The Realities of Socialized Medicine
I
THE National Health Conference that was held in Washington last summer was welcomed unanimously by all who have the nation’s health at heart. It sounded like a bugle call, a signal for action. It. meant that the period of surveys had come to an end and that, at long last, definite steps were to be taken to remedy an untenable situation. I may add that the National Health Conference made a profound impression abroad. I was traveling at the time through ten European countries, and wherever I went I found that the recommendations of the President’s Interdepartmental Committee to Coördinate Health and Welfare Activities and the attitude of the Conference toward them were discussed eagerly. In Europe, American medicine is regarded as being extremely advanced scientifically and technically, but very backward socially. ‘If you are able to carry out this program,’ one of my public-health friends said, ‘you will surpass European medicine definitely. You will set an example to the whole world and will reduce death rates in a way never dreamed of. Humbly we shall send our students to America to learn from you.’
After ten years of extensive surveys by private and government agencies we know what medical conditions are in the United States. No country has ever had more data available on this subject, and our present health and medical situation is unmistakably clear. We now have documentary evidence for the fact that one third of the population has no medical service, or at least not enough. We know that 40 million people live on annual family incomes of $800 or less, which just permits them an emergency standard of living and makes it impossible for them to purchase medical care; on the other hand, it is obvious that this is too large a group to be reached by charity services. We know that there is another third of the population whose family income does not exceed $1500 a year. This group is perfectly willing and able to pay for part of the medical services it needs, but finds it extremely difficult to budget the cost of illness. There are, furthermore, millions of families whose income is more than $1500 a year, but to whom medical care presents a serious problem. They are not indigent and are not entitled to free services; they are walling to pay for what they get, but, again, find it difficult to budget the cost of illness. The group that is able to purchase whatever services it needs without economic hardship is infinitely small.
Such a situation is absurd, particularly when we remember that we have available almost all the personnel and technical equipment necessary to provide complete medical services of high quality, in prevention, diagnosis, and treatment. We have more doctors per capita of the population than any other country in the world. Our medical schools were backward for a very long time, but to-day we have seventy-seven recognized schools which train highly qualified practitioners and produce an enthusiastic medical corps that is eager to serve the public and expects nothing in return but the possibility of making a decent living. We do not need a larger number of physicians — at least not in the near future. We have splendid nurses, and if all of them were permanently employed there would be no immediate need to increase their number substantially. More public-health nurses are wanted, but there are plenty of girls anxious to enter this profession and we have the facilities for training them. The hospital situation was a sore spot for a long time, but conditions have improved tremendously in the last twenty-five years. As a rule the cities are adequately supplied with hospital beds, but more hospitals are needed in rural districts. This, however, is an economic problem that can be solved without much difficulty.
We have excellent research institutions, and since the beginning of the century a generation of medical scientists has grown up that has made valuable contributions to medicine. European physicians who visited this country around 1900 had a superior smile on their lips when they watched our scientists. But conditions have changed. American leadership in medical science is universally recognized, and American publications are studied very carefully all over the world. Our philanthropic foundations are the envy of foreign countries, but let us not forget that medical research is financed to a much larger degree by public than by private agencies. The Federal Government supports some of the most important research institutions of the country. The Department of Agriculture alone is undoubtedly the largest research institute of the nation and probably one of the largest in the world. Great contributions have come from the National Institute of Health of the United States Public Health Service, and the National Cancer Institute will soon be the undisputed centre in the field. Problems of infant and maternal welfare are investigated by the Department of Labor. The states and communities also contribute substantially to the support of research. Thirty-five of the seventy-seven medical schools are tax-supported, and nobody will deny that many of them compare very favorably with some of the best privately endowed institutions. Seventy per cent of all hospital beds are in public hospitals. While private funds are shrinking steadily, more and more public funds will become available for research, and it seems to me most important that the government has recognized its obligation to support research.
In other words, we have a first-rate medical personnel and technical equipment, but at the same time large sections of the population have no, or not enough, medical care. We are told, however, that health conditions are better in this country than abroad, that in spite of unemployment they were better in 1938 than ever before in the history of the United States. This, we hear, proves that medical services are satisfactory, and that there is no reason in the world why we should bother about the present situation.
