I cannot predict the scope of errors and omissions under this law. I do, however, know that there are a number of older people without social security benefits or any private assistance who are in dire need of help.

If we are to have a true social insurance system, then we cannot permit large numbers of our old people to suffer the consequences of legislative and administrative omissions. Therefore, Mr. Chairman, I shall introduce an amendment to H.R. 11865 which would "blanket in" coverage for all those 70 years of age and over who do not presently receive social security.

Within Vermont alone there are 2,500 people 70 years of age or over who are on public assistance but who are not eligible to receive social security retirement pensions. Their plight is serious. They receive not so much as $1 of the $9.3 billion distributed nationally under the social security old-age provisions in 1963. They received not $1 of the $23 million distributed under the old-age provisions in Vermont in 1963. Why? Maybe they made some contributions to the system, but not enough to acquire coverage; perhaps they worked in a field not covered by the program. Perhaps they retired before eligibility. But, whatever the cause, the facts are cold and hard-they are now too old to work, contribute to the system, and receive its benefits. They live from day to day without the benefit of our farthest reaching national program to aid people in their situation.

Mr. Chairman, I have great difficulty trying to tell these people America has not forgotten them. I have great difficulty trying to explain why the law does not provide for them. I have even greater difficulty understanding this patent omission myself.

My amendment would recognize, plainly and simply, that America owes these people something better than poverty and despair. It owes them its thanks and its gratitude for being a part of one of our most creative generations. It owes them its recognition of their lost loved ones and friends in the two World Wars spanning their life. And, it owes them a promise of hope in their twilight years the promise that they will live free from want, the beneficiaries of a new national awareness.

I do not propose that the present system bear the entire burden of costs. While the contributors to the various trust funds would no doubt be willing to absorb all necessary additional expenses, I propose to remove that weighty choice; I offer instead a plan to finance this expanded coverage out of general revenues. In that way, all of us could join in this tribute to older America. But, even if this amendment is adopted, we have not met our obligations head-to-head. Assuming all those age 70 and above who are not now eligible for social security were "blanketed-in" for coverage at the minimum benefit level could we honestly say that they were removed from the threat of poverty? At the present time the minimum benefit level is $40 per month. It doesn't represent much purchasing power in terms of current prices. The average monthly benefit under the old-age provisions of social security is close to $75. but benefit recipients in the lower benefit categories will take little comfort from that fact.

Our whole lower bracket benefit scale is out of tune with reality. Indeed, all benefit levels fail to reflect the elevation of the cost of living over the period since the last adjustment in benefits, but the disparity is most noticeable in the lower brackets where poverty has the greatest inroads.

To partially remedy this unfortunate situation, and to give meaning to my previous amendment, I offer for your consideration a proposal to revise all benefit levels upward. My plan would mean a 10-percent benefit rise for the lowest benefit level with roughly a 5.5-percent rise at the highest levels. The intermediate levels would be proportionately scaled.

In almost every instant this proposal results in a benefit rise in excess of that provided for by the bill which passed the House of Representatives, both in the individual benefits and the maximum family amounts. However, since the greatest increases are at the lower dollar amounts, the additions to the cost of the program are minimized, while more meaningful benefits levels are provided.

I am sorry that the social security system is not in a better financial condition-able to absorb a full transition to a meaningful standard of benefits. But, within the actuarial confines, I feel that my proposal offers a significant addition to meeting the overall objectives of this long-range, far-reaching social insurance program.

Without these amendments, the social security system will never meet its fundamental aim of providing a basic floor against want. But, even if these amendments carry, there are further inequalities to abolish.

For example, as is true in so many of our laws, we take away with one hand what we have just given with the other.

Take the case of one of my constituents. At age 85 he is still running his farm, although he is not in good health. His net farm earnings are quite small. He receives social security payments of $52.20 per month, while his wife receives $18 per month. Last year they paid social security contributions of over $60 based on their farm income. The effect of this transaction was really to require them to pay back most of one month's social security benefits.

Now their farm income was on the order of $1,800. Their total social security receipts were $842.40. They paid no income tax because of their deductions and exemptions. Their total income then was $2,642.40, or some $400 below what some have concluded to be the minimum level of income for an elderly couple as protection against contingent needs. And from that submarginal amount the Federal Government takes a social security contribution of some $60 from an 85-year-old man and his 70-year-old wife to finance his or her retirement, disability or death.

