Senator ELLENDER. Well, they would not be their own free agents. Whatever plans they would foster would have to in a measure receive the okay of the Administrator in Washington?

Mr. ALTMEYER. Subject to the general standards. But on this matter of how they distribute the lump sum that is assigned, they have that same problem under their own plans. Many medical society plans have to write down the bills that are submitted by the doctors, because the amount of money collected is not sufficient to cover the bills; so that is a problem that is common to either voluntary or compulsory health insurance.

SELECTION OF PHYSICIANS

Senator ELLENDER. Well, now about the selection of physicians of one's own choice. Do you expect to touch on that later?

Mr. ALTMEYER. It is perfectly clear that a person may select his own physician.

Senator ELLENDER. That is only in the case that the physicians of a certain community agree to abide by whatever rules and regulations come from Washington.

Mr. ALTMEYER. Well, if the doctor did not want to treat the patient the patients could not select them.

Senator ELLENDER. Let us assume a community where there are 100 physicians and surgeons, and let us further assume that of that number 60 percent of them would be willing to abide by common consent to whatever rules and regulations Washington agreed with, and suppose further that a patient desired a doctor who is not one of the 60 percent. What procedure would that patient have to go through in order to obtain the services of a doctor who happens to be in the 40 percent group, that is, those doctors of that community who do not choose to join the plan?

Mr. ALTMEYER. Well, if the doctor did not want to treat the patient and be reimbursed

Senator ELLENDER. I am not putting it that way, Mr. Altmeyer. You say there is freedom in this bill of a patient selecting a doctor of his own choice.

Mr. ALTMEYER. That is right.

Senator ELLENDER. When you say that, you mean the doctor must abide by the rules and reglations of the administrator, and any doctor in the community who is left out could not be called in by that patient and be compensated out of the common fund.

Mr. ALTMEYER. He could be called in, but the patient would have to pay for it.

Senator ELLENDER. That is what you call freedom of selection?
Mr. ALTMEYER. Yes, of course.

Senator ELLENDER. In other words, you would force every physician in the country to belong to some association or to some group that would in turn deal with Washington.

Mr. ALTMEYER. Many physicions would probably elect―
Senator ELLENDER. But I say, is that correct?

Mr. ALTMEYER. No, because mny physicians as in Great Britain would elect not to practice under the system.

Senator ELLENDER. But what I mean is in order to be paid out of these funds, is that right?

Mr. ALTMEYER. That is right.

Senator ELLENDER. That is what I had in mind.

EFFECT OF BILL ON VOLUNTARY PLANS

Senator DONNELL. Mr. Altmeyer, referring to Senator Ellenderqueries in regard to the effect on the Blue Cross, as I understoo your testimony you do not think that the average individual over the country is getting the service or who is entitled to the servi under the bill, would duplicate the expense by both allowing his percentage to be taken by the Government, and at the same time als buying other service of the same type from the Blue Cross? Mr. ALTMEYER. No, I would not think so.

Senator DONNELL. So the only place that the Blue Cross would b able to sell its services direct to the individuals thereafter would b in supplemental services of such type as you mentioned, specia rooms?

Mr. ALTMEYER. Yes, sir.

Senator DONNELL. And as to the maintenance of hospitals, the the Blue Cross would have to depend upon only two sources of income. would it not, if it is to continue in existence? That would be fir the income if any which it might derive from the Government by co tracting to furnish the Government the services which the Gover ment will furnish under the insurance plans; and secondly, by secur ing from the individuals the payment for these supplemental services That is correct, is it not?

Mr. ALTMEYER. That is correct.

Senator DONNELL. Now, Mr. Altmeyer, it seems reasonable to b lieve, does it not, that the great bulk of such income, if any, as woul be received by the Blue Cross, under that plan, if it were to wors out that way, would be the income received for the normal services, namely, that that it would get from the Government?

Mr. ALTMEYER. Yes, sir.

Senator DONNELL. As to those services, those would be conduct under the regulations of the Government, as the Government mig prescribe. That is correct, is it not?

Mr. ALTMEYER. Yes, sir.