Yes, health conditions are, as a whole, better here than they are in France, Italy, Spain, Yugoslavia, or Greece. They are not much better than in England, Germany, Switzerland, or Holland. And they are certainly not better than in the Scandinavian countries or New Zealand. If health conditions are better here than in certain foreign countries it is not because medical services are superior, but because this country was able to develop a higher standard of living. I have just studied conditions in Yugoslavia, where a public-health man of genius, A. Stampar, has organized a splendid system of social medical services. If, in spite of these services, health conditions there are inferior to ours to-day, it is because the average wage of the industrial worker in Yugoslavia is forty cents a day, and the average-size farm has about ten acres of land. Health conditions have greatly improved there, but health conditions are not determined by medicine alone. Nicotinic acid cures pellagra, but a beefsteak prevents it. And if the United States was able to develop a higher standard of living, it was not because it had a system of its own. It produced food and commodities under the same system as European countries. The higher standard of living was caused by a unique combination of factors that made such a development possible.
II
If health conditions are better in this country, they are certainly not good enough. We still carry an enormous burden of illness, much of which could be prevented. We are far behind other countries in the incidence of venereal diseases. Over half a million people are infected every year with syphilis and over one million with gonorrhea. Annually 60,000 children are born with the handicap of congenital syphilis, and over 50,000 people die from the results of syphilis. There is no justification whatever for having such an enormous number of venereal patients among us. We have the scientific means to diagnose and cure the disease, and there is no reason why wo should not eradicate it as Denmark and a number of other countries have done.
We have one of the lowest tuberculosis death rates in the world, but this low rate still means that we have about 400,000 tubercular patients undergoing treatment every year, and that the disease is the second cause of death for the age group between fifteen and fortyfive years of age. We have a low maternal death rate, but in spite of it 12,500 American families are deprived every year of the wife and mother, and we know that at least half of these tragedies could be prevented. Our low infant death rate means that 69,000 children die during the first month of their life, and 75,000 infants are stillborn; in other words, in any given year 144,000 young women go through the trying period of pregnancy and childbirth, and the result is a dead child or one that will die in a few days or weeks.
Every year 600,000 people are disabled by pneumonia and almost 100,000 die of it, but we have a serum and a drug that could reduce the death rate by at least one half. We have 500,000 mental patients in institutions filling one half of all hospital beds available in the country, and about one million mentally deficient persons outside of institutions. An extension of mental-hygiene services would keep many of these patients socially adjusted. One out of eight persons who reach the age of forty-five dies of cancer, and although the cancer problem is not yet solved we have methods of treatment that could reduce the death rate considerably.
Now that many acute diseases have been overcome, the chronic diseases are in the foreground and affect millions of people. Arthritis alone disables one and a half million persons every year, and even more individuals are suffering from neuralgia, neuritis, and lumbago. Diseases of the heart, the blood vessels, and the kidneys kill over half a million people every year, many of whom have been handicapped by their illness for a long period of time.
I think we cannot be ambitious enough in health matters. The fact that the United States has a higher standard of living and a superior technical equipment gives it possibilities of combating disease that no other country has, and there is no reason why we should not set an example to the world and demonstrate that many diseases can be wiped out entirely and the incidence of many others reduced considerably.
Let us not be sentimental in these matters, nor speak in humanitarian terms. Let us forget that the American citizen has a right to life, liberty, and the pursuit of happiness, which by implication should include the means of preserving and restoring health; let us not think of all the mental misery and anxiety that illness creates for the individual and his family, but let us talk plain business. This country, with its good health conditions, loses every year 10 billion dollars as a result of illness. The population spends 3.7 billion dollars for medical care. Every wage earner loses annually eight calendar or seven working days on account of illness, and the loss of earnings amounts to about half a billion dollars a year. Considering the present status of medical science, about one third of all deaths are premature, and the capital value of these preventable deaths has been estimated to be over 6 billion dollars.
