Government in Medicine

by JAMES HOWARD MEANS, M.D.

1

THE Federal government of the United States in the year 1952 offered varying degrees of medical care to some 25 million people, about one sixth of the nation. It spent for all its medical and health activities close to a billion dollars. Included in this huge sum are charges for research, educational, and public health activities as well as for the medical care of patients.

I lately derived an interesting figure from data contained in a report of the Committee on Labor and Publicc Welfare of the U.S. Senate, entitled “Health Insurance Plans in the United States,” dated May 17, 1951. This report estimates that the total expenditure for medical care of every sort in the whole United States was about 10 billion dollars for the year 1949. If we divide this figure by 150 millions, the population of the United States in 1950, we get $66 per person per year expended for medical care. About 20 per cent of this was spent by government — Federal, state, and local. In 1929 this figure was only 10 per cent. The role of government in medicine thus appears decidedly on the increase.

Government in the United States has assumed medical responsibilities of one sort or another at all three of its levels — Federal, state, and local. On Federal medicine there is a wealth of source material from which we may obtain impressions. Probably the most comprehensive analysis of the situation is that of the “Task Force on Federal Medical Services” of the Hoover Commission which was published in November, 1948. This report stressed first the magnitude of Federal medicine and its lack of an over-all or central plan. An enormous commitment has been entered into, and is being conducted “without even any clear decision as to certain of the large classes of the beneficiaries to be covered, with no estimate of the ultimate cost or of the effect upon other health measures of the nation.”

According to the Hoover Commission study, there are three large and more than thirty smaller Federal. medical systems which are operated independently of one another, going their own ways, making their own plans, building, staffing, and running hospitals and clinics with “little knowledge of and no regard for the operation of the others.”

The three large systems are, of course, those of the Department of Defense, of the Public Health Service, and of the Veterans’ Administration. We may confine our attention to the group of large; Federal medical systems, which on the basis of either total number of patients served or cost amount to 90 per cent or more of the total. In the order of magnitude of the systems, the Veterans’ Administration tops the list, then the armed forces, and finally the Public Health Service. But the Public Health Service stands first of all Federal agencies in the field of medical research and education.

The Hoover Commission’s chief criticism of the medical services provided by the Federal government was not so much that the individual systems are poorly operated, as that they operate without regard to one another, really in competition with one another. Each seeks to build its own empire regardless of the others. The Veterans’ Administration, for example, unquestionably offers well-integrated and high-quality medical care to veterans, but as the Task Force pointed out, the Veterans’ Administration’s hospital construction program conflicts directly “with the government’s policy under the HillBurton Act of aiding non-federal hospitals for the purpose of establishing a sound hospital system for the country as a whole.”

The Veterans’ Administration’s medical establishment is by far the most important of the medical care activities of the Federal government. A report to the Senate by the Committee on Labor and Public Welfare dated August 2, 1951, called the medical care program of the Veterans’ Administration “one of the largest in the world. Potentially affecting some 21 million veterans, it operates on a budget calling for an expenditure of over 650 million dollars a year.” Significantly larger figures for this have been given subsequently.

The Veterans’ Administration hospitals and outpatient departments admit free all veterans for service-connected illness; and when beds are available, they will admit veterans to hospitals for nonservice-connected illness provided they state they cannot pay for the service. The growth potential of the Veterans’ Administration’s hospital system is thus unlimited. If the hospitals are not filled with service-connected cases, they fill up with nonservice-connected cases. Then, since the available beds are full, more beds are needed, and therefore more hospitals are constructed; and so on.

The professional service given has been of good quality, because under the policy inaugurated by General Bradley, selection of staff for the Veterans’ Administration’s hospitals has been through committees of medical deans. The inclusion of nonservice-connected cases, which goes back to 1924, has increased the professional interest of the service because of the more general nature of such cases. More able doctors are thus attracted, and the quality of medical care is improved for all.

