firmed by the present Assistant Secretary of HEW in a statement at the time of the hearing on H.R. 4700 when he said—

There are very few nursing homes that would presently meet the requirements of providing truly skilled nursing home service.

He accordingly did not include nursing homes in a "desirable" program.

H.R. 4222 proposes a new concept for the social security system in this country. It substitutes provision of services for dollar benefits. Government established payment would affect the manner in which medical services are provided by a hospital, would affect the selection, tenure, or compensation of hospital employees, and would affect the quality of care deemed necessary by the physician. Where this level is lowered because of payment limitations, it would be lowered for all age groups.

COSTS, FACTORS INVOLVED

It is very difficult for anyone to give any estimate as to cost of any Government-financed health program. The history of all such plans is that projections were low and the final cost was limited only by arbitrary budget allotment.

It has been estimated that by 1975 we will be a nation of 220 million people. The slowest growing group, the taxpaying segment will increase by about 20 percent. The underage group will increase by 35 percent and those over 65 will increase by 52 percent. This will have an unpredictable effect on future costs of this legislation.

The greatest unmet needs for the over 65 age group today are compansionship and living quarters. I repeat that lacking these, hospitals will carry the burden.

It is my firm conviction that voluntary health programs are more effective than Government programs. Čertainly the experiences in Great Britain have been disastrous.

THE NATIONAL HEALTH SERVICE IN GREAT BRITAIN

"No Government could afford to pay for hospital services as you in the United States have grown to demand them." This was the comment to me from the medical director of a large well-known hospital in Great Britain. In this hospital with wood floors and old iron beds there are 32 beds to a ward and 2 private rooms to each ward. One common bath and tub exist. There is 0.8 of an employee including doctors for each patient. The significance of this figure can be appreciated when one considers that in the United States we have 2.5 employees caring for each patient, excluding doctors. The British hospital solution to an arbitrary reduction in dietary budget was second quality meat, reduction in food varieties, and breakfast without eggs or bacon unless the family furnished the raw food for preparation.

Waiting lists are long for admission to hospitals. Examples of tonsil admissions were cited of a wait from 1 to 7 years. Private philanthropy has ceased to exist. Twenty-one percent of the hospitals were constructed before 1861 and 45 percent before 1891. Hospital construction has almost become nil since the inception of the national

health service system in 1948. There were 2,000 health centers to be built. Only a few have been completed. In 1954 the capital expenditure was one-third that of 1938 and in 1956 only one-half of that spent in 1938 was budgeted. The hospital length of stay is much longer than that in our voluntary system; 19 days overall where in our area 10 days overall is considered excessive.

I saw evidences of abuse, interference, and bureaucratic regimentation.

The dean of a medical school told me that the quality of medical students had deteriorated since the system was established. Leaders in medicine told me that they were sending their own sons to the United States for hospital training because the hospital experiences were on such a higher plane in this country. We know that we are attracting good students from England in our training programs, and they do not wish to go back. The reverse is not true.

The general practitioners to whom I talked, have lost the zeal so important to the practice of medicine. One commented to me that he was only the traffic cop spending most of his time finding a bed for his patient and then he was out of the picture. The hospital is the diagnostic center for inpatient and outpatient. Patients wait for hours in these clinics. Cafeterias are set up to feed them over the meal hour. In one hospital women are examined with a curtain drawn between them and the physicians, five or six, so that the patient is just a number.

There has been a growing resentment to the direct costs which have had to be added to the program because of poor estimates of its cost. It was predicted that the system would cost £170 million and would never go over that because of improved health which would result. The first year cost was £431 million. In 1958 the cost was £763 million. In 1960 the cost was about £800 million in spite of added direct costs and increased taxes, and it is predicted that the cost will be a billion pounds by 1965. The health of the nation has improved but not to the degree of improvement in the United States.

While this may have been the best answer for Great Britain, it is not the acceptable answer to you, me, or the American public.

ALTERNATE PROPOSALS

I object to the principles of H.R. 4222. I believe that a means has been established for assistance to those in need through the Kerr-Mills bill. This measure has not been given ample opportunity to prove itself. Universal implementation should be encouraged. The Government's role in assistance to the needs should be to assist in expansion of community facilities and services for the health care of aged and others.

SUMMARY

In conclusion, I oppose passage of the Health Insurance Benefits Act of 1961 because:

First, a proposed legislation does not answer existing unmet needs, yet advocates a compulsory program irrespective of desire or need, which will answer needs already being met. I have related how one community handles these problems with State-Federal assistance.

Local needs are best known by local authorities and can be best met by team approach. This measure would destroy community initiative and family responsibility.

