What Do People Propose to Do about the Situation?

Although a great many people know that ways must be found so that everyone can secure good medical care more rapidly, and pay for it more easily, there is no such agreement on just how this should be done. In particular, opinions vary a good deal on the government’s role in the future of medical care. Some think no further government activity is necessary. Others think that the government must play a part, but differ as to how big that part should be. Proposals range from tax support for such limited purposes as school health programs, to a complete national health program paid for through “national health insurance and general tax funds.”

Hands of Government!

Present governmental activities in providing health services are .generally accepted. Each American citizen spends about a dollar a year for control of contagious diseases, installation of pure milk and water supplies, and other public health services. That dollar is considered a good investment. Though state-supported hospitals for mental illness and tuberculosis are sometimes criticized as insufficient, no one wants them eliminated. Rather, public pressure is for their improvement and expansion. So on through the long list of local, state, and federally supported health services.

Yet, at first, almost all tax-supported services met violent opposition from small groups whose interests were temporarily affected. When, for example, the testing of dairy cattle for tuberculosis as a means of keeping contaminated milk from the markets was proposed, dairymen bitterly opposed it. They said that any such measure would mean political control and regimentation.

Similar protests have frequently come from representatives of the medical profession, who usually oppose the extension of tax-supported health services. In 1944, for example, the governing body of the American Medical Association, while recognizing the need for improved early diagnosis and treatment of tuberculosis, did not favor increased federal responsibility in this field, and refused to support a bill in Congress extending federal financial aid to the states for the control of tuberculosis. Aware that under present conditions over half the patients admitted to tuberculosis hospitals are already in an advanced stage of the disease, most public health experts considered this bill a vital measure toward the ultimate wiping out of tuberculosis. In spite of the position taken by the American Medical Association, Congress passed the law without a dissenting vote one week later.

The A.M.A. today is strongly opposed to any form of government-sponsored health insurance on the ground that “it would bring political control of medicine and interfere with the personal relationship between patient and physician.” For some years, the A.M.A. has held that the intimate bond between patient and physician is threatened or destroyed when the patient himself does not pay his doctor on a fee-for-service basis. Yet the A.M.A., yielding to public pressure for an easier way of meeting sickness costs, now supports voluntary health insurance run by commercial companies or by medical societies. This is a reversal of its position of ten years ago when the A.M.A. editorialized against proposals for voluntary health insurance as measures of “socialism and communism inciting to revolution.” In July 1945 the A.M.A. declared its position in a program, summarized in a later section of this pamphlet.

Voluntary insurance

Voluntary insurance against the costs of hospitalization and physicians’ services has, however, had a considerable develop? in the United States. The oldest of these insurance plans are those organized in certain industries, especially in mines and railroads, which often operate in remote regions where medical services are scanty. Usually, a monthly deduction of a dollar or two is made from employees’ wages and a like amount is often contributed by employers. These funds are then pooled and are used to pay for the medical care which may be needed by the employee. Employees’ families are sometimes but not generally included. Few new plans of this type have been started in recent years, although one has received wide attention-that organized at the Kaiser ship-yards on the Nest Coast.

The largest recent development in voluntary insurance has been for hospitalization, especially the “Blue Cross” plans approved by the American Hospital Association. Blue Cross subscribers are enlisted voluntarily from among employee groups in the community. Subscribers usually pay about $24 a year for insurance that covers hospitalization for employees and their families for a period of three to four weeks a year. The Blue Cross plans have expanded in the past ten years from less than a million subscribers to more than 18 million.

Plans have also been organized to insure the costs of physicians’ services. These have not been so successful as the hospitalization insurance plans but have nevertheless grown so that they now cover about 4 or 5 million people, chiefly for services limited to surgical operations and obstetrics.

Voluntary insurance plans have also been developed for low-income farmers, under the sponsorship of the Farm Security. Administration, and about 300,000 rural inhabitants are now included in them. Farm families generally pay about $25 to $50 a year in these plans and receive limited medical, surgical, and hospital care.

Commercial insurance companies have made some progress in selling policies to cover the costs of hospitalization, surgical and obstetrical care. Usually these policies are taken out by employers for their employees and their families, both employer and employee making monthly contributions to the fund. Approximately 8 million persons are now-insured under, such policies. .

