Committee on Economic Security (CES)

Volume VII. Health in Relation to Economic Security

MEDICAL ADVISORY BOARD--MINUTES OF MEETINGS

Part 6- Wednesday Evening Session, January 30, 1935

COMMITTEE ON ECONOMIC SECURITY
Medical Advisory Board

Wednesday Evening, January 30, 1935

The session was called to order at 8:30 p.m. by Chairman Sydenstricker.

CHAIRMAN SYDENSTRICKER: I am hoping very much that we will get through the business tonight, and if we want to stay over until tomorrow and debate the advantages of one thing or another and talk about the systems in England, and Denmark and Germany, I shall sit here as an interested spectator and learn a lot, but I should like to get through our job tonight, or if you want to continue tonight into the wee small hours of the morning I will be here also and will stay as long as you want to stay.

When we adjourned at six o'clock we were discussing the two proposals, the one by the staff and the other by Dr. Leland and Mr. Simons who are also members of the staff and all you had to do was to listen to the so-called experts of the staff air their differences. I think I want to call on one more expert, and he is Dr. Davis, and then I want to get the Board to express its opinion.

DR. DAVIS: After what has been said about the definition of an expert, I feel slightly embarrassed. (Laughter)

What I have to say relates both to the discussion of the point we were on just before dinner and Dr. Parran's proposal which involves some of the same principles. On the question of insurance or of the provision against the high cost of illness, or catastrophic illness, the point that I want to direct attention to is a consideration of how much of the problem that would cover and what phases of it could be most readily covered in a practical way. The two main categories of the high cost illnesses are those cared for in institutions and a certain number of the expensive illnesses cared for in bed at home.

If we consider first hospital care, roughly out of a thousand people who have less than 500 cases of recognized illnesses in a year, and of which perhaps 75 or 80 would be hospitalized, speaking about acute illnesses in general and special institutions like the hospital (but you are undoubtedly familiar with the figures) the cost of looking after that relatively small fraction would be as large as the cost of all the rest of the illnesses put together, and if you exclude that proportion of the illness period which is cared for in the home preceding hospitalization or the post-hospital stage after discharge, you still have about 40 per cent of the total expense furnished for all illnesses is due to the period of the illness cared for in the hospital.

The mere mention of that fact indicates that a very large slice of the problem so far as high cost of illness is concerned, so far as the total cost of illness is concerned could be covered if the acute hospitalized illness were covered by insurance, of course including the doctor's fee. Group hospitalization as it is now proceeding does not to any extent touch that problem of doctor's fee except some of the industrial schemes, but if you included the doctor's fee you would have this large slice of the problem of total cost covered.

I think that has other implications because it would be comparatively simple administratively to handle the problem of the institutional case, because if you attempt to handle on an insurance basis the problem of the chronic illness, the long-time illness cared for in the home and cover the cost of professional services and the other costs, such as medicine, a great deal of difficulty will result. The problem of not padding the costs, or extending the period of illness at the desire of the patient or at the desire of the physician, which in some cases might occur, the problem of supervision, of keeping the cost down, or of being compelled to set arbitrarily the number of visits that would be paid for over a given period, which is done in many of these schemes, would present very great difficulties.

I think it would be very difficult to carry out the plan of covering the catastrophic illness in the home whereas I think it would be quite simple to cover the high cost illness in the hospital, either on the basis of approaching it from the angle of public tax-supported services, which already, as you know, cover a considerable proportion of hospital care except that the physician generally isn't paid, or from the standpoint of insurance that is contributed, that is contributory insurance supplemented for the lower paid groups by tax contributions.

It seems to me that, that problem of the hospitalization illness if isolated would present a very significant contribution to the problem. I think that it should also be borne in mind that no foreign country has faced this problem in this way. England has taken it on a voluntary basis quite extensively, but in the main the reason why no foreign country has faced it is because hospital care on the continent of Europe and to a large extent in England has never appeared in the budget of the families because it has grown up on a governmentally-supported basis, or in England either in the government or in the endowed voluntary hospital which until recently never charged their patients anything at all. Hospital care in this country, in the main, has been paid for both to the practitioner and to the hospital and appears in family budgets to this very large extent. In foreign countries for the working mass of the population it has hardly appeared in family budgets at all. It has been a distributed cost from the beginning. I think that is a rather major contrast between the American situation and any European situation, which gives a special reason for the consideration of the problem of dealing with the hospitalized illness as a special problem by a special method.

I want to point out what seems to me to be the serious deficiency or lack in any scheme that covers only the high cost illnesses that are in the hospital or elsewhere. I am speaking now not of rural areas but of the industrial and urban populations. The group of the people who are above the level of the relief or work-relief group, that is who are earning more or less regular wages, and whose incomes run on the weekly basis between $15 and $25 a week (remember I am presuming that the incomes are regular throughout the year) have on the average a very small margin over the absolutely necessary expenditures. I have just been going over some budgets prepared in Detroit (prepared by an expert body there who live at home) which have been used quite widely, and they show that for families of this group, if you classify the expenditures for rent, necessary food, necessary clothing, fuel and light and other things that they absolutely have to have, the margin of income above that group of necessities, depending upon the size of the family and the level, ranges between $2.50 and $5 per week. It is obvious that to such a family a medical cost of $10 per annum is not an insignificant item. It is a serious item to be seriously considered.

I have been trying to get the size of that group and none of us have the figures here, but we think it is probably as large as 15,000,000 people at the present time. The point is that for that large group of people there is need for the insurance principle as applying not only to what we call high cost illnesses but to minor illnesses, and I think it must be frankly faced that, that group of the population is not covered by any scheme that deals with the principle covering the high cost of illness.

So much for that.

I want to say just a word to bridge over to Dr. Parran's plan. It seemed to me that in the rural areas the primary approach is from the point of view of Dr. Parran's memorandum and the proposals which have already been discussed here in relation to two points: hospital provision in the rural areas both as regards building new buildings when they are necessary and as regards assisting in the maintenance of already existing hospitals, and, second, in the more sparsely and poorer rural areas direct subsidy to provide for or increase the number of available physicians. Those two principles if carried out in rural areas would get at the nub of the problem.

Dr. Roberts has pointed out in his discussion of the Ethiopian in his favorite state that a considerable number want to take out insurance. I doubt, however, if the amount of money that they can pay would be sufficient to cover more than a small fraction of the cost. Certainly I don't think that you could cover hospital costs out of the amount they could pay. Personally I believe that it might be possible to set up a plan (and I hope this can be considered) by which the use of public medical grants, that is the tax grant from the state or locality, or possibly supplemented by the Federal Government, would be used as an incentive to get the rural population, that is on a voluntary basis, to join the voluntary local insurance system. I don't think that the compulsory insurance system is practical, but I do think that if there was a substantial subsidy involving the hospital service, and in the poorer areas provision for general medical service, it would be possible to get a very considerable part of the rural population into a scheme which you can either call a public medical service scheme supplemented by individual payments or you can call the insurance scheme combined with a public medical service center.

It seemed to me, therefore, that there are two significant things that lie in this area between public medical service for already accepted things, for the indigents, et cetera, and the health insurance scheme, which are, first the part of the plan that relates to the provision for the cost of hospitalized illness in the industrial areas, and, second, the provision of hospital care plus general subsidy for general medical care in the rural areas. I believe those two points would deal with a substantial part of the problem, although I think we ought to recognize that they would not cover it.

CHAIRMAN SYDENSTRICKER: I shall be very glad to hear from the members of the Board, particularly on the point raised by Dr. Leland, or to put it this way, the two proposals, the one which presumably might include all illnesses -- you will recall that in a memorandum of the staff we suggested that the scope of the insurance plan, so far as the benefits are concerned (on page 18 of the smaller document) would make available to all the beneficiaries, all the insured, any or all of the following services: Care in health and in sickness by a general practitioner of medicine (that takes in all the minor illness, anything that happened to be wrong with them), service in hospitals, clinics, and laboratories, specified dental service, specified nursing service in the home, expensive medicine and appliances, et cetera. So it is perfectly possible under this proposal for a state to apply for Federal subsidy for health insurance alone. It would hardly apply, I imagine, for specialist services alone, or dental service, or nursing service in the home alone, obviously, but it is perfectly possible for a state to apply for Federal subsidy for health insurance (that, of course, would apply to domiciliary and office care by family physicians) to which might be added special services, hospital, dental, nursing and certain types of medicine and appliances.

In contrast with that the proposal made by Dr. Leland and Mr. Simons suggests that insurance should be limited to the catastrophic illnesses. Dr. Parran has gone a bit further than Dr. Leland and Mr. Simons have gone, and specified, in illustrations at least, the types of catastrophic illnesses. That is an important point both as regards the health insurance program which we are charged to consider and also the medical service program which as the result of Dr. Parran's memorandum has been somewhat enlarged. I think that is an extraordinarily important point for us to consider carefully. It is really the heart of the scope of the whole business, and I shall be very glad to hear from members of the Board on that point. I hope we can confine ourselves to that point.

DR. ROBERTS: Would you mind stating that point over once more that you want us to confine ourselves to?

CHAIRMAN SYDENSTRICKER: I think for the present you should confine yourselves to a discussion of whether or not insurance in certain higher income groups should be confined to catastrophic illnesses, the type that Dr. Parran has outlined in his memorandum, or whether it should be general medical care, office and domiciliary, like the British system, for example. In other words, where the physician is a family physician and renders all care in the home or in the office, or specialists, or recommends some specialist's care for the hospital and things of that sort. That is a very important principle in both of these things that we are talking about. It hasn't been raised in the public medical service before today, or before yesterday, when Dr. Parran presented his memorandum, but it is in this plan of health insurance which we are charged to consider and we really want your very thoughtful consideration of that important point.

You can speak as the spirit moves you or I will call on you if you want me to.

You have heard what the staff and its associate members have said, the argument pro and con for this thing. I did that deliberately in order that you might get the benefit of our thinking on it.

Dr. Roberts, will you start off?

DR. ROBERTS: To relieve my friend, Dr. Cushing, my talk will be very brief.

I once heard a mother tell her little boy in the summertime to stop eating so much corn. He ate too much corn and she was rather strenuous in her correction. The little fellow was eating a cob of tender corn and he had another one thriftily on his plate, and he turned to his mother, with his mouth full of corn, and pepper and butter and salt on his lips, and he said, "Mama, when I eat corn, I eat corn."