As veterans become ever more numerous, however, there is the danger that the private and voluntary system of medicine, as we have known it in this country, may become completely encircled by the free (tax-supported) medicine of the Veterans’ Administration. This is a far greater threat to the medical status quo and its voluntary institutions than is compulsory health insurance; but so obsessed is the American Medical Association leadership with the desire to kill the latter, that it has largely ignored the former. Indeed some of the doctors who are fighting what they call “socialized medicine" are serving in the Veterans’ hospitals with the greatest equanimity. Yet if we have anything that approaches socialized medicine in the United States, the medical empire of the Veterans’ Administration is it.

Government medicine in the United States, other than Federal, is to a greater degree public health work, medical education, and hospital service than it is medical care, that is to say, the services of physicians. Dr. R. C. Page, Chairman of the National Doctors’ Committee for Improved Federal Medical Services, gives the following figures for the distribution of all hospital beds in the country: Federal hospitals, 194,000; state, county, and municipal hospitals, 843,000; nongovernmental hospitals, 414,000. Thus it appears that 71 per cent of the nation’s hospitalization function is borne by one of the three levels of government — 13 per cent Federal and .58 per cent state and local. Except in the case of psychiatric, tuberculosis, or other hospitals for chronic disease, however, state and local hospitals are staffed primarily by physicians and surgeons in private practice who give their services or who serve for rather nominal fees.

The state governments are also making a great contribution to medical education in that they own and operate 31 of the total of 72 four-year medical schools of the country.

In the field of directly providing medical care, the state governments are steadily getting in deeper and deeper. They are entering new fields such as cancer, arthritis, and heart disease in ever expanding programs. As more and more doctors work for the Federal government, so too will more and more work for the state and local governments.

2

THE major recommendation of the Hoover Task Force was that all medical activities of the Federal government, except, the military, should be unified under a single national health agency headed by a career director-general and including three main divisions-namely, medical care, public health, and research and training. Furthermore, the Hoover Report recommended that in the continental United States there should also be transferred to this national health agency all general and most station hospitals of the armed forces. For military reasons only it was recommended to leave within the Department of Defense those medical establishments directly serving the armed forces. “The medical service of an armed force,”it was said, “is a necessary and an integral part of that force. To separate it from the force is wholly or largely to destroy its usefulness.”This also seems good sense.

How the integration of Federal medicine should fit in with the’ executive branch of the government in its entirety is a controversial issue. One school of thought is that ii should all be organized in a department of the government —a department, of health headed by a minister of health of full cabinet rank. Another is that a new department of the government should embrace not only health but education and public welfare also. Which of these two solutions has the more merit, I will not presume to say. Either would provide for planning and integration, now quite lacking, and would constitute, therefore, an advance over what we have at the present time.

Such a unification also would make possible effective coöperation between governmental medicine and private medicine. If we need some sort of national health program, a necessary step in achieving it is to put the house of Federal medicine thoroughly in order. It doesn’t, as it now stands, offer anything from which a national health program can be constructed. Only in the event that the continuous, unchecked growth of the Veterans’ Administration’s medical establishment engulfed all else could the emergence of a national health program from present-day Federal medicine be envisaged. Should that state of affairs ever eventuate, then we should be in much the same situation as Britain is today, only we should have got there by default instead of purposefully, as has Britain.

The most promising effort on the part of the Federal government to coöperate with private and local medicine to obtain better medical care for the people on a nation-wide basis is the hospital construction program being carried out under the HillBurton Act. In a country of increasing and gradually aging population, continuous construction of new hospital and public health facilities is imperative. Interruption in civilian hospilal construction during the last war left the country with an estimated 900,000 shortage in total hospital beds. It was in an effort to correct this situation that the Hill-Burton bill was enacted. Under its provisions the Federal government can give in aid from a minimum of one third of the cost to a maximum of two thirds of the cost for the construction of hospital or health facilities by state1, local, or private agencies. Federal funds are allocated to the states in accordance with population, need, and the relative per capita income of the states.

The states are required to assess their own needs in order to obtain Federal aid. Special emphasis is placed on promoting adequate hospitalization in areas of greatest need, originally in rural sections. Thus far 91,000 beds have been provided under the Hill-Burton program, and 1900 projects are being aided. Because well-trained young doctors dislike working without proper facilities, rural hospital construction under the Hill-Burton Act has helped induce them to settle in rural areas. A military objective is also being met, because the locations of hospital constmetion follow the evacuation channels from the large target cities out into the safer rural districts.

