to enabling the practitioner to get a fair return for the services rendered to a reasonable number of people, with the maintenance of qualitative standards, it must cover a population that can afford to contribute sufficient funds so that the doctor can be awarded a fair remuneration for his service on a fair basis.

Therefore, as soon as one attempts to set an upper limit to the number of insured persons for whom a physician may undertake to care he must have a financial basis which can assure the physician a decent total reward for caring for that number of persons. That type of consideration leads to this conclusion, that if the doctor is to be given an assurance of a fair remuneration in order that he shall not carry an excessive burden or shall not be permitted to carry an excessive burden of service, then you must cover an economic fraction of the population sufficiently broad so that they can sustain the costs of good service. To that end we lay down this principle, that this must not be a poor man's system of insurance, that it is not in the professional interests, and, therefore, it is not in the public interests because the fundamental professional interests are determined by what is in the public good. Therefore, we come to the conclusion that it is desirable both from the public's point of view and the profession's point of view that the insured population shall be in respect to income limits as broad as practical, because it is literally true that if we maintain the principle that people shall pay a proportion of their incomes, and not a fixed premium, then the remuneration of the practitioner per person whom he undertakes to care for varies not lineally but almost directly with the income limits of his population. The higher the average income of the insured population the higher the payment per capita that can be made to the physician and to the other practitioners.

I took a moment to explain that point because I think the implications of the statement in that first principle are very important and very far reaching for all the others which follow.

MR. SIMONS: Being on the staff I naturally didn't criticize that because I think you are absolutely sound in all that reasoning, but I wonder if there isn't time here to raise what you might call a little of the political angle, not definitely politics but just this point: After all what we are working on is the possibility of something going through. This plan will hold out to a physician somewhere between $5,000 and $7,000 a year. Is that not about what you figure?

DR. FALK: Not if it is limited to $3,000 and over.

MR. SIMONS: No, I mean the amount of possible income to a physician.

DR. FALK: About $5,000 or $6,000.

MR. SIMONS: I happened to be talking a few days ago with a man who has done quite a great deal of work in state legislatures with medical questions. He was bringing it up in connection with another matter, the income tax as a matter of fact, and he told me that there was an immediate and a unanimous rejection on the part of the committee that he was talking about, and that there wasn't any question about it, to any idea that a physician was entitled to $3,000 a year.

Are we not holding out to the physicians in this something of which there is not the slightest possibility of realization in the states?

CHAIRMAN SYDENSTRICKER: Do you mean to say, Mr. Simons, that in the future we must look--

MR. SIMONS: No, sir, I don't want to say it, but I mean to say as a practical proposition.

CHAIRMAN SYDENSTRICKER: As a practical proposition. I will put it that way.

MR. SIMONS: I have grave doubts that you can go to any state legislature outside of a few in the East. I am quite sure that in the entire Mississippi Valley and I am sure that down in Dr. Roberts' state any proposals of a scheme that would pay the physician over $3,000 a year would be vetoed, and there would be the question of including people over $2,000. It is almost necessary when you get to the Government.

DR. FALK: It is gross income. He pays his own expenses of practicing.

CHAIRMAN SYDENSTRICKER: That is a pretty sad outlook.

MR. SIMONS: It is but I think it is a fact. I know very little about that and I can't speak as an expert.

CHAIRMAN SYDENSTRICKER: Of course, the income of the physician in ordinary days, in 1928 to 1931, was about $3800. What are we going to do, take it all away from him? Get it down to $2000?

MR. SIMONS: That was the exact proposal here. The income tax is what the fight was on, that an income of $3,000 is a good sized income. Mind you, you are talking with farmers, not quite like in Georgia, but farmers to whom $1000 a year is a lot of money.

DR. ROBERTS: Mr. Chairman, now--

DR. CUSHING (Interrupting): You have had your turn. You have already talked.

DR. ROBERTS: You listen to me a minute, it will do you good.

Theoretically I agree with Dr. Falk but practically he is as wrong as night is different from day. Mr. Simons is absolutely correct. He has been wrong most of the time (laughter) but he is absolutely correct this time. I have been sitting here looking at these figures and in one-third of the United States between the Potomac and the Rio Grande, in which there are one-third of the hospitals and one-third of the doctors in the United States, the legislators of those states wouldn't listen ten minutes to your figures, they would kick them out of the door so quickly and say, "If the medical profession is making that much money, let them go to hell." With all reverence--not profanity but reverence--if you want to kill health insurance, if you want all our work here to come to nought, you put in that $60 a month and go talk--

DR. BIERRING (Interrupting): Sixty dollars a week.

DR. ROBERTS: A week and talk about these doctors getting from $5,000 to $7,000 a year. In the peak of prosperity, up to 1929 when we were all crazy, half of the doctors made $3800 and over and half of them made less than $3800, and for every doctor who made $10,000 there were two who made less than $2500. You know that. While the average industrial income in this country is $1507, which is rated as 100 per cent, the income for Michigan industrial workers is $1713 or 1.13 per cent over the average, but more than half the doctors in Michigan made less than $3000 gross in the boom. The average gross income of the doctors in Georgia today is $1500 a year or less. Listen to that: That average is $1500 a year or less.

I am just as much in favor of health insurance as you are, more so maybe, because I see the need of it in this vast country down here, but if you want to kill the chicken (and he won't have any tetanic convulsions either, he won't flop his wings or do anything of that sort; it will be a placid death) you keep on talking about giving the doctors $4,000, $5,000 and $6,000 a year.

In Georgia and in Florida, and it is spreading all over the South, the tax income is being decreased because Florida has already (and Georgia is now doing it) eliminated $5,000 worth of home property from taxation. If you own a home in Florida or Georgia and it is valued up to $5,000 you pay no taxes on it. It is all eliminated.

The new lieutenant governor of Georgia, an old-time man, has been given a salary of $2,000 a year. The governor carried 155 out of 157 counties solely on the platform of reducing the expenses of people. He has reduced the tax tag on ten-ton buses to $3. He admits that he is one of the greatest grafters American politics ever saw. He is an expert. He says it.

If you want to kill health insurance you are going to kill it on that and that is why I was so opposed yesterday to the $60. You are talking in terms of New York City. You are not talking in terms of Dr. Bierring's country or my country. If a farmer gets $60 a week he is pretty nearly a Presbyterian, or an Episcopalian, or an aristocrat.

DR. FALK: I think that I should like to say, as Dr. Roberts usually does, that I want to agree with him, but there are two points on which I do not want to agree with him and cannot agree with him.

The $60 figure I said yesterday has the same meaning as the $250 a month stated in the unemployment insurance bill that is in Congress today, and that isn't going to kill the unemployment insurance. It is not a statement that people up to that limit must be insured. It is a statement that the system which the Federal Government is sponsoring shall apply up to certain limits.

Now if in Georgia the proper limit for the health insurance system in the opinion of the people of that sovereign state is that it shall apply to $1200, let them have $1200 as their limit, or $1500.

DR. ROBERTS: Why not say so?

DR. FALK: I shall be delighted to say it in just that way if that is desirable. The point I want to make is this, that the figure (and it is stated in appropriate places) subject to the necessary adjustments, geographically or otherwise, is a limit which the Committee on Economic Security had already adopted in respect to other risks to security as representing the limit of population which the program for security undertakes to deal with.

The second point I want to make is this: Set those limits in any state where you choose, it still will remain a fact that the lower that limit is the less the doctor's pay will be.

DR. ROBERTS: That is all right.

DR. FALK: That is a principle which you cannot bend by any philosophical, or economic or political argument.

The point I want to leave with you is this, that any physician, or any spokesman for the profession, who argues for a low limit of the insured population, if he does it as a means of breaking a health insurance program he does one thing, but if he effects in a law of a state the establishment of a lower income limit I think he does a very profound disservice to the profession.

I want to leave the thought with you that the meaning of it from the professional point of view is that if the history of fifty years of health insurance in twenty, thirty or forty countries of the world, and covering a hundred million of people or more means anything to the profession, it means that if you have health insurance in any area set the economic limit of that insured population as high as you can make it.

I will make no other arguments on that point.

DR. CUSHING: This is all based on the assumption that we must have health insurance which we haven't discussed yet and which is the fundamental thing.

CHAIRMAN SYDENSTRICKER: That will not be discussed in this place.

DR. CUSHING: In other words the program is already cut and dried?

CHAIRMAN SYDENSTRICKER: Not at all. The president of this committee has asked this staff if and when--a big "if" and a big "when"--we have health insurance what kind of health insurance was going to suit the medical profession.

DR. CUSHING: That isn't why we are asked to meet here. I will quote exactly Miss Perkins' letter. We were asked to aid the technical staff of the Committee on Economic Security in regard to a better distribution of medical care. Nothing is said about health insurance.

CHAIRMAN SYDENSTRICKER: You must take our word for it, Doctor.

DR. CUSHING: It doesn't say it.

CHAIRMAN SYDENSTRICKER: We were assigned the first job off the bat to study health insurance. That is our sole job, and then --

DR. CUSHING (Interrupting): We weren't brought here with that understanding.

CHAIRMAN SYDENSTRICKER: Oh yes, Miss Perkins said that in her address before this group, and I, as a representative of the staff, said it in my introductory remarks, and it was on the insistence of the staff that we include public health and public health medical service that it was included. The Committee did not have that in mind at all until we suggested it. We broadened the scope of this thing that much. You gentlemen--any one of you or all of you--can make any kind of a statement you please about the desirability or not of health insurance. I shall see that the Committee gets it.

DR. CUSHING: But we aren't discussing it.

CHAIRMAN SYDENSTRICKER: Why should we waste time talking about that sort of thing. We have our convictions, our prejudices, and everything of that kind about health insurance. Express them to your heart's content, but don't take the time of this meeting on this proposition; otherwise we might as well adjourn right now.

DR. ROBERTS: May I finish one more thing? I know analogies are dangerous, they are always dangerous if pursued too far, I will admit that, so don't pursue this one too far. If you do, I will lose the argument. I am not arguing, I am just working for sensible health insurance. The great trouble with America to my mind is that we are a pendulum people. At the swaying of the pendulum when 5,000,000 young Americans were in Europe we jumped into absolute prohibition. We didn't allow beer and we didn't allow wine. I am a prohibitionist. One of those few historical remnants that are left. I kept the law, but that is a detail. We jump from the extreme into action. The need for action is our national motto. That ought to be the slogan--the need for action. So it went on ten years and now we withdrew the whole thing and opened up.

Now, Mr. Chairman, we are doing identically the same thing here. Please follow "a". We are taking in one-third of the country (I will leave out the rest from the Potomac to the Rio Grande) and are taking one-third of those people out of private practice and putting them over into health insurance at one fell American sweep. When the pendulum swings to the left we jump into health insurance.

CHAIRMAN SYDENSTRICKER: Dr. Roberts, I have to disagree with you there.

DR. ROBERTS: When you take the people of any state and put 90 per cent of them into health insurance at one fell sweep, I say that is an active, radical, extreme move.

You understand these gentlemen over here. There are two groups in the medical profession. One is the oldsters. They expect something to happen and fear it. That is in Dr. Cushing's mind. I sympathize with him. The youngsters in the profession expect something to happen and want it. That is the difference. My Economic Committee in my Society at home is rampant for health insurance. They are rampant for it. They are just as much for it as some of my other friends are against it, they are absolutely rampant for it, but they represent the younger group. So there are two groups in medicine. Now we must assuage the older group and lead the younger group wisely, and as much as I am in favor of health insurance beware of the prohibition of that logic, and that is what you are doing here.

You know more about this than any or us. I am your friend. You have sat up here behind closed walls and studied statistics and books, and I think you have done it better than any man in the world. (Referring to Dr. Falk) I am for you, I think you are wonderful, but I think you represent a formulating and a formative group, and we represent an experiencing and an experienced group. Now listen: On the frontier--I have laid awake nights and worked at our difference--we must come together and do group thinking, and somehow crush your magnificent ability to formulate and our magnificent experience into a practical, working political scheme, as Mr. Simons said, that will appeal to the legislators, to the governors, and to the people of these United States.

I once went to Lyman Abbott, the friend of Roosevelt, and I asked him to give me what he considered the greatest advice possible for the young man, and he said the greatest mistake in America and the greatest mistake that young people make is when they get hold of a new idea their ideas run so far ahead of reality and they attempt to jump from the little finger to the thumb. When you take any people in the South and jump them from private practice, no matter how much they need adequate medical care, to 90 per cent of it insurance, with one fell act you are going too far. He said, "Go around the fingers slowly." We can enlarge this scheme in five years, or ten years, or fifteen years. We don't have to do it all today or this year.

CHAIRMAN SYDENSTRICKER: I fear that you and some others are under an entire misapprehension of the whole business--absolutely. In the first place I think that it would be much better if we went through this thing and saw what we are talking about before you begin to philosophize.

DR. CUSHING: We have all read it through many times.

CHAIRMAN SYDENSTRICKER: I don't think you properly understand it. We are not talking about putting 90 per cent of the Georgia inhabitants on health insurance unless they want it. It is a permissive proposition all the way through. We are trying to find out something that is perfectly practical to apply to any state if they want it. That is all. It is bound to be a permissive proposition. It has got to be something that suits the state. They don't have to take it if they don't want it.