I am disposed to feel that way about this decision. If a thing is worth doing at all, it is worth doing well. We have 125,000,000 people. I listened with great interest to Dr. Leland's presentation and I had read over well (I mean consistent with my reading ability) his presentation in the appendices, and I thought he did it very well, very calmly, and made as good an argument as he could, but I cannot help but feel the administrative difficulties. One never knows when a cold will shade off into bronchitis, to quote from the layman, or when bronchitis will shade off into pneumonia, and pneumonia into the grave, and I feel, if I can summarize this, that this insurance system that we have eats corn. It does all that the states want or it can do as little as the states want. It gives the state freedom to adopt the plan according to its several needs and abilities to meet the cost. It pretty nearly leaves the practice of medicine as it is.

I feel that insurance, as outlined, is a safe thing in an insurance-minded people.

One of the insurance companies that I, of course, cannot mention, but one of the great companies, in the Christmas week, four days after Christmas, Wednesday, Thursday, Friday and Saturday, received 23,000 insurance applications from the United States alone -- one of the leading companies. We are an insurance-minded people. I feel that there is no very great change after all in this health insurance and that the shock of the change will be greater than the change when it comes and we will wonder that we wondered about it as much as we did. It best meets the demands of adequate care and service, with the least cost, the least friction and administrative difficulty; it is most easily changed or modified as experience corrects errors and advances service. To those ends and with those convictions, I cannot but feel most deeply in favor of what is to me the conservatism of this plan of insurance that the staff has presented. I know that there are going to be errors in it, I know that there will be mistakes, but I make them every day and so do we all. Gorgas said that he tried hard not to make the same mistake twice and we can all try to do that in insurance as we do in our private practice. That is all.

DR. GREENOUGH: I take it that we shall have a further opportunity to discuss Dr. Parran's plan as a whole, and while I am sympathetic with what Dr. Leland wishes to bring about, I fear that one element in the improved service that we propose to give will be, let us say, jeopardized if we introduce a preliminary payment out of the pocket of the individual, in that we shall interfere with his free recourse to his physician on relatively mild symptoms.

If we took away the financial urge which leads him to consult his physician when he has got to get his certificate for receiving cash benefits from the doctor, I should imagine that the occasions would be very much less, and if, on the other hand, we introduce any impediment to that patient's consulting his physician promptly we really do lose much of the advantage that we would otherwise get in the recognition of the disease early, and I would, therefore, feel that while the objective is an excellent one that we could remedy it by the method of separating the cash benefit to a sufficient extent to make the abuse of frequent visits on the part of the patients a minor consideration. On that basis I should prefer to stick to this plan.

CHAIRMAN SYDENSTRICKER: Do you care to express an opinion, Doctor, on the alternative of including all services by the family physician in the insurance plan, or only the so-called catastrophic illnesses?

DR. GREENOUGH: As far as that is concerned, I should feel that we must include all services because I regard the other method as interfering with the man's consulting his physician promptly.

CHAIRMAN SYDENSTRICKER: Dr. Piersol, do you care to speak to it?

DR. PIERSOL: I agree with what has been said here by a number of men, that these catastrophic illnesses are truly the insurable thing and that these minor illnesses really don't cost very much, most of them are not serious, and from the public health standpoint they have very little bearing. On the other hand it seems to me there is the great difficulty in trying to designate just what things fall into the group of catastrophic illnesses. Furthermore from the medical standpoint it has been pointed out there are undeniably a great many illnesses which appear to be insignificant, and are insignificant to the lay mind, that in reality are very serious matters. Take coronary occlusion-many a layman may have a stomach ache and think nothing of it and yet he has a coronary occlusion. So taking it all in all, from the medical standpoint the difficulties in trying to designate which are grave illnesses and which are not, which are the beginning of serious illnesses, I believe it would be safer medically to have those people seen even though their illnesses appear to be trivial, and from the administrative standpoint it would be simpler, and I think it would also lessen the chance of temptation to misrepresent things and inject into the whole system a certain amount of dishonesty which it is very difficult to keep out otherwise. So I would be in favor I think personally of the original Proposal No.1.

DR. BROWN: Mr. Chairman, on June 8, 1934, the President said: "The people want safeguards against misfortunes which cannot be wholly eliminated in this man-made world of ours." That is what we are here to consider in my estimation. Therefore, my nature has always been, and I hope always will continue to be, to look not into the past but into the future, to make medical practice more serviceable to the public.

I am convinced that the medical profession has been extremely derelict in approaching this problem of better service to the public, and that the foundations which are so bitterly condemned by the practitioners of America instead of being condemned should be appreciated and given great praise.

This staff that we have here tonight have expressed their principles in a wise and intelligent way and have given the subject of better medical service to the public much more attention than the medical profession has. I feel that they have made intensive and serious studies not only in America but throughout the world of health insurance. They know something about it which we doctors have little comprehension of, and I, therefore, am strongly in favor of Proposal No. 1 instead of Proposal No. 2.

CHAIRMAN SYDENSTRICKER: Thank you for you kind words, Dr. Brown.

DR. BIERRING: We seem to be discussing, as you say, Proposal No. 1 and Proposal No. 2. Proposal No. 1 is developed I think largely with the non-medical viewpoint while Proposal No. 2 comes from, more strictly, the medical side of this technical staff. I feel very strongly on the point that the profession of America is not yet ready for health insurance as it has been outlined. I feel that you will accomplish just as much with Proposal No. 2 where you may probably expect a much fuller cooperation from the medical profession, and it is purely an extension of a Federal subsidy plan which we have agreed to. It will not require the legislation that Proposal No. 1 requires. It will simply require an additional appropriation. It will escape many of the complications. It is a movement, a system, or plan which many of us feel is still premature and the same results can be arrived at by a more gradual accomplishment, such as is in Proposal No. 2.

CHAIRMAN SYDENSTRICKER: I may be entirely wrong in my conception of Proposal No. 2, but I assume that Proposal No. 2 as far as the catastrophic illnesses are concerned must be covered by insurance not by Federal subsidy.

DR. BIERRING: Perhaps I was influenced by the fact that I coordinated in my mind the plan proposed by Dr. Parran with this.

CHAIRMAN SYDENSTRICKER: We are discussing, for example, from the insurance point of view. How about it, Dr. Leland, wasn't yours an alternative under the insurance?

DR. LELAND: Oh, yes.

CHAIRMAN SYDENSTRICKER: In other words, the people should be insured against catastrophic illness. Dr. Parran's plan is quite a different thing, and that is directly subsidy.

DR. LELAND: Dr. Parran picks up a principle out of this and amplifies it in a different direction.

DR. BIERRING: I appreciate, then, that my remarks should be modified for that reason, because it is amplified for me by the plan of Dr. Parran's, but of the two I would prefer Proposal No. 2.

DR. CUSHING: I would rather wait until we have heard Dr. Parran. He might very much modify my feelings.

CHAIRMAN SYDENSTRICKER: Of course, we are talking now about the principle largely of insurance against either all illnesses or only the catastrophic type of illness. That is what we are talking about -- if we should have insurance, and we are bound to prepare a plan because we are charged to do so, whether we like it or not, for the consideration of the Cabinet committee. They may throw it in the wastebasket, of course. If we have insurance, would you prefer having insurance only for the catastrophic illness?

DR. CUSHING: I think the broader it is the better.

DR. PARRAN: I should like to ask Dr. Leland this question, based on an assumption the premise to which I think all of us adhere -- it was expressed very concisely by the Chairman -- namely, that from an insurance theoretical point of view, it is the catastrophic illness which is the most insurable element in the whole picture. I assume there is no dissent from the opinion the Chairman expressed so well this afternoon on the purely theoretical basis. If that is the case, Dr. Leland, would your objections to insurance against general medical care, as proposed in Proposal No. 1, be different -- your conclusions regarding it be different if we were assured there would be no cash benefits in this system?

DR. LELAND: Of any nature?

DR. PARRAN: Of any nature. Perhaps I would except permanent disability.

CHAIRMAN: That is out of our field.

DR. LELAND: I don't know that would modify it a great deal. We recognize, of course, as the rest of the staff do, that the other would need to be used and that the administrative staff would need to be somewhat different. We also recognize that provisions which were included in No. 1 ought also to be available under No. 2, we haven't narrowed that fields, that these people ought to have domiciliary, office care and that sort of thing, hospital and specialists. We have never committed ourselves to the point of objecting or saying that they shouldn't have that. The point at which we seem to differ is whether the insurance system should provide cash payment for all there is needed.

CHAIRMAN SYDENSTRICKER: Cash payment?

DR. LELAND: Excuse me -- the remuneration to those giving the services, or whether there is a way equitably -- I don't mean to make anyone pay more than he can, but equitably to have the individual assume a certain proportion of that himself, and then apply the insurance principles, as we are trying to here, to the remainder of the burden.

I don't like this term "catastrophic illness". Under the circumstances there wasn't very much else. That is a more or less descriptive and inclusive term. I don't like it because under our conception of this it wouldn't necessarily apply strictly to a catastrophic condition. It would apply in certain instances to any kind of service beyond a certain amount, whether it is office, domiciliary, or what not, but it is assumed that a patient's ability to pay cash reaches a limit at a certain point, depending upon his income level.

CHAIRMAN SYDENSTRICKER: In other words, Dr. Leland, if I understand you correctly, quite aside from cash benefits -- they will be out of the picture for our discussion at the present moment -- you would accept the principle that insurance ought to cover all kinds of illness, provided that patient paid a certain amount at the beginning?

DR. LELAND: Oh, yes, perhaps if is isn't understood by everyone we didn't do the job of writing it well.

CHAIRMAN SYDENSTRICKER: I wanted to restate it so that we could all get it.

DR. LELAND: We have no intention of limiting the service. I mentioned at the beginning that some of this principle stated above was well stated as far as we are concerned, that all services should be available under the insurance system.

CHAIRMAN SYDENSTRICKER: Domiciliary and office and everything else, but provided the patient pays, say, $10 or something of that kind.

DR. LELAND: Some sum to be decided upon.

CHAIRMAN SYDENSTRICKER: If the whole thing only costs $10 it is all right, but if it costs $15 then the extra $5 would be paid by the insurance fund?

DR. LELAND: Yes.

MR. SIMONS: I wonder if they caught it just this way -- one sentence -- that it is very doubtful if more than two or three states would ever be able to put in this entire program that we have. In other words, we assume that Georgia, for instance, is not going to put in this whole thing at first. It couldn't do it even with a reasonable subsidy. Therefore, you are going to choose which one you are going to have. Choosing on the basis of the order in which these come and the order in which 99 chances out of 100 they would be chosen, the only thing that would be given would be the least desirable thing, the G.P. service.

CHAIRMAN SYDENSTRICKER: I am not quite sure about that, Mr. Simons, because there is a tremendous movement for hospital insurance. It might be that the states would come right square under that thing right off the bat.

