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The miracle of cure, however, lies behind scientific research and development not yet undertaken or completed. The discovery of long life through scientific endeavor is a rich testimonial to the doctors and nurses of this and immediately preceding generations. To me it is a recognition of not only their services but their sacrifices that we undertake to extend the degree of their usefulness into houses whose timid purses lack the temerity to appeal for proper health protection.

In preventive medicine, the people of the world are babies groping for light. The diseases of the past have burdened us with the need for concentration of our energies upon their cure. Some strike with lightning velocity and appear to decimate whole populations before they can catch their breath in retaliation; usually the retaliation of the development of specific immunities rather than of immediately effective medical preparations and devices. Against these obstacles, the doctors have given us longevity which, in turn, has presented new obstacles and emphasis on such physical deficiencies as heart disease and cancer, neither of which obviously would have developed in a man or woman past middle age if that person had died young of some other disease. This emphasis has caused scientific inquiries of its own, so that longevity may be enjoyed if not extended.

On the whole, this has been a bewildering century, not less so in medicine than in any other development. Our adjustments to the technological changes should be no less sensible than in any other field. In fact, public health is perhaps the prime essential of community living, and one's own health certainly is the individual's most coveted pursuit.

The rest is a matter of detail. These hearings should demonstrate, as they have in the past, that if we but will, we who pay taxes and we who are accustomed to paying insurance premiums can pay our way through the ordinary modest medical necessities; and those of us who, because of our own poverty or an overdose of bad medical fortune, cannot meet our supposed obligations, will not be a too heavy burden upon those others of us who trip through life gaily without scar or blemish.

This is true in the same way that we did not fail when men, women, and children were hungry or unsheltered in the difficult 1930's. It is true of the young men whose bodies were emaciated by patriotic response to the colors in the long months of war.

There will be those who will present staggering mathematics in open ridicule of any attempt to succor the unfortunate, however modest the figure. It is said that organizations once bitterly opposed to any plan which they contemptuously called socialized medicine a decade ago now openly advocate and endorse public-health plans which have the same features which they opposed at that time.

These are incidents which we must cut through if we are to get anywhere in the present hearings. The reasonable public purse may be opened. No one wishes to attempt the impossible. The authors of these bills are not men whose records would indicate any except a very hardheaded, practical, businesslike approach to the improvement of present health conditions.

Not one of these has failed to enjoy with grateful appreciation the kindly services of his skillful doctor or doctors, but regards the practice and those who engage in it with the highest esteem. It is throwing dust into the eyes of the followers of this movement to make it appear otherwise.

I have not the remotest idea that the same individual who takes the Hippocratic oath and lives up to its demanding features is a grasping, selfish creature whom some zealots have described him to be. Neither are the proponents of adequate medical care suspect. The 1949 hearings bid fair to erase some of the mistrust and calumny that have flavored the approach of some extremists in both camps in the early days of this struggle. It would appear to me that Chairman Murray of the subcommittee on health, and our staff which has worked tirelessly in the preparation of a proper program, have made unusual attempts to see to it that the subject is dealt with fairly. Certainly it will be considered intelligently.

Senator MURRAY. In view of the necessary absence of Senator Thomas, our first witness will be Mr. Donald Kingsley who will present the Federal Security Agency's position on the bills before us. While we are very glad to have Mr. Kingsley appear before us, I should like the record to show our extreme regret that the Honorable Oscar R.

Ewing, Federal Security Administrator, has not yet recovered sufficiently from a serious illness to be able to appear personally. So Mr. Kingsley will be the first witness this morning.

STATEMENT OF J. DONALD KINGSLEY, ACTING FEDERAL
SECURITY ADMINISTRATOR

Mr. KINGSLEY. Mr. Chairman and members of the subcommittee, I appreciate this opportunity to represent the administration in support of President Truman's program for the Nation's health. I regret the fact that Mr. Oscar Ewing, the Federal Security Administrator, cannot be here as the spokesman for a program to which he has contributed so much and which is so close to his heart. He still is convalescing from a prolonged illness, as the chairman said. Although he has returned part-time to his desk, he is not yet equal to any unusual strain.

At the request of the chairman, we have filed report on four bills, S. 1106, S. 1456, and S. 1679. The first is covered in a separate report, since it has little in common with the others and is concerned primarily with the provision of expensive drugs, diagnostic services, and so forth. As for the other three, we have combined our detailed observations under topical headings, comparing the different proposals as they relate to medical care, facilities, services, personnel, research, hospital construction, public health services, and maternal, and child health.

