Medicine and the Public

It has become a tradition in America that European experience in matters social, economic, and political has no significance for us. This appears to be part of a boastful, flag-waving attitude, well characterized by the slogan “100 per cent American.” It is strangely at variance with the placid assumption—no, almost emphatic insistence —that our government and all its agencies are inherently riddled with corruption. Because of these national traits, the American public and the medical profession have remained uninformed or misinformed about European experiments in the dispensation of medical care and suspicious of attempts to initiate similar experiments in this country. There are large numbers in all walks of medical life who see the evils in our medical services and would welcome some reorganization; but how disordered are their views of the direction changes should take is evident from a perusal of “American Medicine,” a compilation of their opinions, published by The American Foundation in 1937.

The general defects in the provisions of medical care here and abroad have been analyzed with the greatest care; the broad directions which remedial measures should take have been explored and tested by experiments. Some of the most significant reports of these investigations and experiments are those of the British Royal Commission on National Health Insurance in 1926, Political and Economic Planning on the British Health Services, the Committee on Scottish Health Services, the Committee on the Costs of Medical Care, our own National Health Survey, and that of the Technical Committee, which was presented at the recent National Health Conference.

Reiteration of the same problems and presentation of the same solutions in all these reports must bring conviction that there are certain defects inherent in the nature of modern medicine which transcend boundaries of time and place. Moreover, because medicine has its roots deeply planted in the natural sciences it offers objective data by which these analyses may be tested and from which surveys and projects may be oriented. This potential objectivity also gives hope that more rapid advances may be made in the provision of medical care than in the provision of other basic necessities, such as shelter, food, and clothing, the approaches to which have not been so clearly defined. At least there seems to be good reason for Dr. Hugh Cabot’s impatience, expressed in a speech before the National Health Conference, to “get over this survey business and get on with the war.”

Since the general aspects of the problem have been so thoroughly described by others, they will be merely sketched in broad lines as a background for a more particular discussion of the interests of the medical profession and of certain points which lend national coloring to the problem in the United States. It is recognized that solutions for these problems cannot be found by physicians alone, but only by the integrated efforts of physicians, other professional groups interested in social welfare, and the government. But physicians occupy a peculiar position as the experts who must implement and execute any plans that may be devised.

The National Health Survey estimated that in 1935-36, in the urban populations investigated, forty per cent of persons came from families with annual incomes less than $1,000, eighty per cent from families with less than $2,000. Somewhere in this scale a line can be drawn below which persons are quite unable to pay for medical care without sacrificing the bare necessities of life. The exact location of this line must vary with local conditions which influence the cost of living and with fluctuations in the real value of money. Probably at the time of the survey and for the population investigated, $1,000 would have been a fair approximation, since over half the population with incomes below this were forced to seek public relief sometime in the course of the year. That forty per cent of our people are too needy to pay for their own medical care is a deplorable and, it may be hoped, a transitory condition connected with the depression. But even in the comparatively prosperous year 1929, only twenty per cent of people came from families with incomes greater than $3,000 and an equal number belonged to families with less than $1,000. Although these proportions may vary, nothing short of a revolution will abolish gross inequalities of income and the presence of dire economic need. Any intelligent social welfare program predicated on evolutionary development must take this need for granted and can meet its fluctuations by measuring relief in proportion to income.

The methods by which medical care can be provided must be examined. Attention has already been called to the lowest class, which can afford to pay for no medical care. At the opposite end of the scale is another class whose members can pay individually for all the medical care they may require. Between these two extremes lies the great mass of the population, whose ability to meet costs of medical care varies from the barest minimum to total independence. Unless those in the lower brackets are to accept service of inferior quality they must receive some financial assistance. Even those higher in the scale may, at any time, be reduced by catastrophic illness or disability to the level of indigence. Illness is a hazard of such unpredictable incidence that it cannot be budgeted in advance like most of the prime necessities of life. It is more disastrous than other hazards because it imposes a double penalty. It deprives the wage earner, at least, of income just when it is most needed to meet the costs of medical care. It is to meet the needs of this great middle class that cost-sharing methods have been devised.