MR. SIMONS: I think in most cases if you put in a compulsory state-wide service that is within the limits that we have, they would probably start with the general practitioner service.

CHAIRMAN SYDENSTRICKER: I rather doubt that. It is a matter of opinion, of course, Mr. Simons, but the public attention has been more centered on hospital insurance, I think, isn't that right, Mr. Davis, than on any other form of health insurance that we have? I rather suspect that if we had a Federal subsidy the first thing they would apply for in most states would be hospital insurance. I think they would go very slowly on the other forms of insurance.

MR. SIMONS: If I am right, you would then set up a real impediment to the most necessary practice.

CHAIRMAN SYDENSTRICKER: What is that?

MR. SIMONS: That is you would have exhausted your resources to a large extent on your minor diseases and you would not be able to give the service that you should--

CHAIRMAN SYDENSTRICKER (Interrupting): If you are right.

MR. SIMONS: If I am right that the general practitioner would generally be the thing that would be taken.

CHAIRMAN SYDENSTRICKER: Why do you think it would exhaust our resources? Let's go on a minute. I want to get this point very clear, because it bears very definitely on the whole thing. Suppose that we have Federal subsidy for this purpose. Well, here is a state that says, "We want to take this item No. 1, that is what we are fond of, care in health and in sickness for the general practitioner. We want employed people on there." There is a demand on the part of employers and the union, the laboring people and everybody else for that sort of thing. Well, later on they say, "We should like to have hospital care too." They apply to the Federal Government for a further subsidy. We don't exhaust our funds.

MR. SIMONS: What I was thinking was--

CHAIRMAN SYDENSTRICKER: We simply have a larger contribution from employees and possibly from employers and a larger contribution from the state and a larger contribution from the Federal Government.

MR. SIMONS: You have to pay up to $3,000, the family, if I am right, paying 30 per cent and the others would pay somewhere around $70, and he would pay around $50 or $60, I think roughly here -- he would have to pay somewhere around $60 and $42 -- it would be about $42 a year. That is a pretty heavy item for persons of those incomes, taking in all of this, and my belief is politically they would begin to cut off and would be apt to cut off. They might possibly give general practitioner and hospital, but it seems to me those two would probably be the best sellers so to speak.

CHAIRMAN SYDENSTRICKER: It is my opinion that they would take the hospital proposition first of all. I may be wrong.

MR. SIMONS: I don't know.

CHAIRMAN SYDENSTRICKER: I don't know either; we are just guessing that.

DR. ROBERTS: Would it be in order, without any semblance of hurry whatever, to pass to Dr. Parran's contribution?

CHAIRMAN SYDENSTRICKER: Yes, you have the floor, Dr. Parran.

DR. PARRAN: I think I will save my time.

CHAIRMAN SYDENSTRICKER: I gather then in a general way the consensus of opinion, putting it this way, is in favor of rather broad coverage on health insurance; yet I gather from what Dr. Leland says there is no essential difference between the two proposals except that one proposal -- I am not talking about your old age stuff now, that gets into another field and I don't think we are competent to pass on that because we have got a separate staff and a separate bunch of advisers and everything else on old age, but the essential difference between Proposal No. 1 and 2 is the payment of $10, isn't it?

DR. LELAND: I have no brief of any particular method whether it be $10.

CHAIRMAN SYDENSTRICKER: Appropriate initial payment?

DR. LELAND: Just merely the principle of the deductible clause in your automobile policy and that works.

CHAIRMAN SYDENSTRICKER: You do not insist that the application of the insurance principle should be limited entirely to the catastrophic?

DR. LELAND: Oh, no, absolutely not. No, it is only the assumption of the risk by the insurance system is beyond a certain point.

CHAIRMAN SYDENSTRICKER: I see, $10 or $15.

DR. CUSHING: Are you thinking of this from the standpoint of its psychological benefit to the person's paying something, because he thinks--

DR. LELAND (Interrupting): Partially so, yes.

DR. CUSHING: We had a Nigger waiterman in Baltimore who made this canny remark once, that he always noticed that if we got something for nothing it was worth just that much. There is a psychological element in the patient paying a little something if he can because he really thinks it is there and he respects it.

CHAIRMAN SYDENSTRICKER: Of course, in insurance systems they are paying something all the time anyway. It is taken out of their pay envelopes anyway every week, and they are just shy that much money every week whether they get sick or not.

Thank you very much for you observations on that whole point.

Dr. Parran, I should like to give you the floor on this thing in the light of the discussions which we have had. We have the memorandum, of course, of the whole thing, but I am particularly interested in the proposal to increase tax-supported medical care not necessarily as an alternative to health insurance. As I understand it, it may be a supplement to it, but it may be chosen by the state as against health insurance. They have a choice of one of the two or may take both. That is the understanding which I have in mind in the discussion. I think we ought to keep that in mind. It may be a supplement to it, and yet from other considerations quite aside from health insurance it has its important place in the care of certain types of diseases and persons of income levels which are far below the possibility of paying insurance premiums.

Dr. Parran, go ahead.

DR. PARRAN: I shall try to be brief, Mr. Chairman.

In the first place I find myself in the dilemma of not being able to arrive at fixed and unchangeable convictions concerning one or another aspects of this problem that we have considered, and yet I have given more or less consideration to this whole problem for a number of years.

I shall not try to read this document. I should like to point out a few of the principles. In the first place on page two, at the bottom of the page, "A body of experience has been accumulated through the conduct of existing services which shows the directions in which improvements are needed and extensions would prove profitable." That is one of the basic facts I think we should keep in mind.

I would rather discuss for a moment the broad problem of about 20,000,000 people with no resources whatever whose contributions for insurance or whose medical care must be furnished out of tax funds, and another group of, shall I say, 30,000,000, roughly, above that economic scale who can provide themselves out of current income with the ordinary cost of uncomplicated illness. Even for that group it is proposed that some Federal funds be contributed in order to provide the sound basis for insurance and in order to prevent the individual contributions being too burdensome.

The basic thought in connection with this system was the principle that the Chairman has accepted, namely, that it is the catastrophic illness for which insurance is most appropriate. Now essentially there is very little difference between contributions and taxes as a means of mutuallizing costs. I will not belabor that point. I think it is very clear to all of us. If that is the case, then why might not we extend the public services which we have already provided in considerable part for the indigent groups of the population, and to some extent as regards special services for the lower income group even though they are not indigent? And so the plan, in brief, on page four, scope No. 1, is obvious: "for all public charges, including the unemployed, those employed on work relief at less than an industrial wage, the aged, the indigent, and dependent children;" in other words, the dependent groups of population, the whole works -- all of the medical care they need and that can be reasonably provided. Of course, they will not have the very best type of service. The service they get now is not too good and I haven't any illusions as to how speedily that service might be made to approach an ideal, but certainly through Federal assistance and standards the quality of the service might be improved.

Then I have taken the next group as defined in the various schemes for social security, or shall I say the $2500 group and have listed some of the services as examples of what might be provided out of tax funds, in whole or in part, depending upon the income of the person and the amount of the cost. I realize that introduces a great many accounting difficulties. Furthermore I think all of us recognize that for this whole group of under $2500 if it were possible to provide out of contributions, or of taxes, all of the medical care they need that would be one of, shall I say, the rather socialistic ways of proceeding. My plan approaches that in part. Perhaps I ought to list some of the practical objections to this method. Some of them have been brought out. Dr. Falk emphasized the difficulties of accounting on a case basis, of balancing income against the actual cost. There are other rather more practical difficulties. In the first place one would lose the incentive to early treatment if the population were required to pay the initial cost of general medical care. In the absence of cash benefits I can't believe that people are too anxious to go to see doctors. I don't believe we will find any great amount of over-medication by people just for the sake of going to doctors and being treated. The whole psychology of the people is in the other direction unless there is a cash reward in terms of a cash benefit to be had, but nevertheless under this plan the incentive to early treatment which is had under an all-inclusive system of health insurance would be lost.

Second, issues will be raised here, as in a system of health insurance as to methods of paying doctors. Obviously there is the full-time salary basis, the part-time salary basis, fee for service, and annual per capitation basis. The medical profession generally will seek a fee-for-service basis as rates as nearly approaching those in private practice as they can get. The taxpayer, on the other hand, with his insistence upon economy, will seek to build up the mass method of treatments, organized methods of treatments in clinics, through part-time salaried physicians. So that will be a continuing issue between the medical and the public groups concerned, just as it is now in many places.

The question of political control, it seems to me that the amount of political control will probably be the same under this system or a system of insurance, because if tax funds go into a system of health insurance, the government, state, local and Federal, inevitably will control in the last analysis. It is something that needs to be recognized and undoubtedly it is recognized in connection with the vast new responsibilities which we are giving to government in other phases of social security, Public Works, Housing, and all of the other things, but it is the fault, shall I say, common to public action. So that political control will be a point that will be raised I think by the profession.

Again it will be labeled as state medicine. It makes it a disadvantage. Some doctors look upon health insurance as state medicine. Others differentiate this type of service and call it state medicine, and yet the state medicine treatments provided out of taxes for the FERA camps where it is given on a fee basis with a minimum of control is not unacceptable to physicians. As the amount of control over professional service becomes more rigid the criticism increases.

Another objection is that a considerable increase in tax support will be necessary to put the plan into operation and it is difficult to get added taxes in the absence of an emergency or in the absence of a plan which carries a wide popular appeal.

Further the states and localities if Federal funds are available will seek, as they have sought under the relief policies of the Government, to unload upon the Federal Government some of the costs they are now bearing.

Cities in general are taking care, more or less in an indifferent manner, of the burden of medical care for the indigent. They will undoubtedly seek to unload a part of that onto the Federal Government rather than extend the scope of tax-supported service.

Finally (and I think this is perhaps one of the most serious of the objections) in spite of any Federal minimum standards that can be set up as a basis of eligibility, we have built up a tradition in this country that free medical care is a matter of public charity. It is being administered by local welfare officers. In some instances they are well trained social workers, but in most instances they are the successors to the officers of the poor.

To pursue that plan further, in New York State we have a law making medical care available to persons who are otherwise self-sustaining but are unable to furnish medical care of themselves. It was designed to care for the catastrophic illness, yet we have great difficulty in making that plan work because of the inherent resistance of the welfare officer to furnishing any public service except to those who are public charges on relief rolls or eligible for relief.

CHAIRMAN SYDENSTRICKER: May I ask, is the money for that out of state funds or local funds?

DR. PARRAN: Seventy-five per cent at the moment is state relief funds. We still have that difficulty.

DR. FALK: What proportion came from state funds before this emergency?

DR. PARRAN: It was entirely local until the emergency.