I am not a business man, but I know enough economics to realize that 10 billion dollars is a heavy tax, and one which is particularly unpleasant because it could very well be reduced considerably. And who carries this enormous burden? Business and industry, which lose the services of their employees and pay high taxes for public curative services; and also the employee who is sick at home without income and spends his last savings for medical care. Every child knows that prevention is not only better than cure, but also cheaper. Mould it not be better business to spend some money to prevent the incidence of illness rather than to spend many times that amount to cure it? If we agree on this principle, why, then, should we not act and organize medical services in such a way that the physicians may reach all the people, whether rich or poor, and that they may apply without restrictions whatever weapons medical science has forged for them?
III
The tendency to organize medical services represents by no means a new development. In the dark days of czarism, as early as 1864, Russia established a complete system of state medicine for the rural districts; since Russia is an agrarian country, this meant that the majority of the population received medical care from salaried district physicians and paid for their services through taxation. In Germany, it was under a conservative régime that Bismarck introduced a comprehensive system of social insurance, including health insurance, in 1883. He did it, not under pressure as we sometimes hear, but because, being a shrewd statesman, he recognized that a healthy working class benefits the employers as well. He found in addition that it was cheaper to make the workers pay for the services they received than to establish public or charity services. Germany’s example was followed by one European country after another, by England in 1911, by France in 1928. When Alsace and Lorraine were returned to France, the two provinces had the German social-insurance system and did not dream of giving it up, so the rest of the country followed suit and adopted it.
No country that ever enjoyed the benefits of social insurance has made the slightest move to relinquish them. On the contrary, there has been a tendency to extend social insurance to include ever larger parts of the population. In the eastern European countries which had to reconstruct their public-health work after the war, medical services were organized very thoroughly. In Yugoslavia 3600 of 5000 physicians are in the service of either the government or the social-insurance organizations. Public services and health coöperatives bring medical care to the rural population, while the wage earners and salaried employees receive services from the social-insurance organizations.
The average American does not know Europe, and is convinced that there is nothing he can learn from foreign countries. There is, however, one group of European nations that he openly admires: the Scandinavian countries. He likes their democratic institutions, their high standard of living, and their high educational standard. In these countries, medicine is almost 100 per cent socialized. Public services and health insurance make the doctors available to everybody, and the health standard is remarkably high.
We often hear the naïve argument that if these European systems were superior to our haphazard distribution of medical care, health conditions in Europe would of necessity be better than in America. But, as I mentioned before, the standard of living is an essential factor of health. Most European countries have not enjoyed all the natural and economic advantages of America, and if they had not organized their medical services they would not have the relatively good health conditions they actually have to-day.
We need not look to Europe alone. In New Zealand the legislature in 1938 passed one of the most comprehensive social-security acts that have over been conceived. It aims to give every individual complete social security and provides an extensive system of pensions for all people who are handicapped economically by illness, invalidity, death of the breadwinner, and old age. It provides, further, all the means required for the protection and restoration of health. The system will in the beginning provide the free services of general practitioners, free hospital or sanatorium treatment, free mental-hospital care, free medicines, and free maternity treatment. It will, as soon as feasible, be extended to include services of specialists. The plan will be financed from three sources: (1) a social-security contribution of one shilling in the pound on the wages and other income of all persons; (2) continuance of the present registration fee of one pound per annum for males over twenty years of age; (3) subsidy from the Consolidated Fund. The price is not too high considering the many benefits that cover almost any risk. It has been estimated that the general practitioner will make an average income of $6000 in our currency. He will receive additional compensation for midwifery, anaesthesia, traveling expenses, and so forth. Consulting specialists will be remunerated according to a fee schedule.
On the South American continent one republic, Chile, has developed in the last fourteen years one of the most progressive systems of social legislation. Social insurance is compulsory for all persons under sixty-five years of age whose annual income is less than 12,000 pesos and whose work is more physical than intellectual. This embraces the great majority of the population. Other persons whose annual income is less than 12,000 pesos can join the social-insurance system voluntarily, provided they are Chilean citizens, less than forty-five years of age, and have passed a previous health examination given by a physician of the Insurance Fund. The insurance system is financed through contributions of employer, employee, and state. In the case of employees working under a labor contract, the employer contributes 5 per cent of the wage bill, the employee 2 per cent, and the state 1 1/2 per cent. Insured persons who work independently and those who are insured voluntarily contribute 4 1/2per cent or 5 1/2 per cent of their income according to the field in which they work, and the state contributes the same amount. The benefits consist of complete medical care, sickness, maternity, and disability benefits, and old-age pensions. Patients are hospitalized in state hospitals and sanatoria, the Insurance Fund paying the hospitals two pesos a day for each patient.