Second, conflicts exist within this bill which are both misleading and contradictory-"prohibition against interference." These conflicts represent a "foot in the door" approach to Federal control of all health services.

Third, the effects of H.R. 4222 lead to a decreased quality and quantity of all health care. Our general hospitals would become chronic hospitals when the need of the over-65 age group is much greater for companionship than for acute medical beds. Philanthropy would not continue under Government-influenced operation. The hospital rather than the family doctor would become the diagnostic center. The young patient with the acute curable disease entity would have his earning power depleted and illness protracted while he waited for a bed used to symptomatically treat an incurable process, which could be treated elsewhere. A new concept is proposed for the social security system in this country, one which substitutes provision of services for dollar benefits.

Fourth, costs for provisions of H.R. 4222 are totally unpredictable and would continue to rise. Needs can be better determined and satisfied locally at much less expense than through a centrally controlled organization.

Fifth, experiences of the national health service in Great Britain are cited which would demonstrate weaknesses in the proposed legislation.

Sixth, alternate proposals include wider implementation of the Kerr-Mills bill, with local responsibility for health care. The role of the Government lies in assistance to local programs. If one part of the population is without food, the Federal Government does not assume responsibility for feeding all of the group. Yet food, shelter, and clothing are primary and without these, there is no need for health care.

No other country on earth boasts better health care for its citizens than does the United States. No other country on earth is freer of governmental intervention in health care. Honorable members of this committee, in my opinion this is not just a coincidence, and I believe that H.R. 4222 establishes governmental intervention.

The CHAIRMAN. Dr. Larrick, in your statement, did you omit any further description of the details of how the medical care program is operated in Great Britain? Do you have that explanation in your statement? If you do, I will not ask you any questions about it. Dr. LARRICK. I omitted a statement as to the amount of hospital construction, new hospital construction.

The CHAIRMAN. No; I meant some of the details. I do not know that it is in this record.

Could you in just a minute or so tell us how the medical care proIgram is set up, and how it operates in Great Britain? I think that is recognized, is it not, as complete socialization?

Dr. LARRICK. It is complete socialization, and the medical care program in Great Britain does not apply wholly to this bill, as proposed, because the medical care over there takes care of doctor care, and a whole pension system. It is a part of a whole pension system.

76123-61-pt. 2- 31

Dr. LARRICK. Yes, sir; of not only the medical profession but health

care.

If I could add one more sentence. Dr. Gober, who was the Deputy Minister of Health, made the statement to me that you could not take out the British medical system as an isolated item and put it in some other form of government; that the British medical system is a part of their whole social system, their whole pension system, and dates clear back to the time of the poor law in 1911 and 1909.

The CHAIRMAN. Did you have occasion to contact people who were patients in these hospitals while you were there?

Dr. LARRICK. I did, sir, including Americans who were there. The CHAIRMAN. What did our Americans think of this system? Dr. LARRICK. It depended completely on the situation in life in which these people existed.

When I talked, for instance, in maternity wards to wives of some of our soldiers who were in these hospitals and having their babies at absolutely no cost-these were people who were just getting out, just getting started-they thought this was fine. It did not cost them anything. It did not even cost them the amount of taxation that the British have, because they were visitors to the country.

But when you talk to people who are accustomed to talking care of themselves, people from our country, who had accidents in Great Britain-they could not get out of the hospital fast enought. They would not stay the full length of time that the doctor wanted them to stay.

One of the worst things that has happened in the British health system-and one which the Minister of Health admitted, to the extent that he said, "If you return in 10 years, I hope we will have this corrected"—is that the general practitioner, the backbone of medicine, has been completely ground out. He is not permitted to follow his patient in the hospital. He can treat the patient with pnuemonia at home with penicillin, but if that patient has to go to the hospital, possibly only for environmental reasons in the home, he is not permitted to treat that patient in the hospital. He loses all his contact with that patient. He cannot deliver a maternity patient in the hospital. The midwife can. He can deliver a maternity case at home, but he cannot do it in the hospital.

As part of the plan, it was proposed that they set up 2,000 clinics, so to speak, health centers they call them. And this was to be where the general practitioner would make his diagnoses and would carry on his diagnostic work. Only a handful of these have been built, because they have not been able to afford it. The cost was much greater than they had anticipated.

If the general practitioner wants an X-ray, if he wants a blood count, if he wants any of the simpler diagnostic procedures, he loses his patient to the hospital. He no longer has contact until the patient comes home.

The CHAIRMAN. Have you reached the conclusion that the health care of the people in Great Britain under this system is not as good as the health care of the people in Great Britain was before this law went into effect?

Dr. LARRICK. No, sir, I would not go so far as to say that. I am not in a position to say it was not as good as it was theretofore.