Senator PEPPER. How long does a member pay for whenever he joins up, for a day or a month or a year or what?

Dr. GOIN. Well, a member who has a pay-roll deduction pays for the period of his pay check.

Senator PEPPER. You use the pay-roll deduction method also?

Dr. GOIN. We do for groups. Those who are no longer in groups can pay quarterly, semiannually or annually, as they prefer.

Senator PEPPER. Can any individual in the group be included if he wants to?

Dr. GOIN. Certainly.

Senator PEPPER. What does a factory do, insure all of its employees-many or all of its employees?

Dr. GOIN. Sometimes, and sometimes the employees want to do it themselves.

Senator PEPPER. But in every case coverage rests upon the individual application, and the payment of the necessary dues by the individual.

Dr. GOIN. That is right.

Senator PEPPER. All right. Now, how long does he pay for when he joins up?

Dr. GOIN. Well, as I say when he joins in an employed group he just joins for the period that his pay check covers.

Senator PEPPER. Say a week or a month or whatever his pay check is? Dr. GOIN. Usually it is 2 weeks or a month.

Senator PEPPER. Supposing this individual feels that he wants to go around to see his doctor, and he is not there. He calls for the doctor, and the doctor does not come or he thinks that the doctor did not give him the care that he should have had. What does he do? Dr. GOIN. Just calls another doctor.

Senator PEPPER. Pardon?

Dr. GOIN. Just calls another doctor, just the same as he would do if he was a private patient of the doctor.

Senator PEPPER. You mean that he calls another doctor who is part of the same program.

Dr. GOIN. Everybody is part of it.

Senator PEPPER. Every doctor in California is a member?

Dr. GOIN. For practical purposes. We have 9,788, and I suppose there are 10,500 doctors practicing.

Senator PEPPER. I see. All right. But suppose he complains; that he goes to the second doctor, and this doctor treats him and he does not give him the right kind of treatment. Then what does he do?

Dr. GOIN. Go to a third doctor. Is that not what you would do if you went to a private physician? There is no difference. If you went to a private physician in your home town and he insulted you, you would walk out. If you went to the second one, and the fellow acted as if he was a little drunk, you would walk out, and that is what this fellow would do.

Senator PEPPER. Suppose he goes to one doctor and the doctor starts a treatment and treats him for a little while, and he decides he does not like that treatment, and he goes to the next doctor and says— this doctor asks him-I guess he asks him whether he had been to any other doctor.

Dr. GOIN. That is the usual practice.

Senator PEPPER. And the second doctor says, "Well, what treatment did you get?" He tells him what treatment he got; and the second doctor says that that is the right treatment, and the patient insists that he wants some other treatment. What does the second doctor do?

Dr. GOIN. The second doctor has got to do what he thinks best.. No doctor does what the patient tells him to do.

Senator PEPPER. All right. Suppose this fellow thinks that he has got a right to the treatment that he should have, the treatment that he is asking for, and he thinks he is not getting the kind of coverage and care that he is entitled to under this system.

Dr. GOIN. Of course, I will tell you, Senator, those things do not actually arise in practice. We have occasionaly a psychopathic patient who asks that the treatment be given this way, and we get them finally caught up with occasionally, and then they are removed from society.

Senator PEPPER. Doctor, I am asking you, do you not have any system by which complaints may be made in your plan?

Dr. GOIN. Just write a letter and complain.

Senator PEPPER. Is there anybody who can hear that complaint? Dr. GOIN. Certainly, I can, for example; the board of trustees can; the medical director can.

Senator PEPPER. Then, does somebody have authority to give redress?

Dr. GOIN. They certainly do. Right now, too.

Senator PEPPER. And if the patient went and insisted that he was entitled to a certain kind of care, and you did not think he should have it and denied it to him, would he not have a right to appeal and complain about it?

Dr. GOIN. I think if a patient went to a doctor and insisted that he should be treated-let us make it simple-with penicillin, and the doctor thought he should have sulfdiazine, I do not think anybody would pay any attention to his complaint. That is not a complaint; that is just the patient trying to superimpose his judgment on the doctor's, and the doctor will not do it, any more than if you are practicing law you would mind what I would want done in a legal case where I retained you for counsel.

Senator PEPPER. All I am asking is, is it not a fact that under your system or any system, either voluntary or compulsory, you have got, in fairness, to give the patient a right, and to establish a procedure by which he may complain, and you provide somebody to hear his complaints?

Dr. GOIN. I do not think so; I do not think so, Senator.

Senator PEPPER. Well, do you not say that is what you do?

