STATEMENT OF RT. REV. MSGR. GEORGE LEWIS SMITH, PRESIDENT, CATHOLIC HOSPITAL ASSOCIATION OF THE UNITED STATES AND CANADA Monsignor SMITH. Mr. Chairman and members of the committee, I am Rt. Rev. Msgr. George Lewis Smith, president of the Catholic Hospital Association of the United States and Canada, and appear on behalf of our association. We have approximately 800 hospitals with over 130,000 beds and bassinets under Catholic auspices in the United States. In 1948 almost 4,000,000 patients were admitted to our Catholic hospitals-3,904,000 out of a total of about 15,160,000 patients admitted to all general hospitals. In other words, more than one out of every four patients admitted to any general hospital in the United States, including Federal and State institutions, was admitted to a Catholic hospital, so you can realize that we have a significant interest in a national health program. The administrative board of the Catholic Hospital Association has considered and discussed the problems and objectives inherent in a national health program at our meetings, conferences, and conventions for the past several years. During the current year we have given much of our time, thought, and effort to this important matter. We have conferred with representatives of the bureau of health and hospitals of the social action department of the National Catholic Welfare Conference and the National Catholic Welfare Conference and the National Conference of Catholic Charities and have reached a consensus of opinion expressing a constructive viewpoint. We have published a joint statement entitled "A Voluntary Approach to a National Health Program" which I ask to be incorporated in full in the minutes of this hearing. Senator MURRAY. It will be incorporated. (The joint statement is as follows:) A VOLUNTARY APPROACH TO A NATIONAL HEALTH PROGRAM (By Bureau of Health and Hospitals of the National Catholic Welfare Conference, the National Conference of Catholic Charities, and the Catholic Hospital Association) FOREWORD The immediate problew under consideration in the following pages is that of developing an adequate national health program. Interest in the subject has become quite intense and widespread. There has been much discussion and much controversy; but unfortunately there has been also much confusion. The confusion arises in large part from the tendency to oversimplify the problems involved and to assume that the cost of medical care is the only obstacle in the way of a great improvement. The lack of institutional facilities and professional personnel has been greatly underestimated by reason of the emphasis placed on the former. In itself the latter is a primary obstacle and equally in need of remedy if the quality of medical care is not to deteriorate into a mere increase in the quantity of patients. A sound national program should provide for the elimination of both obstacles. The controversy revolves in large part around the issue of an exclusive and compulsory Government health insurance system versus private and voluntary effort supported by Government assistance instead of control. Many competent authorities fear that an exclusive state system under a compulsory tax will necessarily involve a loss of freedom for the voluntary health agnecies and put an end to private initiative to the ultimate detriment of the health of the Nation. There is no contra versy or disagreement concerning the advisability or advantage of a prepayment plan to meet the cost of medical care. Acceptance of such plans is practically unanimous. The division of opinion concerns the question whether there should be an exclusive state monopoly or whether there should be a cooperating partnership between the Government and voluntary health agencies. A right approach to the problem depends not only on a correct analysis of the concrete situation, but also on a correct social philosophy. The rights and duties of society, the state, and the individual must be considered in relation to one another. Society is a much broader and more comprehensive concept than that of the state. Government is indeed a necessary agency of society, but it is not the only one. There are many others. Because man is a social being he enters into association with others in order to achieve the benefits which are comprehended in the category of social welfare. These associations of a voluntary nature have as legitimate a right to exist as the state itself. provided they serve the common good. The state has a definite responsibility to help protect and promote the health of the Nation inasmuch as the Government is charged under the fundamental law with the duty of promoting the general welfare and inasmuch as the Government alone has adequate resources to implement a comprehensive program. Voluntary agencies, however, have a definite right and responsibility to exercise an important function in planning as well as in executing such a program. It is socially undesirable to neglect the contribution of either the one or the other. Individualism as a philosophy of life has been discredited, not only because it has failed in practice, but because it stems from a false concept of human nature. Man has a twofold nature, both individual and social. His personal dignity and sacred rights originate in the fact that he is created as a distinct, intelligent and responsible person, with a destiny of his own. His full development as a human being can be achieved only in as far as he is a member of society and only in as