I understand that the hearings opening this morning are to be general in nature-dealing broadly with our national health problems and the various bills before this committee-and that more detailed and specific testimony should be reserved to the time when the separate titles of these bills are considered.

I should like to begin by quoting briefly from President Truman's special message to the Congress of April 22, 1949. In that message, as you will recall, he said:

Good health is the foundation of a nation's strength. It is also the foundation upon which a better standard of living can be built for individuals. To see that our people actually enjoy the good health that medical science knows how to provide is one of the great challenges to our democracy.

Our objective must be twofold: To make available enough medical services to go around, and to see that everybody has a chance to obtain those services. We cannot attain one part of that objective unless we attain the other as well.

We are confronted immediately by three major problems whenever we consider, as this committee is now, how to improve the health of the American people. All three are problems in economics, not in medicine. First is the problem of manpower and facility shortages; second, the problem of manpower and facility distribution; and, underlying all others, the problem of inadequate medical purchasing power in the hands of a substantial proportion of our families.

These recognizable segments of the total problem are the ones for which all interested groups are seeking solutions. They are closely interrelated. Indeed, it is the position of the administration that the ultimate solution of any one of them depends upon finding answers to all three. That is the firm conviction which underlies the comprehensive national health program recommended by the President as long ago as November 1945, and which underlay Mr. Ewing's report to the

President, the Nation's Health. It also is the fundamental assumption, it seems to me, upon which the program provided in S. 1679 is based. At this point, let me say just a few words about these three basic problems and their relationships.

First of all, there is the problem presented by the current aggregate shortage of trained health personnel and health facilities: The shortages of doctors, dentists, and nurses, of clinics and hospitals. These deficiencies are very real. They have been extensively documented and there is widespread agreement that they exist. There is less agreement as to why they are so acute and as to the best means of overcoming them. There is, of course, no simple, inclusive explanation. But a major contributing factor is, unquestionably, a serious shortage of medical purchasing power. We do not have more hospitals, for example-even with the expenditure of substantial Federal funds to assist in their construction-because the people in many shortage areas could not support them if they had them.

Secondly, there is the problem presented by the inequitable distribution of the manpower and health facilities we do have. This results in wide discrepancies in the availability of medical care from one section to another, one State to another, and one community to another. Thus, the top one-fourth of our States-the 12 States with the highest ratio of doctors to population-average 1 doctor to every 667 persons. But the 12 poorest States in this respect average only 1 doctor to every 1,223 of their citizens. Consequently, if you are taken ill today in one of the 12 most-favored States, you have about twice as good a chance of getting a doctor when you need him as you do in one of the 12 least-favored States. Contrasts between individual States and communities within States are even sharper. Moreover, the situation is similar in respect to other health personnel, and in the case of the distribution of hospital beds, the discrepancies are even more marked.

The existing distribution is generally unfavorable to the South and West, in comparison with the Northeast, and to rural areas in comparison with urban. But our most serious health problems today— the highest death rates among mothers and children, for instance, the greatest incidence of disease, the most pressing need for medical manpower and facilities of all kinds-these are found in precisely those areas that are so strikingly discriminated against.

The maldistribution of our existing personnel and facilities seriously aggravates the problem of providing adequate medical care to all of our people. And a significant fact in connection with this pattern of distribution is that, in general, it follows closely the pattern of income distribution. By and large, the sections, States and localities with the highest ratio of health personnel and facilities are those with the highest per capita income. Conversely, the most undernourished areas from the standpoint of medical care are as a rule those with the lowest level of purchasing power. This is not, of course, surprising. Hospitals are built where they can be supported, and doctors naturally settle in areas where they can make a living. To me, this means that the key to a more equitable distribution of health facilities is to be sought in some method of increasing the effective health-purchasing power in the medically undernourished areas a result which is directly accomplished through social insurance,

Thirdly, there is the serious problem presented by the fact that a substantial portion of our people-even those who live in relatively well-supplied areas from a medical standpoint-cannot afford to purchase medical care under a system in which most of the cost of such care falls on the sick. Just what proportion of the population belongs in this category is, perhaps, a matter for honest difference of opinion. The American Medical Association has estimated that no more than 20 percent of our people can meet the cost of a serious illness without assistance in the form of private or public aid. Whatever the number who cannot afford adequate modern care, it is substantial-certainly, at the very least, it includes that half of our population living in families with incomes of $3,000 or less a year. In fact, under the present circumstances, only the relatively rich or the charity poor are in a position to take full advantage of the wonders of modern medicine the rich at inordinate expense and the poor on terms that are humiliating at best. The great middle-income group-the backbone of the country-are left out in the cold, not wealth enough to meet a sudden emergency or to pay for modern preventive care, but too welloff to qualify and too proud to ask for charity. They can only hope and pray that their own immediate families will be spared a serious and bankrupting illness.