Dr. GOIN. We have no change in the practice of medicine under our system, and the patient has the same rights, and the same privileges, and the same recourses that he had if he just goes to me as an ordinary doctor to pay his fee.

Senator PEPPER. Yes, doctor.

Dr. GOIN. He will complain to me. He will complain about me. He will complain to his friends. What else will he do? He just comes as a private citizen

Senator PEPPER. But he has already paid you in this prepayment case, and it is not like going to a private doctor.

Dr. GOIN. He has sometimes paid me my fee even before he has gotten mad at me.

Senator PEPPER. But it, in private practice, ordinarily does not create a situation where the patient pays before you finish with him. Dr. GOIN. No, but sometimes you insist that the patient pay something.

Senator PEPPER. And in that case if he does not like the care you give him he goes to another doctor and just does not pay you when you send him a bill.

Dr. GOIN. That is right.

Senator PEPPER. But in the prepaid cases his fee is already paid. Dr. GOIN. He will just get the care; it is just a heavier burden on the plan, that's all.

Senator PEPPER. Do you or do you not give your patients, those who are covered, an opportunity to complain to some board or agency or some official, and give that board or agency or official the power to hear the complaint, and if it is a justifiable case, give redress?

Dr. GOIN. We have no system set up for hearing complaints. We only treat them in the ordinary courteous manner. We listen to anyone who has a complaint.

Senator PEPPER. When you say "we," who is "we"?

Dr. GOIN. Our system.

Senator PEPPER. Your what?

Dr. GOIN. The California Physicians' Service. The mail which comes in depends on where you address it. I get mail addressed to me personally.

Senator PEPPER. You are the head of it?

Dr. GOIN. I am the president.

Senator PEPPER. You are the president?

Dr. GOIN. But mainly letters go to the office of the California Physicians' Service, and there they are opened by mail girls, and assorted by where they think they should go, and a letter complaining of medical care will arrive at the desk of the medical director, who will make some courteous response. There is no complaint that needs to go through the steps up to an adjudication; we do not have it.

Senator PEPPER. But you do have machinery by which complaints may be made and consideration may be given to the complaint?

Dr. GOIN. No; we really do not. I say some person will eventually get a letter and make a reply to it, but there are actually no steps through which you go to make a complaint or to complain. If you were dissatisfied you would simply write a letter to California Physicians' Service, and state what your complaint was, and presently you would get a letter from someone saying that they received your letter, and they would try to investigate it and straighten it out for you, and try to do so and so.

Senator PEPPER. The individual may not be able to get his money back, and you may treat his complaints in just a perfunctory way, as you indicate you do. I suppose the only redress he has got, as you suggest, is to pull out of the system.

Now if, however, there is to be compulsory payment required, then obviously there would have to be some machinery provided by which complaints could be made and heard, would there not?

Dr. GOIN. Oh, yes. I was not making any complaints about the existence of such a system.

Senator PEPPER. That is all, Doctor. Thank you very much for your views.

Dr. GOIN. Thank you, sir.

Senator PEPPER. The hearings will be recessed until 10 o'clock next Tuesday morning when they will be resumed.

(Whereupon, at 5:05 p. m., the subcommittee adjourned, to reconvene at 10 a. m., Tuesday, May 31, 1949.)

(Subsequently Senator Murray submitted the following personal statement and accompanying article for inclusion in the record:)

Senator MURRAY. Since the San Francisco municipal health service plan represents the only American experience with compulsory health insurance, I think the record should contain the following article setting forth the origin and development of that plan and giving a picture of what it has meant to the municipal employees and the families of those employees in the city of San Francisco. is also worth noting that the firm of Whitaker & Baxter, currently spearheading the American Medical Association's attack on national health insurance, had a hand in the attempt of organized medicine's effort in California to wreck this significant local experiment.

[From the San Francisco Chronicle (This World), February 22, 1948]

It

THE PATIENT'S DILEMMA-San Francisco's Health Service system worked well for 8 years until the city's doctors suddenly saw the specter of socialized medicine. Chronicle staff writer Ruth Newhall herewith reports on this controversy, which threatens the system.

Russell Cardin, who works in the engineering department of the city and county of San Francisco, woke up before dawn early one day last November with pains in his abdomen. The pains were general, and rather nauseating. He thought back over his previous day's diet-but this was no ordinary attack of indigestion. He woke his wife.

Mrs. Cardin (for the purposes of this article) took his temperature and found he had none. Cardin went back to a restless sleep. At 6:30 a. m. he got up and started to dress, and the pain became more intense. His wife sent him back to bed and telephoned a doctor whom we will call Carey Drumm, the physician who had attended the family when they all had flu a few months before.