You mentioned about taking people out of private practice. One of the cardinal points all the way through is that private practice of medicine shall continue as it is at the present time.

DR. CUSHING: But you haven't ever discussed what private practice is like under these systems, because it practically doesn't exist.


DR. CUSHING: Well, it doesn't exist in Great Britain.

CHAIRMAN SYDENSTRICKER: I wonder on what basis of fact that statement is made of Great Britain.

DR. CUSHING: What I am concerned about here is what is going to happen to the doctor.

CHAIRMAN SYDENSTRICKER: You make that statement. I should like some facts.

DR. CUSHING: I will come back to it.

The picture that has been given to the doctors around this table is that a doctor is a highly mercenary person, that there is one group of doctors that prey upon the rich and there is another group of doctors that prey upon the poor, and I think that --

CHAIRMAN SYDENSTRICKER (Interrupting): Who said that?

DR. CUSHING: I don't know that it needs to be said.

CHAIRMAN SYDENSTRICKER: Who made that statement?

DR. CUSHING: Here is the Survey Graphic.

CHAIRMAN SYDENSTRICKER: We don't edit the Survey.

DR. CUSHING: Your articles are in it.

CHAIRMAN SYDENSTRICKER: Factual articles only.

DR. CUSHING: Factual articles, but that is what is fed out to the public as to the idea that the Survey Graphic has about medicine.

CHAIRMAN SYDENSTRICKER: This Committee here is not concerned with the Survey nor is the Economic Security Committee. We can't be responsible for a thing like that.

DR. CUSHING: What I am trying to express is that the general feeling about the profession is that it is a mercenary society.


DR. CUSHING: Our discussion about how much the doctor is to be paid, and that the sop to the doctor is that he is going to get larger returns than he is now getting, and that there is left a certain proportion of the population for the doctor who practices among the rich.

CHAIRMAN SYDENSTRICKER: Do you mean to say that the doctor is not interested in what is going to happen?

DR. CUSHING: The doctor is vitally interested in what is going to happen.

CHAIRMAN SYDENSTRICKER: Do you mean to say that the doctor is not interested in getting a living?

DR. CUSHING: I have done my duty as best I could to this responsibility that we have.

CHAIRMAN SYDENSTRICKER: I think you have got it entirely wrong.

DR. CUSHING: Of course, we can disagree about these things, but I have gone to people who have had experience with the panel system, and I think I should like to read this letter if I may. Here is a letter from a young man (I will amplify it) who is over here on a scholarship from abroad. He is a brilliant young fellow. He comes from a medical family. He says:

"My father was a graduate of Edinburgh, and had a very busy general practice, largely among the poor in Carlisle" (this is for Dr. Davis' information) "(60,000 population). He was a typical family doctor of the old type, that is now rapidly disappearing in England since the introduction of the panel system."

This young man tells me that his father made in our money possibly in a good year $1500. He never sent out any bills, as so many doctors don't do, but his people were devoted to him and they paid him enough to live on. They not only paid him enough to live on, but they paid him enough to send his three boys to Edinburgh. The two older brothers went back to Carlisle to practice, and he says that they have between them about 1800 patients on their panel. On account of the state insurance scheme there is much greater financial security than in his father's time. That you all feel will occur. The doctor is going to be financially secure.

"The work is however no longer one of medical attendant, but is chiefly clerical, filling out certificates and keeping records.

"This I believe to be typical of most of the general practices in England today, i.e. financial improvement and security but an intellectual demoralization for the doctor, and a much greater but very questionably more efficient service for the patient. It is for this reason that most of the general practitioners are in favor of holding on to the state insurance scheme, a viewpoint that you will see often in the British Medical Journal.

"I have done G.P. in England as a locum on many occasions" (he had to work his way through school) "and it served to smash most of my illusions about the family physician as existent today. There is an enormous increase in semi-malingering, owing to the scheme, and which is of course pandered to by the doctor."


DR. CUSHING: This will develop.

"There is in addition a fabulous expenditure and waste on medicines, as every patient demands and gets a bottle of 'something' for the most trivial of ailments, and they come up for 'refills' week after week ad nauseam. All the druggists are therefore wholeheartedly behind the scheme.

"There is unquestionably a grave need for some sort of insurance of medical attendance for the poor, but under the present system there is a gross mismanagement of the funds available. Having made the assumption that all doctors must be thieves, the state has had to pay for hosts of other thieves to watch 'em."

In other words, there is a great bureaucracy on top of these people.

This is the outline of his day. This, of course, is a big industrial district, of which we have many like it. He told me that at eight o'clock in the morning there is a queue of eighty people waiting. They have to be gotten through with in an hour, and that is less than a minute a patient, because it takes three hours to do the paper work afterwards. It is twelve o'clock when the doctor gets his lunch. He has an hour at one o'clock, or it may be at one o'clock he gets his lunch. And an hour later he sees another group of eighty patients. The same thing is gone over with these people.

CHAIRMAN SYDENSTRICKER: How many patients does he see a day?

DR. FALK: You have 160 already.

DR. CUSHING: He sees three times a day eighty patients. That is about the best he can do. It takes him three hours, or the rest of the afternoon, to do his paper work. At seven o'clock he sees another queue of eighty people.

CHAIRMAN SYDENSTRICKER: Another eighty? That is four times a day.

DR. CUSHING: No. At nine o'clock in the morning, at two o'clock in the afternoon, and at seven o'clock in the evening, and he gets through at eight o'clock, and it takes him to midnight to get through with the paper work and his wife has to help as his clerk. If they want to get away they get some fellow out of school to come in and act as their locum. I know that this is probably a very bad picture, but I have got a letter here--

CHAIRMAN SYDENSTRICKER (Interrupting): An extraordinarily bad picture.

DR. CUSHING: I have a letter from Friederich Mueller that gives a much worse picture in Germany; that the system is defeating its own ends by making the desire of the people to enter into medicine so much less that a constantly inferior group of people are going into medicine, and there is less and less good care instead of better and better care because the quality of the people who give the care constantly deteriorates. That is the thing that gives me apprehension and worry about the whole proposition.

CHAIRMAN SYDENSTRICKER: I should say a letter like that would give anybody serious apprehension. If that were typical I would say it would be a dreadful situation.

DR. CUSHING: I think that one can go to England and see some of these men, whom I know very well and of whom I am very fond, and get a very glowing picture of it. If you go to headquarters, if you occasionally have that opportunity, everything is fine, but the man in the trenches feels very differently about it, and he is the man whose reaction you really want to know. There are the people who have to do the work, and I think that is a very serious - - -

CHAIRMAN SYDENSTRICKER (Interrupting): If the picture as you give it, Dr. Cushing, is true and if that is at all typical, I quite agree with you.

DR. CUSHING: We have to get our information as best we can from correspondence.

CHAIRMAN SYDENSTRICKER: I think, however, you haven't all the information.

DR. CUSHING: When people get information they take the information naturally that goes to prove the point that they are interested in, and I admit that my apprehension about this universal sickness insurance is based entirely on what I fear is going to happen, because we are told admirable things about the medical profession and yet I think that this proposal tends to destroy all its gains.

CHAIRMAN SYDENSTRICKER: In the first place, Dr. Cushing (since the matter has been brought up it might as well be thrashed out), I have not sensed, as you have, that the staff is primarily interested in the mercenary side of the medical profession.

DR. CUSHING: No, but it rather puts that sop to the profession.

CHAIRMAN SYDENSTRICKER: I have not sensed that anybody at this table has stressed that out of its due proportion. We must realize, of course, that doctors must live and it has seemed to us that the renderers of medical care ought to be paid a reasonable and adequate basis. If that is fallacious --

DR. CUSHING (Interrupting): The pay in England is possibly $2,000.

CHAIRMAN SYDENSTRICKER: I am not talking about England. I am talking about here in America. It seems to me that when you divide in our prosperous times the doctors in the income classes of $1000 and find the larger proportion and $2000 there is something wrong with present system of renumeration. Of course, I probably should not say anything that. That is too mercenary.

DR. ROBERTS: Let me interrupt you just a minute.

CHAIRMAN SYDENSTRICKER: Just one minute please, if you don't mind, Dr. Roberts. When it comes to a piece of evidence such as Dr. Cushing has given us on the British system, or of insurance in any country, and if that were inevitable in any system of insurance in the United States I would be the first person to say, "Let's not go any further at all." I would take it upon myself to say that this is a terrible thing and we ought not even to consider it.

DR. CUSHING: Let's consider it but let's find out some way of preventing this thing happening. I don't know if we can.

CHAIRMAN SYDENSTRICKER: There you are getting to it, but I am given an impression from a letter, and while I don't deny that there are instances under any insurance system of that type of thing, of course we ought to prevent them. The man had too many patients.

DR. CUSHING: But we speak about the man having 1000 of 1500 patients.

CHAIRMAN SYDENSTRICKER: The average British physician has on his panel list a few less than 1000 persons - not patients.

DR. CUSHING: I mean persons, but these eighty people a day three times a day are these persons who want to get something. They are chiseling under the doctor. How does he keep these patients? You asked the question. "How does he keep these patients?" The patients have their right of choice. They go to the man who just hands out the cards and he hasn't time to do much else. He looks at the man. He has no time to make an examination, he has no time to talk about preventive medicine, and if the man doesn't hand out the card the patient goes back and says, "This is a hard-boiled guy," and he advises everybody to go to a man who is going to be easier.

CHAIRMAN SYDENSTRICKER: As a matter of fact, the average British panel physician has about 900 and some odd persons on his list. If that 900 and some odd persons during a given year possibly 500 will call on him at all. I don't know how you get your - what is it - 300?

DR. FALK: Dr. Cushing's figures lead to approximately 50 office patients a year and the factor is 3 ½.. It indicates they typicality of those figures.

CHAIRMAN SYDENSTRICKER: I do not doubt that illustration at all, but it is not typical. Our study of health insurance hasn't been confined, of course, as Dr. Roberts suggested, to sitting in a library. One time I had a few days in London and I sneaked out to a lot of doctors' offices. I explained frankly that I was from America, in public health service, and that I wanted to inquire. I saw no queues waiting. I asked them whether it bothered them or not, and I received the answer, "Oh, no, I have only 500 on my list."

DR. CUSHING: At nine schillings a person, what is that income?

CHAIRMAN SYDENSTRICKER: He had other income too.

DR. CUSHING: These men have no time to practice. All their time is taken up with doing paper work.

CHAIRMAN SYDENSTRICKER: What is the limit, Dr. Falk?

DR. FALK: Twenty-five hundred.

CHAIRMAN SYDNESTRICKER: Twenty-five hundred is the limit that a British physician can have on his list.

DR.CUSHING: If he makes himself popular and he makes it easy he can get his 2500 patients. However, these 2500 patients are trying constantly to get benefits. That is human nature. They want to get something out of this. They are continually reporting to try to get something for nothing. The doctor has no time to determine what he should do, so what does he do? He gives them cards to go to the hospital. The hospitals are overcrowded.

DR ROBERTS: The staff has already provided that that is not going to happen in this country. Why should we continue to cite the weaknesses of the English system when our staff has already provided against them?


DR. FALK: We have limited the number of persons which a physician may take on his panel as potential patients by prohibiting his taking any number which is larger than he carries now.

DR. ROBERTS: They have separated cash benefits from medical benefits.

DR. BIERRING: I don't see it. You said the limit was 1000.

DR. FALK: No, the British average is 1000. The limit is 2500. We are setting a limit of approximately 1500 as the maximum.

DR. BIERRING: I don't see how that changes the problem. It is twelve years since I made a study in Edinburgh, in southern Scotland and in Northern England. It was at a time when the British medical men were meeting in Glasgow, and I frequently heard the expression, "I saw sixty" or "eighty patients at my surgery last evening." Their limit was 1000 on an average and they repeated themselves.

DR. FALK: I should like to take exception on the fact. The limit was 3500 at the time. If a physician had 1000 he wasn't seeing sixty or eighty except on rare occasions. That is the condition that you find in the blank eye, ear, nose and throat hospitals in New York where the man on the clinic service has seen eighty patients an hour because there aren't enough physicians for the service there. If the British physician had 1000 patients on his list, that is if had only the average, he could not be seeing sixty or eighty patients in his surgery unless he limited his surgery hours to once a month or one in two months. The facts are perfectly clear.

DR. BIERRING: He gives an instance of where he saw eighty patients three times a day.

DR. FALK: But the fact is that the British physicians on the insurance practice are giving their patients three and one-half office visits per potential patient a year. No one has challenged those figures. They are in all the official reports. They are the results of a study made by a committee which represented the British Medical Association, the insurance practice, and the Ministry of Health. They were the bases upon which the new fee payment to the doctor was determined be a joint commission, and nobody has challenged those figures. You can add up the total number of visits that are made in any of these services and you cannot arrive at any such figure as that, but none-the-less if you limit the number of persons --

DR. BIERRING: It is in that general direction.

