a living or to get through his list, and he cannot devote the time to them which he should.

Of course, there is a lot of certificate work, certificate writing involved with these things. How this administration bill would work out, I do not know, but I do not see how a great deal of paper work can be avoided. It seems to depend to a great deal on the system as to the amount of paper work, but if it is on a fee-for-service basis, there would be a tremendous amount of paper work.

Senator DONNELL. Have you seen the regulations in force in England as of a year or so ago?

Dr. BAUER. I think the volume containing the laws is something like 1,300 pages and the volume the doctors were supposed to use every day was somewhere around 600 pages. That is from memory.

Senator DONNELL. What countries have you personally visited in Europe?

Dr. BAUER. England, France, Switzerland, Spain, and before the war I was in Germany and in Italy.

Senator DONNELL. In which of those countries have you made observations with respect to the operation of health insurance plans of the type that you described?

Dr. BAUER. In all of them to a certain extent, except Italy. I did not make any there.

Senator DONNELL. And your net conclusion is that there has been or has not been a deterioration in the quality of medical care in the countries in which you have visited?

Dr. BAUER. I do not know that I could answer that question by saying there has been a deterioration because I was not familiar with what it was before they got it, but I can say that the level of medical care is distinctly lower than it is in the United States under our system.

Senator MURRAY. When did you visit England, Doctor?

Dr. BAUER. I have been in England three times in the last year and a half.

Senator MURRAY. When was your last visit?

Mr. BAUER. My last visit was last September. However, at that time I was there for such a short period I did not have an opportunity to make any personal investigation of the new health act.

Senator MURRAY. And the present health service program had just recently been put in effect?

Dr. BAUER. Just 2 months previous.

Senator MURRAY. It would have been impossible for you to makeDr. BAUER. Any personal observation on that, that is correct. Senator DONNELL. But you did observe the operation of the health act immediately preceding the new act?

Dr. BAUER. Yes, sir.

Senator DONNELL. The point has been made with respect to S. 1581 that inasmuch as it confines its grants-in-aid to the States for the purpose of aiding those who are in need of medical assistance and cannot provide it for themselves, at least in full, that a certain humiliation would attach to the recipients who would avail themselves of the service.

What is your judgment in regard to that point?

Dr. BAUER. I cannot see that myself. I have read a lot about the means test. It seems every one of us has to go through a means test. Every time you put in an income tax you are going through a means test. I cannot see anything humiliating about it.

Senator MURRAY. I would like to see a law abandoning the income

tax.

Dr. BAUER. I would be in favor of it.

Senator MURRAY. We would not have so many headaches.

Senator DONNELL. Is it your judgment that S. 1581 is properly to be condemned on the theory that the administration of aid to persons who need it, as distinguished from those who do not, would be humiliating?

Dr. BAUER. The so-called Taft bill?

Senator DONNELL. Yes, sir.

Dr. BAUER. No, sir; I do not think it is to be condemned on that at all.

Senator DONNELL. That is all, Mr. Chairman.

Senator MURRAY. Doctor, I would like to call your attention to some analysis of the 12 points that you have presented here.

Dr. BAUER. Yes, sir.

Senator MURRAY. Dr. Channing Frothingham, chairman of the Committee for the Nation's Health, a member of the AMA, and twice president of the Massachusetts Medical Society, has this criticism to make. He says:

Some of the AMA's 12 points are mere pious platitudes calling for expansion of present Government activities such as health education and industrial medicine (No. 8 and No. 11). Some already are incorporated in law such as Government aid for construction of hospitals (No. 5) and a program for mental hygiene (No. 7). Others are included in legislation now pending before Congress, such as creation of a national science foundation (No. 2); State medical care authorities (No. 4); aid for local public-health services (No. 6); and expansion of medical, dental, and nursing education (No. 12). The AMA has initiated none of these advances.

The AMA's first proposal-for creation of a Federal Department of Health with cabinet status-was rejected by the Eightieth Congress and more recently turned down by the Hoover Commission and the House Expenditures Committee after hearing the AMA spokesman. The proposal for putting a doctor in the Cabinet is as out of step with American tradition as for the Army to demand a general in the Cabinet. The American people trust their doctors to deal with disease just as they trust their generals to win battles, but they are firmly set against permitting these specialists to determine broad public policy.