A still more progressive bill, to enforce preventive medicine, was passed in Chile in May 1938, It requires periodic examination at least once a year, but more often if necessary, for all persons coming under the Social Insurance Act. The chief objective is the eradication of tuberculosis, syphilis, heart diseases, and occupational diseases. The examination must include a Wassermann test and an X-ray. In each case the complete clinical history and social history must be taken and a report must be made on the working conditions of the person examined. If in such an examination the doctors find that an individual is not sick but run-down, they must, as a measure to prevent disease, prescribe for him either a complete vacation or a period of halftime work, wherein the loss of wages is compensated for by the Insurance Fund. And no employee can be dismissed from his job in such a case.
IV
These facts make it evident that the organization of medical services is not a new phenomenon, or limited to certain types of countries. It is a world-wide development. In some countries the process is finished and services are completely organized, others are halfway in the development, and in others it is just beginning; but no country can possibly escape the trend. Some people say, however, that this organization of medical services is nothing but the socialization of medicine, and the word ‘socialization’ is a bogey—it smells of Communism. We should not be afraid of the word, but should recognize that the socialization of services is the logical and unavoidable consequence of the industrialization of the world. If we are opposed to socialization we must also oppose industrialism and must advocate a return to the Middle Ages.
We must realize that the structure of society has undergone tremendous changes in the last one hundred years as a result of industrialization. A hundred years ago, one out of five gainfully employed persons was a wage earner, and four owned their own means of production, while to-day four out of five are wage earners or salaried employees, and the number of independent producers has been reduced to a minimum. In a society in which four fifths of the whole gainfully employed population depend for an income on the labor market, there is of necessity a strong feeling of insecurity and as a result a pressing demand for security.
It is to satisfy this demand that social-insurance systems are introduced everywhere in order to spread unpredictable risks among as many people as possible and to pool resources. The insecurity created by illness is merely one aspect of the general insecurity resulting from our general social-economic system. In the period of transition in which we are living to-day more and more aspects of our economic life will become socialized, and we have the choice only between two possibilities, either to socialize gradually or to let things go and wait until the pressure becomes so strong that it bursts forth in revolution.
When we look at the development of medicine in the last hundred years we find another explanation for the present situation. Not only has the cost of medical care increased considerably with the progress of medical science, but medicine, originally a private relationship between physician and patient, is tending to become a social institution. With the progress of medical science, the scope of medicine has broadened considerably. The law could not be administered without the expert advice of the psychiatrist. The sanitation of dwelling places, the protection of society against epidemics, the protection of mother and child, the care of tubercular and mental patients, the hospitalization of the indigent, are tasks of such magnitude that they could not possibly be carried out in an unorganized, haphazard way. They require the power and scope of the state, and therefore public-health services have increased tremendously. In the United States we already have well-organized efficient state medicine in our public-health services — federal, state, and municipal; and nobody will deny that they are largely responsible for improved health conditions.
The development of industry, on the other hand, has created so many new sources of danger that provisions had to be made to protect the worker, not only in his own interest but also in the interest of the employer. Workmen’s Compensation Acts are operating to-day in all but one state, and they guarantee the worker medical care and compensation for the loss of wages. These acts virtually amount to compulsory insurance against sickness caused by industrial accidents and occupational diseases. The principle has been generally accepted, even by the American Medical Association.
A great variety of voluntary insurance schemes have been applied with more or less success, and the tendency to spread the cost of medical care and to make the rich pay for the services given to the poor is expressed in charity services and in the sliding scale commonly applied by physicians. Thus we already have socialized medicine in the country, and I. S. Falk estimates that in normal years over 800 million dollars are spent for medical care through group payments under systems that are more or less socialized.
The problem we are facing to-day is, therefore, not to introduce some basically new principle, but to develop already existing services. The population still spends three billion dollars in a haphazard way, with the result that many millions of people do not have enough medical care. If this same amount of money could be spent systematically, it would carry us a long way, and comparatively few additional funds would be required to provide medical service for everybody and reduce the incidence of illness considerably.
