Has a National Health Program Been Put Before Congress?
Do these principles of a national health program appear in practical form in the legislative proposals brought before Congress? What manner of national health program is it any-way that has been advanced for public discussion and eventual Congressional decision?
Beginning in 1943 with the original Wagner-Murray-Dingell Bill to add health insurance to the Social Security system, several bills have been proposed embodying the principles. They include the Hill-Burton Hospital Construction Bill, a new version of the Wagner- Murray-Dingell Bill introduced in May 1945, and a still later revision of November 1945.
The First Wagner-Murray-Dingell Bill
National health insurance was but one of several provisions of this bill. Other provisions, such as extension of Social Security, the nationalization of unemployment compensation, and federal aid for general relief, are beyond the scope of this discussion.
The bill provided that health insurance would be established by the creation of a national medical care and hospitalization fund, to which employers and employees would each contribute 1.5 percent of the first $3,000 of annual wages, making 3 percent in all. Self-employed would contribute the entire 3 percent themselves. Contributions amounting to an additional 4.5 percent of wages would be made by employers and employees, 9 percent in all, to pay for the other benefits of the bill. Two of these latter provisions have an important bearing on health, namely, those providing for cash payments during temporary and permanent disability.
For every insured person and his family, the. medical care and hospitalization fund would pay for unlimited doctors’ care including specialists, for hospitalization up to 30 days, X rays, and laboratory tests. Dental care, nursing, medicines and drugs would not be paid for.
Patients would be free to choose their physicians from among those participating in the program, whether engaged in individual or group practice. Standards of competence for specialists and hospitals would be established by the Surgeon General of the United States Public Health Service. Any licensed physician could participate in the program as a general practitioner.
The national fund would pay physicians for the services rendered to patients covered by the system through any of several methods-fee-for-service, capitation, part-time or full-time salaries, or by a combination of these methods. The physicians of each area would choose by majority vote the
method of payment to be adopted in that area. Hospitals would be paid up to $6 per day for each day of care they furnished.
Reaction to the bill
The 1943 Wagner- Murray-Dingell Bill never came to a vote in Congress. Nevertheless it caused a storm of comment. Backed enthusiastically by organized labor and some farm organizations, it was considered by them “so enormous an improvement over our present social security provisions that no responsible person, deeply concerned with the welfare of our country, can fail to support it.”
At the same time, it was vigorously opposed by representatives of organized physicians, in those minds it was “socialized medicine.” The opposition groups said that the bill implied that sick people would have to depend on a doctor paid by the government to work only eight hours daily-emergency cases would have to wait until the doctor checked in. Patients would have to go to the doctor assigned to them by political bureaucrats, and doctors would become incompetent because methods and remedies would be fixed by bureaucratic superiors. Largely to oppose this bill, physicians and drug houses raised and spent over a quarter of a million dollars in giving out “information” of this nature. Extremes were reached with statements like, “It is doubtful if even Nazidom confers on its gauleiters the powers which this measure would confer on the Surgeon-General of the U. S. Public Health Service.”
One group of physicians attempted to promote a national movement to boycott any legislative program such as the Wagner-Murray-Dingell Bill, giving physicians this advice: “If such legislation as the Wagner-Murray-Dingell Bill passes and your patients come to you for services under the plan, tell them you don’t serve the politicians, you serve there. If they want to know what they are going to get for the money deducted from their pay checks for health insurance, you don’t know.”
It is of course debatable whether an insurance scheme such as that proposed in the bill would in fact have the disastrous effects predicted by its opponents. Certainly the bill itself had no provisions for assigning patients to doctors, for regulating physicians’ hours of work, income, or methods of practice, except for the elementary requirement that specialists meet national standards of competence in their particular fields. Many persons in favor of federal legislation for health and medical care felt, however, that the first Wagner-Murray-Dingell Bill fell far short of providing a truly adequate health program for the nation. They pointed out that it included, for example, no provision for the construction of hospitals and health centers. It contained nothing to encourage the expansion of preventive health services. It offered nothing to induce physicians to modernize their methods of practice by joining together in groups instead of continuing in the traditional solo practice of the old-time family physician.
Some felt, too, that the whole population should be protected under the plan, rather than merely employed persons and their families. For this reason, and to promote preventive health services, support from general taxes as well as from the pay-roll contributions of employer and employee was urged.
Finally, disinterested critics generally felt that the bill permitted too centralized an administration of the program. They said that the program did not require sufficient participation by state and local governments nor by local representatives of the professions and the public. The American Bar Association made the additional point that it failed to provide for court review of administrative decisions.
The new Wagner-Murray-Dingell bills
A revised Wagner-Murray-Dingell Bill, introduced into Congress in May 1945, proposes a pattern essentially similar to
the earlier one, but has added features which meet some of the criticisms made of the original. It had not been acted upon when President Truman sent to Congress his special message of November 19 asking national health legislation.
The President strongly advocated a program of five related proposals for action by the federal government
1. Financial and other assistance for the construction of hospitals and other health facilities where they are most needed.
2. Increased grants to the states for public health services and maternal and child health care programs.
3. Support of medical education and research.
4. Expansion of compulsory insurance under the Social Security system to cover medical, hospital, nursing, laboratory, and dental care.