The only hint of anything new in the AMA program is in point 9, the proposal for facilities for the care and rehabilitation of the aged and those with chronic disease. If really carried out, this would cost billions of dollars of the taxpayers' money.

The AMA has fought national health insurance, the cost of which would be borne by the beneficiaries and their employers, as too expensive. It has made no estimate of the cost of its own point 9, or its proposal to subsidize AMAcontrolled voluntary-insurance plans. We challenge the American Medical Association to make such estimates. They might disclose that organized medicine is more concerned over who controls the finances of medical care than how much it costs the people.

Do you have any comment to make on that?

Dr. BAUER. Yes, sir; I have several comments. Dr. Frothingham is not president of the Massachusetts Medical Society. He was but is not at the present time.

Senator MURRAY. I said he had been twice president of the Massachusetts Medical Society and a member of the AMA.

Dr. BAUER. A great many of these things, I agree, are in the process of accomplishment, but in presenting any program the whole field should be covered.

Senator MURRAY. Most of the things he refers to are things already pending in Congress.

Dr. BAUER. They are pending, but they have not been adopted and I do not think they should be neglected.

Senator MURRAY. I do not see how you can call it a new program if it is already being considered in the Congress.

Dr. BAUER. I do not think that is true for all of it. It is true that the Federal Department of Health has been asked for since 1884, I think. The Hoover Commission, I believe, did recommend that there be an independent agency with a doctor at its head and all Federal activities pertaining to health should be under that particular department.

The National Science Foundation was backed by the American Medical Association. As you know, it was passed by Congress and vetoed by the President due, I believe, to his dislike of the method of selecting a director. I believe that has been straightened out. It is still something not yet accomplished.

On the question of new facilities, it is true that the Hill-Burton Act took care of that to a certain extent, and I think you will recall, I am sure many of the Senators will, that the AMA was very active in promoting the passage of that bill. We feel that it still needs to be expanded. I think they have done fairly well in the provision of hospitals, but they have not done so well with the provision of diagnostic facilities. You cannot expect doctors to go in a community and, after having spent 10 to 15 years of their lives in training, practice medicine which was in vogue 10 or 15 years ago. The community would be better off without him. You have to give him tools with which to work. The expansion of those facilities will to a certain extent attract doctors, if you give them hospitals and diagnostic facilities, although there are other factors.

On the question of public health, I would like to remind the committee that the whole public-health field was originally activated by the American Medical Association and its subsidiaries. I think there is not a single State or county health department in existence today that was not sponsored by the local medical society. The United States Public Health Service itself was originally sponsored by the American Medical Association.

Senator MURRAY. I had understood it grew out of the early establishment of a compulsory system of medical care.

Dr. BAUER. I do not think that is entirely true, Senator, although that may have been a background of it.

Senator MURRAY. The officials of the Public Health Service seem to admit, in their statement that they make, that it came from the early establishment of that system for the care of sailors.

Dr. BAUER. That was merely one phase of public-health activity. Public health now covers a great many other phases, and we have sponsored many of those and still do, and we have been anxious to see the country covered by public-health units.

By so doing, you are going to prevent a lot of need for medical care because you are going to eliminate disease at the source by having

proper control of food, water, mosquitoes, flies, and general methods of sanitation.

I think it was brought out in testimony before this committee that there are some 25,000,000 people in this country without any sewerage facilities and some 843,000 rural homes without any toilet facilities whatever. Those are conditions that certainly are breeders of disease and should be remedied.

On this matter of chronic disease in the aged, I would like to say that the American Medical Association, the American Public Health Association, the American Public Welfare Association, and the American Hospital Association are now collaborating in a program to develop a program for the care of chronic diseases and the aged; and that program-the first report will be issued very soon--is being financed at the present time by the American Medical Association, and it was hoped that a program can be set up in each State.