Before these methods are considered, however, a more fundamental question must be decided. Is it to the advantage of society to provide for the health needs of the whole population? From a purely humanitarian standpoint the answer would undoubtedly be affirmative, but humanitarianism sometimes has to yield to economics. Whether a comprehensive program against sickness and disability would yield returns commensurate with its costs is harder to answer. It has been estimated that losses through illness are three or more times as great as expenditures on medical care. Undoubtedly, if these expenditures and the care which they purchase were better organized, the losses could be greatly reduced. Dr. Louis I. Dublin, at the National Health Conference, stated: “Studies which have been thoroughly confirmed show that on the score of the nation’s assets, human beings are valued in terms of their productive capacity at five times the value of all other assets.” And in another passage: “Again and again health departments, insurance companies, private agencies, have proved to the hilt that there is no finer investment than an investment in the prevention of disease and the care of the sick.” These predictions are not without factual support; but if they were merely statements of opinion, it is often opinion rather than fact that determines action. At the National Health Conference, there was unanimous admission of the existence in this country of a great unmet need for medical care and clamorous insistence by all organizations of consumers for some action to meet this need. That care must be provided to the truly indigent by the government is more and more generally accepted. Roth the public and the medical profession recognize that physicians cannot supply all the service required gratuitously. Private philanthropic efforts are so dependent upon emotional appeals that they can probably never be effectively organized and directed to meet the demands of such a broad social problem. Governmental aid recommends itself also on the score of equity. Voluntary philanthropy puts a penalty on generosity. The physician can bear the burden only by mulcting his rich patients for the sake of the poor. Moreover, the demand for gratuitous services falls heaviest on those who can least afford to give them, practitioners in needy communities. But all these details become insignificant before the one fundamental fact that the truly needy can receive medical care only by subsidies derived from the pockets of the wealthy, whether they come in the form of taxes or gifts.

If the decision is made to provide for the needy, certain inevitable consequences must be faced. Although poverty is not a sign of delinquency, no premium should be put upon it. Those just above the level of absolute need cannot with justice be treated worse than their poorer brethren. Yet this is inevitable if public aid is given only to the truly needy. Those just above the income boundary of indigence must be reduced to the ranks of public charges by illness or disability before they can receive help. To escape this dilemma many will delay or forego medical care not urgently necessary.

It is to enable persons in this middle class to secure medical care that various cost-sharing methods have been devised. Of these, health insurance deserves major consideration because it has been more widely tested than any other procedure and because in theory, at least, it is more exclusively directed to meeting costs. This latter point cannot be too much emphasized. Insurance is only a method by which people combine to meet collectively a hazard which, for the individual, has a variable and unpredictable incidence. Because methods for the distribution and administration of medical care under health insurance have rather generally followed a conventional pattern, it has been too much assumed that this pattern is implicit in all health insurance systems. If this were the case, the imminence of health insurance under the growing pressure of public demands would be cause for serious anxiety. There can be little doubt, from the experience in Great Britain and other European countries, that the adoption of health insurance, conventionally patterned, would improve the health of the people at large and the economic status of the physician. The imposition of such a uniform system, however, especially if it gave momentary satisfaction, might ultimately delay progress by checking experimentation. Errors in the present health insurance systems have been discerned and should not be repeated in this country. Some of the chief errors arise, I think, from uniformity in the methods of administering medical care.

If insurance is to cover all those to whom it is applicable it must be compulsory; voluntary health insurance can never provide for the population as a whole. It will assure individuals in any income stratum better care than they could otherwise afford, but it does not abolish the income strata. Consequently, it continues with only slight modification the present order in which care is proportioned to wealth. If the system is to be supported entirely by the insured on the contributory principle, the same difficulty is encountered. Those in the lowest income brackets can buy only an inferior grade of medicine. The higher standards of care are set, the more limited becomes the class which insurance can cover and the larger grows the group which must receive public support. Employers’ contributions are more adapted to provide disability benefits than to purchase medical care, because they can be levied only for the benefit of wage earners to the neglect of the unemployed and dependent members of the population. If a high quality of medical care is to be provided to the whole of the otherwise self-supporting middle class, the premiums of those in the lower income brackets must be supplemented by the government.

Evidently insurance must be scrutinized with some care. If improvement of the health of all the people is the goal, the rich will have to contribute through taxes to provide subsidies for the needy. If the problems of the intermediate class are to be solved by health insurance, premiums must be graduated according to income and must be supplemented by government contributions graduated in the reverse direction. If such a system is subjected to analysis, it at once becomes apparent that insurance is no more than a special form of taxation imposed upon a certain portion of the population. It may have certain advantages over a wholly tax-supported system; but these advantages have not the same weight under all conditions. The recommendations of a large minority of the Scottish Commission are worth quoting in this respect: “The insurance principle becomes continuously less appropriate as the field covered is widened. It has pre-eminent merits as a device for raising money for purposes that are sectional; but when the whole, or substantially the whole, of the population are potential beneficiaries, the retention of the insurance system means the retention of a considerable amount of machinery to achieve an end that might be compassed more simply.”

