3. Family expenditures for medical care under the proposed nationalhealth insurance bill, for people in comparable income groups, would be as follows: 34 4. The above two tables show that the total average family expenditures for medical care under the national-health insurance bill (2) would be lower than they were in 1941 under the present system. Senator PEPPER. I want to ask a few more questions. Do you think t is an easy matter for either the Federal Government or State authorties to lay down a means test which is to be the criterion for the giving of medical care such as is contemplated in S. 545? Dr. PARRAN. It would be a difficult task. It would offer difficulties because, for instance, a person's status will change. We may well assume that he will be needy if it is necessary for him to be hospitalized for 6 months and to have 3 nurses a day during the critical part of his illness. Most of us would be needy under those circumstances. He may not be needy for visits to the dentist or a visit to the doctor. He may be out of a job today and be needy, and tomorrow he may have a job and be able to pay a part of his medical expense. However, I don't mean to say that a means test is impossible adminstratively, difficult as it would be, because of the experience we had in New York State during depression days. The policy was developed of providing medical care for persons otherwise self-sustaining, especially rural families who had food and some clothing and shelter, but no cash in hand with which to meet medical costs. Senator SMITH. You mean the medically indigent as distinguished from the indigent; is that correct? Dr. PARRAN. That is correct, Mr. Chairman. In other words, this has been done and to some extent is being done by welfare agencies nd in the administration of our relief laws. As to the social desirability of such a means test, that is quite another hing. Senator PEPPER. Would you state to us out of your experience as Surgeon General of the United States and your experience with the Public Health Service whether or not the appropriation contemplated y S. 545, together with the funds which the States must put up to hatch the Federal appropriation, will provide adequate health care o the people of the United States? Dr. PARRAN. It would fall far short of doing that, Senator Pepper, nd as I understand it, the authors of the bill recognize that. Senator SMITH. The point is being constantly made as though it is ipposed to be an over-all coverage. That is not claimed. It is a tep in the direction of the kind of health service we want to arrive t. Introduced in May 1947, by Senators Wagner, Murray, Chavez, Pepper, Taylor, and cGrath. "Senate Committee Print No. 5. 79th Cong., July 8, 1946, p. 158. Dr. PARRAN. I hope I was quoting correctly. Senator PEPPER. If the theory of S. 545 is carried out-that is not requiring the individuals to make a public contribution or contribute through a tax or any other kind of compulsory payment, but the money is provided out of the Treasury-does that approach what might be called the socialized system of providing medical services free to the people, free of any direct contribution from them other than through taxes or through the insurance system? Dr. PARRAN. I think that is a question primarily for the taxation experts because a compulsory contribution is a tax such as income tax is a tax. Senator PEPPER. I don't know if you happen to know, and I am not sure I am right, but it is my understanding that one difference, for example, between the Soviet system and the British system is that the Soviet system does not require any tax from the citizens. The citizen goes to a hospital and gets medical care, goes to a doctor and gets medical care, just as a man or woman in the Army or Navy goes to the dispensary or to the hospital and get medical care as a service furnished by the Government without paying directly for the service; whereas in Britain they are required to make payments, some kind of pay-roll tax, or some sort of compulsory payment. Am I correct in that general understanding? Dr. PARRAN. That is my understanding. Senator PEPPER. If we furnished through the method of S. 545, the State appropriation, that would be a little nearer to the Soviet system than to the British system, would it not? I am sure the authors would not want to be in that position. Senator SMITH. I object to the comparison. They both are taxes, either way you put it, pay-roll tax or the others. It is not insurance, it is a tax. Each fellow pays according to his means. The Govern ment undertakes to perform the service. I would like to ask you this question: Would you think it wise, as suming we adopt a plan like S. 1320, to have the compensation paid in dollars and let the person use the dollars to get the service or should we have an elaborate scheme to determine the set-up of doctors working it out? Dr. PARRAN. The only way I can see you have any choice of doctors is to be paid money benefits just as we pay unemployment benefits, You would have the patients use that money for contracting for any service needed. That would be in line with our unemployment compensation. That would be the comparison. If a