That, to my mind, is one of the crying needs of our present system of medical care, care for the chronic diseases, of which we are going to have an increasing amount in all probability because of this increased span of life. There are too few facilities for the care of chronic disease. They do not need the elaborate set-ups we are required to have for acute diseases such as are prevalent in general hospitals.

They should be, in our opinion, close to general hospitals so that, if the need arises, they may obtain those facilities, but they do not need them 7 days a week or 29 days out of 30 days a month. They can be taken care of under such facilities, most of it very largely custodial care, certainly not more than a third of the cost required for beds in general hospitals, and thereby, when they do occupy those generalhospital beds, keeping acutely ill patients out of those beds.

I do not want to take up too much of your time on this, but this is a set of principles, and the American Medical Association plans to go into more detail on those as to how these things may be accomplished. This is simply a platform, and the various supporting information for it will be available at a later time.

The AMA does not subsidize any of these voluntary-insurance plans. They are not subsidized by the AMA. I did not get that from your statement, but it apparently was made.

Senator MURRAY. Thank you, Doctor.
We will recess until 12:30.

(Whereupon, at 12:45 p. m., the committee recessed to reconvene at 2:30 p.m. on the same day.)

AFTERNOON SESSION

Senator PEPPER. The committee will come to order.

Dr. Lowell S. Goin, of Los Angeles, Calif., on behalf of the American Medical Association, is the remaining witness. Doctor, we will be glad to have you proceed.

Dr. GOIN. Mr. Chairman, I have a short statement to give, but since I have written this statement it has come to my notice that there have been several rather harsh statements made about the American Medical Association, and I would like your permission to introduce à supplemental statement to this one.

STATEMENT OF LOWELL S. GOIN, M. D., PRESIDENT, CALIFORNIA PHYSICIANS' SERVICE, LOS ANGELES, CALIF.

Dr. GOIN. I am Lowell S. Goin, M. D., of Los Angeles, Calif. I am a practicing physician, and I happen to be president of California Physicians' Service, the voluntary health-care plan of California. I had as well say at once that I am in complete opposition to this legislation, and I speak now of the so-called health-insurance bill (S. 1679). I oppose it as a physician because I am persuaded that its enactment would result in great and continuing decrease in the quality of medical care available to our people. I oppose it as an American because I am persuaded that this type of legislation is one of the final steps on the road to state socialism. In this opposition, I am confident that I am supported by the overwhelming majority of American physicians.

Specifically, my opposition is based upon five premises which I propose to state briefly, thereafter developing each one.

No. 1. The assumption that the health of the American people is bad is a false assumption.

No. 2. The assumption that the enactment of compulsory sicknesstax legislation would be in the interest of the public health is totally unfounded.

No. 3. Medical care is not the sole factor in the problem of health, and there are many other things that Government could properly do which would benefit the health of the public far more than the proposed legislation.

No. 4. The cost of such plans, rather lightly passed over by the President and the Social Security Administrator, are totally unpredictable and almost certain to be extremely high.

No. 5. Voluntary health-care plans, which are truly in the American tradition, are giving good medical and hospital care to our people, and must be allowed to develop unhampered by bureaucracy. Let me now consider these points in its turn.

The health of the American people is bad, perhaps, but it isn't just because someone in the Social Security Administration says it is. Fortunately, it is a matter which may be investigated, and in which conclusions can be based on known facts rather than on emotional statements. Consider then, if you please, that the life expectancy at birth is steadily increasing, being now about 65 years for a male and 69 years for a female. It is materially less in Great Britain, and was still less in prewar German. Both of these countries have long enjoyed the blessing of compulsory sickness insurance.

The death rate from diphtheria per 100,000 of population, in the last year for which comparative figures were available, was 11.6 for Great Britain, 11.4 for Germany, but in the United States, with freeenterprise system of medical care, it was less than 6. Why? Diphtheria is both preventable and curable; why didn't the governmentoperated medical systems produce a death rate lower than ours?

In the Public Health Reports for August 1946, the United States Public Health Service presents a table showing the death rate from tuberculosis in all countries. In the United States the rate was 47 per 100,000. In England and Wales it was 62. In France it was 137, and in Russia, 160. All of those except the United States have na