DR. FALK: I think that is an important point.

DR. FALK: That last point leads me to one conclusion I have about the future of the administration of medical services, and that is if we expect to place them on some basis above that of the paupers, it will be necessary I think to devise a new method of administering medical relief or health insurance, or the public medial service -- under whatever name you call it or whatever system we adopt. I think we need to take it out of the hands of the local welfare officer and put it on the basis that I think it belongs and that is a public health activity of the Government.

We have that experience in tuberculosis where originally only the paupers received public care administered by welfare officers. That more recently has been taken over by public health authorities and persons other than indigents have been made eligible for care and treatment. The same thing is in process in this country now as regards venereal diseases, and the same thing as regards crippled children, and other services which are being given to people who are otherwise self-sustaining but are unable to meet these larger emergencies of illness.

It seems to me that (this is aside from the merits of this immediate plan) we have an opportunity in this country to reestablish medical leadership in public health and public medical activities. The whole tendency at the moment it seems to me is to make the medically trained person a technician in the departments of social welfare under lay control, to make the medical person a technician in departments of education, and more recently to make the doctor a technical adviser or technician in departments of labor as a part of the current social security movement. So unless this plan were administered under medical direction I do not believe it would prove successful.

You will note on page six under "Requirements", requirement No. 6 is that all preventive, diagnostic and treatment services should be integrated administratively under medical, not lay direction." You will note I say "integrated" and not "coordinated".

I have cited some of the objections. This isn't a plan that I am trying to defend. As I have thought of the problem I think in just about three more minutes I can sum up my conclusions up until now, and they are, first, that if a system of health insurance is to be adopted this Committee should recommend against cash benefits, so that the whole issue of a dual system of administration, the whole issue of pressure for certification, the whole issue of calling a doctor on the first day of illness, so that a record of seven days' sickness can be built up so that on the eighty day cash benefits will be paid will be eliminated from the picture.

Medical benefits are increasingly important and if a system of health insurance is to be put into effect I should like to see a definite recommendation that cash benefits should not be included at all -- not even as an unemployment proposition, and that is a little different from the memorandum that I have written here -- but that the permanently disabled, the invalid should presumably be brought under some system whereby cash relief will be given.

The second point is that I believe hospital insurance is the most important single form of insurance. Under hospital insurance I would include laboratory and payment of the doctor who renders a service in the hospital. Now conceivably one could have a reasonably good system if hospital insurance were provided and if public medical service such as I have outlined here were provided.

I would be inclined to give, as I have done, states the option of selecting any one or all of the following services, and perhaps that needs modification because obviously one service, such as nursing service in the home, is not going to be provided and receive Federal subsidy for it.

MR. SIMONS: Excuse me, I didn't catch that.

DR. PARRAN: I would favor a recommendation that if a state elects to put in a system of health insurance as outlined here under proposal No. 1 it should be permitted to do it. If it elects to put in a system of hospital insurance alone it should be allowed Federal subsidies. If it elects to extend public medical service along the line I have outlined it should be permitted to get Federal subsidy -- assuming in every instance proper standards and that sort of thing.

In other words, as I have sat here I feel much less sure concerning any one or another of these proposals, and the greater latitude that could be allowed to states in developing one or another system it seems to me would add to our experience and point the way for future development and more rigid requirements.

DR. BIERRING: What would be your thought in the nature of this development as you say further development -- what would you begin with?

CHAIRMAN SYDENSTRICKER: For instance, what would you do in your state?

DR. PARRAN: There one must consider both the scientific needs and the political implication, I think all of us realize that, and the same problem affects every state.

CHAIRMAN SYDENSTRICKER: Quite aside from the fact that you have a good governor and things of that kind, but just from the point of view of a medical man and a health man.

DR. PARRAN: I would be inclined to recommend (I will be very glad to answer as frankly as I can) hospital insurance including payments of specialists and the incidental services, as x ray, laboratory, and so on.

MR. SIMONS: Did you intentionally omit school health here?

DR. PARRAN: I think that the doctor is a technician in the education department; nor did I mention other public health procedures. I list that presumably under public health procedures.

DR. GREENOUGH: Did you consider splitting these possible services horizontally instead of vertically; in other words, is it not possible that a plan such as you have outlined might be a little better applied to the rural district in comparison with a system of voluntary health insurance on this basis -- I mean a system of health insurance or even merely hospital insurance in the urban district?

DR. PARRAN: You have stated my opinion better than I could. I neglected to include that. I do think that a system of state medicine is more appropriate for the rural area than it is for the industrial primarily because compulsory insurance can't reach the rural.

First, hospital insurance with Federal subsidy; second, from the administrative standpoint placing all medical care paid for out of public funds under the supervision of the health authorities, under medical direction with the necessary advisory board representing the profession.

The first direction in which I would extend tax support would be in providing nursing care. I have omitted that in this first hasty draft. Bedside nursing care particularly in the rural districts. That is taken care of reasonably well now in the city through visiting nurse associations.

CHAIRMAN SYDENSTRICKER: That is for people who contribute to the old age pension fund.

DR. PARRAN: Up to that level or as far up as I could get the nurses to provide a service -- the poorer rural people generally speaking.

I would extend our present already well developed system of diagnostic laboratories. They are not only public health laboratories, but clinical laboratories -- Dr. Roberts' friend, for example, Dr. Abbott -- in counties of 30,000 run a laboratory supported by tax funds to which any doctor in the county may go for any type of public health or clinical laboratory examination without cost to himself or his patient. It is a service that is welcomed by the doctor. Dr. Abbott is a consultant to the physicians of that county on any difficult case requiring a laboratory diagnosis.

DR. BIERRING: Is that open to everyone of all stages of income?

DR. PARRAN: Yes, completely.

DR. ROBERTS: Completely. That is one of the most remarkable things in American medicine that he has instituted.

DR. BIERRING: What do the clinical laboratory people say about that down there?

DR. ROBERTS: They all died.

DR. PARRAN: They have good jobs at $6,000, $8,000 or $9,000 a year as directors of these laboratories.

MR. SIMONS: Would you mind sketching your idea of just what part the private practitioner plays in this plan?

DR. PARRAN: May I go a little bit further in trying to outline the next steps as I see them? General medical care of the indigent and the whole medical service under health direction would imply continuation of our present fee-for-service basis for general medical care in the rural areas, obstetrical care and that sort of thing. In our cities it would provide for tax payments to physicians who render service in clinics, both preventive and curative clinics, on an hourly basis or session basis. We already have made a start on that in connection with the venereal diseases and others, well baby conferences and such.

With hospital insurance these payments of doctors who treat patients on in-patient service would be cared for.

DR. FALK: It would include the physician's cost in your conception of hospital insurance?

DR. PARRAN: I would.

DR. DAVIS: Would you include the item of diagnosis in connection with the hospital?

DR. PARRAN: It goes in the point that I have stated here, namely, a free diagnostic service for persons under $2500 income, or something of that range, ordinarily upon request of the practicing physician -- complicated, expensive diagnostic service, supported out of tax funds. We are now treating tuberculosis and syphilis. Specifically I think we need to extend facilities for the treatment of cancer, radium and expensive x rays, and the next disease after that which would come under public control would be the whole group of arthritic conditions. Already there is considerable medical pressure upon health authorities to do something about arthritis in the way of centers for the study of these cases.

DR. BIERRING: I have been trying to define state medicine as something that is competitive with the practicing physician. You are getting kind of close to it now.

DR. PARRAN: On the dental side -- that is something that we have left out so far -- it seems to me that the pre-school children is a group that we should attack through public funds and should render a prophylactic and filling service for that group. For the indigents, of course, you need to pay dentists for care. Over and above that I don't know that we can go further.

DR. BIERRING: How would these tax funds be provided, first by Federal subsidy, and how much?

DR. PARRAN: I should say the same amount as proposed under Dr. Falk's general proposal. I think he suggested 30 per cent of the costs. I think the Federal Government will need to continue to bear a large share of the responsibility for the medical care of the indigent if it is going to be done well. They are turning back to the states the unemployable, but I think the Federal Government will still need to accept the responsibility for their medical care in somewhat the proportion they accept it for the care of the aged -- on a fifty-fifty basis that happens to be.

DR. ROBERTS: Do you think 30 per cent is enough for the Federal Government?

DR. PARRAN: For the indigent now or for the $2500 group?

DR. ROBERTS: For the indigent and for the under $2500 group, if you wish to distinguish.

DR. PARRAN: I would say one-half of the cost of the medical care of the indigent. It would take about that much to put it on an adequate basis taking what states are now spending, and I think 25 to 30 per cent of the rest for the group between indigency and $2500 would be enough to implement it -- take 25 to 30 per cent of the additional service that I am proposing.

DR. FALK: I think the Federal Government is paying 66 ½ per cent of all it costs for relief for the population, and our Federal subsidy as tentatively suggested for the general health insurance plan is roughly 20 per cent on the more or less flat basis and an additional 10 per cent in the aggregate available to be distributed among the states on the basis of need. I take it that is the sort of thing you have in mind.

DR. PARRAN: I must confess I hadn't thought out fully what would be the most equitable division of costs as between Federal, state and local government.

DR. FALK: But you would retain the same proposals, namely, that it would have to be a very large share of the cost borne from Federal sources for those who are dependent and who have been accepted as public charges by the Federal Government during this emergency, and a substantial proportion of the cost for those who are between the indigent and, say, $2500?

DR. PARRAN: Yes.

DR. CRILE: What are you proposing for indigents up to $2500.

DR. PARRAN: For the group above or the group below?

DR. CRILE: The group above the indigents.

DR. PARRAN: Essentially hospital insurance, free diagnostic service, home nursing care.

DR. CUSHING: This would mean enlarging your diagnostic laboratory in the hospital, the doctor meanwhile feeling these things and the rest of it take care of itself.

DR. PARRAN: Yes, except that the doctor would be paid for the care of the indigents whether in the home or office.

CHAIRMAN SYDENSTRICKER: I don't like to ask embarrassing questions because we have another health officer here, but maybe Dr. Bierring would be willing to say what he would do if he had the say-so in the State of Iowa.

DR. BIERRING: I feel that one could extend the present subsidies--

CHAIRMAN SYDENSTRICKER (Interrupting): Assuming you have the subsidy, assuming you have the money you would get from the Federal Government, how far would you go in this thing that Dr. Parran has outlined for the indigents and for the group up to $2500? It is a terrible question to ask you.

DR. BIERRING: Yes, I appreciate it is. (Laughter) I would take 50 per cent for the indigent and I think about 30 per cent of the income class. The Federal Relief now has agreed, I understand, to 50 per cent of those on relief as the accepted fee basis or fee charges and then this remaining 50 per cent, of course, would be furnished by the state.