far as the obligations of social justice and social charity are fully activated. Ethical and religious ideals which furnish the highest motivation in the care of the sick as in all social service can function more effectively in voluntary associations than through the medium of the modern secularist state. The Bureau of Health and Hospitals of the Social Action Department, N. C. W. C., the administrative board of the Catholic Hospital Association, and the directors of Catholic Charities have given careful consideration to the varied phases of a national health program, and in formulating their conclusions they approach the problem not from a negative but from a positive viewpoint. They recognize the existence of social responsibility but at the same time they reject the concept of an exclusive state responsibility for the health and well-being of the American people. They reaffirm their conviction that a partnership between the state and voluntary associations provides the better solution and is more consistent with our democratic processes. Monopoly means control: partnership means freedom. They entertain the hope that the following statement will throw new light on the subject and that a genuine cooperation of all parties at interest will produce a constructive program adapted to the needs of the Nation and effective in promoting the highest standards of health and well-being. Most Reverend KARL J. ALTER, Bishop of Toledo, Episcopal Chairman, Bureau of Health and Hospitals, PREAMBLE During the past several years, legislative proposals have been introduced into the Congress calling for a compulsory Government health insurance system. President Truman, in his address on the state of the Nation, January 4, 1949, for the third time requested Congress to enact legislation in favor of a compulsory health program for the people of the United States of America. In order to evaluate the proposals it is highly important that we make a clear and definite distinction between the general obiective, namely, the health and physical wellbeing of the Nation and the specific legislation which is proposed to implement this policy. There is a sound and valid distinction between a national health program and the proposed compulsory Government health insurance law. There is very little difference of opinion concerning the main objective, namely, the need and importance of promoting the health of the people of this country by prevention and by providing adequate care in periods of sickness or disability. There is, however, a decided difference of opinion with regard to the methods that should be followed in securing this objective. One school of thought places a comprehensive and almost exclusive responsibility on the Federal Government and minimizes the function of voluntary organizations, such as hospital associations, medical associations, Blue Cross, Blue Shield, Medical Indemnities, etc. There is another school ofthought which follows the social principle of "subsidiary function" and places in consequence chief responsibility on voluntary associations and private initiative without, however, excluding Government financial support. Evaluation of Needs Many competent authorities reject the policy of a compulsory Government insurance program which sets up definite controls (either expressed or implied) over hospitals, medical practitioners, dentists, nurses and the auxiliary services concerned with the problems of health and sickness. Health care in the legislation proposed becomes practically a Government monopoly. It is recognized that some effort has been made to provide for voluntary and private initiative in determining the program but it reduces such efforts to a minor or subordinate role. On January 16, 1949, an independent and highly competent investigating agency, namely, the National Research Council, stated that compulsory health insurance is not a major factor in the health of a country. "The principal factors in health are an adequate number of doctors, nurses, and hospitals; adequate nutrition and high living standards." The report continues with the statement: "There is a good reason to believe that better (health) results might be expected from paying careful attention to the improvement of living standards, to good nutrition, the elimination of economic and social inequalities bettwen races, development of medical facilities, preventative health measures, and other factors which directly affect the health of the people." Another highly competent investigating agency, the Brookings Institution, in its report on "The Issue of Compulsory Health Insurance" published in 1948, includes the following in its conclusions. "It is apparent that the United States under its voluntary system of medical care has made greater progress in the application of medical and sanitary science than any other country. * * * There is every reason to believe that these trends will continue unabated under our present system of medical care. "Compulsory health insurance would necessitate a high degree of governmental regulation and control over the personnel and the agencies engaged in providing medical care. This field of regulation and control would be far more difficult than any other large field previously entered by the Government, and past experience with the governmental regulations and control in the United States causes doubt as to whether it encourages initiative and development. "The experience of the United States since 1932 seems to have demonstrated