person has tuberculosis, why not pay for that as well as unemployment? Senator SMITH. I admit that analogy, but then you get money bene fits and then you get into this complicated question of how to deal with the medical profession. Dr. PARRAN. I would favor money benefits only in partial compen sation for wages lost by the breadwinner, by the wage earner, and not for the giving of professional service. I don't believe that a system of cash benefits would be nearly so effective as service benefits. Senator SMITH. To organize the service and make it practical is the problem. Dr. PARRAN. It is a tremendous job in a country as huge and diverse as this. Senator SMITH. I want to emphasize the point that it does differ from the social-security idea where you do expect under your unemployment and social-security to pay out cash benefits under such contingencies. This program contemplates organizing, developing, and getting under obligation on the part of the Government to deliver a service. We have got to take that as part of the program, and that is the thing that we have got to explore, very thoroughly before we turn over our whole country to something as new and novel and different as that; and I haven't yet been convinced that any country that tried it has shown any success whatever. I haven't been convinced of that. It is just a question of how we can do this thing in the most practical way, and whether you call it a compulsory health insurance or call it anything else, it is a tax. Any thing you are compelled to pay is a tax. Senator DONNELL. The bill back in 1939, the Wagner bill, S. 1620, was that a bill as you construe it for the provision of health insurance for needy persons or was that one for the general public at large? I call your attention to page 34 of that bill. I will just read a little of section 1301: For the purpose of enabling each State so far as practicable under the conditions in such State, especially in rural areas and among individuals suffering from severe economic stress to extend and improve medical care, including all services and supplies necessary for the prevention, diagnosis, and treatment of illness and disability, and to develop more effective measures for carrying out the purposes of this title, including the training of personnel, there is hereby authorized to be appropriated for the fiscal year ending June 30, 1940, the sum of $35,000,000— and so forth. Dr. PARRAN. Senator Donnell, I hoped you would sense-in fact I know you do the importance of the word "especially in rural areas and among individuals." Senator DONNELL. Yes. Dr. PARRAN. While the related provisions of S. 545 seem to be | limited to the provision of medical care for needy persons. Senator DONNELL. Could I ask you one further question about S. 1320? There has been much emphasis made, not so much today, but in earlier testimony, on this matter of the so-called means test. Now, I call your attention to the fact that, which of course you know, section 204 (a) of S. 1320, the Murray bill, provides as follows: Every individual shall be eligible for benefits under this title throughout any benefit year after he receives payments, and so forth. Then section 205 (a) is entitled "Provision of Benefits for NonInsured Needy and Other Individuals," and reads as follows: Any or all benefits provided under this title to individuals eligible for such benefits may be furnished to individuals (including the needy) not otherwise eligible therefor, for any period which equitable reimbursements to the account on behalf of such needy or other individuals have been made, or for which reasonable assurance of such reimbursements have been given, by public agencies of the United States, the several States, or any of them or of their political subdivisions, such reimbursements to be in accordance with agreements and working arrangements negotiated with such public agencies. Services furnished to such needy or individuals as benefits shall be of the same quality, be furnished 64431-48-pt. 3—11 by the same methods, and be paid for through the same arrangements as services furnished to individuals eligible for benefits under this title. I ask you whether or not it is a fact that in order to determine who the needy persons are to whom any or all of these benefits provided under the title in S. 1320 may be furnished-I say in determining who are these needy persons, would not it necessarily involve a test of some kind to determine whether they are financially capable or not? In other words, is there not a means test provided there to the extent that S. 1320 provides for benefits for persons who are not eligible under the earlier definition of the bill? Dr. PARRAN. Senator Donnell, I understand this section to contemplate two groups of individuals, generally speaking. They are those who have already been subjected to a means test and are recipients of relief. This seems to be an invitation to the local public-welfare authorities to pay into the fund equitable reimbursements so that persons on relief or those who have been declared by the public-welfare officers to be medically needy would get care under the one administrative system. Secondly, I interpret