The hospital construction program of the HillBurton Act gives an excellent demonstration of how government can coöperate with voluntary effort to achieve a nation-wide program within the field of health. But since it has nothing directly to do with the distribution of doctors, it is incomplete, and it is for this very reason that it has not been opposed by organized medicine. It is very good so far as it goes, but it does not go far enough. Better distribution of medical personnel, for one thing, and coordination with the hospital building program of the Veterans’ Administration are also needed.

I saw an editorial not long ago in a county medical journal in which the Hoover Report’s account of the irresponsible building of hospitals by competing Federal agencies was cited. The point was made, however, that voluntary hospitals at times are guilty of this sin also. They too compete with one another. An example was given in which one voluntary hospital put up a new and large obstetric wing coincidentally with the closing of such service for lack of patients in several other hospitals in the same community. There should be planning, so this editorial writer claimed, in order that the total hospital beds in an area should efficiently meet community needs. Some community agency such as Red Feather or Hospital Council should exercise control of the distribution of hospital facilities in its area.

I entirely agree, in principle, with this sentiment, but I would say to this editor, let’s go a little farther and do some planning for t he distribution of doctors as well and organize them for the purpose of best meeting the people’s needs. There I am sure he would part company with me, for when it comes to the affairs of doctors, his journal has always been very conservative. Let Uncle Sam plan his hospital building efficiently; let voluntary hospitals so plan theirs; but when it comes to doctors, economic freedom of the professional individual must be preserved. Only the law of supply and demand may be allowed to operate upon the doctors. Let it determine their distribution. When it comes to medical care, however, the law of supply and demand does not meet human needs. This was one of the reasons why Britain adopted its National Health Service.

3

ANOTHER area in which government has coöperated successfully with voluntary effort is research. This is a field which affects medical practice only to the extent of giving it new knowledge, better methods of diagnosis and treatment, better professional armamentaria. The politicians, who in response to popular demand like to do something toward meeting the health needs of the people, are disposed to make liberal appropriations to further the investigation of the nature and causes of disease, because in this area there is no likelihood of stirring up political hornets’ nests.

Various agencies of the government have medical research establishments of their own — the armed forces, for example, and the U.S. Public Health Service. At Bethesda, Maryland, an array of imposing buildings suggesting a large university on a beautiful campus is in fact, the National Institutes of Health of the U.S. Public Health Service, a group of research institutes for the study of great problems such as cancer, heart disease, arthritis, and other enemies of man. Arising in the midst of the Institutes is a huge new edifice, the Clinical Center, actually a hospital of 500 beds where patients with diseases which it is desired to investigate can be cared for while their cases are under scientific study. This unit is to be opened for use early this spring. The Clinical Center is analogous to the well-known hospital of the Rockefeller Institute in New York, but on a very much larger scale.

In addition to operating their own research establishments, the armed forces and the Public Health Service also expend large appropriations in support of medical research by making grants-in-aid to university and other research institutions throughout the country. These have been of great importance in accelerating the tempo and, we hope, improving the quality of medical investigation. Not only are going projects reinforced, but new research foci are discovered and nurtured. I know of no finer contribution of the Federal government to medical progress than the research grants program of the Public Health Service. There is no coercion or regimentation of investigators, and no political influence whatever enters into the distribution of the aid. Applications for aid originate with the investigators, who are free agents, and aid is granted entirely on the basis of the scientific merit of the projects submitted as judged by groups of neutral experts. It is a fine example of coöperation between government and independent agencies to improve the health of the people.

The practice of medicine is in the nature of a public utility, such as transportation or communication, served largely in our country by private enterprise. Because such private enterprises tend to be monopolistic, while at the same time their services are needed by everybody, some governmental control of them is necessary.