DR. PARRAN: The state or localities together.

CHAIRMAN SYDENSTRICKER: In principle, then, you would favor the complete medical care of the indigents, the wholly dependent individuals?

DR. BIERRING: Yes.

CHAIRMAN SYDENSTRICKER: If you had the money to do it with.

DR. BIERRING: I feel that they would get better care by an arrangement of this kind than they are getting now.

CHAIRMAN SYDENSTRICKER: Now in the class above the indigent class, up to $2500 that Dr. Parran proposes, in other words people who are contributors to the fund, defining the class, he suggests that a part or all of the services which are expensive and require special skill be provided, and he suggests diagnostic service upon request of the attending physician; treatment for disabling chronic illness, including cancer, syphilis, tuberculosis and arthritis; major surgery and pneumonias, including hospital and nursing charges; obstetrical care, one-half or all. Would you go the whole hog there, Dr. Bierring?

DR. BIERRING: We are furnishing free laboratory service now for everything that pertains to infectious diseases. Of course, it will require the establishment of more complete diagnostic laboratories. I think that would have to be on the fifty-fifty basis too in order to get it started.

CHAIRMAN SYDENSTRICKER: Assuming that you had the money, do you think it would be all right to give free diagnostic service to all people under $2500 in your state?

DR. BIERRING: I am not so sure about that myself right now. I am having difficulty as it is in my state with giving free service on Wassermans and other laboratory tests of different diseases.

DR. CUSHING: Even though they are privileged to go and get it for nothing?

DR. BIERRING: Yes. The laboratory directors of the state have made a strong protest to the State Medical Society. The laboratory tests have been furnished free except Wassermanns for which a charge of one dollar has been made, and they are now to be free for that also. There is a great protest from the profession and yet we do not see how we can carry on public health work if we charge for it. It is contrary to all public health purposes.

DR. BROWN: My impression of Dr. Parran's plan is that it is an extension of or a glorification of the health center idea which was debated pro and con in Los Angeles last spring. Dr. Bierring and Dr. Parran were participants in the discussion, and almost the entire medical profession of the State of California is in opposition to or resistant to the health center plan. Wasn't that correct?

DR. BIERRING: How do we stand on it?

DR. BROWN: Your point of view is the one you are expressing now and Dr. Parran's point of view is the one that he expressed in Los Angeles. The debate was between Dr. Vaughn, of Detroit, the Detroit Plan, and Dr. Pomeroy, of Los Angeles, the Los Angeles plan, and Dr. Bierring and Dr. Parran are expressing the points of view tonight that they expressed in Los Angeles.

DR. ROBERTS: They are consistent.

DR. PARRAN: Might it be appropriate to clarify the issue which was being debated there? The issue was not whether or not public taxes should be used in the payment in this instance for preventive service (I have carried this plan now into the treatment services), but in Los Angeles the debate was how public funds should be expended in providing preventive service -- diphtheria immunization, for example. Dr. Vaughn attempts to provide it by paying fees to doctors and he received universal medical approbation for it. Dr. Pomeroy proposes to furnish it to salaried physicians in centers. He uses that procedure as to method of payment.

DR. BIERRING: The remarks a moment ago referred only to laboratory service. They did not include immunization, which I feel should be made available to the practicing physician.

DR. BROWN: My statement tonight was that Dr. Parran's proposal tonight actually means an extension of public health service or a glorification of the health center idea.

DR. PARRAN: Plus hospital insurance, plus the use of fee-for-service basis, or the Detroit Plan for those services for which it is adapted, namely, general medical care in the rural area, childbirth both rural and to a large extent urban.

DR. BROWN: That is what I mean by extension.

DR. BIERRING: I don't believe it is exactly an extension because here the doctor is to receive pay for his services in this plan and in your health plan he did not.

DR. PARRAN: Just to complete the record in case any of you do not know the extent to which the preventive services are now being carried I may say that we not only furnish complete laboratory service but we distribute biological products manufactured by the state without cost to every citizen irrespective of his ability to pay; we distribute the arsphenamine and other drugs in the treatment of syphilis without cost to any doctor, without question as to whether or not he receives pay from his patient; we provide tuberculosis care for practically everybody. Are there any other treatment phases that we have gotten to in general?

CHAIRMAN SYDENSTRICKER: That is about all.

DR. PARRAN: We are spending $7,000 or $8,000 a month in buying instruments for the Relief Administration.

DR. LELAND: What are you doing for the orthopedic cases?

DR. PARRAN: I should have mentioned that. The state has declared a policy to see to it that no child is handicapped in acquiring an education or in engaging in a useful occupation by reason of any remedial defect or disease -- crippling condition. For that around $1,000,000 a year is being spent for medical care and education of the crippled child, and in two ways: Through a state reconstruction home with a salaried staff and through the payment of fees for services to private doctors. The two systems are in operation.

There is one more point and that is under a county and city general hospital law, counties and cities are authorized to establish public general hospitals which must be open to any citizen of the county without charge if he is unable to pay, at part rates if he is able to pay part rates, and at full rates as determined by the board of managers if he is able to pay full rates. We have several such rural operations in operation serving the whole county on a graduate scale depending upon ability to pay.

DR. DAVIS: The physician is able to collect a fee?

DR. PARRAN: The physician collects a fee either from the patient individually if he is able to pay, although the hospital care may be given free, or the county pays a fee to the physician, or in some instances a flat amount per year for the care of all county patients.

DR. CRILE: Would you mind just cataloguing the services for which fees may be paid under your plan to a physician?

DR. PARRAN: All special services embraced within the scope of hospital insurance. Any service which is not necessarily for the whole indigent group. In other words, we have at the present time in New York State the full-time salaried physician, the part-time salaried physician, and the physician paid on a fee basis. I think we have to arrive at our present situation fortuitously and that is the communities have to develop one or another plan which best suits the particular condition to be treated or the particular circumstance in their cities.

CHAIRMAN SYDENSTRICKER: Would you include, Doctor -- I can see where major surgery and pneumonias would come in under hospital insurance, of course, where there are hospitals, but take the obstetrical care in areas where there are no maternity beds and hardly any hospitals at all. I recall one county that had great difficulty in getting hospitals for the poorer class of women. There is no public hospital there in that county -- Cattaraugus I am talking about. Will your plan pay for obstetrical care of all women in that $2500 group, or part of it, say? Would that include the prenatal side or the postpartum?

DR. PARRAN: If it paid at all it ought to pay for the complete service as an inducement to get women to register early with the physician and get the complete service. I would say part or all. I would leave that as a question to be decided in such an area. From public funds I would pay for nursing assistance to the physician at the time of delivery -- before and after delivery.

CHAIRMAN SYDENSTRICKER: Dr. Parran, you wouldn't subscribe wholly to a plan such as the one in Detroit for the immunization of diphtheria which costs the public from ten to twenty times as much as is done by the public. Would you endorse that completely?

DR. PARRAN: Quite the contrary. I don't think it would be fair to the taxpayers to ask them to pay such rates for the treatment which lends itself so readily to mass methods.

CHAIRMAN SYDENSTRICKER: You mentioned that Detroit Plan a minute ago on the payment of fees basis.

DR. PARRAN: On the other hand, the care in child-birth which is a service which on the contrary distinctly lends itself to a payment-on-fee-for-service basis.

DR. BIERRING: Don't you think also immunization programs could be carried out in such a way so that the fee for those who are able to pay would be very small and yet in the aggregate, if the work is done on an hourly or a daily basis, would give remuneration to the physician?

CHAIRMAN SYDENSTRICKER: In his office?

DR. BIERRING: In his office or in a central place.

DR. PARRAN: There is a long story involved in answer to that, Dr. Bierring, but I think I can summarize it, that beginning eight years ago New York communities tried every suggested method of dealing with the problem. After an experience of that length of time practically every community is giving the immunization in public clinics, paying the doctor on an hourly basis or some other predetermined basis for doing it.

DR. BIERRING: That is all right. He gets paid though. That is what I mean.

CHAIRMAN SYDENSTRICKER: Before the discussion becomes general. I should like to ask your advice on this point. I think it is an extraordinarily interesting suggestion Dr. Parran has made. It goes considerably beyond the proposals which the staff has placed before you. We have assumed, of course, that full medical care should be given the indigent and people who are without money to pay for anything at all. That is all right. We have gone a little further and we have figured in a general way that the population that is not indigent at least becomes a health insurance plan the premiums of those people being paid by the public funds. Dr. Parran comes now with the further suggestion that people who are not indigent but who can pay to some extent, but who are medically dependent we may say, or almost medically dependent, up to, say, $2500, should have certain services given to them free, plus the suggestion that they should be included in the hospital insurance plan.

Now we have to make a report to the Committee on Economic Security. I should like to get your views as to the wisdom of including this suggestion along with our health insurance proposition.

DR. CUSHING: As an alternative?

CHAIRMAN SYDENSTRICKER: I don't mean as an alternative necessarily -- as a plan. It doesn't cover the thing as fully as health insurance does. If we should adopt Dr. Leland's suggestion and say that a man has to pay $10 before he gets any free service out of the health insurance plan, it would be good to consider that, but this is not necessarily an alternative.

DR. BIERRING: This is a new plan.

CHAIRMAN SYDENSTRICKER: It is a new plan. It may be an alternative plan. It may be we will have to consider this very carefully and I want your advice on it.

DR. CUSHING: I had an idea that if you were a laboratory worker and you had these two propositions you would immediately put them to a test to contrast them. Would it be possible for the Government to suggest to certain comparative states that they try out these two plans for a year or two before coming to some conclusion as to what is best for the country? Meanwhile every doctor in the country is going to be as interested as he can be.

CHAIRMAN SYDENSTRICKER: I think your suggestion, Doctor, is admirable, but it is awfully hard to persuade them. You have got legislatures to deal with and all that sort of thing, you have got the doctors to deal with, and the citizens.

DR. CUSHING: If they are the prize selected states, do they want to get the benefit and have the opportunity of being of that service to mankind?

CHAIRMAN SYDENSTRICKER: If you can persuade two states, one to try one plan and one to try the other, I will be most happy to spend two or three years trying to observe results.

DR. LELAND: I am not clear on one point. It is stated here that this is a new plan. In one sense it is. It is a plan that we haven't considered before. But in another sense it occurs to me that it is not entirely new in that it is an attempt to correlate certain things that are already being done and in so far as that is concerned it appeals to me as not being new. Indigents are being taken care of after a fashion and we all know it is being done miserably. Hospital insurance is being done in certain places but by no means universally, and likewise there are other things that are being done.