the wisdom of these recommendations of the majority of the members of the Committee on the Costs of Medical Care. It would seem unwise at this time to substitute for these developments a system of compulsory health insurance by national law which would have the unfortunate tendency to freeze policies and eventually retard medical progress." Unwarranted Government monopoly It is not so much the principle of taxation for health protection which is opposed. Rather it is the monopoly which would be the inevitable result under the Government system, and the misnomer of calling the tax an insurance. Insurance, according to accepted terminology, implies uniform and specific benefits supported by standard adequate reserves proportioned to premiums; definite actuarial basis in determining cost of benefits; voluntary election of the protection offered. The proposed compulsory Government health insurance system has none of these features. Opposition is expressed against Senate bill 5 because it could not fulfill its promises under existing shortages of personnel and institutional facilities; because it would not by adequate action cure these shortages; because it would necessarily create a huge bureaucracy to administer its complicated regulations; because it would impose unequal burdens for construction of institutional facilities on the incomes of people in the lower income brackets; because it would destroy voluntary agencies which have rendered valuable aid to their members at low cost; because it would of necessity, in the judgment of the 1 Pp. 68, 69, 72. majority engaged in health care, interfere-in spite of protestations to the contrary-with the functional operations of hospitals, medical practice, and nursing service. This result would be inevitable if the provisions contained in the 84 pages of S. 5 were to become operative in determining the conditions, the quality, the quantity, and the personnel of the health service. As is evident in subsequent constructive proposals no opposition is voiced to the principle of having Government assume limited responsibility to promote public health, but rather opposition is pronounced against the unwarranted assumption of excessive social functions by the state. The Bureau of Health and Hospitals of the Social Action Department N. C. W. C. in conjunction with the Catholic Hospital Association and the directors of Catholic Charities, after prolonged discussion of the many-sided problem have reached a consensus of opinion which may be formulated in the following statement: STATEMENT OF THE CASE The idea of personal individual responsibility for one's spiritual and material welfare is not only a basic doctrine of the church, but it is the cornerstone of American life. Many thoughtful people feel that we are losing our grip on this fundamental principle of personal responsibility, and submerging the dignity and personality of our citizens in a "welfare state." We do not ignore but rather emphasize the existence of a concomitant responsibility of society to create such conditions that the individual can readily achieve a state of physical and material well-being. It is the business of society through private and voluntary associations as well as through public agencies to see to it that the necessary means are available for the social welfare of the individual. It is not, however, the business of the state to assume all the functions of society, nor to relieve the individual of his own responsibility and deprive him of his freedom of choice. It is most necessary we feel that these truths be recognized as the strength and fiber of the state. There is both an individual and a social responsibility. To ignore either phase of this working relationship is fatal to the commonweal. The question at issue, therefore, is not the promotion of better health care for the Nation-concerning which there is agreement-but rather a determination of the methods and policies which conform best to sound social principles. Health care should be made available to all people not only in terms of institutional facilities and trained personnel, but also in terms of reasonable cost to the public. GOVERNMENT SUPPLEMENTS PRIVATE INITIATIVE In accordance with sound social doctrine, we invoke the principle of subsidiarity. The workingman should have available adequate health service in times of sickness by either public or private insurance. We call attention to the alternative in the statement. We submit that a program of service by voluntary associations and private initiative backed by Government financial support is more in keeping with this sound social principle than a Federal compulsory health insurance system. The latter would impose a grave additional responsibility on the state, "which is now encumbered with all the burdens once borne by associations rendered extinct by it and in consequence submerged and overwhelmed by an infinity of affairs and duties." The first and fundamental consideration in approaching the problem of the Nation's health is to determine definitely and clearly the shortages which now exist in terms of institutional facilities, personnel and technical services required to meet an adequate standard of health and physical well-being. The second consideration is to work out a program which will eliminate the existing shortages most effectively without violating sound social principles. Many surveys have demonstrated these shortages. Proceeding in accordance with this criterion, and on the responsibility of the Government report entitled "The Nation's Health" we enumerate the following shortages: (1) Shortage of hospital beds.