Clearly, here is a point when the philosophy of compulsory social security crashes against the rocks of reason. When the program was initiated, contribution was made mandatory so that those imprudent enough to elect not to be covered while young would not be unfinanced wards of the state while old. But this reason surely will not justify or support the taking of needed living expenses from people in their situation of life. There is a point when this paltry $60 per year represents a form of self-insurance against immediate want.

Mr. Chairman, I shall therefore introduce an amendment which permits a fully insured person, age 65 or over, to choose whether or not his subsequent earnings should be taxed for social security purposes and taken into consideration for recomputations of benefits. Surely, it makes little sense to ask these people to "put something away for a rainy day."

At a time when we are concerned, not only with providing a floor against want for our older citizens, but also attempting to preserve their dignity, it seems incredulous to me that our program penalizes those who desire to work in their later years. Now, of course, to be consonant with its role as a floor of protection, the social security program must not finance the whims and caprices of the elderly of means. But, at the same time, it seems to make little sense to tell an employed person over 65 that he must limit his earnings to $1,200 per year if he hopes to receive the full benefits to which he is otherwise entitled.

Take the situation of a person receiving the minimum monthly benefit of $40 under existing law. Suppose his yearly income from earnings is $1,200; his total income is $1,680 ($40 times 12 plus $1,200). Now, under present law he is told that if he earns over $1,200 per year his benefits will be reduced. What we are saying then, to this man, is that the Congress deems $1,680 per year to be a livable income, any excess above which must come at the expense of his right to collect full social security benefits. Mr. Chairman, the cost of living has increased some 121 percent since benefits first became payable in 1940. The average weekly earnings of production workers in manufacturing has increased 32 percent since the $1.200 earning limitation was imposed in 1954. Over the same period the cost of living index has risen some 14 percent. The time has come to take another look at this problem.

I have long supported proposals raising the earnings limitations. As long as our senior citizens are restricted to $1,200 per year outside earnings, I think we are defeating our purpose. We do not permit them to have a meaningful standard of living with or without social security. They are damned if they work full time and damned if they don't. Yet, over the years these people have made their contributions into the social security system. Look at their situation. John D. X retires from his executive position at age 65 because of company retirement rules. He was granted stock options while employed which he timely executed. He has an income of $5,000 per month from dividends, with a maximum social security benefit of $114 per month under existing law. His social security benefit will buy one weekend's gas for his yacht.

John D. Y has worked all his life as a printer. At age 65 he elects semiretirement and commences receiving his social security benefits. However, he continues working 20 hours a week rather than sit home clipping coupons. If his earnings exceed $1,700 per year he will lose all his social security benefits. But his counterpart, John D. X has $5,114 income per month and suffers no

diminution in his social security. It is only when John D. Y reaches age 72 that he can earn in excess of $1,700 without losing his social security. In the meantime, however, John D. X has amassed 60 months of income at a monthly rate three times that of John D. Y's annual income without losing a single penny of social security.

Mr. Chairman, clearly something is amiss. First of all, the annual earnings limitation should be liberalized; secondly, the age after which earnings may be unlimited without an effect on social security payments should be reduced; finally, some review should be made of the role played by passive income in the overall income limitations. I cannot think that the framers of the original Social Security Act meant for social security to be paid to those who have large dividend or interest incomes and not to those who choose to or have to keep working for a living.

Finally, Mr. Chairman, something in the House debate on this measure disturbed me. As the bill now stands, veterans receiving benefits under certain veterans' pensions stand a chance of losing that pension if the additional benefits provided for by this bill put them over a certain income limit.

This provision is equally as senseless as the provision which requires a loss of social security benefits for certain earnings in excess of $1,200 per year. For a $1 increase in social security a veteran could theoretically lose all of a much valued veteran's pension.

Therefore, I shall introduce an amendment to the House bill which would prohibit the inclusion of the increases in benefits provided by the bill from being taken into consideration in the computation of income limitations for veterans' pensions. The amendment further recognizes that this is a stopgap effort and directs the Administrator of Veterans' Affairs to study this problem and make recommendations for permanent legislation to the Congress no later than June 30, 1965.