CHAIRMAN SYDENSTRICKER: You are right, it is not entirely new, but it is a new thing for the Federal Government to propose a subsidy to do it. That is very new.

DR. GREENOUGH: From our own experience in Massachusetts, with its progressive public health department that is disposed to introduce various measures, I think that if this were adopted in toto it would be looked upon with great anxiety, or if in any sense as replacing the health insurance plan it would be regarded as a very socialistic move by the medical profession. I can see that there are certain advantages, especially from the point of view of administration, in making use and expanding existing facilities rather than setting up a new system all around, but I should feel that the best possible application of this plan might well come from division brought about perhaps by the choice of individual states depending again partly on their typography as between urban and rural regions. I can't help thinking that it would be far easier and more satisfactory and more effective to develop Dr. Parran's plan in the rural districts in the rural states.

CHAIRMAN SYDENSTRICKER: As a matter of fact the state could have both.

DR. GREENOUGH: But it would also be possible to develop the industrial insurance plan in the larger cities and perhaps that would fit in certain states and not make it necessary to adopt this. I am especially intrigued by the idea of offering to the states the opportunity to make their own selection just as we offered them the opportunity of including this, that or the other service in the health insurance program. I should like to see this worked up. Of course, I appreciate it isn't in such shape that it could be passed upon finally tonight, but I should like to see this plan worked up as a possible alternative to be submitted to the individual states as a project in the direction of providing security in health matters to the population of those states which were approved by the Federal Government to the extent of justifying Federal subsidy to the same extent, let us say, as the health insurance plan.

DR. CUSHING: Would any state legislature be capable of passing on the relative merits?

DR. GREENOUGH: Haven't they got to eventually decide whether they will select a full-blown health insurance or just hospital insurance, and won't they have to do that under the advice of their own medical people, guided somewhat by the indicated recommendations of the Government?

DR. CRILE: May I ask this question: In this event it would seem to me at first sight that it would minimize enormously the necessity for local people to raise such large funds as they are now doing for community chests, et cetera.

DR. GREENOUGH: Wouldn't this require all of the resources of the present conduct of medical and public health services?

DR. PARRAN: As I visualize it, it would and one of the great dangers would be the drying up of local support.

DR. CRILE: But they have so many other things to do and besides that they will have to pay more taxes to do this. I would think, just off-hand, that would be an argument you could put to people, they will have to pay more taxes and will object to it, but on the other hand they will be relieved of a lot of pressure for private philanthropy, et cetera.

CHAIRMAN SYDENSTRICKER: By the way, Dr. Parran, I don't know that I quite agree with your statement as regards contributions and taxes being the same, in the compulsory insurance plan. I quite agree that the principle is exactly the same, that the people who are insured are compelled to pay a certain amount of money. That is tax, but it isn't a tax in the general sense of the term when it is levied on all the population and most of the money comes from the upper classes.

DR. PARRAN: Except that the whole population pays the increased cost of the manufactured product. The whole population would still need to pay for the long-continued illness, tuberculosis and mental disease, out of taxes. The whole population would need to pay the tax contributions to insurance under Dr. Falk's plan.

DR. CRILE: I suggest that an analysis go along with the plan. An analysis of cost, you relieve it here and you extend it there, et cetera, would be an interesting thing to add to the plan.

DR. FALK: If we consider Dr. Greenough's suggestion or the idea which he has several times put forward, that health insurance may be particularly applicable to urban areas and an extension of tax-supported or public-supported medical attention in rural areas (tax-supported definitely means the use of tax funds for the rural part of the state), as a practical measure I suppose in any state it would, therefore, be necessary to contemplate an equivalent per capita expenditure of tax funds for the urban population. In other words, a corollary of Dr. Parran's proposal I think would mean that we would expect the state to contribute toward the cost of health insurance for the urban population, such a proportion of the total cost of that system as is equivalent per capita to the cost of extending pubic medical services to rural areas. Isn't there that equivalent as an inevitable consequence if these are considered correllative plans to be applied to different sections of the state?

DR. ROBERTS: May I ask you this question: Here is a state with an able health officer, a progressive state and a wealthy state, and you have done certain very progressive things which almost shock me, I am not at all displeased with it, but I am just shocked by amazement and admiration that you can give biological products to all the people, or $8,000 monthly for Insulin.

DR. PARRAN: That may be an exaggeration.

DR. ROBERTS: Or a million dollars for education or remedial services, or a fee-for-service basis for crippled children.

If health insurance were recommended and adopted, would you not also adopt it in your state, either in part or in toto.

DR. PARRAN: Dr. Kopesky, speaking of the House of Delegates being entertained here tonight, would give a very different answer that I would. In general there is a great unrest on the part of the doctors in our state, and very justly so. They are being called upon in the clinics of New York City and in other cities to render free service without any compensation whatever, and the unvocal part of the medical profession, not the presidents of the societies, not the delegates to the A.M.A., but the young doctor getting started and the forgotten doctor is under tremendous economic pressure. As a result nearly one thousand doctors in New York City have joined a league for socialized medicine which proposes nothing short of complete social medicine, putting every doctor on a salary. That is one radical point of view.

The more conservative point of view is that the state health department now, as a great institution for socializing medicine, has gone much too far, has made great inroads on the practice of the doctor, but I think that last statement is based upon a misconception of where the inroads have come. The inroads have come from the hospitals and the hospital out-patient departments which have been flooded in our city with the indigent board in which the doctors are rendering services without cost, and yet the objection is not so vocal chiefly because the medical leaders of every community are the chiefs of the staff on the various services in the hospitals. I think that is a point that we need to bear in mind.

This matter of immunizing against diphtheria and a few minor things that we are doing is not a drop in the bucket as regards inroads on the private practitioners.

DR. ROBERTS: Were your laboratories criticized?

DR. PARRAN: The laboratory is the most welcome form of state medicine we have. It puts better tools in the hands of the physician. The biological products is another very much applauded form of state medicine. The present laboratory service is another very welcome form. I should mention the other, namely, the fee-for-service basis, on which our rural and small town physicians are being paid for treating the indigent again is a very welcome form of state medicine, and a form which has saved many a rural doctor from bankruptcy during recent years, but those benefits have been inequitably distributed geographically. In the city the doctor is under tremendous economic pressure.

Now your question would the state adopt health insurance, I don't believe the profession in New York State now is ready for health insurance. A bill has been introduced in the Legislature, proposed by the American Association for Economic Security, or social legislation, or something like that, and I assume that the medical profession in so far as it is represented, with the exception of the small radical group in New York City, will appear there in united opposition to it. Don't you feel that way, Mr. Sydenstricker?

CHAIRMAN SYDENSTRICKER: Oh, yes.

DR. CUSHING: I think it depends entirely on what you call the psychology of the people. That is one reason I think this has got, in a way, an unfortunate name attached to it -- sickness insurance. These people have read a lot on both sides of this problem and they have an idea that it is unpopular in some places. Admirable as the plan is I think that it would have difficulties. It should be given an entirely new name, as though this were a new thing. It has some novel aspects. If we could call it The American Plan in contradiction to this, just the very fact that this is called The American Plan as distinct from other people's plan, the psychology of the American citizen being such as it is, he would say, "That is the plan I want."

CHAIRMAN SYDENSTRICKER: I should like to hear more comments on this, as to how far we shall go in our report with this whole question of medical service.

DR. BIERRING: May I ask how you would carry on or inaugurate the plan of hospital insurance? How would that be done?

DR. PARRAN: I confess that my addition of hospital insurance to this came out of our discussion here in the last couple of days and I have a very tentative opinion about it.

It seems to me that, speaking now from a practical standpoint of what might be accomplished through state legislatures and public acceptance and professional acceptance, we are probably ready in this country for a system of hospital insurance, and I am just thinking of ways and means in which that might be made effective in the sense unemployment insurance is going to be made effective.

CHAIRMAN SYDENSTRICKER: I don't know; there is a lot of opposition.

DR. FALK: It might be done through Federal subsidy, statewide plan of hospital insurance -- much as this has been worked out.

DR. PARRAN: How would that apply to rural areas? I think this is the answer. In industrial areas contributions from employer and employee could be collected. The same Federal subsidy might be made available to any rural area, using a county as a basis, in which more than a specified percentage of the population came in voluntarily, and with the inducement of Federal and possibly state funds I think they would come in voluntarily in order to qualify as to number for the Federal aid.

DR. FALK: Couldn't you use the Saskatchewan plan for hospital insurance just as it is in use in Saskatchewan, Manitoba?

DR. PARRAN: Are you talking about general hospital insurance, or--

DR. FALK: I say apply the principle which they use, which is, namely, the local community taxes itself the equivalent of the contribution from pay rolls.

DR. PARRAN: That would be very difficult with our rural government, but I am thinking of this alternative way of the Federal bait, shall we say, to induce more than half -- more than some other specified percentage of the population -- to enroll under a hospital insurance plan.

DR. FALK: You mean a special bait above and beyond what would be offered urban areas?

DR. PARRAN: No, the same bait.

DR. DAVIS: I don't think there is really much difficulty about that hospital problem in the large cities if you have the problem of standardizing your hospitals and getting them to work together, but once a governmental subsidy, state and Federal, was available as a bait it would wipe out the difficulties almost at once. I think in the rural areas it would be relatively simple, because you have usually only a single or two hospitals in the area, and the problem of getting people to come in voluntarily I think would be very slight provided there was a sufficient subsidy, which doesn't have to be paid to the people, but it goes directly to the hospital, meeting part of their expense, so that the amount that will have to be paid by the individual instead of being $6 or $8 a year may be cut to half that.

On the voluntary insurance plan where the cost is low enough the whole England experience shows when you get the cost down low enough, England has a larger number of people enrolled on the voluntary insurance scheme than they have on the compulsory insurance scheme. You take a city like Akron, Ohio, with the two large rubber companies, they have voluntarily enrolled 40,000 people in the city of Akron within the last three or four years, because they have been able, with very large units, with almost no administrative costs because the companies have paid the administrative costs, to cut the cost down to barely $4 a year instead of $6, or $8 or $9 which is customary in experimental plans now.

I believe it would be possible. Of course, undoubtedly professional medical service would add approximately 50 per cent to the cost, but even so there is every indication from the demand for it the response will be very prompt when you once set it up in a way that it commands confidence, as the confidence of the profession gives it standing with the public and there is the confidence of the public that the thing is going to be administered on a financial basis and not by some irresponsible concern.

I feel that there will be very little difficulty in working out either the financial or administrative feature of it on the voluntary basis, providing there is a sufficient subsidy, even 30 per cent subsidy and administrative costs would attract a very large proportion of the costs.