the wage range to be an invitation to the States and their political subdivisions to permit the joining of the system by the public employees. Senator DONNELL. However, Doctor, this section 205 (a) does provide that benefits provided under this title, any or all of the benefits, may be furnished to individuals, including the needy, not otherwise eligible therefor. Dr. PARRAN. It provides that. I would again underline the fact that the other provisions of S. 1320 would in times of normal employment perhaps embrace as many as 85 percent of the population, so that the volume of medically needy persons would be much less than contemplated under S. 545, and in respect of most of the "needy persons" referred to in section 205 (a), their needs for all necessities of life probably would have been already determined. Senator MURRAY. To be determined by the States. Dr. PARRAN. It would have been determined precisely by the local public-welfare agencies. Senator MURRAY. They wouldn't be on the pay rolls. Our bill contemplates all those receiving medical care are people having deducted from their pay certain sums each month so that these people who would be needy would be people who are not employed or who are unable to be employed; and, therefore, it would be a very simple matter to determine who they are because the State would be able to furnish the list and there would be no need for a means test under the administration of this act. Senator DONNELL. Doctor, do you know of any means test by which you can find out whether a person is needy without imposing some sort of means test? Dr. PARRAN. I don't know of any way. Senator MURRAY. The State determines that. Senator DONNELL. The State would determine it in any case. Senator MURRAY. The State has already determined it; I assume the people are on relief. Senator DONNELL. The point I am making is that under S. 1320 there is a provision as follows: Any or all benefits provided under this title to individuals eligible for such benefits may be furnished to individuals, including the needy. Now, you know of no way by which it can be determined whether a person is needy without applying some test? Dr. PARRAN. I know of no other way. Senator DONNELL. One final question, and that is this: Have you made any study as to the cost to the Nation of putting into effect S. 1320? Dr. PARRAN. I have not made any detailed studies of that question, Senator Donnell. The current amount which we are paying for medical care is estimated--and we have no firm basis for a precise estimate at around $5,000,000,000. How much more would be required to carry out all of the provisions of S. 1320 I am not prepared to say. Perhaps the social-security people, who have made more studies of this problem than I, would be prepared to offer testimony on that point. Mr. Chairman, with your permission I should like to offer for insertion in the record a statement of 21% pages entitled, "Need for and Costs of Additional Medical Personnel and Facilities." The next is "Costs of Training Needed Medical Personnel." In offering this I do so with some temerity, since there has been no national agreement as to the extent of need for Federal assistance in connection with training of physicians and related personnel. We would hope that during the coming year we can develop, as I indicated in my testimony, more facts dealing with this program. I have a short note of one page on "State Variations in Mortality," which is one indication of unmet national medical needs. Here is a further note on the need for new hospital facilities, with some revised estimates as to the over-all cost in the light of present construction costs, which information supplements the information we submitted to this committee in connection with the hearings held on the Hospital Survey and Construction Act. I have another note on the status of the State hospital survey and construction program, in which there is listed the number of additional beds being proposed by three States which have submitted plans and have had their plans approved, over-all State plans for hospital construction. This gives us for the first time the results of detailed State surveys in these three States for which plans have been approved during the past 2 or 3 days. Senator SMITH. That is in the light of last year's bill? Dr. PARRAN. That is correct, Mr. Chairman. Senator SMITH. They will be inserted in the record. (The documents referred to above are as follows:) THE NEED FOR AND THE COSTS OF ADDITIONAL MEDICAL PERSONNEL AND FACILITIES A. THE NEED FOR MEDICAL AND RELATED PERSONNEL 1. Physicians.--Tremendous confusion exists concerning the adequacy of the Nation's supply of physicians. Distinction must be made between the effective economic demand for doctors' services and the potential requirements that would be necessary to meet the real needs of the population. Under the current cir. cumstances, the total number of physicians may possibly be sufficient to meet the going demand for their services-at least in certain urban centers. In times of economic crisis, however, when purchasing power is deficient, an apparent doctor surplus may even appear, as in the depression of the 1930's. |