DR. FALK: But it isn't that. Dr. Cushing and I must clear that . If this is an authentic case and is not an unusual occurrence in the time of an influenza epidemic, or some such other period, it cannot be taken as typical because it does not accord with the facts.

CHAIRMAN SYDENSTRICKER: If he opened his surgery once or twice a month he might have to go through that sort of proposition, but those things are simply contrary to all the recorded facts and to the opinion of the British medical profession.

DR. CUSHING: He gets nine shillings a patient.

DR. FALK: Potential patient.

DR. CUSHING: Per registered patient on his list.

DR. BROWN: In this scheme as outlined by Dr. Falk the average American doctor would see approximately four patients a day - isn't that correct - 365 days a year?

DR. FALK: If he had 1000 persons and they were receiving three and one-half office visits a year, that would give you, roughly, 3500 or ten visits a day.

DR. SINAI: That is providing the figure would run up to three and one-half.

DR. FALK: I say granting the factor figure is correct. It is nothing like that. That is where you open the door wide and where you have the physician doing both the physical service and certifying for disability. That has been wiped out. As emphatically as we have done anything we have made that fundamental separation.

CHAIRMAN SYDENSTRICKER: I would suggest that some of the members of this board inform themselves on the facts of the case. They are available to everybody. To draw conclusions for Great Britain from a letter like that of Dr. Cushing's that on the face of it arithmetically is absurd, absolutely absurd and couldn't possibly have happened unless he only opened his surgery once a month or twice a month, or something of that kind, is unworthy of a scientific group.

DR. GREENOUGH: Are we not reaching an impasse here and could we not go back to what we understand to be the function of this committee, namely, to aid as far as we can from a professional point of view the study of methods of providing security from the medical point of view to certain classes of population that do not now receive it? I should feel that we couldn't very well help in the study of health insurance without some discussion of it, but it is at least conceivable to me that the question of the breadth of the application of health insurance to the country's population at the present time is a very vital element in any recommendation that your committee may make. The fact that it is permissive only as far as the states are concerned will take it somewhat out of the hands of the medical profession - I mean the opportunity for advising in regard to the form that national legislation shall take, because when this project is put before a state legislature undoubtedly the opinion of the medical profession of that state will be given an opportunity for expression, but the action will be taken by the state legislature and the state legislatures at this present moment are very strongly tinctured with members of the legislature who are engaged in offering to the public all sorts of things, some of which we accept as being impossible. Therefore, if there are to be any restrictions on the extent of the health insurance offered by the Federal Government they must come into the recommendations that your board makes to the Committee on Economic Security.

I would, therefore, feel that it is perfectly proper for this Advisory Council to discuss the question of how broad an application of health insurance is advisable from the professional point of view at the present moment. As a matter of fact we all admit that there is a class of the population which is not at present getting the kind of service we think it should. The members of that class in different states will differ. We have already considered - and I think wisely - extension of the public health service and extension of the public medical services as far as your recommendations to the Committee on Economic Security are concerned, and with those recommendations the Advisory Council has agreed there remains a group which comes between the indigent and an undetermined limit in the economic scale for which we all feel something must be done.

The question is what, from the professional point of view, is the best way to meet that particular difficulty. We have before us at present two propositions. One is Dr. Parrans's and the other is the health insurance plan. It is not impossible that after due deliberation this committee might feel that even that group could be again split, say as between urban and rural, and that Dr. Parran's plan providing better service for rural districts might seem from a professional point of view to be somewhat better that the health insurance, and on the other hand to be the urban population the health insurance, restricted to a group of industrial workers who are not able to pay all of their medical needs, but without aid - I mean from taxation - might well seem to this Council to be the wisest disposition of this particular subject. How can we attempt to come to any conclusion of that sort if we shut off all discussion on health insurance? I don't see how that is possible.

Dr. Falk makes the point that the breadth of the application of the health insurance plan is very important as far as the relation to the physician is concerned. There is a little fallacy in that because the broader you spread the application of health insurance the further do you remove from private practice a group of people who are now not very badly off, who are able to pay minimum fees and are glad to do it. If those people want to establish voluntary insurance plans, whether for hospital or for medical service or both, they are at perfect liberty to do so, and with the general advantages of the insurance method of paying for things which has been developed in this country it is not at all impossible that they should do it, but they don't need legal aid in doing that; that is something which can develop very readily and I think is developing all over the country voluntarily on the part of the medical profession, or groups of the medical profession, and people in the upper moderate means group.

But for the ones who need in addition to anything they can do some sort of additional financial support the problem is still an open one. My feeling is that if we do see fit to establish a standard, say, of $1500 as far as determining to what extent Federal aid should be given to states, we might perhaps find that far less disturbing to the medical profession; that if we split off that group, the rural population, on the ground that it can actually be administered better by the plan that Dr. Parran suggests, then we still find it less difficult to persuade the medical profession that it is a wise decision.

I would urge that these matters be considered, but as far as shutting off discussion of health insurance is concerned, I don't see how it can be done if we are going to do this job intelligently.

CHAIRMAN SYDENSTRICKER: I wasn't intending to shut off the discussion of health insurance, that is what we are here for, but I think such discussions as we have had this morning - such philosophical discussions, if you please, as the dragging in of letters like Dr. Cushing did - is a propless sort of proposition. I prefer for you to consider what we have before us on its merits - strictly on its merits. We are commissioned to study this thing. If we do not care to study it, very well, I shall be very glad for the meeting to be adjourned, but that is our job.

DR. ROBERTS: I move that we proceed with our job. It is our loyal duty to the Government to do it and to our Commission.

CHAIRMAN SYDENSTRICKER: If any of you have any views on the general subject of health insurance from the philosophical point of view, I shall be very glad to receive them and I will proceed to get them to the Committee on Economic Security, but I cannot see to save myself any particular province in discussing the general philosophical basis and value of health insurance when apparently the people who discuss it don't know a damn thing about it. I don't mean to be impolite, but that is a fact.

DR. CRILE: That is rather interesting - almost too interesting. I should like to discuss Dr. Falk's suggestions and that is right on our program. I don't agree at all with his reasoning. For instance, why can't we attempt to solve the problem that you say is a reason for our being here, namely, the people the people who do not get adequate care, the low income groups? Why is it necessary to enter into the biggest buying power the United states has got and despoil that for medicine as it is in order to do the duty toward the low income groups? Why not think of another way of doing that? Why not take the low income group, as another way of working it out probably, or give subsidy if need be, but I think that when you go into that other group, which is the largest purchasing power that this country has got (I think 85 per cent of the purchasing power is in that group you are talking about) well, medicine is finished then as we know it now. I think it will upset very gravely and seriously all our conceptions of medicine, the incentives of medicine as a career. It will upset it very seriously. I sympathize completely with Dr. Cushing's point of view about the effect upon the doctors themselves, and that is a very serious thing for us to consider.

CHAIRMAN SYDENSTRICKER: What effect upon the doctor?

DR. CRILE: Well, for instance, if I thought that this plan were going through and that I would become the type of person whom you have in the panel physicians in Europe --

CHAIRMAN SYDENSTRICKER: How do you know it? Have you the factual basis for that statement?

DR.CRILE: I will give you the factual basis. It isn't because I have been a statistician or economist. I am telling you what I am not because economists are all defeated during this period. They disagree among themselves. I have had many communications and talks with the people who live over there, and it is my impression that German medicine has gone down steadily for long time, very largely due to that, and, as a matter of fact, American medicine has been rising while European medicine has been falling.

CHAIRMAN SYDENSTRICKER: That is due to insurance?

DR. CRILE: I think that is a large factor. We are having brought into medicine at the present time an exceedingly able, venturesome, fine type of young man. The colleges have many applicants, and the most outstanding men in the universities are going into medicine.

DR. CUSHING: Now they are doubting it.

DR. CRILE: Now they are doubting. Now you are changing the whole thing. For what reason? God only knows why you should despoil the whole great field, interfere with it, despoil it for a purely theoretical point of view.

CHAIRMAN SYDENSTRICKER: I am very interested to get that point of view. I want these facts on this thing and not simply impressions.

DR. CRILE: Just listen. But we can't have philosophy there and no reasoning from this side. There is no trouble to give you facts. For instance, it takes four years and about $10,000 for a boy to go through medicine now. From one to five years more he is in the process of furthering his education. He is about twenty-eight, or twenty-nine, or thirty years of age before he enters practice. He is doing that now on account of a whole lot of things; the urge of the profession, the A.M.A., and the medical schools, the competition in medicine, and its freedom as a career, and all that sort of thing except the preparation to become a Jesuit priest. I don't think the type of men who are coming in now will take that long, grueling preparation to be panel doctors. That is the fundamental reason why I question very much whether it is necessary with this group that we are speaking about. I am for anything down where it is needed and should like to do anything in the world to improve the situation where it is required, but I don't want to see it at the risk of changing the type of men who are going into medicine, because American medicine has been built up from a pretty low level, with very great effort, for a long time. You gentlemen don't know what will happen. You don't even credit yourselves with knowing what will happen, but statistically if you will study it, those of us who have been in medicine for a long time you must credit with having some knowledge of what medicine is, its feelings, its aspirations, and what it is that makes men ambitious, and what the competitive scheme is as compared with this scheme.

CHAIRMAN SYDENSTRICKER: May I have just one word with Dr. Crile and then I will turn it over to you, Dr. Falk?

I have lived and worked with doctors for twenty years. I am not entirely ignorant of the ambitions and the ideals of physicians. I respect them more than any profession in the world. I respect them and I am not entirely a statistician. In my thirty years or work I have lived among the people, studying them and working with them, on different commissions and things of that sort. It has been my life work. I am not an isolated statistical shark working with a bunch of figures. My job has been going out and gathering the facts and then trying to interpret them by statistical methods. So it isn't that. Moreover I realize - and that is the reason you are here - that we must get the experience and the views of the people in the medical profession in studying this whole thing, but I think I must question some of the reasoning that has been brought out this morning. I fail to see (I will be glad to find out) wherein a scheme which has for its main purpose the maintenance of private practice, professional control, and in which the only thing that affects the physician at all is properly safeguarded, in that he doesn't have to send his bills for a certain part of our population to the people themselves, can destroy medical practice and idealism. If that destroys medical practice and idealism I should like to know how it does it.

Dr. CRILE: I will tell you how it does it. It is a very simple thing to tell you how it does it. You put any person on the panel, let us say --

CHAIRMAN SYDENSTRICKER (Interrupting): We are not talking about panels. We are not having any panels in our scheme.

DR. CRILE: All right. You tell us that one of the reasons is to improve the position of the physician. Of course, one appreciates that, but the profession hasn't asked for it, has it?

CHAIRMAN SYDENSTRICKER: Hasn't asked for it? What?

DR. CRILE: For health insurance.

CHAIRMAN SYDENSTRICKER: I am not talking about health insurance. You said something about the improved position of the physicians. Do you mean to say that the doctors of this country do not want to get a living wage?

DR. CRILE: Well, that is quite all right about getting a living wage, but what we are talking about now is not the only way to do it. The point I am making is that I feel very sure that you will become an intermediary on the insurance basis of taking away the free field, the large free field for the middle practice of our profession.

CHAIRMAN SYDENSTRICKER: We are not doing that.

DR. FALK: There are two points which have been made by Dr. Crile, by Dr. Greenough, and others, which I think would have been cleared if we had gone on with this record. The first one implied that we are taking away competition and the second one that we are doing something to take away this purchasing power from the doctor.

The fact in the case on competition is that we are leaving every element of competition except only one. We are letting the doctors compete for these insurance patients and for all non-insurance patients, except on one basis, that the competition does not rest on the size of the doctor's fee. The competition is still there. The patient has the free choice of a doctor. The doctor has the privilege to accept or reject the patient. The only element of competition that is being removed is that the choice of the doctor is not to be determined on the patient's part by his fee.

CHAIRMAN SYDENSTRICKER: For the insured group?

DR. FALK: For the insured group. As for competition for any other person, we are not proposing to disturb that.

On the second point about the purchasing power, we are not taking away this purchasing power from the doctors. There are still private practitioners whom patients may choose if they prefer.

DR. CRILE: What patients?

DR. FALK: The insurance patients.

DR. CRILE: Suppose there are 3,000 to 5,000.

DR. FALK: Up to 3,000. We have never proposed anything over 3,000. Up to 3,000.

DR. CRILE: You yourself said 3500 yesterday.

DR. FALK: Twenty-five hundred to 3,000.

DR. CRILE: You said 3500. At any rate, it doesn't matter.

DR. FALK: Let me make this point, please, as to this purchasing power that you think we are taking away. We are not taking it away. We are increasing it. All of these proposals are predicated that on the regular, periodic payment basis these people can afford to spend more money for the physician, for the dentists, for the nurse, and for the hospital than they ordinarily spend. Our budgets are worked out and any proposed taxation to implement the machinery, or Federal subsidy, on the basis that they will pay more for medical care than they customarily pay, and that money, less 5 per cent, or 6 per cent, or 7 per cent, or whatever the administration costs are, must go back to the doctor, and the dentist, and the nurse, and the hospital.