The Technical Committee on Medical Care, which was appointed by the President, presented its report on February 14, 1938. The National Health Conference, consisting of representatives of all groups of the population, met in Washington on July 18-20, 1938, discussed the program, and endorsed it enthusiastically. On January 23, 1939, the President transmitted his annual message on health security to Congress, and on February 28, 1939, Senator Wagner introduced a bill (S. 1620) ‘to provide for the general welfare by enabling the several States to make more adequate provision for public health, prevention and control of disease, maternal and child health services, construction and maintenance of needed hospitals and health centres, care of the sick, disability insurance, and training of personnel.’ The bill is an amendment to the Social Security Act. It aims to provide funds to put the National Health Program into practice and sets minimum standards.
We no longer need discuss the health situation in abstract terms. We have a precise program before us, and the question is whether we shall accept or reject it. The initiative is up to the states. The Federal Government does not try to impose a definite scheme upon them, but is ready to subsidize any state that develops a sound health program which meets with the minimum requirements established by federal legislation. The National Health Program aims to extend existing facilities and to develop principles that have already been accepted by the people.
What are its recommendations? Public health services have developed tremendously in the last few decades and nobody can deny that they have proved their usefulness. They are primarily responsible for the reduction in the infant death rate, death rate of tuberculosis, incidence of venereal diseases, and similar achievements. An extension of such services will of necessity improve health conditions still further. This is merely a question of funds and personnel. The state health budgets average eleven cents per capita, which is not enough. The municipal budgets run from a few cents to one dollar per capita, but very few cities can boast of the latter figure. Less than one third of the counties and still fewer cities have a full-time professional health officer. With federal subsidies the states could develop their public services, and the results would be felt very soon. Such services in no way interfere with the private practitioner. Their task lies in a totally different field, and, as they address themselves primarily to the needy population, they relieve the practitioner of a burden he could not possibly carry.
The second recommendation provides the extension of hospital facilities, particularly in the rural districts. More than 40 per cent of all counties — a population of 17 million — have no registered general hospital. Many counties have hospitals, but they are small and are neither financially nor technically prepared to admit a larger number of free patients. Many needy patients, therefore, have to be hospitalized in the large cities, or they are not hospitalized at all, as happens very frequently. It has been estimated that the establishment of 360,000 new hospital beds would solve the problem, and the Federal Government is ready to give grants-in-aid to construct and improve needed hospitals and to provide special temporary grants toward defraying the operating costs in the initial period. At the same time, outpatient clinics could be developed and diagnostic centres established, particularly in the rural areas where there is a definite lack of such facilities.
Another recommendation that seems to be generally accepted concerns the compensation for the loss of wages due to illness. Once we accept the principle of unemployment insurance, there is no reason why we should not extend it to unemployment resulting, not from economic crises, but from illness. The causes may be different, but the result is the same, and the hardship on the worker just as great. The fear that such a scheme would lead to malingering is not justified. Compensation would amount, to only a percentage of the wages and would be granted after a waiting period of a few days. And even if it should induce a few unbalanced individuals to malingering, it would bring tremendous benefit to the whole working population.
Two other recommendations are controversial, and indeed they touch problems which are infinitely more difficult to solve. We know that one third of the population live on an emergency standard, and it is perfectly obvious that they cannot possibly purchase medical care in the open market. It is equally obvious that medical services provided for this group can be financed only through public funds. I think everyone agrees that such services should be complete, including physician, dentist, nurse, hospital, drugs, and appliances, and that they should be of high quality. In a democracy the welfare of every individual counts, and every life is valuable. If we are unable to overcome poverty, unable to provide a job for every man and woman willing to work and to guarantee a decent standard of living to everybody, we are collectively responsible for such a condition, and the least we can do is to provide the means of protecting and restoring health to everyone who needs them.