-The Ewing report of September 2, 1948, states that the country needs at the present time 900,000 more hospital beds for the care of acute sickness in general hospitals; a large increase is also needed to meet the shortage of beds in our chronic hospitals which serve the mentally afflicted, the tubercular, orthopedic, and similar categories of disabled and afflicted (see pp. 16-38 of report). (2) Shortage of physicians.-The Ewing report states that whereas there are 190,000 physicians qualified to practice medicine at present, the number actually required to meet the needs of the American people within the immediate future is 254,000, provided the same ratio is maintained for the country as a whole which now prevails in the top-level States. It must be remembered, furthermore, that only 5,600 graduates become available each year from our medical schools, whereas, 4,000 retire from practice, because of death, disability, or transfer to other activities (see pp. 16-38 of report). (3) Shortage of dentists.-The Ewing report states that whereas we have at present 75,000 dentists, we need within the immediate future 95,000 in order to meet adequate health standards for the American people. The present ratio is approximately 1 dentist for every 1,850. Unless the number of dentists graduating annually from our dental colleges is increased, we shall have a worse shortage in the years to come (see pp. 17-42 of report). (4) Shortage of nursing services.—The Ewing report states (p. 17) that our present supply of nurses is only 318,000 for the Nation, whereas 443,000 are needed in the immediate future. The American Nurses Association has estimated the current shortage of nurses at 42,000. Many more thousands will be needed by 1960 to staff the many new hospitals and local centers which must be built (see pp. 17-43 of report). (5) Shortage of community or public health centers.-The Ewing report stated that the country needs within the immediate future 1,900 additional local health units. To staff these health units and to provide technical service for them as well as for hospitals and doctors and dentists, a very large increase in trained personnel is required. Observations (1) The proposed legislation known as S. 5 calls for universal compulsory Government health insurance for the income-earning groups in the United States of America. Except for a token increase to the appropriation under Public Law 725 and some provision for research and education, it depends upon the general economic law of supply and demand to eliminate the deficiencies. It should be pointed out that since hospitals and similar agencies are nonprofit institutions, they cannot respond to the law of supply and demand in the same fashion as commercial enterprises. A direct attack on the above-mentioned shortages is to be preferred to the indirect and delayed improvement which the proposed legislation has adopted as its technique or policy. The primary attack made by S. 5 upon existing shortages, is that which is concerned with the lack of purchasing power for health care. (2) The Bureau of Health and Hospitals of the Social Action Department, National Catholic Welfare Conference, and the Catholic Hospital Association have long recognized this problem of shortages and have repeatedly made proposals to remedy the deficiencies. We shall take occasion later in this statement to outline specific measures to improve the situation. We recognize that a system of prepayment of costs for hospitals, medical, dental, and nursing care is highly desirable and warrants our full approbation. We have endorsed the program of Blue Cross, Blue Shield, and other forms of voluntary insurance. We have advocated an extension of benefits as rapidly as conditions permit. We recognize that so far medical benefits are inadequate, but we do not admit that they cannot be improved and made comprehensive for the American people within a reasonable future, without resorting to compulsory Government health in surance. (3) We wish to point out that in addition to the shortages of institutional facilities and technical services there are other factors which militate against the health and well-being of the Nation's citizens. We call attention particularly to the maldistribution of services and facilities between such States as New York and Mississippi or Arkansas. New York, for example, has 4.8 hospital beds for 1,000 of the population, whereas Mississippi and Arkansas have 1.9 and 1.8 respectively. The same disproportion exists in relation to medical, dental, and nursing service. No compulsory Government health-insurance program by itself can remedy this difficulty or maldistribution. Other means must be made use of to distribute our facilities and services more in accordance with need. (4) It should not be overlooked furthermore that the compulsory Government health-insurance system makes only vague and general but no definite and concrete provisions for the medically indigent who constitute a large part of the problem of national well-being. No form of insurance predicated on a wage and income basis will take care of the many hundreds of thousands of widows, orphans, disabled, and dependent aged. Specific prouvisions should be made for this group who now constitute a heavy burden on public and private charity and frequently because of meager resources receive inadequate care. 91626-49-pt. 1—33 |