DR. ROBERTS: May I ask why a subsidy would be necessary for the middle and upper income groups?

DR. DAVIS: The subsidy would be paid in this way, the subsidy would be so based that it would aim to provide a share of the cost of the low rate accommodation, what we call at least the ward accommodations, so that automatically the people would go into the low priced accommodations. Your subsidy would not need to touch the people who take what we now call semi-private or private room accommodations.

DR. GREENOUGH: May I ask Dr. Parran one thing and that is how about the political control of the organization which is built up; that is, is there anything that could be done in this measure which would safeguard the continuance of the progressive department of public health and not have it liable to be thrown overboard as a result or a new election?

DR. PARRAN: That is a very fundamental question. It applies not only to the department of health but to any new department which would be set up to handle health insurance or medical relief, and the problem applies equally to any other governmental venture.

CHAIRMAN SYDENSTRICKER: We have to take our chances that is all. Watch our state.

DR. CRILE: I just want to ask you at what time this report must be concluded.

CHAIRMAN SYDENSTRICKER: I think, unless somebody else has some particular question to ask, we will take these suggestions of Dr. Parran, and I hope that Dr. Parran can spare some time so that we may be able to work them out in more detail. Our report has got to be in before March 1^st.

DR. CRILE: At what time do you need this completion in order to prepare your report for March 1^st?

CHAIRMAN SYDENSTRICKER: We have got to have it as soon as we can. Of course, for the next six or seven days we have meetings with other advisory groups, which knocks us out of constructive work. It helps us a lot, of course, but we can't do any writing or work. We have a very short time in which to prepare our report. The report itself that will be given to the Economic Security Committee will not be a document like this. They won't stand for that. You have got to get it down to twenty pages or something of that sort.

DR. CRILE: You would like another meeting before you make this report?

CHAIRMAN SYDENSTRICKER: I don't think so, unless you all feel that you want to meet again.

That raises a very important question which I want to be perfectly frank about. The report, of course, has got to be the staff report. We are charged with that job. You all have been good enough, at the invitation of the committee, to advise us. I know we are going to say things in this report that individually you will not agree with. That is inevitable. If you agreed with all we had we would probably phrase it in the wrong way and you wouldn't be able to subscribe to it. I should like to have a formula some way or other by which we could absolve you from responsibility for what we say and yet give you credit for the help which you have given us.

DR. CRILE: I don't think we mind the credit part. I think you can proceed.

CHAIRMAN SYDENSTRICKER: But I don't want it to go out that you all are in any way responsible for the staff report. Of course, any statement that any one of you and any group of you want to incorporate in the report, to add to the report, we may take it in and make it a part of the report if you wish it, if it seems best to us, but it will go to the committee and be considered. Of course, one statement has gone in from the American Medical Association even before this committee was ever created -- quite a good sized document which has gone to the Cabinet committee.

DR. BIERRING: Which report is that?

CHAIRMAN SYDENSTRICKER: I don't know. It is a great, long document.

DR. FALK: It is entitled "A Report on Health Insurance," or something like that, prepared by the Bureau of Medical Economics of the American Medical Association. This was a special document prepared for the Cabinet committee and transmitted to them by Dr. West.

CHAIRMAN SYDENSTRICKER: We can have any kind of comments that you would like to transmit, but the point I am worried about is this: I want to be sure to protect you fellows in this whole thing. I don't want anybody to accuse you.

DR. BIERRING: We will get panned enough, don't worry about it.

DR. CUSHING: I want to be cleared up about something. I can quite understand, in view of the labor that you put on this document and these months of study that you put on this, that you should be willing to shift or accept an alternate plan so readily. Do you feel that this plan and your plan are equally good?

CHAIRMAN SYDENSTRICKER: I should like to consider it carefully. I haven't had time to think about it.

DR. CUSHING: Would it be your proposal to present them as alternative plans?

CHAIRMAN SYDENSTRICKER: In one sense of the word they are not alternative; they might be thought of as complementary.

DR. CUSHING: I mean it offers a choice for states as to acceptance.

CHAIRMAN SYDENSTRICKER: We have already suggested choices.

DR. CUSHING: Those are choices within one report, but here are two separate reports.

CHAIRMAN SYDENSTRICKER: I could not answer that question, Dr. Cushing until I have had time to think about it.

DR. CUSHING: But I mean sentimentally and every way you have no objection. I think this thing could clear up a great many difficulties, I mean from the standpoint of having anything introduced.

CHAIRMAN SYDENSTRICKER: I don't know how the medical profession would react to the thing that Dr. Parran has suggested.

DR. CUSHING: As I said a moment ago, if you put this out as The American Plan they will rise to the bait immediately.

CHAIRMAN SYDENSTRICKER: But I do want to get that straight. I want to get your advice on how to phrase this thing. We will take you into our confidence while you are here, because in the next three weeks we have got to get this report in. This Committee on Economic Security has the machinery. There is the staff headed up by Mr. Williams. Then we have a technical board of twenty experts from the Government. Our report must go before a subcommittee of that board and then before the whole board. It took me two weeks to get the public health thing through all these boards and committees. Then we have got an advisory council composed of outside people, employers and labor and social lodges and things of that kind.

DR. BIERRING: Are they interested in anything like this?

CHAIRMAN SYDENSTRICKER: Sure.

DR. BIERRING: Do they know anything about it?

CHAIRMAN SYDENSTRICKER: They don't know very much about it but they have got to pass on it. Then the Cabinet committee itself must pass on it. Then it goes to the President. Of course, it will get to the President in some sort of shape and what the President will do with it I haven't the slightest idea at all, no more than you have from reading the papers. So we have got to do a lot of work on it. The document when we get it done will be about the size of our smaller one here, a very brief outline. Of course, we will have a supporting larger document explaining the whole thing, but the press release for publication will be a small outline.

I know a lot of things that we have proposed here you don't agree with individually, some of you don't, and if I could get a formula of some sort absolving the Medical Advisory Board from any responsibility for wild-eyed radicals of the staff, I would be very happy.

DR. ROBERTS: Mr. Chairman, here is this report to the President of the Committee on Economic Security. In the back of it is listed the different committees, and it is headed, "List of committees advisory to the Committee on Economic Security." This is our country. We accepted the invitation and came here, we have given our advice and suggestions as best we could, and for one, since it is my country, and personally I felt honored to be permitted to come here and to try to do my duty, I don't want to be absolved from anything. I want to take my stand as I have taken it here, and personally I don't want any explanation, any praise, or any relief of responsibility. I would feel that the less said about it the better, and the least that can be said is nothing. I am not ashamed of it, I am just speaking my own mind, and I would prefer, if I may express my own feeling, that nothing be said. I am willing to stand and be responsible for being on this committee and take whatever the future brings.

DR. BROWN: I feel the same way about it, Mr. Chairman.

DR. ROBERTS: I don't want anybody to apologize or defend me. I will do that myself.

DR. BIERRING: Then, if I am to understand, any action that may be represented in this report will not in any way represent or concern us individually, is that way you mean?

DR. ROBERTS: Well, I used the personal pronoun "I" and the objective case "me" and you said "us". (Laughter) Do you see? I just let John speak for himself and John spoke. The staff is responsible for the report.

DR. BIERRING: We are not responsible for that?

DR. ROBERTS: No, sir, and I am willing to let it go at that. A man is never safe until he can stand anything.

CHAIRMAN SYDENSTRICKER: That is very nice of you, Doctor, but how would it do for us to say in the report that in the formulation of this report responsibility for it, of course, rests with the staff, but that we are thankful for the constructive and critical advice of the various boards of the Council? I think that ought to be said. I realize the situation which you are in, and it may be an embarrassing one from time to time. I don't expect endorsement of the committee of all we have got because we don't know yet ourselves what is going to be in the final report.

MR. SIMONS: Had you noticed the formula on page three here which sort of covers it, in the Report to the President of the Committee on Economic Security, beginning with "The responsibility for"?

CHAIRMAN SYDENSTRICKER: Where is that?

DR. LELAND: Page ten. "X" that means 10.

CHAIRMAN SYDENSTRICKER: I don't see any "X" in mine.

DR. LELAND: In the letter of transmittal, on the second page.

MR. SIMONS: This is the President's message to Congress.

CHAIRMAN SYDENSTRICKER: Oh, well, I haven't got that letter.

DR. LELAND: It reads as follows, which might be modified:

"The responsibility for the recommendations we offer is our own. As was inevitable in view of the wide differences of opinion which prevail regarding the best methods of providing protection against the hazards leading to destitution and dependency, we could not accept all of the advice and suggestions offered, but it was distinctly helpful to have all points of view presented and considered."

DR. FALK: It is the last paragraph on Roman page six, I believe, of the committee's report to the President. It is the same paragraph. That is the same document except that this is merely the committee's report to the President and this is an appendix to the President's message.

CHAIRMAN SYDENSTRICKER: "The responsibility for the recommendations we offer is our own," well something like that would be all right, wouldn't it?

DR. LELAND: That expresses exactly what you had in mind.

CHAIRMAN SYDENSTRICKER: I wanted to tell you about it. I wanted to have this point discussed before we left because we won't be able to have another meeting. I may want to correspond with you on a point or two, but we have got to work in a hurry. We have the Dental Group, the Hospital Management Group, and then the nurses got rampant and we had to get together a group of nurses of all kinds. We have got to spend a day with them and let them talk.

DR. ROBERTS: Will the staff bear in mind the point about having one or two members of the family, giving them the right to ask for consultation in the insurance scheme?

DR. FALK: That is in the minutes and it will be given prayerful consideration.

DR. CUSHING: Personally I can't see why we can't leave this to your good judgment what to say. You know how we feel and I quite agree with Dr. Roberts' "we".

CHAIRMAN SYDENSTRICKER: I don't want to let anybody have the chance to say that because you worked with us, or any one of you worked with us, that you are in favor of health insurance or state medicine or something of that kind.

DR. PIERSOL: I doubt very much if the rank and file of the medical profession quite appreciate our position in this matter. I think you are quite right about that. I am sure that the vast majority of them if asked tonight would say that we are down here to decide whether or not health insurance for the United States was to be instituted, and I am quite sure that they will be ready, if they don't approve of it, to pin the blame on us, but I feel exactly like Dr. Roberts -- what if they do?

DR. CUSHING: I think that we might avoid that blame if we can lay emphasis upon the fact that an alternate plan has been suggested which met with special favor on the part of the Advisory Committee.

CHAIRMAN SYDENSTRICKER: Of course, I don't know what is going to happen to it before the staff gets through with it. They may say, "That is no good; go back and do the job over again."