Senator DONNELL. Have you made any study to estimate wha would probably be the volume of these supplemental services tha individuals would buy, over and above what the Government wou provide? Have you made any studies designed to give us any est mate on that?

Mr. ALTMEYER. No, sir.

Senator DONNELL. So that it would look pretty clear, would it no that unless these supplemental services are going to amount to a very considerable volume, that Senator Ellender's point is good, that th Blue Cross would virtually be forced out of business?

Mr. ALTMEYER. No. I do not think that that necessarily followbecause they are really essentially producers' organizations, repr senting the hospitals. There are very few that have any represent tion of the subscribers on them. The hospitals apparently find ther of advantage to them, and the hospitals might very well conside them of advantage in dealing with the Government.

Senator DONNELL. At any rate the great bulk of the services which the Blue Cross, if it were to continue in existence at all, would normally perform would be those for the Government. That is correct, is it not?

Mr. ALTMEYER. That is right, on behalf of their hospital members.

FREEDOM OF CHOICE UNDER THE BILL

Senator DONNELL. Now, Mr. Altmeyer, referring to the second point that Senator Ellender made, namely, the question as to the freedom of choice by individual persons of physicians, as I understand it, and if I am wrong I wish that you would check me on this-as I understand it, if an individual has this compulsory insurance and wants to get a doctor who has not complied with the regulations of the Federal Government, the individual would only have the freedom of choice of going out and getting that doctor at his own expense?

Mr. ALTMEYER. That is right.

Senator DONNELL. In other words, he has no freedom of choice whatsoever as to employing that doctor to perform the services for which the Government would pay. That is correct, is it not? Mr. ALTMEYER. That is right.

Senator DONNELL. So the only freedom of choice is just to spend his own money?

Mr. ALTMEYER. He has freedom of choice to select, but he would have to pay for that service.

Senator DONNELL. That is no freedom of choice under the bill.

That

is just the freedom of choice that any individual has to go out and get any doctor that he wants?

Mr. ALTMEYER. Yes, sir.

Senator ELLENDER. So that he would have to pay twice.

Senator DONNELL. He would be paying to the Government, and if he did not like the Government's doctor, or the man the Government approved, then if he wants to get another doctor he would have to contribute not only the amount to the Government but also pay separately out of his own pocket, independently of his governmental contributions, is that right?

Mr. ALTMEYER. That is right.

Senator AIKEN. May I ask a question. I would like to ask Mr. Altmeyer, is there any doubt in his mind that the Federal Government would approve any doctor who complied with the standards established by the State in which he was practicing?

Mr. ALTMEYER. It is specifically provided in the bill that any doctor licensed to practice shall have the right to participate.

Senator AIKEN. That is what I wanted to bring out, that you could not deny the doctor his right to participate.

Senator DONNELL. Where is that in the bill, if you have it. I am not familiar with it.

Mr. ALTMEYER. That is section 205, on page 45 of the bill.

SEC. 205. (a) Any physician, dentist, or nurse legally qualified by a State to furnish any services included as personal health service benefits under this title shall be qualified to furnish such services as benefits under this title (except as otherwise provided in subsection (c) of this section or in subsection (f) of section 214), and this provision shall extend to any group of physicians, dentists, or nurses or combinations thereof whose members are similarly qualified.

Now, subsection (c) refers to specialists or consultant services; and (f) of section 214 refers to nurses, because most States do not have registration or standards for practical nurses.

Senator DONNELL. If an individual wanted to get a specialist in a heart treatment, for illustration, is such a person under the exception set forth in subdivision (c), or subsection (c) of section 205?

Mr. ALTMEYER. The reason that is put in there is because no State has licensing of the various kinds of specialists. Somebody has to de cide whether a person who says he is a specialist is really a qualified specialist.

Now I am getting into professional questions which I am not competent really to testify about, but in my understanding the Surgeot. General as Administrator would consult with and probably be largely guided wherever there is a professional organization that has issued any certification of specialty.