The success of voluntary efforts in providing insurance against the costs of medical and hospital care has encouraged some groups to hope that all the major problems of health and medical care can be solved by voluntary measures, without the participation of government. As mentioned above, the American Medical Association takes this point of view. The United States Chamber of Commerce also advocates further trial of voluntary methods.

Others feel that voluntary insurance, whether it is under the auspices of nonprofit organizations of physicians and hospitals or of commercial insurance companies is too limited -to solve the problem. They point to the fact that, despite the rapid growth of some plans, not more than 20 or 30 million persons are subscribers to such plans in the United States up to the present time and that the insurance coverage of even these persons is largely confined to surgical, obstetrical, and hospital care.

Furthermore they offer the objection that most existing voluntary insurance schemes include no general medical expenses, no preventive care, and little family care. They feel that such insurance provides no incentives for improving the quality of medical practice and that its cost limits its sale to a rather narrow section of the population. In the case of commercial policies, they say that it is no great bargain-companies on the average pay out in benefits only about half of what they receive in premiums.

Those who believe that voluntary efforts cannot fully solve the problem emphasize two difficulties encountered by such insurance. In the first place, voluntary plans, by their very nature, face the problem of securing and retaining subscribers. There is an inevitable tendency for healthy families to stay out of the plans and for those inclined toward illness to enter and remain in them. This fact is apt to bring about financial difficulties. Because of the spotty, uneven coverage of the population, the healthier families do not bear a full share of the costs. The second difficulty is that, if voluntary plans charge high enough premiums to cover the costs of complete medical and hospital care, they are so expensive that the lower-income groups, who need this care the most, cannot afford to subscribe.

Government aid for special programs

George Washington was still alive when the Marine Hospital Service for sick merchant seamen (now the United States Public Health Service) was established. Since that day a variety of tax-supported health services have one by one been added to the functions of government. Local and state governments and, to a minor degree, the federal government provide funds for a large number of hospitals, public health services, and medical care programs. These funds may be used either to combat particular diseases, such as malaria, tuberculosis, or syphilis, or to give all types of care to certain groups of the population, for instance, veterans, men and women in the Army and Navy, Indians, or the needy.

That such government programs can be successful in delivering medical service of high quality is attested by the brilliant record of Army and Navy medicine in World War II. Official records of the War Department show, for example, that whereas 8.3 percent of the hospitalized wounded, excluding gas casualties, died in World War I, only about 4 percent died in this war. Although warfare in the fever-ridden tropics meant an increase in the number of men hospitalized overseas for disease, the annual deaths from overseas hospitalized illness amounted to only 6 per 10,000 men, as compared with 128 in World War I. Deaths from hospitalized illness in the continental United States accounted for another 6 per 10,000 men in contrast to 156 in World War I.

Such results are to be explained, in part, by recent scientific developments like penicillin, the sulfa drugs, use of plasma, DDT, and airborne evacuation of the hounded. But even these discoveries could not .have been made effective without good organization, good direction, good equipment, good doctors and nurses, and good use of doctors and nurses.

Not all government-aided medical programs have the enviable record of the Army and Navy, but they have met important special needs. Nevertheless, for the total civilian population, these special programs do not meet other equally pressing needs. There are, and will continue to be, all sorts of proposals to fill in the gaps between existing tax-supported services.

The new tuberculosis control law is a good illustration of how an established state program can be expanded by the use of additional federal funds. An all-inclusive service of early diagnosis, hospital care, and rehabilitation is being developed from a meager program of treatment.

Venereal disease clinics in a way fit into state mental hospital programs. Early discovery and treatment of syphilis at a clinic can free from this disease vast numbers who might otherwise end up in mental institutions twenty years later.

Other diseases might be attacked in the same way through use of tax funds. Rheumatic fever, for one, which every year kills more children than all other childhood infectious diseases combined, might be much reduced in amount and severity by a concentrated program of attack.

Government aid will undoubtedly be requested for other special groups of the population. For example, tax funds might be sought to help needy parents provide their children with the medical and dental care recommended by school doctors or to help care for the needy in nongovernmental hospitals.