Dr. Drumm arrived, and Mrs. Cardin reminded him that they belonged to the municipal employees' health service system, and gave him their system number. He took a case history, asking questions about Mr. Cardin's diet the day before, whether he had frequent indigestion, whether the pain was constant or recurring. Fairly constant now, Cardin said, and a little more concentrated on the right side. The doctor found his temperature was 101° by this time.

At that point, of course, most amateur diagnosticians would have shouted: "Appendicitis!" They would have been right. Dr. Drumm went at it a little more cautiously, probing Cardin's midriff first on the left until he worked over to the sensitive spot that drew up Cardin's right leg and made him grimace in a spasm of pain.

The doctor called Stanford Hospital, arranged for a bed in the surgical ward, asked them to be ready for immediate blood counts and to prepare surgery. He then called HEmlock 1-7100, and asked to speak to Dr. Keenan, medical director of the health service system. He informed Dr. Keenan that Russell Cardin was being hospitalized for an emergency appendectomy. (Actually, since the operation was an emergency, Dr. Keenan's approval was not necessary.)

Mrs. Cardin sent for an ambulance, gave their health service system number, and asked the ambulance people to bill the system directly.

The rest of it was regular procedure the ear-pricking for blood count, the trip in the gurney to the fourth-floor surgery, the dull awakening, the camara

derie of ward convalescense. The best part of it all was that Russel Cardin's biggest worry was when his scar would heal. The fact that the total charges for operation, hospital, and associated services added up to more than his $350 monthly salary did not bother him a bit.

Cardin's only outlay on his faulty appendix was $3.50 for some medicine prescribed by his doctor. The rest of it was taken care of by the health service system. Out of each monthly pay check Cardin had had $12 deducted-$3.40 each for himself and his wife; $2.60 for each of his small daughters. He was now collecting the benefits.

But on November 12, the fourth day of convalescense, his wife brought him a letter which had been written to them by Dr. Drumm. It said, in part:

"In accord with the action of more than 900 of my colleagues in the medical profession, I have submitted my resignation as a member of the medical staff of the health service system, effective November 10, 1947.

"This decision is not arbitrary on my part and I am deeply regretful that it is necessary, but I cannot in good conscience remain on the staff of a system which denies you adequate medical and hospital care in time of illness. * * *” To Russell Cardin, who had just received more than adequate medical care at the system's hands, the whole thing was a little puzzling. To the other 19,000 members and dependents in the system, it was confusing though not unexpected. A battle had long been raging in the press and pamphlets between the municipal employees' health service system and the San Francisco County Medical Society. This was the culmination.

The implication of the dispute went beyond the matter of municipal employees; it was a problem which concerned every citizen. The Health Service System, as the only compulsory municipal prepaid medical plan in the Nation, is a pattern, in a small way, of various plans that have been drawn up for state-wide and nation-wide public health insurance.

Like many other medical service systems, the San Francisco Health Service System grew out of the depression, when a large proportion of the public realized that it could not afford to get sick, and that there was something to be done about it.

Medical insurance plans were born all over the Nation, and were fought to the last ditch by the American Medical Association, which preached the "sacred personal relationship between doctor and patient" but which overlooked the fact that many doctors were going broke and patients were dying of neglected ailments, because they had no money to pay.

The growth of prepaid medical care in the 1930's swung the medical associations around to the point where they found their best defense was offense. They took to supporting group plans which met with their approval, or even to sponsoring their own. Such a sponsored plan is the California Physicians' Service. By going along with voluntary insurance plans, the medical associations have hoped to protect their members from compulsory or State-controlled medical plans. Some 50,000,000 people in the United States today are now enrolled in medical insurance plans, of one sort or another.

The organizers of the San Francisco municipal health insurance plan decided to make the plan compulsory, on two grounds: First, it would help insure the city against loss of efficiency through neglected health; second, it would keep the expense per employee lower, since the chronically well would help foot the bill for the chronically ill.

After city employees had voted 8 to 1 in favor of some sort of compulsory health insurance for themselves, the matter was submitted to San Francisco voters as a charter amendment. In March, 1937, the people voted it into the charter.

The amendment provided that all employees of the city, county, and Board of Education would have money automatically deducted from their pay checks to support a health system. Conscientious objectors, like Christian Scientists, were exempted, and the board was given the additional power to exempt people already "adequately" covered by other health plans, or employees earning over $4,500 yearly.

The charter amendment went into considerable detail. It provided that the employees' health system would be run by a board of nine, to be elected by members of the system. The specific plan for providing medical care would be up to the board.

The board itself, composed of clerks, teachers, firemen and other such nonexperts, labored long and mightily to discover how to operate a health insurance plan.