Senator DONNELL. You think, as I understand it, and if I am wrong please check me, that the term "specialist" as used in subsection (c) of section 205, would include a heart specialist, for illustration?

Mr. ALTMEYER. I really do not know.

Senator DONNELL. You think that that would be something that the Surgeon General would be better qualified to testify on?

Mr. ALTMEYER. That is right.

Senator ELLENDER. I may be giving you an extreme case, but suppos in a community where there are, say, 10 doctors, and none of the agree to abide by the rules and regulations from Washington, how would the patients in that locality who contribute to this fund be ab to obtain medical services?

Mr. ALTMEYER. Well, I imagine the Surgeon General would undertake to induce other physicians to come into that community wh would be willing.

Senator ELLENDER. He would have to go outside for help?
Mr. ALTMEYER. Yes, sir.

Senator DONNELL. That would have the effect of putting out of business those physicians and surgeons to whom Senator Ellende referred?

Mr. ALTMEYER. That is an assumption contrary to fact, I think, for this reason, that this bill provides not only that the majority of phy sicians of the community elect the method remuneration, but ar individual in the minority who wants a different method can mak arrangements for it.

Senator ELLENDER. The point is that you force them to join the plan "or else," is that true?

Mr. ALTMEYER. You force them to charge the Government rather than charge the patient, if that is what you mean. I do not see why there would be any objection to charging the Government.

Senator ELLENDER. I do not know whether the Government pays: or the patient, but I was trying to demonstrate this freedom tha we are speaking about.

Mr. ALTMEYER. That is freedom between the patient and the phys cian, each one to select the other, but as you point out the factor payment affects the choice that is made.

Senator ELLENDER. Of course, I presume that as time went or rather than starve, a lot of doctors would see themselves forced to jo.. or else give up their profession, is that not true?

Mr. ALTMEYER. I do not think any doctors would give up their profession.

Senator ELLENDER. That could happen under this bill, however. Mr. ALTMEYER. It has never happened under any other health insurance plans put into effect in other countries.

Senator AIKEN. We have an insurance plan in this country, I believe by the Farm Security Administration. Do you know of any instances where the local doctors have refused to participate in this insurance plan which is set up by the Farm Security? It simply means that they participate and they get their money, and if they do not, they either do not visit the person who is ill at all, or if they do visit them they take a chance on not getting their money. Therefore, they all have participated.

I come from the State which has Farm Security health insurance on a State-wide scale. I think that it has worked out very well there, and I think that all of the doctors in the State participate if they have a patient in that class. I do not think that there has been any trouble on that, when it is a question of getting part of their pay or getting none of it.

Senator ELLENDER. But all of that has been through voluntary agreements entered into by the profession, which I think would be the case. Senator AIKEN. They entered into an agreement with the cooperative set up by the Farm Security. It has worked out very well. I do not want anyone to think that just because I am asking questions that I am going to favor a system of Government doctors, but I want to make sure that this bill does not set up a system of Government controlled doctors.

Senator ELLENDER. Speaking for myself, I do not want to be judged as to what I am going to do about this bill by the questions I am asking. All I am trying to do is obtain from all witnesses what the bills means, where it will lead to, and that is all.

Senator AIKEN. That is my position exactly.

HEALTH INSURANCE IN OTHER COUNTRIES

Senator DONNELL. May I ask one further question. Mr. Altmeyer, you referred to the other countries in which there is health insurance. Would you mind telling us which are the major countries in which health insurance of a compulsory nature has prevailed?

Mr. ALTMEYER. There are about 35 countries that have compulsory health insurance, including nearly all of the industrialized countries. Great Britain is one, and France and Germany, Norway, and Spain, New Zealand, Denmark, Holland and Belgium, most of the South American countries; and in fact, off-hand I cannot think of the ones that do not have it.

Senator AIKEN. Are those plans financed in a manner similar to that proposed in this bill?

Mr. ALTMEYER. They rely upon the health insurance approach. The oustanding exception is Russia, which has a system of state medicine, and salaried physicians.

Senator AIKEN. This bill as I understand it, simply sets forth that money must be provided, and it does not provide the means of getting that money, does it?