There is no removing of the purchasing power of these people. We are simply making certain that payments will be made by the public and will be disbursed to those who furnish the service, and I cannot for the life of me, I must confess, see why, if you have read the subsequent passages which are being anticipated here, there is any question about leaving the private practice of medicine and supporting it, making it firmer. The practice practitioner is there, the free choice of doctor by the patient is there, and the guarantee of payment is there. The only implication that I can see is one which I cannot believe any group of physicians can sustain, namely, that the quality of medical care deteriorates because it is paid for.

DR. CUSHING: What is the underlying cause of the English doctors forming a union to protect themselves?

DR. FALK: Which group are you referring to, the 5,000 physicians who are in the union or the 16,000 who are insurance practitioners?

DR. CUSHING: I don't know the figure. There are 5,000 in the union. Why should 5,000 form a union?

DR. FALK: I should suspect for the same reason that there are now 900 in the league in New York City for socialized medicine, because they feel that their views are not represented by the insurance practitioners or by the British Medical Association, whether there may be justice in them or not.

MR SIMONS: I think there is another explanation, if you will, on that, that doesn't change the attitude at all. These 6,000 are those who are on salaries, the health department, and so on.

DR. FALK: I said whose views are not represented by organized machinery.

MR. SIMONS: I think there is another explanation, if you will, on that, that doesn't change the attitude at all. These 6,000 are those who are on salaries, the health departments, and so on.

DR. FALK: I said whose views are not represented by organized machinery.

MR. SIMONS: Their presence it seems to me in that is that they see in the movement, which seems to be accepted by the British Medical Association and others, that they are moving on to a completely salaried system and they are getting ready for it.

DR. FALK: Mr. Simons, I would take complete issue with you on that point, but it seems to me that is not one that is germane to us, because it seems to me that the issue that is germane to us is this: If it is true that the views which are expressed by the American Medical Association represent the organized profession, it is equally true that the views expressed by the British Medical Association represent the views of the British physician. The proportion of the physicians in the British Empire who are in the British Medical Association happens to be within half of a per cent the same proportion as exists in the American Medical Association Directory and those who are members of the A.M.A. by the last figure published by Dr. West in his minutes of the last meeting.

The point which you must keep in mind is that Mr. Sydenstricker, Dr. Davis, Dr. Sinai, Mr. Simons, and I may go to England and to Germany and other countries and observe for ourselves and talk with panel doctors, non-panel doctors, and others, and make our own personal observations. When we get through we cannot avoid this point, that in addition to what is said by those who practice under this scheme the main complaint of the British Medical Association as such, as we have been speaking about British insurance, deals primarily with the fact that the trouble with health insurance in Britain is that it is limited to too low a population, that the scope of its service is too narrow because it is restricted to the general population it covers, that it should be extended to cover the dependents.

The British Medical Association is on record over and over again, and finally, a few years ago, published a long document, a memorial, stating the plan of the Insurance Commission, as viewed by the official commission which deliberated for several years, representing the views of the British Medical Association.

It is not sufficient for us to consider what a brilliant young student says who comes over to the United States to study at the Yale Medical School. If we are to consider the views of physicians we must deal with more than incidental and single illustrations. We must consider the views of those who have practiced under the system, and we must consider more seriously I think the views of the British Medical Association, and of men like Sir Henry Brackenbury, who is Chairman of the Council of the British Medical Association.

DR. ROBERTS: May I confirm what you say and say that not only what you say is true, but the British Medical Association recommended that the insurance system be extended to the entire population when that report was published. I read the motion myself. It doesn't seem to me that it can be true, if our friends in Great Britain recommend that the whole insurance system be extended from the workingmen's group where it was started to the whole population of Great Britain. I remember it myself. Those facts have not been brought out in this country, and so far as I can tell organized medicine in this country has not brought out any of the favorable things in health insurance, as far as I can see them.

DR. BROWN: I move that we go on with the study of this transcript.

DR. ROBERTS: I second the motion.

CHAIRMAN SYDENSTRICKER: I was going to say that the staff greatly appreciates the courtesy on the part of this group of really considering this proposal rather than trying to judge these proposals by alleged statements about Great Britain or any other countries.

DR. HORSLEY: May I make an inquiry that I think is probably appropriate? It was said that the certificates for compensation for loss of wages shall be made not by the practicing physician but by a salaried physician. What salaried physician is deputized to do that, and is he to be a salaried physician especially employed by the Government for that purpose, or how is that to be worked?

DR. FALK: You will remember that our proposal is very specific that the administration of cash benefits shall be shifted to unemployment or some other form of cash benefit insurance.

DR. BROWN: It is all in the transcript, if we will study it.

DR. FALK: Now then, the certification of disability shall be the responsibility of a salaried physician, presumably employed by the unemployment scheme or other insurance schemes which administer cash benefits. We have taken the position on that whole subject that the result of our study requires us to propose that that shall not be part of a system of health insurance. Presumably an administrative authority might then specify that those salaried physicians might not be less than a certain age, shall be graduates of certain number of years of practice in medicine.

DR. HORSLEY: They are really officers of the different departments of the unemployed.

DR. FALK: They would be more or less analogous to the salaried non-competing physician in the British system, who is a regional supervisor and deals with disputes and investigates certificates of disability when he thinks they are given too laxly, with the notable exception that instead of as under the British system where he is a salaried officer under the Ministry of Health which administers health insurance, he would be a salaried officer of a system which administers cash benefits and which is not the health insurance system.

DR. BIERRING: Are we still considering "a" as to the inclusion of this insurance?

DR. CUSHING: I apologize for injecting all of this, but I think that has clarified the atmosphere greatly because I think we understand now our feelings, and I quite agree to go ahead with this.

CHAIRMAN SYDENSTRICKER: I think if we had considered this first rather than considering the bad aspects of Great Britain or Germany, or any other kind of insurance, it might have helped us a little bit. We have tried to avoid some of the things that are bad in those places. That is all I ask of you.

DR. BIERRING : Are we still considering "a"?

CHAIRMAN SYDENSTRICKER : I think we want to get your advice finally on this whole question of the scope.

DR. BIERRING : It refers to how inclusive this insured population shall be, and since it has been intimated that this Advisory Board is to rely entirely upon statistics and not on professional knowledge, I should like to know what Dr. Falk means by inclusive. How does that include? How much does that leave for the competitive phase of medical practice?

DR. FALK : I should say, Dr. Bierring, on the advice of physicians whom we have consulted and who have urged upon us the importance of leaving what they have called--

DR. BIERRING (Interruption) : I mean within the $3,000. How much of the population does that include, if you say that this insured population should include up to $3,000 income?

DR. FALK : It would be about 73,000,000 of people if you included everybody under that income group.

DR. CUSHING : Ninety per cent of the population.

DR. FALK : Seventy-three million would be about 65 or 68 per cent.

DR. CUSHING : An economist at Yale told me the other day this is 90 per cent of the population.

DR. FALK : I am quoting to you now the figure devised by an associate member of our staff, Mr. Maurice Leven, whom I think Mr. Simons will admit knows something about the income of the United States.

MR. SIMONS : That is on the '29 census, isn't it?

DR. FALK : This is on the basis of the 1929 census.

MR. SIMONS : There is quite a little bit of difference since then.

DR. FALK : It will be a smaller proportion now, sir, because you have to take out 23,000,000 at the bottom-most of income recipiency in 1929 who are now on relief. We are talking at the moment about the contributory population.

Let me finish my statement to Dr. Bierring, please.

If we say we will cover the whole population which in normal circumstances are under $3,000, you have got your 73,000,000. Now we have to make certain deductions. First there are certain limitations in respect to how these proposals may apply to the rural population. Certain of these limitations have already been submitted and discussed. Then you have further limitation which is proposed here, that this shall apply only to persons in industrial establishments of more than four workers, which would exclude another substantial proportion of persons who are employed in smaller establishments or are self-employed. It would exclude the domestic servants and classes of that kind, and further it would exclude obviously from any contributory scheme those who cannot be brought into a contributory scheme because they have nothing to contribute. Therefore, the net effect of such consideration is that we are dealing with something like 25,000,000 included in the consideration of health insurance?

DR. FALK : If you set the maximum under a maximum limit of $3,000 the compulsory contributory insured population with the limitations which I have indicated would amount to approximately 25,000,000 to 30,000,000 of people as the basis of the present discussion - maximum. If any and all states set lower limits than $3,000 you would obviously reduce those figures by the exclusion of people between that limit and the $3,000.

DR. BIERRING : And you further amplified that by saying that they could be handled by 30,000 physicians, from 1 to 1000?

DR. FALK : I don't think we could say that, Dr. Bierring, because obviously many physicians, if they come into insurance, will carry only 100 patients, or 200, or 300 or 500. Some will try, and will be able, to carry the limit of, say, 1500.

It follows that if your service in any state, or in all states, is limited, as it is in the British system to practitioner's service obviously only a fraction of the general practitioners will come in, but if you include a specialist service they are free to come in. I should say that the potentiality is this, that the scope of the service benefits is broad, if it includes all kinds of services as obviously it cannot in the whole United States, but if it could include all the licensed physicians of the country. As between that and some lower limit, I don't know where the figure would be, but it would be this, that on the average, if you have a thousand potential patients per doctor, it would mean that all of the service could be furnished by 30,000 physicians, but obviously it would not.

MR. SIMONS : Right on this point here, I will preface it with one sentence, that I came into this under protest, but nevertheless I accepted and worked the best I possibly could to develop what in my opinion would be the most desirable, or the least desirable system of insurance, and I will also say that I think we have developed a superior plan to what exists anywhere.

But now on this point: I agree absolutely with Dr. Falk, that you can't give a good service and you can't maintain that service by attracting the proper people into the medical profession without the rates that we have here, but I think in the presence of this Advisory Committee it would be equally unfair not to state what I referred to before, that I think if we led the medical profession to believe that this system is a political possibility and that they will receive the sums that are set forth here and it will enable them to maintain the high system that we have, we would be holding out promises that are not justifiable. You ought to recognize that fact.

CHAIRMAN SYDENSTRICKER : What is your basis for that statement?

MR. SIMONS : Just as was said before, that I don't believe that there is any possibility of any state legislature, especially where there is a large rural population, considering a plan which will only include people up to $3,000. If they don't, much of our subsequent reasoning falls to the ground, the character of the service and the reward to the physician. I don't believe that it is possible for such a scheme to go through, and, after all, we ought fairly to face the fact that we may work out as ideal a scheme as we have, but it isn't quite fair to sell that scheme to the public and to the physicians without considering their possibility.

CHAIRMAN SYDENSTRICKER : I am glad you made that point because it ought to be in our proposals here that such and such things will happen if this limit is $3,000, but if you have less than that you will have to have less benefits and less of this and that. See? Is that right?

MR. SIMONS : I should like to see that go in. I didn't propose it because I took it in that very narrow sense that we were supposed to say if we were dictators what would be the best possible system.

CHAIRMAN SYDENSTRICKER : But it might be wise from the point of view of practical politics, and in my opinion Dr. Roberts' area, and Dr. Bierring's area, and other areas, to say, "If you can't work it out that way, then we ought to have a $1500 limit or a $1200 limit."

MR. SIMONS : I would say that you should be fair enough to say that when you do that you have dropped the level of your medical service and you have dropped the level of your return to your practitioners.

CHAIRMAN SYDENSTRICKER : I think that ought to be stated.

DR. HORSLEY : Would it be possible in some way to lower the upper limit say to $2,000 and to subsidize by some form of taxation, for instance, such as subsidizing the old age pension?

MR. SIMONS : The states have that privilege. It is in here.

DR. HORSLEY : That would permit lowering of the limit to some extent would it not?

CHAIRMAN SYDENSTRICKER : If they want to bring a part of the public medical service into the insurance scheme, with the state in other words paying the premium of the government out of public funds - paying the premium from the lower group - it is in here. As I said yesterday, we have got it in several ways. That is possible in suggesting this draft.

DR. LELAND: I think that our interest in this matter is to state this thing fairly and yet to provide something that will safeguard the ideals, or let's say the things that we have present here, and rather than go to the extent of making the alternate proposals of different amounts for different states, which already they have a right to do under this proposal, it seems to me that it might be helpful to say a little explanatory note that this is predicated on the supposition, or on the basis of $3,000. We might cite two or three other levels to show what might happen if the states proposed to reduce the maximum to $2,000 or to $1200, but put that in as a note and do not make it an integral part of this proposal.

CHAIRMAN SYDENSTRICKER : All right, we will take a note of that. I think it is a very good idea.

In that case are you willing to pass over this thing we have spoken of?

DR. BIERRING : I think that gives us a working basis.

DR. ROBERTS: I move that we pass on.

CHAIRMAN SYDENSTRICKER: Now the next point is the question of the partial replacement of wage-loss. If furnished as an insurance benefit, it would cost approximately 1.0 to 1.25 per cent of the earnings. I don't know how much you are interested in that.

DR. BIERRING : Which part is that?