A final element in the question concerns the components of medical care. It is this dimension of the problem with which physicians are chiefly concerned and in which their expert services are indispensable. Methods of financing medical care are primarily the responsibility of economists. The public-spirited and liberal members of the medical profession are solicitous only that sufficient resources be made available without detrimental restrictions. The American Medical Association has expressed itself rather unf elicitously in this connection. The ten official principles of the Association, intended to preserve freedom of action and initiative to its members, place major emphasis on the maintenance of financial competition and the direct passage of fees from patient to physician. This unfortunate attitude will probably prove transitory. It is quite similar to that which the American Medical Association adopted at first towards workmen’s compensation and which the British Medical Association initially took towards national health insurance. Both have found their anticipatory fears unwarranted and have learned that remuneration by the government or other intermediary agencies is quite as useful and more dependable than direct compensation from patients. Unhappily these temporary misapprehensions divert attention from the more important subject, the nature and quality of medical care.

The very minimum of medical services is the provision of public health measures. In the beginning, these included only measures to eliminate environmental factors conducive to ill health or physical disability and to prevent the dissemination of contagious diseases, together with the custodial care of the mentally deficient and insane. More recently the care of certain chronic diseases, notably tuberculosis, has been entrusted to the government. Public health departments in certain communities are now engaged in providing diagnostic and therapeutic facilities for physicians, in the rehabilitation of crippled children, in reducing the hazards of maternity and improving the medical care of infants, and in preventing or eliminating industrial hazards. Although the assumption of many of these functions by governmental agencies was contested by the medical profession, at the present time the need for their further expansion under the same auspices is quite generally accepted. Efforts should be made to bring public health services throughout the country up to the high standards which now obtain in only a small part of the nation, and to integrate them more closely with the medical services.

Without sickness or disability benefits as a provision against the economic distress that comes from illness, medical care for the needy or near needy becomes almost an empty gesture. This, private philanthropy has but ill provided and the medical profession cannot give. It is logical to believe that unemployment insurance will soon be stretched to cover it. There is no good reason why unemployment through illness or disability should be distinguished from unemployment incurred for other reasons. Sickness benefits, although they are necessary adjuncts to any comprehensive program for the conservation of health, are not directly medical, but economic measures. Their costs should not be confused with those for medical care, nor should the burden for their administration fall upon physicians. The latter will undoubtedly have to participate in the process of certifying disability; but their duties in this respect should be minimal lest they be diverted from the more important functions which they alone can serve.

Although the general practitioner is and must remain the fundamental unit in any medical system, the mere distribution of medical attention, exposure of patients to physicians, cannot be interpreted as the provision of adequate care. It is the greatest weakness of national health insurance systems that this has hitherto been almost their sole objective. Undoubtedly they have bettered the general health of the people somewhat by bringing more persons into contact with physicians. In this day, however, a practitioner with only stethoscope and prescription pad can offer but a small part of the benefits which medicine has to contribute. Like every pursuit which is founded on science, medicine has undergone a technological revolution. Today, the scientific practice of medicine demands knowledge, expert technical training, diagnostic and therapeutic facilities undreamed of ten years ago; the armamentarium which it will require in another ten years is beyond prediction. If the world is to reap the benefits of these scientific discoveries, they must be made available to the public.

It is hard to see how this can be efficiently accomplished without some departure from the present individualistic system of practice. No one man could acquire the knowledge and technical proficiency to practice all the skills of medicine, even if he had the money to possess and the time to manipulate all the apparatus. The general practitioner is to be congratulated if he can keep aware of new developments and recognize the indications for their use. Specialization, especially in the use of technical procedures, has become essential. However, specialties should not be practiced for their own sake; they are merely ancillary to the broader functions of medicine and must be coordinated by some method. Co-ordination is essential for another reason. The physical equipment required for the modern practice of medicine is so costly that it becomes ever more important that it be utilized with the greatest efficiency. The overhead expense incurred in the purchase, maintenance and operation of this apparatus, which makes up no small part of the cost of specialist services, becomes unduly large under an individualistic competitive system because of the reduplication of equipment that such a system entails. It is almost too obvious to mention that under even the most efficient system, with these accessories and with the greater educational preparation which is demanded of physicians, doctors can no longer afford to give medical care gratuitously to the increasing proportion of the population that cannot afford to purchase it.

