cigarettes a day, or of a movie a week, will pay all your medical bills and something over." That is an indication of what can be done, and if we are thinking in terms of fullest possible employment in the postwar period, certainly it seems to me that an educational program to get people to budget a small amount toward medical care would be a very great advance toward meeting this question that we are talking about. Senator TUNNELL. What you suggest, I think, certainly has appeal to a certain percentage of young men. That is, they would like to go where they are needed. I think we all have a little of that feeling, namely, that we would like to go where we can be useful. Senator AIKEN. I would like to ask Dr. Proger another question. That is, whether the Farm Security medical program has been of help to the doctors as well as to the communities. Dr. PROGER. I am not very familiar with that. It is my impression that that has been limited largely to Aroostook County, and I don't know just how it has worked. I have only a vague impression of that. Senator TUNNELL. Well, gentlemen, we thank you. Is Dr. Sensenich here now? Dr. Sensenich, would you care to testify now? And Dr. Stone, if he is here, might come up at the same time. Gentlemen, if you will just give your names for the record, and your positions. TESTIMONY OF R. L. SENSENICH, M. D., TRUSTEE OF THE AMERICAN MEDICAL ASSOCIATION, AND HARVEY B. STONE, M. D., COUNCIL ON MEDICAL EDUCATION AND HOSPITALS, AMERICAN MEDICAL ASSOCIATION Dr. SENSENICH. Dr. R. L. Sensenich, trustee of the American Medical Association. Senator TUNNELL. And Dr. Stone? Dr. STONE. Harvey B. Stone, council on medical education and hospitals, American Medical Association. Senator TUNNELL. Now, you gentlemen can proceed as you like. Dr. SENSENICH. Very well, Senator. You have the statements covering the subjects that were submitted to both Dr. Stone and me. (Following are the prepared statements submitted by Dr. Sensenich and Dr. Stone:) STATEMENT BY R. L. SENSENICH M. D., TRUSTEE, AMERICAN MEDICAL ASSOCIATION SIGNIFICANCE OF SELECTIVE SERVICE AND INDUCTION STATION The examination data of selective service and induction stations as reported before this committee has been extremely interesting. This information has particular value in that it is based upon examinations of a very large number of registrants within certain age groups-a cross-section of those from the various geographic areas varying in educational training, financial resources, and social status. Furthermore, the findings from the various areas may be compared. Such information as is obtainable as to the history of physical and mental health and personality pattern is evaluated according to a formula provided by an overall directing agency and the formulary conclusions are final. The physical examinations and interpretations of findings follow especially rigid direction. The physical and mental standards, to which specifications the formula of examinations is directed, aims at the selection of those whose qualifications will be According most valuable to the armed forces under the severe conditions of war. to the same terms the rejections from the armed forces, of necessity, must be based not only upon the present physical impairments but upon an estimation of potential physical and mental failures of performance under projected possible conditions of combat. The objective is a degree of perfection in which it must be recognized that qualities peculiarly important to armed service are especially emphasized; assuming that each man selected may be exposed to the same be recognized that qualities peculiarly important to armed service are especially conditions of stress. The difficulty in obtaining a sufficient number of men for the armed services, according to early high standards, required easing of requirements and acceptance of men previously rejected. The percentage of rejections in various groups by date of examination has varied accordingly. The deferment without examination of well-trained essential men excluded many of high qualification from these statistics. The deferment of married men without examination obviously resulted in a greatly disproportionate concentration, in the reports, of those with venereal disease and other physical and mental conditions disqualifying for marriage. The results reported are thought provoking. However, these factual limits must be recognized in considering the findings. An attempt to translate them into terms of the general health of the whole population of the country of all age groups, educational training and social status may lead to unwarrantable broad and misleading conclusions. The extent to which the selective service rejections may be used to determine the adequacy of medical service available to the registrants is very limited. Information, not contained in the general reports to the public of selective service or induction station examinations in many instances would point to the determining factors leading to rejection. It would be impractical to discuss in detail here each item of the report. It is noteworthy that according to Selective Service testimony before this committee 35.3 percent, or more than one-third of the total rejected registrants, were rejected because of mental disease (16.6 percent), neurological disorders (5.1 percent), and mental deficiency, including illiteracy (13.8 percent)-a quarter million of rejectees because of illiteracy without other disqualifying defects. The causes of these startling conditions are properly of interest