Mr. Chairman, I realize the pressure of adjournment are great. But, measures of this importance cannot easily be put aside. I hope that you will find time before the close of this session to have the Committee on Finance give careful consideration to these proposals.

STATEMENT OF THE AMERICAN COLLEGE OF RADIOLOGY RE AMENDMENTS 1163 AND 1178 To H.R. 11865

The members of the American College of Radiology appreciate the opportunity to submit this statement in regard to amendments 1163 and 1178 to H.R. 11865. Members of the American College of Radiology are 6,000 doctors of medicine in the United States who specialize in the use of X-rays and radioactive substance in the diagnosis and treatment of disease and injury.

We are opposed to enactment of either of these amendments, or any other legislation that defines the medical specialty of radiology as a part of services properly rendered by or through hospitals. We are further opposed to legislation that establishes sickness benefits as a part of the social security system to be financed by social security taxation.

We specifically oppose these amendments because:

(1) Enactment of either will adversely affect the care physicians are able to render all patients now, and will gradually destroy the medical specialty of radiology.

(2) Enactment is not necessary and is for many reasons positively undesirable.

If we believed that adoption of either of these amendments would improve medical care, we would support one, or both.

THE PRACTICE OF RADIOLOGY

We have stated that enactment of this proposed legislation will gradually destroy radiology. We will review what radiology is and why we believe as we do.

Training

After completing a 4-year course in medical school and 1 year of internship, a physician is eligible to undertake from 3 to 4 years of additional, concentrated training in a teaching institution in the use of X-rays and radioactive substances in medical diagnosis and treatment. After such training he is eligible to be

examined by the American Board of Radiology, a group of selected, senior specialists in radiology. Approximately three out of four candidates are successful the first time they are examined. Those who do pass are then recognized as radiologists.

But this is only a beginning. To retain abilities, to keep abreast of new developments and to continue to perform radiologic services at a high level of competence, requires two things. First, and foremost, it requires full time application of skills and knowledge to the practice of radiology. Second, it requires a lifetime of continuous study.

From 85 to 90 percent of radiological practice involves making diagnoses based upon radiological examination of patients; from 10 to 15 percent involves treating patients with diseases-principally cancer.

Radiation therapy

Radiation is probably the most used modality in cancer therapy. Approximately 70 percent of all patients with cancer are treated by radiologists. There are other diseases and conditions in which radiation is the treatment of choice. In treating with radiation, adequate equipment is desirable and necessary, but the apparatus is far less important than the competence of the physician using it. The radiologist must decide whether, how and when to treat each individual patient who is referred. The patient's age, sex, physical condition, psychologic state, family situation and the like all have a bearing on the medical decisions that must be made. This is the so-called art of medicine and it has tremendous bearing on whether and how a patient reacts to treatment.

Diagnostic radiology

There is no system of the body that radiologists are not now examining with X-rays and radioisotopes. Diagnostic radiology is the single most important adjunct in the development of modern medical diagnosis. It cuts across all fields of medicine. Radiologists consult with all other physicians.

With refinements of the familiar chest X-ray, we can now identify and differentiate chest conditions: cancer, pneumonia, emphysema, etc., with greater accuracy than in the past. With variations in the common gastrointestinal examination, we now recognize new indications of disease, anomaly and injury. With neurologic and vascular studies, we are now able to predict strokes and recommend prophylactic surgery. Our examinations of the kidney and other organs now allow patients to avoid exploratory surgery that was at one time routine. With cardiovascular studies we can now anticipate heart failure and recommend how to avoid it. With techniques combining fluoroscopy, television, and motion pictures, we can now study and restudy complex problems.

It is to be emphasized that this composite of improvements in old and familiar examinations, plus new knowledge, belongs to men-not machines. An estimated $650 million is invested in equipment in radiologic installations used by radiologists in medical practice. This investment is all but valueless without radiologists who can medically interpret the data these installations will allow trained people to produce.