5. Cash benefits to cover some of the wage losses during periods of sickness and disability.
In order to meet, at least in part, the President’s request, Senators Wagner and Murray and Representative Dingell promptly lifted, rewrote, and introduced as a separate bill the health provisions of their earlier measure.
These health provisions include, besides medical care insurance, increased federal grants to the states for public health work and for the care of mothers and children, but no funds for construction of hospitals and health centers. Benefits of the medical care insurance have been increased by adding limited home nursing and dental care. An attempt has been made, too, to increase the responsibility of states and communities through advisory committees, although the final administrative control remains in the federal government. Court review of administrative decisions is, however, specifically authorized.
Groups of physicians, as well as individual practitioners, may participate in the plan but they are not expressly encouraged. The physicians of an area may still decide by vote how they wish to be paid, but such a vote is no longer binding upon all the doctors of the area. General taxes are to be used more generously to supplement the funds contributed by employers and employees, but the plan does not yet cover the entire population.
Summary of opinion
Discussion of national legislation for health will doubtless be focused about the Truman proposals and the latest Wagner-Murray-Dingell Bill for some time to come. It will be useful, therefore, to repeat the principal arguments for and against the original bill. The groups supporting the 1943 measure emphasized the necessity for nation-wide action in order to equalize the opportunity for health services among all groups of the population in whatever part of the country they happen to live. They also stressed the need for a method of paying for medical service by which people can pay in known, regular amounts, month by month, in accordance with their earnings.
Those opposed to the first bill, on the other hand, made an issue of the danger of political control over medical matters, of a possible threat to the individual freedom of patients and doctors, and of the limitations that it might impose upon physicians in professional status and-by implication-income.
The nation-wide discussion that took place as a result of the introduction of the bill had broad educational value. It stimulated people everywhere to greater awareness of the issues. It provoked painstaking inquiry by numerous nonprofessional organizations and groups as to the true facts of medical care in their own communities and in the nation as a whole. All this served in some degree to clear the air, to dispel false notions and groundless fears, and to aid the country in facing realities. With this increased interest and knowledge as a background, the public is better prepared, with the introduction of the November 1943 bill, ‘to resolve differences of opinion and to focus its attention upon specific points for action.
The Hill-Burton Hospital Construction Bill
This measure, introduced in the spring of 1945, would provide federal grants to states for the construction of hospitals and health centers. Designed to encourage over-all planning by the states of an ordered network of health facilities, the bill calls for each state to study its existing hospital resources and unmet needs, in order to develop a master plan of construction. The federal treasury, after state plans had been approved by the Surgeon General of the United States Public Health Service, would supplement funds for construction raised within the states, paying a larger share of federal funds in poorer states, and a smaller share in richer ones.
Besides providing for the construction and improvement of state, city, and county hospitals for general care, mental illness, and tuberculosis, this bill would also aid in the construction of those nongovernmental community hospitals which are not operated for profit.
Supported by the American Hospital Association, organized labor, farm groups, and the American Medical Association, this bill has aroused little opposition. It fits into the principles of a national program in the following ways:
1. Differences between states in availability of hospital facilities might be greatly lessened because national tax funds would share the costs of construction.
2. Improved organization of services centered around hospitals is ?ide possible if hospital administrators, physicians, and the public wish to avail themselves of the opportunity, because construction would be based on state-wide planning.
3. Decentralized administration within the states, subject only to general national standards, would reflect the particular needs and circumstances of the various states and communities. ,
4. The principle that private, nonprofit agencies can maintain individuality within a national, tax-aided program is recognized by the inclusion of improvements and new construction for this type of hospital.
The bill, however, is criticized to some extent by farm and labor groups because the general public, who would use the
hospitals, would not have a great deal to say about where they are to be located. As provided in the bill at present, the committees who determine the location of the hospitals would he composed largely of hospital administrators and physicians.
The most serious criticism of the Hill-Burton Bill is that it can meet only limited needs. It does not attack the problem of paying doctors’ and hospital bills. A modern, well-equipped hospital is of little value to a community if the people in that community cannot afford to use it. At present, it is the sad truth that areas which have the least hospital facilities in proportion to population are also the areas where such hospitals as do exist are the least used. In other words, where communities are too poor to build adequate hospitals, the people living there are too poor to pay for hospital care under present arrangements. To guard against the possibility of putting up white elephants, in the shape of hospitals which would not be used, this bill provides that communities wanting new hospitals must show ability to support them after they are built. If this cannot be shown, no federal money would be forthcoming.
Were the Hill-Burton Bill passed in this form-and in the absence of any measure to meet the patient’s problem of paying hospital charges-some critics think that most new hospitals would be built in wealthy areas which need them less than other localities but which can afford to support them after they are built.
The Hill-Burton hospital construction bill is of great significance because it is the first national measure related to medical care which has received support from all major professional groups as well as major farm and labor groups. Yet even its most ardent sponsors recognize that at best it can meet only limited needs as long as the problems of paying doctors’ and hospital bills are still unsolved and that at worst it might result in an even less equitable distribution of general hospital beds than at present.