to the 'medical profession. This would seem to reflect badly upon the processes of education. Basic education to remove illiteracy as a cause of disqualification would seem to be of unquestioned importance. The classification, mental disease, herein apparently covers a broad group, including the emotionally unstable and those indicating personality deficiencies, but along with them the very large proportion whose rejection is based upon lesser evidence of failure to adjust. Educators may be interested in possible methods of teaching for self-discipline and more adaquate adjustment to problems presenting in the average life. The public gives too little thought to heredity and marriage qualification. The committee is no doubt interested in the educational problems involved. Obviously, a very large percentage of the above 35.3 percent could not be benefited by medical care. Many of the remainder are leading lives of satisfactory social status. Not infrequently rejectees in this group occupy responsible positions and enjoy excellent financial earnings, but were rejected because of doubt as to ability to adjust to military life. Medical care is available if needed but is not desired in this group. Congenital defects of varied kinds and vision and hearing below the standards fixed, not correctable and yet not seriously impairing in normal living, were the basis of a large number of rejections. It is interesting to note that Brig. Gen. LeRoy Pearson, director of selective service in Michigan, was recently quoted in the press to the effect that in Michigan, as of June 30, 1944, 5.2 percent of registrants were in class 2-A, 20.3 percent in class 2-B, 5 percent in class 2-C and 17.3 percent in class 4-F-apparently a lesser number of rejectees than in the national report. This suggests that there may be other States in which the number of rejectees may be nearer to Michigan in number of those disqualified. Some other States must then have very much higher rates of rejection. SELECTIVE SERVICE REJECTION RATES To make an intelligent approach to the question of causes and remedies it would be necessary to have selective service reports from the separate States giving the number of rejections and the reasons for rejection. According to the testimony before the committee, Negroes contributed more than 44 percent of the rejections for mental deficiency and more than 60 percent of the rejections for venereal diseases. Concentrations of diseases vary and differences were reported between rural and urban areas. Local conditions should then be studied and possible remedies, if any, be properly evaluated. It was estimated that approximately only one out of six were rejected because of remediable defects. It must not be assumed that because the defects were considered to be remediable that failure to have a possible correction was due to inability to obtain such medical service. More often failure is due to lack of interest or unwillingness to accept treatment to correct the condition. Less often it is due to ignorance of the importance of correction or failure to inquire if such service is available to the individual. There are numerous provisions for those unable to pay for medical service. Final failure to obtain needed medical care if it is sought rests generally upon failure of some agency of government to carry out the purpose to which it is directed in assistance to those in need. The greatest significance in reports of rejections for the armed forces would seem to be in the notable lack of self-interest and effort to secure or maintain a high level of mental and physical fitness. Those without recognizable defects fail to observe even the simplest program of regulation or discipline directed to the maintenance of good health. Routines of living for purpose of hardening or attainment of physical vigor are often referred to only with contempt. Education is needed. More attention to the teaching of health in schools, efforts to stimulate the individual in the home and group to give attention to better health. Beyond the freedom from disease he must be stimulated to recognize the value of and seek physical fitness as a source of well-being, ability to accomplish and enjoy the fullness of life. Plans are well along in preparation for the broadest National activity to stimulate an interest in physical fitness. This will be directed to the homes, schools, churches, labor and industry, and social and professional groups. This activity is being organized under the leadership of a joint committee from the American Medical Association and the Committee on Physical Fitness of the Federal Security Agency. The work will be financed from many private sources. The activity gives promise of being by far the greatest national movement undertaken to stimulate interest and effort toward physical fitness. This represents in a striking way the desire and readiness of the public to organize its efforts and work together as a voluntary association of citizens to meet National problems when the need is recognized. Col. Leonard G. Rowntree, Chief of Medical Division, Selective Service System, gave information before the committee concerning this constructive program for physical fitness. AVAILABILITY OF GOOD MEDICAL CARE Is good medical care available to all the people of the United States? The American Medical Association has made the most complete survey to determine the availability of medical care to all the people and constantly inquires into local situations. The war has made it necessary to give special consideration