It is of the utmost significance, I believe, that a common financial problem underlies all these others: The current shortage of personnel and facilities; the inequitable distribution of those we have; and the inability of large numbers of our people to utilize them fully. Indeed, in undertaking to improve the Nation's health, we can be fully confident, in my judgment, that the doctors are doing their part of the job magnificently; the results they achieve in those areas where they are given a fair chance are proof of that. The problem now is one for the economist and the statesman.

With this introduction, I should like to turn now to a consideration of what seems to me to be the central issue raised by the three major bills before your committee: That is, the various means by which all of them seek to make medical care available to those who need it. The methods proposed are different and the results would vary widely, but the broad objectives, it seems to me, are similar.

After all, everybody concerned with this problem is interested in the same thing. All want to work out some arrangement to assure the widest possible application of the knowledge and skills our medical profession has developed. All would like to see every American citizen in a position to buy all the medical care he needs, both preventive and curative. It would be good for him, good for the medical profession, and good for the Nation.

Everybody would like to make this possible without resorting to the further extension of State medicine and without restricting the freedom of the patient or the doctor, the hospital or the medical profession as a whole.

As I read these three principal bills, the most significant impression I have is not that they are so widely different, but that they are so much alike. They indicate that a very broad basis of agreement has been reached.

For instance, there is general agreement, with some difference in emphasis, that we do have a serious shortage of medical personnel, facilities, and services-largely as I have outlined it. Moreover, nearly

everybody apparently agrees that the Federal Government must contribute, out of general revenues, to the relief of these shortages. Opinions differ as to detail and scope, but not as to principle.

Beyond this, it appears to be agreed that our present system of payment for medical care is totally inadequate. The provisions of all of these bills reflect common recognition of the fact that, as things stand today, a substantial proportion of our population must depend upon public or private charity or go without the type of medical care that modern science knows how to provide.

Most important, perhaps, it seems that almost everybody has now agreed with the conclusion of the National Health Assembly last year, that some sort of health insurance is the only method by which adequate medical care can be made available to most people without expanding State medicine or public charity. Of course, all sorts of problems arise when you examine the details, but there is no doubt that we now have general agreement on this basic point.

As I see it, this represents tremendous progress-far more, perhaps, than the average doctor or patient has been able to discern, struggling as he is to stay afloat in a 312-million-dollar sea of angry words.

With this broad basis of agreement in mind, I should like to review, as I can see them, some of the underlying realities in this problem of medical care upon which a final solution must be built.

At the outset, however, I want to stress the conviction that unless a comprehensive system of prepayment such as that provided in S. 1679 is established, it will be impossible to meet the Nation's medical needs without an ever-increasing measure of State medicine.

The extent to which Government already is involved in the direct provision of medical care to individuals is often overlooked, I am afraid, in our zeal to identify our system for the care of the sick with our business system of private enterprise. Perhaps it would be more useful to our purpose if we were to face frankly the fact that medical care does not rest upon the same basis at all. Incidentally, I think it would be fairer to private enterprise.

By its very nature medical care is uneconomic. In modern times, it has never rested on the rule of the marketplace, because the public interest has required that illness be treated somehow, whether the individual could afford it or not. But while we never have relied exclusively upon the rule of supply and demand, neither have we worked out a rational and reliable substitute for it which would provide a sound economic basis for our medical system. Instead, medical care has been financed, from the earliest times, in a haphazard way. From the beginning, the economic basis of medicine has been a loosely defined triple standard: First, a rough-and-ready sliding scale of prices for the well-to-do, depending upon how well-to-do and adjusted arbitrarily in individual cases by the physician or the hospital; second, private charity in various forms, both organized and unorganized, for the "medically indigent," meaning those who are self-supporting except in emergency; and, third, Government medicine and various forms of public charity for the poor. It is a makeshift system that "just growed."

In spite of these catch-as-catch-can financial arrangements, the medical profession has made remarkable progress. This is not a tribute to the system of payment, however, but to the devotion of the

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