Radiation protection

Finally, in the essential field of radiation safety and protection, involving as it does the present and future interests of all living matter, radiologists occupy a vital position. Better and safer use of ionizing radiation in agricultural, astrophysical, biological, commercial, and military fields requires medical radiological guidance. Radiologists are the group of physicians whose training and experience enable them to provide such guidance. It is a fact that radiologists have supplied leadership in radiation protection in the United States for over 40 years (via the National Committee on Radiation Protection and Measurements) and have staffed the International Commission on Units and Protection since the 1920's.

EFFECTS OF ENACTMENT ON RADIOLOGY

This has been of necessity an immodest presentation of what is involved in the practice of radiology insofar as patients and the public are concerned. We have had to make such a statement because both amendments under consideration purport to provide social security beneficiaries with hospital benefits, but in so doing include the medical specialty of radiology. The services of other physicians are specifically excluded from these amendments. Under these proposals only a hospital can be designated as a "provider of services" and yet both proposals cover the services we provide patients in the practice of medicine.

The present

The proposed legislation would, we believe, swamp many hospitals with neglected and mildly infirm people over 65; the seriously ill of any age would often find it difficult to obtain a bed. It is reported that in Great Britain and New Zealand, patients who are entitled to beds aften wait 6 months to obtain such.

As an example, in Saskatchewan, approximately 95 percent of the population is covered by a compulsory tax-supported Government plan. In Indiana a large proportion of the population is covered by voluntary hospitalization insurance. For those 65 and over, the Saskatchewan hospital admission rate per thousand is reported as 173 percent of the Indiana rate.

Our colleagues in Canada tell us that nonemergency outpatients have had to be refused radiologic examination in Canadian hospitals in order that adequate examination be available to inpatients.

The quality of medical services included in the proposed amendments will unavoidably drop. Departments of radiology in hospitals will be crowded with senior citizens requesting examinations. It is a fact of radiologic practice that demand for X-rays almost always exceeds need. If these radiologic examinations are "free" (as in VA hospitals), the utilization greatly exceeds the actual need. There are approximately 6,500 radiologists in active practice in the United States today. This is approximately 1 radiologist for each 30,000 patients. These men are all busy-many of them overly busy. As the complexity of examinations has increased, so has the need for a greater number of radiologists to take care of the same volume of practice. Our considerable current efforts in regard to recruitment of physicians into radiological practice are discussed later, but we here assure you that any substantial increase in the volume of radiologic examinations requested will unquestionably and immediately result in a loss of quality of service. It is axiomatic in the practice of medicine that volume is the enemy of quality.

The future

Under the discriminatory provisions of the proposed amendments, radiology, as a medical specialty, will not be able to recruit young physicians. Domination of radiologists by hospitals is inherent in these measures. Under these amendments hospitals would provide our services to patients under contract with the Federal Government. If we become captives of such a scheme, we will not be able to compete for bright young men.

If we cannot attract young physicians into the specialty of radiology, there will be a gradual attrition in numbers-and in quality too-which would seem to assure the demise of this medical specialty. This will adversely affect the services that all physicians are able to render patients.

We already encounter recruitment difficulties which we believe are based upon:

(1) The attack on the professional independence of radiologists by the organized hospital world; and

(2) The threat to radiology posed by the amendments under consideration and similar legislation that has been proposed annually for many years. In 1962, among 24 specialties listed as offering residency training programs by the American Medical Association, radiology ranked 16th in percentage of residencies filled. In 1963, a year later, among 23 specialties so listed, radiology ranked 17th. Of those ranking below radiology in both years, three-pathology. physical medicine and anesthesiology-are also included as a part of hospitalization in the proposed amendments.

We are trying to eliminate the recruitment difficulty in several ways. We believe that we are gradually escaping from hospital domination of the practice of radiology. In this connection, the trend in radiologist-hospital practice arrangements has been away from salaried employment. In 1939, 37 percent of radiologists practicing in hospitals were on a salary; by 1947 the percentage had dropped to 32 percent; and in 1960 and 1961, the percentage had dropped to 11 percent. In addition, twice as many radiologists now present bills to patients for their services than was true 6 years ago.

We are currently working on a series of films with which to teach medical students, radiologic technologists, and others anatomy and physiology. The principal purpose of these films is to make a positive contribution to medical education, but we hope that they will also tend to excite the interest of medical students in our specialty and that some of these men will then enter radiological training.