The type of medical establishment in any country — how much of it governmental, how much private or voluntary — will depend upon the political philosophy of the country which it serves. In totalitarian Russia there is totalitarian medicine; in socialized Britain socialized medicine; and in the United States, which still believes in private enterprise, one finds a large private enterprise component in medical practice and in medical education and research. At the present time, however, our government and private medicine combined are not giving all our people the best medicine in the world, which they might have if our total medical effort were better planned and integrated.

The G.O.P. is on record as being opposed to Federal compulsory health insurance. It also insists that the health of the people as well as their proper medical care cannot be maintained if subject to Federal bureaucratic dictation. In the second of his ten pledges published on November 2, General Eisenhower, however, pledged that the “social gains achieved by the people, whether enacted by a Republican or Democratic administration, are not only here to stay, but are to be improved and extended.” Inasmuch as Eisenhower had previously said that he is against socialized medicine, and even that he regards Federal aid to medical education as the first step toward the socialization of medicine, it is heartening to find him later pledging that social gains are to be extended. In the field of health legislation it. will be interesting to see what form this extension will take.

In planning its constructive action the new regime will have the advantage of the excellent report made in December, 1952, by the President’s Commission on the Health Needs of the Nation, a body appointed a year ago by Mr. Truman, Dr. Paul B. Magnuson chairman. It is greatly to be hoped that both Congress and the new administration will give the Commission’s report very earnest consideration. Its recommendations cannot be regarded by any fair-minded person as in any sense radical. It does not recommend national compulsory health insurance, but instead suggests supplementing private prepayment plans by government in areas where the former prove inadequate. To me it looks like a good middle road program.

4

ONE of the very pressing matters emphasized in this report is the support of medical education. Federal aid to medical education to overcome the growing shortages of doctors, nurses, and other trained health personnel has repeatedly been advocated. No informed person can dispute the necessity for a sufficient supply of such personnel. Of those who have been opposing Federal aid, it should be asked, where do they expect to get the necessary support? At present no adequate source other than government has been discovered.

In my opinion the most needed items for extension of health legislation are Federal aid to medical education, integration of the Federal medical services, and a program for coöperation between the Federal medical establishment and local or regional health plans, whether voluntary or governmental. Two of the major recommendations of the President’s Commission on the Health Needs of the Nation were: first, the strengthening of centers of public health activities; and second, the offering of Federal aid to the medical care of patients through grants-in-aid to the states, in a manner analogous to Hill-Burton aid to hospital care.

It is very significant that Eisenhower in his speech on October 9 at New Orleans admitted the inadequacy of private health insurance and said that the usefulness of Federal loans or other aid to local health plans should be explored.

One great advantage which we in the United States have over Britain, which has gone the whole way in the nationalization of its medical establishment, is that, being still largely a free enterprise country, we have freedom to try experiments in the provision of medical care and in the coöperation between government and voluntary effort.

The Canadians, who have in the main a medical situation that more closely resembles ours than Britain’s, have shown more willingness than we to try experiments. A poll by the Canadian Institute of Public Opinion in 1949 showed 80 per cent, of the people in favor of a national health insurance plan under the auspices of the Federal government, which would include both hospital and medical care. All three political parties have endorsed such a scheme in principle, and the Canadian Medical Association favors national health insurance of some sort, but preferably not administered by a government agency. Two Canadian provinces, Saskatchewan and British Columbia, have set up complete compulsory hospital plans, and Alberta and Newfoundland’ have partial health insurance services. In other parts of Canada a variety of health plans are in operation — some entirely doctor-run, some consumers’ coöperatives, some sponsored by private insurance companies.

In 1948 the Dominion government inaugurated a five-year national health grants program to strengthen and improve, in coöperation with the provincial governments, the health and hospital facilities available to the people of Canada. In a speech made before both houses of Parliament on November 20, 1952, the Governor General said that his government proposes to ask that Parliament give consideration to the extension of this program of coöperation between Dominion and provincial governments. Thus it appears that nation-wide searching for better ways to bring health to all the people, particularly with reference to the role of government therein, is far more in evidence in Canada than it is in our own country. Planning at all levels — national, state, and local — is absolutely necessary, and it is to be hoped that the medical profession in the United States will see fit to cooperate with government along some such line as that which the Canadians are following at the present time.