In spite of the apparently inevitable implications of medical evolution, efforts at co-ordination are still in the most elementary stage. Physicians trained in various specialties have formed private groups which can offer more comprehensive service than any individual in the group could give alone. The economies effected by such voluntary aggregations, even if its members are activated by the highest motives, under a competitive system with fees more or less standardized, accrue to the physicians rather than to the patients. The formation of groups or co-operative organizations which provide general care on a prepayment basis, although in theory it would seem a sound procedure, has met the bitterest opposition of organized medicine. The reasons advanced to explain this opposition seem to the initiated not altogether consistent nor convincing. It is claimed that it will destroy the professional status of the physician, as if medicine were still comparable to the law, a pursuit that can be conducted without special properties or technical aids. There are strong objections to the exploitation of physicians and patients for profit and to the control of groups by organizations or persons with interests foreign to those of the patient. Fear of such dangers and fear lest the element of personal responsibility be removed from the physician justify injunctions against the corporate practice of medicine. Advertising and soliciting patients are likely to have a degrading influence. Experiments have proved, however, that these dangers and nuisances can be avoided in co-operative enterprises instituted to furnish medical care to organized groups of the population, so long as no third party is permitted to profit from the undertaking. If insistence that each patient have the right to free choice of a physician expresses more than a desire to preserve unrestricted competition among physicians, no one can dispute the remark made by Dr. C. E. A. Winslow before the National Health Conference: “I have great sympathy with the principle of freedom of choice of physicians, but I should like to point out that any acceptable definition of freedom of choice of physicians must include the right of a group of patients to choose a group of physicians of their choice. Any artificial attempts to interfere with that freedom cannot stand.” The following passage from the latest official resolution of the American Medical Association concerning hospital insurance is at best an inept manner of conveying the idea that the sacred personal relation between patient and physician must be preserved: “If for any reason it is found desirable or necessary to include special medical services such as anesthesia, radiology, pathology or medical services provided by out-patient departments, these services may be included only on the condition that specified cash payments be made by the hospitalization organization directly to the subscribers for the cost of the service.” My respect for American physicians will not allow me to admit that their services will be influenced predominantly by the hands through which they receive their compensation. But the emphasis in their resolutions and in the statements of their official spokesmen has been unfortunately placed. Equally unfelicitous is the insinuation that if salaries are substituted for fees the quality of medical service will deteriorate. Such an insinuation is not even entirely ingenuous. For generations young men have served on salaries without objection as assistants to their professional elders. Specialists employ assistants on salary without criticism. Our public hospitals and universities present, among their salaried physicians, examples of unsurpassed industry and enthusiasm.

The great scientific achievements of America and the high standards of its medical schools are cited as reasons for eschewing change in the present methods of medical practice, as if the twp were related. How much credit for the rapid advances in investigation and education should redound to the general organization of medicine is debatable; that the tempo of these advances would have been retarded, had there been less co-operative activity, cannot be questioned. Nor can there be any doubt that the association of specialists, often on salary, in our teaching hospitals has greatly accelerated the elucidation of clinical problems. The exemplary nature of the clinical work done in such institutions and by similar groups less intimately connected with universities— such as the Mayo Clinic—has won them international recognition. Is it not the height of paradox to obstruct wider dissemination of the group system when our medical schools are teaching and demonstrating its practical advantages?

Co-operative and group health systems are steadily increasing in numbers and strength. Their extension was recommended by the majority of the Committee on the Costs of Medical Care. They seem peculiarly adapted to meet the requirements of certain portions of the population and certain geographical areas. There is no reason to believe that the group principle could not function under an insurance system or one that was financed by taxation. A movement so obviously conducive to efficiency and economy will not be checked by mere obstructive tactics. It would appear to be better policy for the medical profession to anticipate inevitable trends. If they participate in experimentation they may influence its direction. If the standards of medical service and the personnel of co-operative ventures were not satisfactory—which has not been demonstrated — some blame would attach to the medical societies which have discouraged or prohibited their members from entering such ventures. If co-operatives encroach upon established practice, practitioners will not better their position by abstaining from participation. If they reduce some incomes, they may increase the general level of income and offer greater security. If, by promoting efficiency, they increase the capacity of physicians to care for patients, they also increase the capacity of patients to pay for these services and enlarge the demand for services. Individual choice of physician may be conserved so far as it is compatible with the best service. Finally, the union of a group of men in a common enterprise furthers education through mutual stimulation and criticism. The best patterns for such enterprises undoubtedly remain to be found; no single pattern is likely to prove suitable for all communities. But the general principle that a higher quality of medicine can be provided by a group of physicians with individually differentiated training and functions, working in co-ordination, than by individual physicians operating competitively, has sound theoretical and practical support.