CHAIRMAN SYDENSTRICKER : It starts on the bottom of page 16 and it is item No. 17. That is the cash benefit and there is nothing particularly new in what is here. it I something that we, or course, already have in the country in many ways, on a voluntary basis and all that sort of thing, and it is, of course, one of the main features of the foreign systems.

As Dr. Falk has explained, we recommend that the administration be in entirely different offices than that of the medical practice, and, as stated here, the certification would be by salaried physicians. Of course, eligibility to cash benefits must require an adequate qualifying period of insured employment. We can't have a man come in one day and get sick and draw benefits at once. He has got to have a certain time to have been employed. This is true of unemployment insurance too. There must be a waiting period ordinarily of certified disability before he can draw any benefits. That is the usual provision. In our country the sick benefit schemes, of course, vary. Sometimes there are only two or three days. In one concern that I happen to know about it begins with the first day. In some places you must wait one week or two weeks and then draw from the first day.

MR. SIMONS : Is that safeguarded against retroactivity?

DR. FALK : There is a statement where the more detailed presentation is made from the eighth day on.

CHAIRMAN SYDENSTRICKER : "Remuneration of 50 per cent of ordinary earnings and do not exceed (say) $15 a week." That is an arbitrary figure, and we want to make that coincide somewhat with the unemployment insurance benefits because is it the same sort of thing.

"Duration limited to 25 weeks in any 52 consecutive weeks; resumption of eligibility to require a qualifying period of employment in the succeeding period;

"Eligibility to receive 'extended' benefit for those who lose their insured status be reason of change of residence or of occupation."

Do you want to go into that in detail. it is not a medical matter.

DR. GREENOUGH: I move that it be approved.

DR. PARRAN : May I make a few suggestions under 'a waiting period of one calendar week"? Insert the words "at least one calendar week".

CHAIRMAN SYDENSTRICKER: I will be willing to accept that. the only point there is that we want to make it as far as possible conform to the unemployment insurance scheme.

DR. PARRAN: In other words conceivable some states may want to have it longer than this.

The second point is I don't find the larger appendix or in here any detailed discussion of the administrative handling of certification for cash benefits by salaried physicians.

I have had some experience with the present type of salaried physicians employed by the state departments of labor in connection with supervising the employees' compensation law, which experience hasn't been too happy as regards the quality of those people.

It would seem to me that a study of how this group of persons might be employed and controlled from a professional standpoint would merit very careful, perhaps further study and some recommendations from your committee.

CHAIRMAN SYDENSTRICKER: We rather assumed that if they took cash benefits under some other form of insurance that would be a matter to pass the buck on that thing, or if there should be some agency of the Federal Government dealing with medical service or care it would be their job.

I think that your point os a good one and that we have not given that much attention as we should because we are not so much interested in the cash benefits.

On page 17: "Maternity cash benefits and their administration, if furnished under insurance, would cost approximately (or less than) 64 cents per capita if defined to yield:

"a. Cash benefit, equivalent to wage-loss benefit for 12 weeks, for gainfully occupied women who abstain from gainful employment and receive prenatal care for at least four months prior to delivery."

Of course, that might look like Mussolini's stunt and trying to increase our birth rate, but the joker, of course, from the preventive side is to make the proviso that they must get prenatal care before they can get benefits.

DR. ROBERTS: I am in hearty sympathy with Section 18 and I would be more in sympathy with it were you and the staff to add a reference to the farmer's wife. it speaks only of those women who are gainfully employed, and it seems to me, as I stated yesterday, that the farmer's wife certainly should come in that.

DR. FALK: "a" you see defines disability benefits in the case where disability is caused by pregnancy, but "b" is not so limited. It is a lump sum each insured woman who is gainfully occupied, to the dependent wife of an insured person, or to the widow of an insured person; therefore, if the insurance system covers the rural population 'b' would automatically apply to the farmer's wife, and the intention of 'b', which has been urged upon us that we shall at least attempt to define it whether or not we recommend it, is that it shall provide a lump sum of which the woman may purchase a layette and obtain such necessary household assistance and care as the lower income classes need and cannot ordinarily afford. So I hope that Dr. Roberts will find that "b" covers the point he has in mind.

DR. LELAND: It seems to me that is a bit of helpful information. I think this is what is in Dr. Roberts' mind: Apparently this pertains to the compulsory system but explain whether this maternity cash benefit also pertains to the voluntary.

DR, FALK: Of course, we have made no restrictions with respect to voluntary or compulsory in these definitions, but I didn't mean to object to any restatement which made that clear. I mean merely to point out that I think that the benefit as defined there ans the computations upon which the costs are estimated are such as would cover the suggestion which Dr. Roberts has I think quite properly made.

DR. ROBERTS: If you will excuse me, you used "gainfully occupied women" in "a" and then the restrictive personal pronoun in "b" the first line, "A lump sum of $15 to each insured woman who is gainfully occupied."

DR, FALK: Yes, and then a comma and then continue "to the dependent wife of an insured person."

DR. ROBERTS: Wouldn't it be better to say "and the dependent"?

DR. FALK: We can clarify that.

DR. CUSHING: Is the widow of an insured person very likely to need maternity cash benefits?

DR. FALK: There is a legal question there. The wife will give a posthumous birth. the insurance premiums will have been computed to provide coverage, you see, and therefore, she is entitled to the benefit. The legal experts begin to qualify that by "within ten months" because then months is the limit to which such benefits can apply in forms of insurance where they do apply.

CHAIRMAN SYDENSTRICKER: Is there any further discussion of that?

DR. ROBERTS: I move it adoption.

CHAIRMAN SYDENSTRICKER: If there is no objection we will assume that ut us all right.

Now we come to an extraordinarily important section, "Medical care", and there are two proposals. One of them was referred to by Dr. Parran. we want to return again to Dr. Parra's's proposed suggestion, and it might be well for us to defer consideration of this whole section so that we can join them a little more closely with D. Parra's proposals.

DR. FALK : I would suggest, Mr. Chairman, that you run through it so that the members of the Board will have in mind what the substance of each one is.

CHAIRMAN SYDENSTRICKER : "Medical care. What scope pf care should the federal standards require?" There are two proposals. "In respect to medical benefits and the general plan for their provision, two proposals of different scope are presented for consideration.

"Proposal I is presented by the staff of the Committee on Economic Security and two associate member, Dr. Davis and Dr. Sinai.

"Proposal II is presented by two other associate members of the staff, Dr. Leland and Mr. Simons.

"i. Care in health and in sickness by a general practitioner of medicine."

That is both domiciliary and office care for all types of sickness, or any, if you want to put it that way, alleged sickness.

"ii. Specialist services

"iii. Services in hospitals, clinics, and laboratories

"iv. Specified dental services

"v. Specified nursing service in the home

"vi. Expensive medicines and appliances (not ordinary drugs and medicines)

"This proposal contemplates that persons shall receive care in health and in sickness without waiting period and without payment by themselves, at the time service is to be receive, except through their previous contributions with certain exceptions and limitations as are specified in the full statement of the proposals in Appendix 5-V, 'Medical Benefits'.

'b. Proposal II. provides for coverage against serious or 'catastrophic' illness only on the assumption that most employed persons can pay for ordinary illness on the usual basis, but require protection against the risk on the usual basis, but require protection against the risk of the occasional high cost illness, such as, for instance, involves a long period of disability, a major surgical operation, or unusually expensive procedures in diagnosis of treatment.

"To encourage greater attention to the serious diseases and more time and thoroughness in the examination and instruction of patients, some portion of the cost of caring for minor illnesses should be borne by the individual either at the time the service is given or by an unusual charge on individual accounts.

"Administratively, this might be accomplished by"

"A. A small charge for the first service in any illness;

b. Payment from the central fund of any sum for individual or family services in excess of some sum such as $10.00 annually, which amount should be paid by the insured.

"C. Isolation of a certain percentage of contributions in individual savings accounts from which the cost of medical services should be paid each year, the remainder, if any, to be returned to the individual at the specified age. That portion of the contributions not so isolated would be placed on the general fund to meet the costs of serious or catastrophic illness suffered by any of the insured group.

"The essential features of these proposals lined in Appendix 6, 'Distribution of Burden.'"

the second proposal has been used to a certain extent by Dr. Parra in his suggestions of yesterday and we want to return those, and it occurred to us that it might be well to consider this whole section immediately before we take up the question again of Dr. Parra's suggestions because we will have the two things pretty close together. Does that meet your approval? All right.

On page 19 the next point is also of extraordinary importance it seems from the medical point of view and we ought to give serious consideration to it.

"Professional relations and responsibilities. In addition to the general principle (paragraph 15 above), Appendix 5-VI, 'Relation with Those who Furnish Services.' outlines further proposals. The following are particularly important." I will go over the ones that are particularly important, and if you want to go over the whole appendix we can do so. You see I have always assumed that you have read and studied this thing before you came here.

"a. Adequate recognition and broad responsibility to the medical professions in respect to the control of professional personnel and practices, the supervision of professional services, the maintenance of high standards of practice, the solution of professional problems, and the disciplinary actions for practitioner guilty of infraction of professional agreements or of ethical standards;

"b. Administrative separation of professional responsibility for cash and service benefits, so that the physician who furnishes service is not also responsible for the certification of disability ( this should be effected by making the certification of disability a responsibility of salaried, non-computing, personnel);

"c. Complete exclusion of proprietary or profit-making agencies and of any intermediary between the practitioner and the potential or actual patient;

"d. Freedom of all competent practitioners wh subscribe to necessary rules of procedure to engage in insurance practice; freedom of all persons to choose their physician from among all local practitioners who engage in insurance practice; and freedom of each insurance practitioner to accept or reject insured persons who choose him;

"e. Freedom of the insurance practitioner to engage in private, non-insurance practice to the extent that it does not interfere with his obligations to insurance patients."

Of course, he can limit his own number of insurance patients if he wants to. He doesn't have to take 1000 or 500. He can take any number of them he wants to.

"f. The general principle of health insurance administration should include a coordinate financial and professional set-up in the state, district, and local authorities. each group headed by the appropriate official or professional officer with a professional committee or committees in an advisory relation to the professional officer on purely professional questions, and with a council or board having official relation to the administrative authority on financial and on mixed questions. The medical officers and the administrative officers, and their respective councils and the committees should be set up so as to be parallel at the state, district, and local levels of administration. Each has its appropriate province of action. Since the financial power ultimately rests in the state, the medical groups must necessarily be subject to the ultimate control of the public authority, in so far as the funds available affect the issues and problems of the medical services. However, the general plan should make adequate provision to assure that professional advice and the counsel have been secured before administrative action is taken."

These are the ones that we regard as some of the more important ones. We want to go to some of the others and will be glad to do so, but we might discuss these first.

DR. FALK : Mr. Chairman, if it is appropriate I should like to mention one point to which some of us have given a good deal of though and upon which we had not come to a definite conclusion at the time this was drafter, and which I have had a chance to mention only very briefly to Dr. Leland but which I think is deserving of consideration in connection with that series of abstract statements on professional relations.

I have been personally very much impressed with the fact that in the British system of health insurance, which I think most observers of the subject agree works better in respect to the professional relations than any other large system of insurance, upon the advice of the British medical profession they have introduced provisions which exist in the British system and which are notably lacking in some other insurance countries where the professional and administrative relations are not as god as they are in the British, is this provision in the British system of administration, that while a great many matters of professional concern are determined by the professional groups in the local communities, certain basic professional relations are settled not locally but centrally for England, Wales and Scotland as a whole.

There is the provision for central negotiation between central authorities, and cental or national representations of the profession on matters which affect all areas. It operates through the joint deliberations of the Ministry of Health, deputes of the Ministry of Health, and central committees which represent the British medical profession.

Latterly I have been inclined to feel that something of that sort should be written into these provisions. It seems to me that it is worthy of very careful considerations as the possibility of laying down as one of the Federal proposals that there shall be a central arrangement federally which will represent the Federal administrative authority or authorities and properly define representatives of the medical profession (perhaps all other professions concerned with other features of the benefits) in the further definition of administrative standards and administrative procedure. I think that it nowhere in the document, because I don't believe any other member of the staff has been as much impressed with the desirability of such proposals as I have been latterly, as I have been re-reading and reconsidering the question of just what are the features of the British system which have been responsible for the unquestionable superior professional relations by comparison with other systems, and I think that is one of the point with perhaps has not been given as full weights as it deserves.

DR. DAVIS : I think there should be added to this the relation to the German system because despite the innumerable disputes and difficulties there for many years, there was practically no adequate central representation- I mean for the whole nation- of the medical profession, and I think there has been a distinct improvement since the establishment of the central medical committee, which, although its relationship has been almost wished on it, has certainly contributed to the same point.

DR. CUSHING : Does this mean that you think that the Ministry of Health will make the system work?

DR. FALK : I think that whatever the administrative authorities say in the dispensing of the Federal aid to the state it should operate with legally constituted agent who represent the profession. Obviously it must be in an advisory capacity, but the legal provisions could be such that the administrator has to take those groups into consideration before those administrative standards are laid down.