The question is what form of services should be provided for this needy group, and this is best discussed in connection with the medical problem of the middle class. Many millions of otherwise self-supporting families — as a matter of fact, the overwhelming majority of the population — find it very difficult to budget the cost of illness, and many a budget has been wrecked by sudden illness, with very serious results. A plan that would permit families to finance the cost of treatment through periodic paymerits in proportion to their income would guarantee the regularity of medical services and necessarily improve health conditions. The Federal Government is willing to subsidize states that develop such a plan.
V
The possibilities of organizing medical care are limited. They are, to put it briefly, public services, health insurance, or a combination of both. Medical services can be made public services, financed through taxation and available to all without charge, like education or the administration of the law. This is, in my opinion, the ideal solution to which every country will come ultimately. This country, however, is not yet prepared to take such a far-reaching step. The next possibility, therefore, is health insurance, which can be voluntary or compulsory — compulsory for all or only for certain groups.
Many experiments have been made in recent years with voluntary insurance, and Coöperative Health Associations, once the initial difficulties were overcome, have given satisfaction to all persons involved. Their great advantage is that they practise group medicine, which is a superior form of medical service, the only one that permits the application of all resources of medical science. They are a solution of the problem wherever there is a large, economically homogeneous group to be served. They do not represent a general solution, however, because they do not reach all the people who need protection. Still less do the voluntary insurance schemes initiated by Medical Societies in order to compete with Group Clinics and Health Associations. They are not health-insurance but fee-insurance plans, and perpetuate the present haphazard form of medical service.
If health insurance is to be effective it must be compulsory. Compulsory for whom? For all those who need help and protection — that is, first of all, the wage earners and salaried employees up to a certain income. Most European systems include only low-income brackets. We must do more. The Capper Bill (S. 658), introduced in the Senate on January 16, 1939, — a bill that sets minimum requirements for the approval of a state system of health insurance, — provides compulsory insurance for all manual laborers and such employees whose wages do not exceed $60 per week, which is a fair limit. For some reason unknown to me, it excludes farm laborers and domestic servants, who need protection just as badly. It does not exclude them entirely, but permits them to join voluntarily, as may all such persons whose weekly income does not exceed $100. Persons who are receiving old-age or unemployment benefits or relief could be included under such a system, whereby the premium would be paid by the agency distributing the benefits.
Under any insurance scheme the benefits must be available to the insured persons and their family members, and must include complete medical service with emphasis on prevention (immunizations and periodic physical examinations), maternity benefits, and cash benefits to compensate for the loss of wages. Funds should be used for health education and research.
The fairest way to finance such a scheme is to have all those groups contribute who benefit by improved health conditions — namely, the state, the employers, and the employees, whose contributions should be in proportion to their wages. The Capper Bill foresees employees’ contributions scaled from 1 to 3 per cent according to whether the weekly wages amount to $20 or less, $21 to $40, or more than $40.
The Capper Bill has had very little publicity. It has some weak points, but as a whole is a very sound and constructive project that certainly deserves to be widely discussed. It is undoubtedly a great improvement on all European schemes and demonstrates that the overwhelming majority of the population, including the needy group, can be embraced by such a combination of compulsory and voluntary insurance.
Every system of distribution of medical care requires the cooperation of the physicians. The collection of premiums and the distribution of cash benefits are administrative matters, but the medical benefits are entirely in the hands of the doctors. So far the American Medical Association and its constituent societies have violently opposed the idea of compulsory health insurance. It is not easy to understand this opposition. The A. M. A. has accepted the principle of compulsory insurance for accidents and occupational diseases. In other words, it agrees that if a worker suffers from lead poisoning, as a result of his occupation, it is unobjectionable for him to be treated under an insurance plan by a doctor who may be a salaried physician and not the doctor of his own choice. The personal relationship between physician and patient will not. suffer, and the patient may be compensated for his loss of wages. If, however, his lead poisoning is due to adulterated food, the A. M. A. considers that the situation is entirely different and that insurance is undesirable. This discrimination is not very logical.
One very important reason for the physician’s opposition must be that the doctor is ill-informed in these questions. He is trained as a scientist and knows very little about economics and sociology. As long as the A. M. A. had purely medical problems to solve, it did a very good job, but now it is facing a problem that is also social and economic. The Journal of the A. M. A. was biased in these matters from the very beginning, precluding any open discussion.