The necessity for many such special programs is generally recognized. Few attack them as undesirable, yet it is frequently felt that approaching the problem of medical care in this piecemeal fashion, disease by disease or by one special population group after another, is unsound. This approach, it is said, has led in the past to a piling up of agencies having to do with medical care-some local, some state, some federal.

Each has different standards and differing procedures for the patients to go through before securing care and which the doctors must follow before getting paid. Many, such as public city hospitals, are still run as charities which most people use only as a last resort.

Tax-supported services are so scattered and uneven that most people don’t even know which ones they are entitled to use or how to go about getting them. Under most such programs, the patient must in effect prove that he is entitled to care not just because he is sick, but because he is eligible to become a beneficiary under some particular law.

As new health programs are added, critics of the piecemeal approach maintain, it is increasingly important that they fit into an organized system and not bring along their own particular brands of red tape. “There is no functional or administrative justification,” says the American Public Health Association, “for dividing human beings or illnesses into many categories to be dealt with by numerous independent administrations.”

The A.M.A. has long maintained that all federal activities in the field of health should be brought together in a single government agency, headed by a cabinet member, instead of being scattered among different departments and agencies. Such a move might be beneficial in tying together some of the federally supported services, which, except for the Army and Navy, form a relatively small part of all tax-supported activities. But many feel that no fundamental change would be achieved by such a move alone. Confusion in the administration of existing health services is the inevitable result of a variety of laws and allocations for strictly limited purposes, they say. Until a person is entitled to medical care just because he is sick, and not because he is a sick soldier, or a sick Indian, or a sick orphan-until then there is bound to be a variety of standards and procedures to fit the needs of each separate program.

So, while some groups want no further government action and others see the role of government limited to special programs where there are certain dramatic health needs, still others feel that an over-all national health program is the only satisfactory way to assure good medical care to all who need it.

A nation-wide health program

What do those who want an over-all health service plan have in mind? Two reports have recently been published outlining the principles under which the respective backers believe progress in national health can best be achieved. One is a statement of the American Public Health Association (A.P.H.A.), a second is a report of the Health Program Conference, a group of physicians, economists, and others interested in progressive health planning., These are not, of course, the only documents ever brought out in favor of a national health program. The demand goes back many years and has taken many forms. These two reports are used to represent the all-out program here because they are recent, comprehensive, and authoritative.

Neither report came out with a model law, in fact neither group supposed that a single law would cover all its recommendations. The reports were designed instead as guides to future action. Their goal is the same—a plan which would make good medical care, preventive, diagnostic, and curative, equally available to all the people, in all areas of the country.

Why national?

A comprehensive health plan must be national in scope, according to the views expressed in both these reports. Health programs organized on a state-by-state basis, with no federal aid, they maintain, would fall into the same unequal pattern as at present. The same economic factors which make some wealthy states able to maintain good private and public health facilities would also lead to successful health plans in these

areas. And the relative poverty of other states, which is now reflected in their scarcity of doctors and hospitals, would like-wise mean very inadequate health plans among them.

The A.P.H.A. and Health Program Conference reports also maintain that certain national standards are necessary to make sure that the quality of medical service everywhere meets at least minimum requirements. Because people in our country are always moving from place to place, national standards for the amounts and methods of payment to hospitals and doctors, conditions of service, and adjustment of complaints would also be desirable, they say. These, however, should be administered in a way that would take account of the differences in requirements between various parts of the nation, they agree, because a health program in the hills of Kentucky, for instance, would present vastly different problems from a health pro-gram in Seattle.

Critics of a national program say that it would mean regimentation. In their view, it would be better to have state programs, even granting that the people in some states would be far better served than in others, rather than to run the risk of rigid government control.

Both reports assume that government regimentation is by no means inevitable if, in the framing of laws, flexible administration is recognized as all important. They agree that actual operation of a health program must be directed largely in each individual community and state, and the program should be -responsive to local needs. Strictly medical matters must be kept in the hands of the medical profession, which alone is competent to set medical standards, they say, and questions of public concern, such as financing and distribution of services must be in the hands of the public’

Concluding that a wholly satisfactory health program must be nation-wide in scope, the A.P.H.A. and the Health Program Conference reports go on to outline what seem to them the essentials of any such plan.