May I cite just one or two illustrations of how it is done in Great Britain> For example, on such questions as defining the privileges of physicians in respect to procedures of remuneration, or what constitutes fair procedures in the supervision of medical practice or of investigation of certification of disability, or of disciplinary action where the local profession and the insurance committee, which are primarily a professional group, considered such action necessary.

The general rules which are issued by the Ministry of Health are the first considered jointly by the Minister of Health and his deputies and I think three members, if I remember correctly, from the British Medical Association. There are certain provisions there, and we know that if any such scheme of health insurance is being discussed here should be established, obviously there will be a Federal administrative authority, whether that is the Social Insurance Board or the United States Public Health Service, or some other new agency there, it would have to be that perhaps we should propose that the administrative standards and rules that may be laid down by that central authority should be done only after he, or if such a board or such authority, has had the advice and counsel of representatives of the American Medical Association, or of the profession, however you define representatives of the various professional associations.

DR. DAVIS : I think that would properly go on page 23 in the section on Administration, which defines more briefly the Federal standards. It would be easier to write in a paragraph there incorporating the suggestion that the Federal Administration itself shall incorporate the principle.

CHAIRMAN SYDENSTRICKER : I think that it is very wise to bring it in here because it does not bear on this question.

I should like to refer to the appendix in view of some of the discussion we have had here in our meeting (at the bottom of page 51, the last paragraph) and it leads up to one of the things we have here:

"We are not unmindful of the work of the professional associations which are constantly attempting to improve the quality of medical care nor do we underestimate their contributions to the public welfare through the improvements they are bringing about in medical education, in the requirements for licensure, in the encouragement of postgraduate education, in the establishment of standards for specialists, in the inspection and registration of the hospitals, in restraining unethical practices, and in the encouragement of postgraduate education, in the establishment of standards of specialists, in the inspection and registration of hospitals, in restraining unethical practices, and in numerous other ways. These efforts need encouragement and strengthening. Appropriate provisions in a health insurance plan could make a substantial contribution to strengthen the role of the professions in improving the quality of professional services.

"Thus, as a compliment to the principle which would guarantee the rights and opportunities of insurance practitioners, we would offer as a twelfth proposal:

"(12) That the administrative arrangement should include adequate provisions for the proper professional supervision of the work of insurance practitioners, and shall include opportunities of requirements for periodic postgraduate study or for other procedures designed constantly to maintain and elevate the quality of medical practice among insured persons."

That is on the broad ground from the point of the public interest. That is an obligation. If the public pays and contributes to the insurance fund it ought to get the best medical care that it can.

DR. BIERRING : Since constant reference is made to the British system, how does it provide for this particular paragraph?

DR. FALK : It does only in a very minor way. There is a small central fund which is set apart each year when the allocations are being made. There is so much to pay the doctor, so much for this fund, so much mileage and special remuneration for practicing in sparsely settled areas. There is also set aside a small fund which is used for disbursements to physicians who practice in areas where they have to dispense drugs and medicines. And a small fund to make it possible for physicians in certain areas who need the opportunity and who wish the opportunity to go to the medical centers for postgraduate education or experience.

In our proposals we have gone much beyond that. We have made, as a part of the estimates, the provision which would enable every physician who comes in as an insurance practitioner to have on the average two weeks each year, or four weeks ever other year, or its equivalent in a longer period, for such postgraduate experience, training, or education, as he may choose or maybe desirable.

Matters of that kind are, of course, in Great Britain properly within the sphere of the joint board which represents the ministry of Health and the British Medical Association, but what we have done in that respect is to take that good feature which is in practice used only in a very limited way in Great Britain and made it far more pervading and a far more important item in our proposals.

MR. SIMONS : Have you had any legal counsel as to whether it is possible to write to any such provisions into the law? That is to say in the British system it is a representative of the Ministry of Health, a representative of the E.M.A. and the third man is usually some judge official who is the last and final authority in disputes. it is possible under our Constitution to provide for the introduction of a representative of an association or organization of that kind?

DR. FALK : I have discussed this question only one as far with the staff's counsel. I don't know, for example, whether the American Medical Association could be specified by name, but our counsel gave me the guiding rule: He said that in any proposal which deals specifically, as these do, and very deliberately and unquestionable with health, almost anything that you may wish to do could be properly come under the welfare Clause of the Constitution. His attitudes was: Proceed and tell us what is desirable and we will approach it from the point of view of using all means at our disposal to see that the matter is presented in such a way is legal. the attitude of counsel in the matter is that the door is wide open and that the attitude of the legal person will be to find ways and means to make those provisions rather than to raise objections to them.

DR. DAVIS : There can be no doubt, however, that as far as the states are concerned it would be within the power of any state government because there are precedents for that.

MR. SIMONS : Lawyers tell me that those have never been tested in the higher courts, and there is still a question that you have to appoint from the panel--

DR. DAVIS (Interrupting): I mean the provision of some of the state laws whereby the medical society of the state has official relation. In some states it is constituted the state board of health. But the state, of course, isn't the body of restricted legal power as the Federal Government is, and there might be some question of applying the Federal law, which would apply to the state.

DR. LELAND: In talking to Dr.Falk about this it appealed to me as being very worth while provision if it can be done. If we grant that some health insurance measure may be enacted, a Federal permissive bill or act, I am thinking now of the effect that it would have on the general profession if they might feel that they had some representation in the formulation of the principles and regulations and rules and controls, rather than leaving the entire thing to the procedure that has been reported to them as undesirable in some places of being told largely or political bodies what to do. It seems to me that if it can be done it might get over quite a hurdle of obstacles in the way of a better professional, understanding.

CHAIRMAN SYDENSTRICKER : That question raised by Mr. Simons, of course, related to the administration side which we will take up on page 23.

MR. SIMONS : I don't know, I was asking purely for information. The question was raised to me by attorneys and I just wondered if anybody had any better information.

CHAIRMAN SYDENSTRICKER : The point that I am making is that we will discuss it later when we get to the administration side.

DR, ROBERTS : Mr. Chairman, I have just been engaged on a pecuniary basis, with a very learned lawyer, on a study of the Welfare Clause of the Constitution, which called forth tremendous arguments and long debates for its adoption, and the feeling among the liberalization of interpretation of the Welfare Clause of the Constitution in regard to social relations. I have no doubt, since it is being interpreted very liberally, that this world, as your counsel intimated, be liberally interpreted from the standpoint of health.

It wouldn't hurt any of us to read that Welfare Clause in the Constitution. It came from Massachusetts.

CHAIRMAN SYDENSTRICKER: Shall we proceed with our regular order on page 19 and 20 and the additional one which I just read on the appendix?

I was very glad to get your views on any of these proposals on page 19 in the smaller document.

DR. ROBERTS : Have we approved No. 12 which you just read?

CHAIRMAN SYDENSTRICKER : I will be glad to have discussion on that if you wish to.

DR. ROBERTS : I should like to say that I think the scheme is lacking unless it has this in it, and I am heartily in favor of it.

DR. FALK : It is merely an oversight that a member of items which were in the appendices were not included in the briefer memorandum. There was no intention there. It was simply in the very hurried last days when this was being put together we didn't do as good a job as I wished we had in preparing this abstract, but so far as our deliberations are concerned everything that is in the appendices is in the picture. We have merely tried to brief the material down to facilitate.

DR. ROBERT : Dr. Bierring, would you favor that from the standpoint of organized medicine?

DR. BIERRING : Yes, and I am concerned with part "a" of No. 20, aren't you?

CHAIRMAN SYDENSTRICKER: You asked about this No. 1 on page 52 of the appendix. I will read it again:

"That the administrative arrangements should include adequate provisions for the proper professional supervision of the work of insurance practitioners, and shall include opportunities or requirements for periodic postgraduate study or for other procedures designed constantly to maintain and elevate the quality of medical practice among insured persons."

There are really two important things. One is professional supervision of the work of insurance practitioners, and the other is the opportunity for insurance practitioners for further study.

MR. SIMONS : I think that a vital point which has not been made entirely clear and may be possible of being cleared up is the implementing of that. As I understand it, the enforcement of these provisions would depend very largely on the administrative regulations and orders. it is possible to write anything into a Federal law which would strengthen this thing?

The opposition is going to come from certain states, and certain states if they pass a health insurance law are not going to want to have anything to do with the medical profession if they can help it. To just what extent is it possible to put into a Federal law anything that would make this really a condition? Would we have to depend merely upon the fact that the approval for a Federal subsidy would rest in some administrative body that would be guided by these general principle?

DR. FALK : I should think, Mr. Chairman, that although we might wish to go further if it were to be practical, we probably cannot go any further than to say that Federal aid is available for costs in the system which apply to these purposes. Then if in California they choose not to require periodic attendance by physicians upon certain opportunities for postgraduate observation or study, they needn't do it. The Federal Government might not feel free to coerce them into it, but if a state chooses to do so, it will receive Federal aid for that purpose. I recognize that isn't as far as I should personally like to go in the matter, but I think we should also recognize that may be as far as we may be advised to go by other members of the Committee's staff.

DR. GREENOUGH : The first part of that section is one that you would not wish to give up I take it. That is proper professional supervision of the work of the insurance practitioners, because that is a very necessary feature, and that, therefore, would have to stand as a condition, let us say, of Federal subsidy.

DR. FALK : We shall not give that up. It is a condition specified, if by no others, at least by the statisticians. (Laughter)

DR. BIERRING : How are you going to safeguard that? What is the decision about including organized medicine in a definite term?

DR. FALK : I think that we will come to that when we discuss these administrative features.

CHAIRMAN SYDENSTRICKER : Really two proposals are in that. They ought to be separated, and I think you ought to do that.

DR. FALK : Yes, we will take care of that. It will be in the minutes.

DR. ROBERTS : It seems to me that there is no objection to either of them. I am much in favor of both.

DR. BIERRING : Yes, if they are properly safeguarded.

CHAIRMAN SYDENSTRICKER. : Of course, the actual carrying out of a proposal of this sort may be differ in different states. You may have different ways of supervising insurance practitioners in different states which will carry out the meaning of this proposal. if you get up administrative machinery, outline it very definitely. the detail of that machinery may kill the whole idea.

DR. CUSHING : It is true about detail machinery. Where is the man who is taking postgraduate instruction going to get it? You want to bind it up so that a man can go some place, because if a man goes two weeks it takes him almost a week to get something done. If he wants to learn how to test sugar in the blood it takes him longer than two weeks to learn how.

DR. FALK : We are making adequate provision in the provision in the budget so that it allows for travel expenses and for the equivalent of a substitute for that physician, so that there is no charity service or friendly gesture by anybody. it is part of the cost of the system on the grounds that a measure which undertakes to enable the practitioner to remain a better man and to constantly improve himself is a proper cost of medical care and should be recognized as such.

DR. ROBERTS: I might say, if you will permit me, that the commonwealth fund tried that in Virginia and in Kentucky and in Tennessee. Your beloved Virginia offered $350 a month for three months, and only one practitioner accepted. He went off for three months' study and became a much matter man, and one other mane came in to the authorities of the commonwealth funs and said, " That fellow is getting ahead and the folks are going to him and leaving me. I guess you had better leave me off for three months." It was a commercial impetus that moved the second man rather than an intelligent one, and the commonwealth fund was greatly disturbed at the lack of acceptance of some of our friends in common work. Of course, I should much prefer to have said Georgia than Virginia. (Laughter)

CHAIRMAN SYDENSTRICKER : Are there any other comments on this No. 12?

DR. BIERRING : What do you propose to do with this No. 12? Do you want to add this to Section 20?

CHAIRMAN SYDENSTRICKER : Of course, that is an abstract. This is the more complete report. I may say, parenthetically, that the Economic Security Committee probably has about twenty pages. That is all they will stand for. it has got to be awfully brief. We wrote a beautiful, long report on public health of a hundred pages, of which we were very proud and they told us to stew it down to five.

MR. SIMONS : They must have a newspaper editor there. (Laughter)

CHAIRMAN BIERRING : Are there any more comments on this 12? There are really two propositions there. I assume that you don't object to it, that you rather favor it.

DR. GREENOUGH : I move that it be approved.

DR. ROBERTS : Second the motion, but divide it into two principle.

DR. BIERRING : You will define "professional supervision", the word "professional"?

CHAIRMAN SYDENSTRICKER : Define it? How do you mean define it? You don't want an osteopath? No. All right. (Laughter)

DR. BIERRING : I don't want a Middlesex graduate.

DR. ROBERTS : What is a Middlesex graduate?

DR. BIERRING : That is an unrecognized school but recognized by the state boards of Massachusetts and Arkansas.

DR. ROBERTS : Not Massachusetts?

DR. BIERRING : Yes, that is where it lives and you can't get a law through that legislature disturbing it.

DR. ROBERTS : Where are we, Mr. Chairman?

CHAIRMAN SYDENSTRICKER : We are on page 19, Section 20, which has a, b, c, d, e and f. Those are general statements.

DR. PARRA : Under "b" I would suggest that paragraph "b" be prefaced by the clause: "If there is to be cash as well as service benefits, administrative separation of professional responsibility . . ."

CHAIRMAN SYDENSTRICKER : I assume that we will all agree to "b", don't we?

