What are the achievements of American medicine? Do its services reach the people who need them? Is the battle against sickness a public question like the battle against illiteracy? What role should local, state, and national government agencies play in supplementing private effort?

A widely accepted answer to the first two questions was given by the Senate Subcommittee on Wartime Health and Education (the Pepper Committee) when it said in its report “The quality of American medicine at its best is very high. Unfortunately, American medicine at its best reaches only a relatively small part of the population.”

The other questions—on the stake of the general public in preventing ill health and the role of government in the struggle against disease—are not new ones. Community responsibility for public health has long been recognized in laws and ordinances for sanitation, food inspection, and the prevention of communicable diseases. Does public interest also extend to bringing better medical care of all kinds to more people at less cost? This pamphlet presents some of the most widely discussed programs for national health and the arguments pro and con touching them.

What are some of the facts and figures that have made the issues seem too important to be left to private effort or to public health agencies as they now exist?

In 1935, more than 23 million people in the country had a chronic disease or a physical impairment. In spite of tremendous advances in medical science, the death rate among low-income groups in our large cities is still as high as the national rate fifty years ago. Deaths among mothers and babies could be cut about one-third if all got good medical care.

The fact that struck hardest and startled the public most was the revelation from the Selective Service figures that 30 percent of the men of military age were unfit for general military duty.

The-gap between what modern medicine has to offer and the kind of medical care people actually receive is usually blamed on two things: people’s inability to pay for good medical care under present arrangements, and the way health services are organized.

Modern medicine comes high

Modern first-class medical care is necessarily an expensive commodity. Many people cannot meet its full cost regardless of the method of payment. The cheapest medical and dental service compatible with good quality and high standards would probably cost about $150 a year for the average-sized family. But studies of family spending show that most families under the $2,000 level—or about half our population—simply cannot pay a full $150 a year for this purpose. If their medical needs are to be fully met, such people need assistance: As it stands today, people in low-income groups, though they have twice as many days of sickness as the well to do, receive only about half as much physicians’ care.

Not only does good medical care cost a lot, but the need for it cannot be predicted. If you can’t foretell when illness will strike or how serious it will be, how can you prepare to meet its costs? Many a family able to budget $150 a year for medical expenses is staggered or financially crushed for years to come by the cost of a single serious illness. Moreover, having to pay a fee for the doctor’s services is a frightening prospect to people whose incomes barely cover living expenses-so they often put off going to the doctor. Thus they lose the benefits of preventive measures, early diagnosis and treatment, and perhaps have to pay more in the end.

Fortunately, though no one can predict when or how seriously an individual will be sick or injured, the frequency of such ills can be figured in advance with reasonable accuracy for groups of people. These facts led the Pepper Committee to conclude:

“The ‘pay-as-you-go’ or fee-for-service system, which is now the predominant method of payment for medical services, is not well suited to the needs of most people or to the widest possible distribution of high-quality medical care. It tends to keep people away from the doctor until illness has reached a stage where treatment is likely to be prolonged and medical bills large. It deters patients from seeking services which are some-times essential, such as specialist care, laboratory and X-ray examinations, and hospitalization. Individuals with low incomes, whose need is greatest, are more likely to postpone or forego diagnosis and treatment.”

Health, wealth, and geography

Cost is widely recognized as a barrier between individual people and the medical services they need. Another difficulty is that people in some parts of the country don’t have enough medical services at hand-regardless of price or ability to pay. The extent of health services actually available in different parts of the country varies according to the wealth of whole communities. Counties, cities, and states which are well off have enough doctors, nurses, and hospitals, and adequate public health facilities; those which are poor have desperately few.

In New York State before the war, for example, there was one doctor in practice for every 500 people, while in Mississippi there was one for 1,500-exactly three times the number of people to be served by each physician. Moreover, the density of population in Mississippi is about one-tenth that of New York, so that not only does each physician have more persons to serve, but on the average, he has to travel farther to serve them.

In New York there was one general hospital bed for every 200 people, but in Mississippi one to every 650. Variations between counties are even more striking-17 million people live in 1,300 counties that have no recognized general hospital at all. Thus, where communities are too poor to attract sufficient doctors or to build and maintain other health facilities, not only do the needy have to go without necessary medical services, but so do those who can afford to pay but cannot seek care elsewhere.

Health services are unorganized

Even the best general practitioner cannot adequately cope with emergencies or with baffling and complicated cases if he does not have the resources of a well-equipped hospital within reach and does not have colleagues in surgery and the other specialties available when needed. Even where there are first-rate hospitals, the general practitioner may not have the right to use them. In Baltimore, for example, almost half, the general practitioners cannot care for their patients in hospitals.

Specialists usually set up offices in cities of some size. They are, not easily accessible to country doctors or country patients. Moreover, specialists are not as a rule organized to work in combination with general physicians. Such teamwork can be found, however, in many of the leading hospitals and clinics where medicine is taught and in the outstanding group practice clinics such as, for example, the Mayo Clinic.

In today’s medical schools students are trained under a system of group medical practice, centered about a hospital, where the best available equipment and techniques can be employed and where the combined skills of a variety of specialists can be brought to bear on a puzzling case. Yet, when they graduate, they go out into a kind of isolated practice similar to that of their grandfathers’ day. That this is professionally unsatisfactory to physicians is shown by the fact that over half the doctors in the Army stated that they “would like to go into group practice on returning to civilian life.”

To sum up the problems of American medicine, then, Americans receive the benefits of medical science in a very uneven manner, partly because of the high cost of modern medicine, partly because medical services are not organized to serve everyone equally—regardless of where he happens to live or how much he can pay.

Clearly, then, the problem of paying for health services is very complex. Can some way be found for families to budget these costs and to assist those families which cannot reasonably afford the total costs? And can facilities for rendering health services be made more equally available in all parts of the country?

What’s to be done?

President Roosevelt, in his “economic bill of rights” put before the nation early in 1944, included “the right to adequate medical care and the opportunity to achieve and enjoy good health.” Wendell Willkie declared in 1944, “Complete medical care should be available to all.” Secretary Wallace recently said, “Your federal and state governments have just as much responsibility for the health of their people as they have for providing them with education and police and fire protection.” Governor Thomas E. Dewey appointed in 1944 a commission on medical care “in order to devise programs for medical care for persons of all groups and classes in New York State.” In his special message of November 19, 1945 asking Congress to adopt a five-point national health program, President Truman said, “We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.”

Thus leaders of both political parties have followed the demand of farm, labor, and business organizations and of the public at large, as shown in various opinion polls, for an improvement in the way medical care is distributed.

Some professional medical organizations echo the cry. The American Public Health Association, an organization of physicians, nurses, sanitary engineers, and others engaged in public health work, adopted in the fall of 1944 an official policy which states that “a national program for medical care should make available to the entire population, regardless o f the financial means of the individual, the family, or the community, all essential preventive, diagnostic and curative services.” The American Dental Association has declared that “dental care should be available to all, regardless of income or geographic location.” The American Medical Association, representing the majority of private practitioners and on the record as a conservative professional organization, now recognizes the fact that there is a problem in the distribution of medical care. Up to a few years ago, it often asserted that, except in isolated instances, everyone needing medical care was able to get it, by paying for it or through charity.

From EM 29: Is Your Health the Nation's Business? (1946)