to the distribution of physicians and the number of patients who can be cared for by a physician. The local needs were appraised by medical men familiar with the local situation and the actual volume of medical care required by residents of that community. Transportation possibilities, habits of the people in seeking medical care, and in general, the direction of their preferences. The results of those considerations were not unlike all other investigations. Before the war the number of doctors per population in local communities varied from one to a few hundred, to one to several thousand. However, in the main, a doctor was found wherever the medical care requested by the population and the facilities available made the practice of medicine possible, provided the economic conditions of the community were such that he could support himself. The mistake has been made of concluding that because a sizable community had no physician and should have one that the people were actually conscious of their need for a physician and would employ him. Physicians going into these communities even with financial support while getting established, very frequently found this to be in error. People must be sufficiently well informed as to what medical care can do for them, before they will avail themselves of the services of a physician or any medical facilities available to them. Even in populous centers many people fear to go to hospitals and ignorance and superstition still are formidable powers in many communities. Any effort to establish medical facilities and support physicians in communities not previously having them must be accompanied by a well-organized effort to educate the residents to the usefulness of the services of a physician and medical care in trained hands. The war has intensified the needs of physicians and medical care in communities in which war industries are located. Rural communities have mushroomed into populous centers. Many times the medical profession in nearby cities have organized their efforts so as to extend medical service to these areas. The local industry has permitted its industrial physicians to care for the employees and their families in addition to their plant duties when there was need. The Procurement and Assignment Service for Physicians, Dentists, and Veterinarians has done an excellent job in preventing serious depletion of medical personnel where their services were needed by the civilian population. On the other hand, no armed force of any other nation has ever had medical care equal to that provided to our forces by the medical profession in cooperation with the Procurement and Assignment Service. Sanitary engineers and trained nurses have also been added to the group of professional personnel for whom the Procurement and Assignment Service is responsible. Plans are under way to secure a better post-war distribution of physicians and nurses and medical facilities to be accompanied by proper efforts at health education. Dr. Roger I. Lee president-elect of the American Medical Association and chairman of the joint committee on post-war medical service, may give more information on those plans. THE COST OF GOOD MEDICAL CARE The cost of good medical care is not prohibitive to the average earner. The average illness is not beyond his ability to pay without hardship. More than average sickness costs may be paid in small budgeted installments. Many medical societies have agencies to adjust total payments and installments, to the patient's ability to pay without hardship. The national total amount of commitments to time payment of medical bills according to economists is small when compared with commitments generally approved for less important items. Prepayment plans for medical care will be discussed later. The employed are protected against the results of injury in industry. An outstanding step has recently been made in advancing standards of health in industry. The Council on Industrial Health of the American Medical Association invited representatives of the American Federation of Labor, the Congress of Industrial Organizations, the National Association of Manufacturers, the United States Chamber of Commerce, and the Joint Claims Committee of the Stock and Mutual Casualty Insurance Companies, to discuss health in industry. The conference led to agreement as to the following objectives: Health education, health examinations, examination for placement in jobs suited to physical state, records of the examinations are to be confidential and imparted only to the designated personal physician of the employee, minimum standards of medical facilities and service in plants were fixed, review and appeal where provided for when the report of physical examination would have an adverse effect upon the employment of the worker. Copy of the plan is attached. (See exhibit A, p. 1901.) Research into the effects of various industrial processes upon workers will continue. Workmen's compensation and rehabilitation have been repeatedly discussed in joint conferences and the mechanisms of adjustment are being simplified, standardized, and liberalized. The council on industrial health of the American Medical Association has also prepared memoranda setting forth principles for guidance in the development of over-all medical care plans for employees in industry and their dependents. These have been approved by the house of delegates of the American Medical Association. It is reported that plans are in development in industry. Medical care is provided for old age pensioners, under