DR. GREENOUGH : Would it strengthen it any to substitute the word "full" for "broad" in paragraph "a"? It still is restricted in respect to the control of the professional personnel.

CHAIRMAN SYDENSTRICKER : I think probably it would.

DR. GREENOUGH : We all have some anxiety about legislative bodies. For instance, these remarks that have just been made about Middlesex, our troubles with Middlesex are due to the fact that the legislature continues it and we can't make them stop it. A man who is a prime mover in the Middlesex Medical School is a member of the legislature. Therefore, I think that the more definite and positive we make the responsibility of the medical profession for its part in this project the better it will be.

CHAIRMAN SYDENSTRICKER : I think that probably it strengthens it, if you all agree to that. That is the statement of the broad principles that we hope will be written into the report.

DR. HORSLEY : Would it be sufficient to eliminate "broad" and make it read, "Adequate recognition and responsibility"?

CHAIRMAN SYDENSTRICKER : Which do you prefer? Do you prefer to have a strengthening adjective before "responsibility" or just leave it out?

MR. SIMONS : I think that we should make this just as strong as we can, for the simple reason that after all they are a certain extent pious wishes. It is going to be very hard actually to enforce them, but the stronger they read the more likely they are to interpret them not too broadly.

DR. FALK : I think it should be understood ( perhaps it has been) that if a report of this kind, with such statements of principles, were accepted by the Committee on Economic Security, and they, or the President, or the Administration, proposed the law, then most of these, or all of them, would appear not in the form of principles but in the form of legal statements of standards, or of legal statements of requirements, which a state must meet in order to qualify for Federal aid. So they would cease to be in that sense pious wishes which they are in this form. They would become statements of proposed law.

CHAIRMAN SYDENSTRICKER : Unless you specify at least, you will never get anywhere at all, but we have to press it.

DR. CUSHING : But "adequate recognition to the medical profession" is the way it reads - "adequate recognition to the medical profession and full responsibility to the medical profession."

CHAIRMAN SYDENSTRICKER : And "c" os "Complete exclusion of proprietary or profit-making agencies and of any intermediary between the practitioner and the potential or actual patient." I assume that will not meet with any opposition. It cuts out the commercial insurance company and all that sort of thing.

"d. Freedom of all competent practitioners who subscribe to necessary rules of procedure to engage in insurance practice" ( we use the words "necessary rules of procedure" because that is the phrase that we rather agreed upon at out last meeting) "freedom of all persons to choose their physicians from among all local practitioners who engage in insurance practice; and freedom of each insurance practitioner to accept or reject insured persons who choose him." In other words, I think that last thing is a very important point for the practitioner.

MR. SIMONS : That last, however, will have to have this modification the same as they do in the British system; if the physicians have some particular pest whom they don't want, the panel committee says to someone, " You have to take him."

DR. FALK : Or there is one other alternative. He may choose a physician who will accept him who is not an insurance practitioner, and the insurance fund will pay the cost. In the British system an insured person doesn't have to use an insurance practitioner, and a small sum (it amounts to only $50,000 or $60,000 I think a year) is spent in paying for services rendered by non-insurance practitioners and non-insurance agencies, for patients who are away from their normal places of residence and can't see their insurance practitioners or those who cannot find an insurance practitioner who will accept them.

CHAIRMAN SYDENSTRICKER : That is a pretty good provision, isn't it?

DR. CRILE : Have you got that in there?

DR. FALK : It isn't in detail. Perhaps it should be written in.

DR. CRILE : I think so.

DR. FALK : It isn't in the British system where there is such a specific provision. It is a trivial matter, but it is used on rare occasions.

DR. GREENOUGH : To go back to "d". Did I understand you to say that you adopted the term "competent practitioners" because in other places you have spoken about legally qualified practitioners?

DR. PARRAN : I wonder if the idea of the specialist is not included in the concept of "d"?

DR. FALK : This is much broader. This must deal with a broader series of provisions that the general principle which permits any physician to come in. Later we lay down certain restrictions on the specialist, for example, not allowing any man to come in and say, " I am a surgeon, " or " I am a neurologist" or " I am an internist." The word "competent" is there deliberately to conform with certain other restrictions which will come into the text in another page or two.

DR. GREENOUGH : If the word " competent" is to remain, just how is his competency to be determined?

DR. FALK : If I remember correctly that will come up. For example, isn't there a section on the definition of specialists, and matters of that sort?

CHAIRMAN SYDENSTRICKER : I think you raise a good point there.

DR. DAVIS : It seems to me that could be covered in this way, if at this point you leave out "legally qualified" and under necessary rules of procedure you cover the idea that these rules of procedure will be laid down professionally to govern the selection of specialists.

DR. FALK: At one stage in our studies we were discussing with a number of physicians one of the possible procedures of employing the proposal in respect to postgraduate study and periodic opportunity for a man to refresh himself. We were giving a good deal of thought to the suggestion that at the outset in a particular state the insurance system might permit every legally qualified physician to come in, but it may further lay down the rule that each such physician must every two years, or every three years, meet certain requirements in respect to postgraduate study thereafter. That means, then, that his recertification as an insurance physician after two years, or three years, or four years, becomes dependent not merely upon the fact that he is a legally qualified practitioner but that he has satisfied certain requirements which the professional body which supervises him has laid down in such matters as postgraduate education. Then you get a distinction between the phrase "legally qualified" and the word "competent". In a sense, if we keep the last phrase you could strike this out, or you could retain the phrase "legally qualified but who subscribe to the necessary rules of procedure."

DR. GREENOUGH: Would it be advantageous to read now, "Freedom of all legally qualified practitioners"?

DR. CUSHING: May I ask about "c" for a moment, Dr. Falk? Is there any possible way in which the agencies that prey on the public in medical matters, over the radio, as they do constantly, often selling dangerous things, can be curbed? Was this formulated with that idea?

DR. FALK: No, it was not intended to deal with that type of problem.

DR. CUSHING: That is, of course, one of the most serious problems.

DR. FALK: We deal with that in another way.

DR. CUSHING: That is why most people spend their money for Krazy Crystals, and so on.

...Dr. Falk assumed the chair...

CHAIRMAN FALK: I think you will find when we return to the discussion of the scope of medical benefits that we have tried to deal with that problem by excluding form the insurance benefits any drugs and medicine, home remedies, et cetera, except the unusually expensive items, so that there would be no advantage under our proposals for the Krazy Crystals Company, or whatever their name may be, to urge upon the insurance population that they use Krazy Crystals because the insurance population have to pay for that out of their private purses and do not receive it as an insurance benefit. That is a matter which we will have to return to when we consider the scope of the benefits, and it is a very serious matter.

Is there any further discussion on these statements or principles in respect to professional relations? If not, we might turn to Section 21 on Professional Remuneration, and again this is merely a brief abstract of the longer discussion in the appendix, which in turn is only an abstract. Perhaps I should read the text, so that we have it before us for discussion.

"Federal laws cannot prescribe the rates or methods of remuneration in state insurance systems, but should set forth the general principle (included in Paragraph 15-i) that those who furnish professional services should be adequately remunerated. The federal standards should further require that state laws should provide for a system of payment designed in accord with the following principles:

"a. The system of payment for professional services should be sufficiently flexible to provide for payment on a fee, salary, or capitation basis as may be required: (i) by the conditions of a given locality, or (ii) by the characteristics of various types of medical services;

"b. The system of remuneration should provide incentives for: (i) the maintenance of high standards of quality, (ii) the provision of prompt and efficient care, (iii) the encouragement of coordinated interrelations among practitioners and institutions, and (iv) the prevention of disease;

"c. The state medical authority in collaboration with the state administrative authority will draw up schedules for fees, salaries and capitation, as a basis for the remuneration of general practitioners, and may include different rates applying to different sized communities; or maximum or minimum rates.

"d. The general practitioners of a district who have accepted insurance practice shall have the right to select that form of remuneration which they prefer, subject to the approval by the state medical and the state administrative authority."

You will recognize that what we are trying to do is to lay the basis of these principles of standards which might be written into the Federal law, which gives on the one hand necessary flexibility to the state, and yet the necessary freedom to the practitioners to determine matters which are properly within their province for them to determine for themselves.

"e. The state authorities shall prescribe maximum limits to the number of potential patients which any insurance practitioner may accept. Such limits may be so specified as to differ according to the conditions in different sections or types of communities within a state; since in some areas a limit as low as 500 or 600 might be appropriate, whereas a limit as high as 2,000 might be necessary in other areas."

I should like to say on that point, which I think is an extremely important one, that I am not sure that the technical staff is altogether in agreement on the form in which it is stated. One or two of us I think would prefer that the maximum limit should be stated much more explicitly, that the Federal standards might specify, for example, that the limit should in no case exceed 1500 or 1600, or some such limit as that, although flexibility below that upper limit must be permitted the states in respect to the differing conditions and the needs of different types of communities which are embraced by a state.

DR. DAVIS: It seems to me that under the very great diversity of the number of physicians to population in different parts of the country, the setting of a maximum limit by the Federal authorities involves the danger that the limit might be put so high as to make it at least likely to be lowered by the state authority. The important point is that the limit from the standpoint of the sufficiency of the service should be as low as conditions make it possible. That can only be done by the process of the state considering its own situation. So that my feeling was that it would be wiser not to set a maximum limit by the Federal authority, but to require that the states shall set maximum limits. You could provide that in cities the limit shall be such-and-such, or that in rural communities in that same state it shall be such-and-such.

CHAIRMAN FALK: I think that perhaps we might run through these first in general and then return for more detailed consideration.

"f. Two associate members of the staff (R.G. Leland and A.M. Simons)-the staff and other associate members dissenting-propose that all arrangements or contracts for service shall be with individual physicians only. (See Appendix 7.)"

And you will note that the word "note" was placed in the margin to call to your attention that this is the second point in this document upon which there are disagreements among the staff. You will recall that it was the intention of this Board that the staff, in studying these matters, should indicate at this meeting in general the points upon which there is agreement and the points upon which there is disagreement.

I would suggest that we return to the more detailed consideration of this matter a little later when there should be opportunity for full discussion of it, because it is an extremely important point. Are you all clear, or need we discuss it at the moment to make sure whether or not it needs clarification as to what it means? Perhaps we might return to that.

"g. The state medical authority (state medical board, with the state medical officer) will prepare a list of services which are regarded as specialist services. The local medical authorities will prepare lists of physicians regarded as capable of rendering these various types of services from among those physicians who express desire to render such. These lists must be approved by the state medical authority.

"Flexibility is necessary, since in small communities the same standards cannot be applied for admitting a physician to a list qualified to render certain specialist services, as would be applied in a large city.

"h. In general the plan of payment for the specialist will be on the basis of fees for services rendered or on a salary basis for a given amount of time.

"i. In determining the method of payment adopted for specialists the administrative authority is responsible for selecting that method which (i) will yield a quality of service satisfactory to the medical authority, and (ii) will be most economical in cost. The medical authority (primarily local, with appeal when necessary to state medical authority) is responsible for passing on quality of service rendered, not on method of payment. A given method of payment, if claimed by a medical group to involve or lead to unsatisfactory service, must be reconsidered by the final administrative authority."

There are two paragraphs which deal somewhat specifically with the provisions with reference to special methods of payment for specialist service.

"j. (Salary Basis) A schedule for the full or part-time employment of physicians on a salary basis for rendering specialist services will be drawn up by the state medical authority and may include different rates, applying to different sized communities, or maximum and minimum rates. Local medical authorities will present proposals for the rates which may be applicable to their areas, which are to be approved for these particular localities by the state medical authority and by the state administrative authority before becoming effective.

"k. (Fee Basis) A schedule of fees for various specialist services will be prepared by the state medical authority, and may include different rates, applicable to different sized communities, or maximum and minimum rates. Local medical authorities will present proposals for the rates to be applicable to their areas, which are to be approved by the state medical authority and by the state administrative authority before becoming effective.

"l. Fees to specialists may be paid to individual physicians for services rendered under the local schedule, or may be paid under a group plan. Under the latter plan a total sum will be agreed upon by the local administrative and the local medical authority, to be applied to the payment for specialist services to be rendered by a designated group of physicians; and this lump sum may be paid to the physicians concerned and be divided by them among their members in proportion to the amount and nature of the services rendered according to the locally applicable schedule.

"The administrative authorities shall be empowered to enter into contractual arrangements with hospitals, clinics, laboratories, individuals or organizations furnishing medicines, appliance, supplies, for the appropriate services or commodities; or to make arrangements with associations of these several bodies, such as local or state hospital organizations.

"Systems of remuneration for dental services shall permit flexibility in respect to different procedures to be used in paying for: (i) minimal dental services which are to be available to all persons eligible to receive the services, and (ii) additional dental services whose costs may be divided between the insurance funds and the individuals served.

"This point requires further study and is submitted as a basis of consideration by the Dental Advisory Committee."

There is reference to Appendix 8, which I think was not sent to the members of the Board, it was not completed at the time the material was sent to you, but it has been completed since then, but it deals quite exclusively with matters which deal with dental problems and we did not think it was necessary to burden you with it. However, if any of you would like to have it, you are entirely welcome to have it. We have some extra copies available.