DR. PARRAN: They may say, "Bring in a compulsory plan of health insurance, with Federal facts, et cetera, to employ to coerce the states into putting it into effect.

CHAIRMAN SYDENSTRICKER: They may put in a bill like the Wagner-Lewis Bill. They may go counter to the staff's own idea on this.

...Discussion off the record...

DR. PARRAN: I would move that the Chairman be requested to request the Chairman of the Committee on Economic Security, Secretary Perkins, to approve Dr. Bierring's presentation to the House of Delegates of the American Medical Association of such parts on all of the discussions that have been had in the Medical Advisory Board as he thinks appropriate, with the understanding that no publication thereof will be made, shall I say, of all or part.

CHAIRMAN SYDENSTRICKER: I don't think it is necessary even to get the permission of the Secretary.

DR. PARRAN: It might be a courtesy.

DR. FALK: May I add a supplementary part for your consideration of that motion, that no publication thereof, either in the Journal of the American Medical Association, or in any journal edited by any member of the House of Delegates, or otherwise, be permitted. My point is merely that you would have a dual responsibility there.

CHAIRMAN SYDENSTRICKER: I remember that after the last meeting Dr. Leland wrote me and asked me whether or not it would be all right to show these documents to some of the heads of department, and I wrote back, "By all means; we want all the help we can get."

DR. LELAND: I might amend Dr. Falk's suggestion. If you wish to be specific and correct about it, you should say, "Any state or county medical association journals or bulletins."

DR. PARRAN: Any publication whatsoever.

DR. LELAND: Because the members of the House of Delegates as a rule don't edit any of these things. There are separate editors, don't you see?

DR. FALK: I merely had in mind that Dr. Bierring would, of course, understand that, and we should like for the officers and the Journal of the American Medical association to appreciate the executive and confidential nature of the document. I mention it merely to bring out that before any presentation is made before the House of Delegates it would have to be unanimously agreed by the House of Delegates that they were not to transmit it outside of their group.

DR. BIERRING: What would be the limit on this publication in time?

CHAIRMAN SYDENSTRICKER: These documents are confidential until the President releases the report. We are bound by that. There have been some leaks somewhere in it, I don't know whether in the Advisory Council; probably, I suspect that, and that is where you get these garbled newspaper reports.

DR. ROBERTS: I feel sure that Dr. Bierring will agree with me when I say that whatever is said before the House of Delegates even with closed doors will be spread medically from one end of the country to the other, to every gathering of doctors in this country. It will go over the state within a week. Your motion is that he have free reign to quote any discussions in this body. If you want to spread that over the country, by the very fact of the frailty of human nature and the linguistic ease of using the tongue, it will be done and it won't be Dr. Bierring's fault.

DR. LELAND: May I say a word, please? I brought this subject up once before as you will recall, perhaps at the first meeting, that the medical profession of the entire country would sense that something was going on here. They know something about it. They don't know all about it, they don't know the actual details, but they know that some program is being considered. I have no way of predicting what actions, if any, may be taken at the House of Delegates in this special session. I have ways of knowing, as has been expressed here today, perhaps more direct in some ways, that there is a great deal of anxiety among physicians, not alone about their particular economic situation but over the uncertainty of just what is going to happen.

I hesitate, although I have already submitted a statement of my own in which I refer to this same meeting, suggesting that if it were possible the House of Delegates be requested to consider this. However, you consider it, the House of Delegates is the House of Delegates of the American Medical Association, the legislative body of the only big organization in the country, and it is nothing more than a bit of courtesy, perhaps of attempting to help a little bit. Maybe it can't be done, maybe it isn't wise to be done, but I feel as though certainly something is necessary to prepare the medical profession for something that is coming, and I think that the sooner that can be done the better. This is an opportune time. A special meeting of the House of Delegates isn't called every year. It is the first time that I know anything about it and it is an extraordinary session. The men who are from your states are your representatives, and whether they be clothed with the frailty of human nature or not, they are delegates to the American Medical Association and they are going to study the question of sickness insurance. Is there any way in which some consideration can be given to this so that it won't appear as though some gag rule were being applied to it?

DR. CUSHING: Wasn't that our understanding at our last meeting, that this committee hoped to be able to deal with the Journal of the A.M.A. to ease this out to the profession and it was even suggested that the committee see the publications before they are freed? That would ease your minds about it, wouldn't it?

DR. PARRAN: Would Dr. Bierring care to tell us what he would like to present to the Association? He has a big responsibility here and I think all of us would like to be helpful to Dr. Bierring in any way it is possible.

DR. BIERRING: They will naturally expect some form of a report from me. They say, "You were selected as an individual; nevertheless you have in a sense represented the viewpoint of the organized society." I feel if I could first of all allay their fears that the revised documents protect and safeguard not only the qualification but the quality of the care that is to be given that would mean a lot to them, and then in a general way outline what the proposed or probable plan of health insurance contains, the manner in which it is to be presented, and then the alternate or complementary proposal, which is possibly less suggestive of health insurance, to which they are in principle apparently at present opposed, that --

DR. CUSHING: We all see that situation. Before any release is made by the A.M.A. could the Committee on Economic Security, including yourself, see this and pass on it with the understanding that it is issued to ease the situation among a lot of agitated doctors, so that you could see what is in it, or if you object to it, just object to it?

CHAIRMAN SYDENSTRICKER: It is most unfortunate, Dr. Bierring, that the House of Delegates should be called to discuss the question of health insurance. I will tell you our situation. We cannot make public these documents because in the first place they are not completed. We ourselves can't outline to you exactly what we will put in our report. We have got your advice on lots of points, and we want to take it on some points and we may reject it on some, without disparaging you, and we don't know. That is one thing. This is an incomplete thing, and, second, even if it were complete, and we could put our final finis on the last page tonight, and say, "That is the report we are going to give," we are bound not to make it public until the President makes it public.

DR. ROBERTS: This is a Government body.

CHAIRMAN SYDENSTRICKER: This is a Government body.

That is the second point; that is the general thing.

I think, Dr. Bierring, if you could tell the House of Delegates that the report is not done, that you feel, as you have expressed your views just now that we are not proceeding along the radical lines that have been feared, but you are not at liberty to disclose the details of the contents of the plan, that will be all right, if you want to reassure them a bit and I will be most happy if you feel that way about it.

I will go one step further. I will be glad to put this thing up to the Chairman of the Committee, and if she agrees to letting you divulge the general content of this thing, realizing it is a mere tentative proposition, it is out of my hands, but I am rather bound not to do it. I don't think that I could handle it myself.

DR. LELAND: I believe that you stated it was unfortunate that this meeting was to be called just at this time. There are certain considerations that I believe I am not violating any confidence in telling you that determine certain things in a body of that kind rather than waiting on a group of this kind. We have reports here that were issued that state certain principles.

CHAIRMAN SYDENSTRICKER: They are principles and observation; they are both.

DR. LELAND: Not in detail of the exact thing that we have been doing and they suspect something of the nature of insurance is about to be proposed, or may be proposed, or may be considered we might put it that way.

CHAIRMAN SYDENSTRICKER: They know it is going to be considered.

DR. LELAND: But that is not the chief reason. We have reasons to believe from one source or another that the members of the Congress are interested in placing some sort of a bill before Congress, and we know positively it has been stated that the American Association for Social Security is going to attempt to place a bill quite different from this in state legislatures. That is vital. It has been done. That is quite a different matter from the tactical point of view, and the concern of the medical profession and I believe we might say the concern of the public -- it is quite a different matter than the consideration here, and, therefore, we believed that it was not wise to postpone until some future time, maybe any other time, to consider some steps that might be taken, some consideration of this thing which is actually being rushed onto the American public.

CHAIRMAN SYDENSTRICKER: I got a letter from Dr. Fishbein, who was kind enough to submit me proof of his last editorial -- a very good editorial. Even in this Section on Health Insurance in this committee's report it is nothing in the world but an interim, progress report, and it says, "Until the results of this are available, we cannot present a specific plan of health insurance...." That tells plenty, doesn't it?

Dr. Fishbein said that the House of Delegates will consider these principles. I don't presume to suggest that they ought to be told at all, but that is not our final report.

DR. LELAND: I haven't been instructed, Mr. Chairman, to ask for any information from this board. What I have said I have done on my own initiative, but that is the only document that can be placed before the House of Delegates, representing what is going on in the field of health insurance here.

CHAIRMAN SYDENSTRICKER: We couldn't, as you suggested to me in the memorandum, place these documents before the House of Delegates.

DR. LELAND: I didn't expect it.

CHAIRMAN SYDENSTRICKER: Because we haven't completed them.

DR. FALK: You couldn't even if you had completed them until they had been released by superior authority.

CHAIRMAN SYDENSTRICKER: I would say then in reply to Dr. Bierring, we would appreciate it very much if you would express your general opinion of the thing and say that you are not at liberty to divulge the details of this thing, but you can give general impression. I wouldn't say that we have an alternate or anything of that kind. I would just give the general idea about it and say you are not at liberty as a member of a Government advisory board to divulge what the discussions have been. That would be my suggestion, but if you wish I shall promptly take it up with Miss Perkins and ask her whether you could go any further, and if she gives you permission, all right.

DR. BIERRING: I wish you would. I am thinking of sort of extending the hand to men whom we have to depend upon in the future for support of this thing. If we can come to them in a fair way and say, not in details, but if we can assure them that they are going to be protected in this and that it is going to be built up around principles such as they have promulgated in the past--

CHAIRMAN SYDENSTRICKER: I see no harm in saying that, that is perfectly all right. We would feel, however, that you should suggest to the House of Delegates, and thus to organized medicine everywhere, that they withhold their judgment on our proposal until it is made public.

DR. BIERRING: I think that would be perfectly all right, and then if they wished to again reaffirm their previous stand and say that they are in favor of such and such regulations, then that will represent their attitude, you see.

CHAIRMAN SYDENSTRICKER: Are there any other matters that you would like to bring up?

DR. ROBERTS: I move a vote of appreciation to the staff, and particularly to the Chairman for his long patience with each one of us individually and collectively.

...The motion was seconded by Dr. Piersol...

CHAIRMAN SYDENSTRICKER: Thank you all very much. I think the thanks are due to you. This happens to be my job and you have all had to leave your jobs, and, as Mr. Whittier said, pay most of your own expenses in order to do this arduous thing, and I will promise you that we will use all the advice that you gave us that we possibly can. We have got to make our own report the way we see it, but the advice has been very helpful -- very illuminating. As you see our documents this time are changed radically from what they were first and we will probably make a lot more changes, I know we will, in the final report.

Unless there is some other matter before us, we will stand adjourned sine die.

...The meeting adjourned at 11:00 p.m....