State plans from Government funds. Crippled children receive excellent services under State programs. Medical care is provided for the blind by the State. Rehabilitation is now being carried on under several governmental agencies. The indigent are the repsonsibility of local government agencies and in most areas are adequately cared for. The relatively high concentrations of persons with minor mental abnormalities, not sufficiently ill to require institutional care, and those in the older ages with chronic conditions, although receiving medical care, provide an unhappy background for which there is no satisfactory solution at this time. This is not essentially a medical problem. The American Medical Association has given more study over a longer period of time to medical service plans, built upon budgeting or insurance, than any of the institutions or individuals advocating such systems. This study has covered all existing systems throughout the world. Many years ago the house of delegates of the American Medical Association stated in substance that there is nothing inherently good or bad, from a medical point of view, in different methods of collection. Insurance, budgeting, and advance financing are only methods of conducting an economic transaction. However, experience has shown that in compulsory government insurance the economic soon becomes the dominant factor and quality of service is secondary. In effect, compulsory government insurance quickly becomes more than an economic transaction. Government as a controlling third party fixes the terms to the purchaser of the insurance and compels him to pay. It likewise fixes the terms upon which the physician must furnish the service and most often under conditions that then make it impossible for the individual to have the best service or to have the services of the physician he would select. Quality of service deteriorates. Better men are no longer attracted to the field of medicine, and for the insured, the medical service deteriorates to the dead level of mediocrity and minimal service. The government becomes the employer and the close personal relation of patient and physician and personal responsibility so necessary to helpful medical care disappears. This is not speculation as to a tendency. It is written throughout the history of government compulsory systems. If any of the better medical service survives in a nation under government systems it is not generally for the insured group. Medical guidance in prevention of sickness or physical and mental disorders is of the greatest importance. General measures for prevention of disease may be planned for the group but there is no blueprint that can be applied to the problems of each individual. He requires a personal physician friend in whom he has confidence who may advise and treat. The American Medical Association has for years approved of expermientation in medical service plans by State and county medical soceities. This was for the purpose of exploring the possibilities of extending medical care to income groups to whom severe illness was especially burdensome. The efforts to be directed to determining conditions under which medical care might be maintained at high levels and personal relationship between the patient and physician might be preserved. Twenty States now have such plans in operation or are in process of preliminary study, enabling act or experimentation sponsored by the State medical society. In addition to these, 38 States cooperate with the Farm Security Administration. Most of the State plans of State societies are now on a sound financial basis. The service offered varies but changes are brought about as actuarial information is gained. Most of the Nation may soon be included in these State plans. The house of delegates of the American Medical Association recently approved the recommendation of the Council on Medical Services that the study of voluntary insurance, diagnostic clinics and medical service bureaus be continued. It was reported that the collection of information and data concerning medical care and its distribution, its availability, cost, and control in various parts of the United States was planned. It was stated that the information thus collected will be made available to the medical profession and other appropriate agencies interested in the extension of medical service and the provision of medical care, and related subjects. Various experiments are being studied for the best possible methods of prepayment for medical care at the lowest cost consistent with the best service to the insured. Government insurance is not necessarily low cost if all the costs to the insured as contributor and taxpayer for less satisfactory service are recognized. Many regular insurance groups are studying the possibility of providing broad coverage at low cost. Broad surveys of opinion expressed by those in the income groups who might be expected to be interested in prepayment plans leads to the impression that many are interested in possible prepayment plans but an overwhelming majority of the whole number interviewed were opposed to government compulsory insurance and pay roll deductions. It is evident that no plan would cover the needs of everyone or provide the best service to everyone on a single basis. The indigent, of course, can be provided for only on the basis of public support. It must be recognized that like all other social activities, there may be many methods to meet all needs, but that in the best interest of the public no method should be |