"Financial aid from the Federal Government shall not apply to expenditures for specified professional services, which for a state as a whole, exceed a prescribed sum per person eligible to receive the services."

The point being made there, which you will recognize is one which has been made a number of times before, that any state may go just so far as it chooses in respect to furnishing specialist service and spending as much money as it wishes for it. The Federal restrictions do not impose restrictions on the state. They merely impose restrictions as to how far the cost may go toward which Federal aid will be applied.

"Schedules of professional remuneration established within states shall be subject to periodic readjustment with due regard to the general financial status of the insurance system.

"Further details on professional remuneration are given in Appendix 5-VII."

...Mr. Sydenstricker again assumed the chair...

CHAIRMAN SYDENSTRICKER: Now the sordid part of our report but it has to be considered.

DR. BIERRING: It is pretty close to one o'clock.

CHAIRMAN SYDENSTRICKER: It is twenty-five minutes of one. Would you prefer to defer this until after lunch?

DR. ROBERTS: Mr. Chairman, could we work until one and return at two? An hour is enough for what little we should eat. (Laughter)

CHAIRMAN SYDENSTRICKER: If you all want to, we will continue until one. Is that all right?

DR. BIERRING: Are we to go over 22?

CHAIRMAN SYDENSTRICKER: I think we had better take up 21 first, don't you think so?

DR. PARRAN: In order to promote discussion I would move approval of items "a" to "e" inclusive.

CHAIRMAN SYDENSTRICKER: Dr. Parran has moved approved of items "a" to "e" inclusive.

DR. PARRAN: As to the upper limit?

DR. FALK: Yes, it you think it requires a further definition. I indicated when you were out that there was some little difference of opinion among the staff. While I am fully sympathetic with the point that Dr. Davis quite properly makes, I have in mind that there might be this statement does (I have not yet had a chance to discuss this with Dr. Davis since this mimeographing was done), yet also specify an upper limit, which might recognize perhaps say 1500 or 1750 might not be impractical in some areas, having in mind a consideration of the condition under which such a limit would work a hardship in sparsely settled areas and in certain very poor areas, and whether doctors should be permitted to carry, let us say, 2,000 patients because the patients are so widely scattered that they couldn't possibly call upon many for any extensive service and yet enable him to earn a somewhat better income from his practice. That would be precisely the type of area to which the Federal Government should give special consideration when the Federal aid is being dispensed on the grounds of need.

You will find later when we discuss this point of the definition of Federal aid that among the items which would enter in determining the size of the Federal aid to the state should enter the question of the need of the state for Federal aid, and in an area where there should be available funds to encourage the settling of physicians in certain types of communities, there is proper ground for that state receiving Federal aid which recognizes the special needs of such areas. If that type of analysis is sound, then I think there is more reason than we thought at our last staff meeting for keeping an upper limit, even though it works a hardship, but which in turn would provide a stronger argument for additional Federal aid to a state in which that hardship would occur. I don't want to make the point too strongly because there are many good reasons for following the plan which is contained in the present statement of principle, but I think it is a matter which deserves consideration.

MR. SIMONS: It was never my understanding that this problem of a large number was a rural problem. The complaints, as I have seen them, have been that the excessive numbers were in the cities and especially in industrial towns where they probably had a large proportion of very poor patients, and, therefore, they had a few patients for insurance and they got a very large panel which led to the sort of conditions which Dr. Cushing has described.

DR. FALK: I agree, Mr. Simons, and I think we had that in mind at our staff meeting. We discussed the matter and I think have taken care of it. What I am a little uncertain about now is whether in disposing of what is undoubtedly the major problem we have taken fully into account the necessary disposition of a minor phase of the subject.

CHAIRMAN SYDENSTRICKER: In the statement, Dr. Falk, that you have made here you have not said "shall" or "must" or anything of that kind. You have said "might". "The limit of 2,000 might be necessary." You have made it very broad and left it to the discretion of the states. You have simply indicated in a general way about what the upper limit ought to be and have left it at that.

DR. ROBERTS: I must agree with the staff and with Dr. Falk. For example, here is a county that I have been studying in middle Georgia with 16,000 people and four physicians. Only 4,000 people in that county are able to pay a doctor. They would have to come in on some sort of insurance. That would leave in that county 3,000 patients to each physician if they were all chosen equally.

DR. BIERRING: You would have to import one in there too.

DR. ROBERTS: I believe that your suggestion is true. We won't have to import him if this insurance idea goes in. The doctors will migrate from the cities. Here is Atlanta with 500 or 600 doctors and half of them hardly making a living. In the adjoining county, which is about one-third the size of Taylor County, Peach County, the center of the peach industry in Georgia, there are twelve doctors in one-third the geographical or acreage area. My only criticism of this would be to leave it like it is and add, "If it is necessary for a physician to have more than 2,000 people on his list, he shall have an assistant."

CHAIRMAN SYDENSTRICKER: You would put 2,000 as the absolute upper limit?

DR. ROBERTS: I would.

MR. SIMONS: I think you don't realize that probably more rows are raised in Great Britain over that assistant proposition. I think if they could get rid of that they would be very glad to do it. I believe that in this rural proposition, which we have come back to several times, practically every system of insurance has been forced to put in special schemes like the highlands and islands and the mountain districts of Switzerland and some of the rural districts of Germany, where they practically put a salaried physician in and put in an entirely new system to a large extent. I think you will have to face the fact that this does not fit much of the sparsely settled areas. You would have to have a very heavy subsidy to carry that population of 16,000 down there, if there weren't more than 4,000 of them who could afford to come into a compulsory system.

CHAIRMAN SYDENSTRICKER: It isn't true that this will fit all of our areas. I am not deluded by that whatsoever, and that is the reason we have certain proposals on extension of public medical service particularly for rural areas. You take an area like you are talking about there, and unless an insurance system brings in doctors, you haven't got enough doctors from that bunch, or you take an area where there are no doctors at all and there is no use of contributing to any insurance system because they have no doctors. That has got to be taken care of by another method.

DR. HORSLEY: If such a large percentage is indigent that really wouldn't come under the head of insurance at all, would it?

CHAIRMAN SYDENSTRICKER: Surely. I think we have got to have as a program a double-barreled affair. That we will talk about later on.

How do you stand on Dr. Parran's motion that he made purely for purposes of discussion? Are you willing to agree to "a" through "e"?

DR. PARRAN: May I suggest an amendment to the motion? It wasn't intended as a formal action. Approval of paragraphs "a" to "e" inclusive be given and the staff authorized to make such amendments to Section "e" regarding the upper permissible limit of insureds for any practitioner as it desires. I feel that they are much more competent to deal with that than I am.

DR. GREENOUGH: May we not hear from Dr. Leland about his dissenting?

CHAIRMAN SYDENSTRICKER: That doesn't take in "e"; that is on "f".

DR. PARRAN: I made my motion so that we could get to that.

CHAIRMAN SYDENSTRICKER: How do you all feel, gentlemen, on this "a" to "e"?

DR. CRILE: Of course, naturally we can't do more than lay down principles and this is as good as we could do the thing if we discussed it for hours.

DR. ROBERTS: I am in hearty agreement, but to say that the upper limit shall be 2,000 without an assistant will tend to stimulate the younger man to get out of the city and to get where there is some business. The men in these counties have been trying to get assistants for years, but they can't get them, and you would be surprised most of these Negroes in this county would come into the insurance scheme gladly.

DR. BIERRING: Are they wage earners or indigents?

DR. ROBERTS: They are farmers and farm laborers-mostly tenants.

DR. BIERRING: Do they have incomes?

DR. ROBERTS: Yes, sir, they have incomes. Even a Georgian can have an income. (Laughter)

DR. FALK: I should like to say just one thing on this matter of assistants. I take it that Dr. Roberts means to permit assistants in the rural areas. The implications of opening a broad clause which permits assistants are very much larger than I think we want to take the time for. We spent a good deal of time on that in the staff, and it is a long and very complicated subject. The possible abuses of it in the urban areas are very considerable. It is a very large subject. I hope that Dr. Roberts meant his suggestion to apply in respect to any upper limit that may be set as applying to rural areas.

DR. ROBERTS: Yes, I do.

DR. FALK: I think that most of the difficulties that we were concerned with in the staff were if it was opened to general application in urban areas. Do you agree with that, Mr. Simons?

MR. SIMONS: I am not struck with the idea that this is so tremendously important in its administrative features, if you carry out the rest of it.

CHAIRMAN SYDENSTRICKER: If there is no further discussion, we will assume that there is no further objection to "a" through "e".

"Two associate members of the staff (Dr. Leland and Mr. Simon) proposed that all arrangements or contracts for service shall be with individual physicians only." I think it is very important that we should take up their statement. It is in Appendix 7, page 106 of the larger document. I am a very poor reader, so would you mind reading that, Dr. Leland?

DR. LELAND: "Contracts of Service with Individual Physicians. The principle that the individual physician should be the medical unit of an insurance system has been accepted. This will be impossible if he is not also the unit through which financial relations are arranged with the administrative machinery.

"If any group or organized body of physicians or of physicians and lay managers or assistants is permitted as an organization to enter as a body into the administrative or financial set-up of the system, this will tend to create inequality and discrimination within the system.

"This position does not necessarily involve any criticism or appraisal of group practice."

I discussed this matter at quite some length with Dr. Brown yesterday, and I think he has had a good deal of experience, as has Dr. Crile, with group practice. We are not challenging the validity or the desirability of group practice per se.

"It does not imply that there should be any restriction on the formation of groups or other organizations by physicians practicing in an insurance system. If relations are exclusively and directly with the individual physician he is entirely free to avail himself of association with any group, clinic, hospital or other organization which he may consider helpful. It does imply, however, that such an organization may not be used for bargaining purposes with the insurance administration to the disadvantage of those physicians who are not so organized.

"Experience in a considerable number of existing sickness insurance systems strengthens this position. Whenever groups, clinics or other organizations have been permitted to enter as units of medical care, with direct relations as organizations with the administration of any system, the result has been friction and injury to the operation of the system.

"Group medical organizations, which claim to introduce economies into medical practice, must have a large demand for their services in order to cover 'overhead'. In every sickness insurance system and to some extent in non-insurance countries medical groups seek business by commercial competition which tends to introduce methods of competitive bidding." Examples of that can be cited in various parts of the country, and I am referring not to the ethical groups as we know them. I refer to instances in Chicago and elsewhere of groups that are not considered ethical.

"Wherever such groups have been admitted into systems of insurance, there still remains wide disagreement as to whether they have produced any economies in the cost of medical care. There is almost unanimous agreement as to the fact that they have been used to force down the incomes of physicians in general and the standards of medical care. Such group medical organizations are always urged by lay insurance carriers and some of their spokesmen have frankly stated that their main value is to 'tame' the physician and to compel him to recognize the authority of these carriers."

Inasmuch as we are not contemplating carriers in this system, this remark is perhaps a little beside the point but it is merely offered as a bit of evidence.

"On the other hand, some of these carriers after experimenting with clinics for many years have concluded that, in spite of the advantages claimed by the carriers in their bargaining contests with independent physicians, groups are economically so wasteful as to be undesirable."

Perhaps that should be qualified. We don't mean all groups. We have made a study of group practice and we don't mean that to be an inclusive statement.

"If relations are to be permitted with an organized group, no method has been found by which to eliminate from the sickness insurance system those organizations which use undesirable methods of publicity, salesmanship and exploitation of the individual physician, or which are dominated by employers, or which form subsidiary systems of insurance in violation of the principles and the safe guards against abuses which may have been set up in the general system.

"If a system of sickness insurance is to be adopted for the United States, the only necessary provision in the federal law to insure the maintenance of this principle would seem to be a clause stating that all contracts for the care of the insured individual patients should be with individual physicians."

That statement was prepared to express our views on this point with special concern for the individual practitioners of medicine in communities in which there is a variety of methods of practicing medicine. In some communities, of course, there are no groups and the problem doesn't exist, but in other places there are groups and good ones. In other words, there are places in which there are groups that are not so good, and the profession recognizes that. It seemed to us that if the door was opened to dealing with groups it would be a somewhat difficult matter to differentiate between groups, the good and the bad variety, since we have already recognized the principle of legally qualified physicians. These groups constitute legally qualified physicians, and, therefore, it seemed to us to be a little fairer in our dealings with the profession if we dealt with them individually rather than an organization or group. We recognize, of course, that we are expressing an opinion and that other members have a right to their opinions also, and likewise the members of the Medical Advisory Board have a right to their opinion. (Laughter)

CHAIRMAN SYDENSTRICKER: That is very generous of you.

DR. ROBERTS: That is fine! (Laughter)

DR. BIERRING: May I ask, Dr. Leland, if that individual relationship complicates the procedure?

DR. LELAND: That is again a matter of opinion. We feel that it would not.

CHAIRMAN SYDENSTRICKER: Dr. Leland, I think that the hour which Dr. Roberts has reserved for eating has arrived and I suggest the we take this point up after lunch.

...The meeting recessed at 1:00 p.m. until 2:00...