Hospitals must be included in the medical services that are contemplated and must be made generally accessible. A recent spot map showing a hospital within thirty miles of every person outside of the uninhabitable portions of the Rockies is quite meaningless. It is clear from the report of the Technical Committee, eloquently confirmed by numerous speakers at the National Health Conference, that there are not sufficient hospitals accessible to the members of communities about them, equipped and staffed to provide care of high quality. Construction of further hospitals alone will not meet the need; those already in existence, both public and private, must be improved and made more available. The services of modern hospitals are not confined to their inmates. They provide, in addition, diagnostic and therapeutic facilities to their out-patients and for the patients of physicians in the communities in which they are located.

Finally, no program for the improvement of medical care can neglect education and investigation, the institutions which train the professional personnel and develop newer and more efficient methods to prevent and combat disease. Support for these institutions must be measured out with no niggardly hand to meet the demand for more and finer products. And the process of education must not stop at the exit from the school. Under a purely competitive economy, the obligation of the medical schools to meet the demand for “refresher” courses for practitioners out of their present meager means and by adding burdens to their already overtaxed faculties is questionable. If they are to satisfy this obligation under any system, further resources must be found. This burden will be partly removed by the formation of properly constituted groups and medical centers and adequate provision of hospitals. A modern hospital or clinic, properly staffed, equipped, and conducted, has all the potentialities of an educational institution. Moreover, the efficient organization of work should grant the workers more opportunity and incentive for self-improvement without impairing accomplishment. It is to be anticipated also that those gifted with curiosity and originality will devote some of this time to investigations that will further speed the advance of medicine.

Means must be found by which personnel and facilities may be selected on the basis of competence and quality; standards, not on stereotyped models, must be established; authoritative bodies, which can exercise judicial powers without fear of political pressure from within or without the medical profession, must be constituted. Although professional or trade organizations have been found inherently unfitted to assume such functions, the medical organization, if it would rid itself of a jealously defensive attitude, could do much to forward discovery of a proper formula.

At present federal, state, county, and city governments all share the load of public health services. No one of them can be eliminated. There is reason to believe that the part that all will play in the provision of medical care will increase. If this is so, the allocation of responsibility is a matter for intelligent consideration, not one that should be predetermined by political ballyhoo or unreasoning prejudice. It is feared that intrusion of government in medical affairs will necessarily bring bureaucracy, regimentation, corruption, and inefficiency. Federal intrusion is particularly feared because of its potential magnitude. Those who admit the necessity for federal financial aid prefer that administrative control be left to the states and counties. Although local autonomy seems to offer more chance for intelligent variation by constituting units of manageable proportions, our experience with social security gives little reason to believe that political inefficiency and corruption will be eliminated by entrusting administration to local governments. If federal funds are to be spent, the federal government must reserve some right to condition the manner in which they are expended. All these anticipations would be robbed of some of their menace if those with expert knowledge, especially physicians, would enter wholeheartedly into the projection of plans, instead of confining themselves to objections.

Certain virtues our federal government has displayed: a great interest in social and economic problems and a capacity to probe them by investigation. There is not space to discuss in detail the National Health Survey, the Report of the Technical Committee, nor the comprehensive program for the improvement of medical care presented before the National Health Conference; but certain characteristics of this program must be stressed. Now that attention is no longer focused on the details that aroused personal and factional animosities at the Conference, it is seen that the program bears the marks of statesmanship, rising above political expediency. The problem is clearly defined and measures for the treatment of each major phase are outlined. The federal government is not given undue predominance; administration is entrusted to local and state authorities; proposals are stated in general terms only; the means to implement them and the machinery to execute them are wisely consigned to further discussion and experiment; gradual, evolutionary development is contemplated. Provision of some kind is made for each of the components of medical care, with proposals for financing them in accordance with the economic status of the population. Undoubtedly, objections can be raised to details of the plan; but it provides a basis for discussion hitherto unequaled. Consumer groups have almost unanimously accepted its chief provisions, hailing especially those that deal with means of providing care to the middle class on cost-sharing principles. On the other hand, it is just these proposals that the American Medical Association officially refuses to accept. It admits in principle the necessity for all the others. It even acknowledges the desirability of cash benefits for disability due to sickness. A certain amount of experimentation with voluntary insurance, carefully conditioned, it is willing to countenance. But compulsory health insurance or other comprehensive programs to meet the needs of the marginal income class are excluded from consideration. Such a division between laymen and physicians can have only deplorable results. The temper of the public will not brook complete inaction. Will organized medicine, by offering co-operation, aid in the development of an intelligent comprehensive plan for the provision of medical care, or will it wait until some system is imposed upon the country with defects that can be removed only by years of further effort?