I have read dozens of articles and pamphlets written against health insurance in the last few years, and I found them full of mistakes and wrong statements. Men who are critical scientists in their own fields seem to lose every critical sense as soon as they approach a social problem.
There must be some reason for this vague fear of socialized medicine. Some doctors are afraid of mistakes and abuses that are apparent in European systems. There is no reason why we should copy these mistakes. On the contrary, we should be grateful to Europe for having clone the experimental work so that we can learn from it.
Some fear political interference. Granted that this may be a menace — it is one that can be avoided. If the people have no confidence in the men whom they themselves elect to governmental posilions, they can make the health-insurance system an independent corporation managed by representatives of all the groups involved: employers, employees, physicians, and government.
Others are afraid of bureaucracy. Whether there is much bureaucracy or not in such a system depends entirely on the physicians. If they are willing to serve on salaries — which can be differentiated considerably according to experience and responsibility — there will be a minimum of red tape. It will be tremendous, however, if doctors insist on being remunerated on a fee-for-service basis which requires an extensive system of checking.
But the quality of medical care will suffer under any such scheme, we are told. Is it really so very high to-day? Is it adequate in rural districts, where many doctors practise the horse-and-buggy medicine they learned in a third-grade medical school forty or fifty years ago? Quality will not be improved if insurance funds are used merely to pay the doctor’s bill under the present haphazard system. It will be improved considerably, however, if funds are used to develop group medicine in health centres.
But then, we hear, the free choice of physician will be limited. The idea of unlimited free choice of physician is fine, but the fact does not exist and never has existed. The indigent patient who seeks help in a dispensary has no choice at all, but the A. M. A. has never objected to that. The patient in rural districts where only a few doctors are available has a very limited choice, and in cities the pocketbook sets definite limits to the free choice.
Some members of the medical profession are afraid of the economic consequences that health insurance may have upon them. They do not know that in every country where it has been established health insurance has always brought more money to the doctors. They pride themselves that every day they are giving one million dollars’ worth of medical service free of charge. That is, they pride themselves publicly. Privately, I have heard many a doctor bitterly complain that he could not collect his bills. The Committee on the Costs of Medical Care revealed that doctors with high incomes in the cities collected as much as 80 per cent of their bills, but those with low incomes in small towns collected only 20 per cent. This is not just. There is no reason why the physician should not be remunerated for honest work. Health insurance would ensure that he would be; it would relieve him of a great burden.
By systematically obstructing experimentation, the American Medical Association has greatly harmed the reputation of the medical profession. Its indictment by the District Court of the United States for the District of Columbia has deeply impressed the public. Lawyers will have to decide whether the Sherman Act can be applied to the practice of medicine, but, whatever the outcome of the trial may be, the fact will remain that medical organizations have applied methods of coercion that are condemned when business applies them. The public, however, should know that the rank and file of the medical profession do not blindly follow their leaders. They feel greatly disturbed and do not know what policy they should follow. The Medical Society of the County of New York recently held a poll asking its members whether they would favor compulsory health insurance or not. The result was significant: two thirds of the members had no opinion and abstained from voting; only 24 1/3 per cent were opposed and 9 per cent in favor of compulsory insurance. The rank and file will continue to perform their duty, and I have no doubt that they will coöperate joyfully the moment they are convinced that socialized medicine benefits the patient as well as the profession.
Health insurance is not a panacea. It is not the ideal system, but I think that, under the present social and economic conditions of the country, compulsory health insurance combined with an extension of public-health services is the best possible solution.
Medicine has had a very short history, of but 5000 years, and it has become really efficient only in the last 100 years. For 5000 years people fell sick and, once they were sick, called for a doctor. It is time that we should change this relationship and devise a system under which the doctor will call on the potential patient in the home, in the workshop, or on the farm. Such a program wall not lead to regimentation, but, on the contrary, to an application of the principle of family practice never before realized.
I am confident that our medical problem will be solved in a not distant future. I believe in the common sense of the people. I know that new problems call for new leaders, and that physicians of great reputation and integrity such as Dr. Hugh Cabot and Dr. John P. Peters find an ever-increasing audience. And, most of all, I have faith in the young medical generation that is growing up under our eyes.