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Medical Care for the American People
Draft manuscript. Publication status unknown.
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The demand for placing medical care under a system of social security is based on the fact that health is essential to the happiness and efficiency of the individual, and that under present methods of medical practice adequate care is beyond the ability of a great percentage of our people to obtain. Preventable illness is one of the greatest of all social problems. Every year over 600,000,000 work-days are lost through illness, much of it preventable illness which, at $5 a day, amounts to $3,000,000,000. Statistics show that there is more illness and that it causes most suffering among the low-income groups, but that they receive much less medical care than they need, and only a fraction of that given to the well-to-do. In 1929 the peak of the Golden Era of industry, about sixty per cent of American families had an income under $2,000. Incomes decreased to very low levels during the depression, but are temporarily high during present war conditions.
Many families, especially those who live in the cities, are unable to live as self-respecting citizens and lay aside sufficient funds to meet so unpredictable an expense as that caused by illness; especially severe or protracted illness which, according to statistics, comes on an average to each family once in about five years. If hospitalization is necessary, they are often unable to have either the physician or institution of their choice, but must be governed by the cost; and even then are not always able to meet the expense. Not infrequently they are compelled to seek charity, or allow themselves to drift without proper medical aid until they reach a serious state of incapacity.
The answer usually made by the medical profession to these statements is that the situation is exaggerated and that everyone can have medical care without destroying present methods of practice; and furthermore, the move to socialize medical practice is bureaucratic and not in keeping with the freedom of our American democracy, where individualism has existed since the foundation of the Republic. Research, prevention, an successful practice have flourished under existing conditions, and such a change would lower these standards. Great stress is laid on the fact that in America the practice of medicine should be a free enterprise and all who pay their own physicians should have the freedom of choosing who shall treat them. This is considered necessary to the maintenance of the ideal physician-patient relationship.
These conflicting opinions deserve more than partisan discussion.
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Medicine naturally divides into its clinical and preventive phases –the care of those who are ill, and the prevention of illness. Yet those divisions dovetail into each other at every turn. Both have their social as well as scientific aspects. While medicine is a profession, the care of those who are ill has aspects of the ordinary commercial enterprise in that the physician sells his services for a price. Nevertheless it differs from purely commercial enterprises in that it is bound by certain traditions which are universally respected; first, the physician gives forth without compensation any remedy or measure which he knows or devices which may relieve suffering, prolong life or prevent disease; and second, following the Hippocratic Oath he gives aid to the needy either with or without compensation. Every physician gives services without compensation, and every physician practises preventive medicine in his daily ministrations.
Public Health, as compared with the practice of medicine, is not a commercial enterprise from which the medical profession derives profit, on the contrary, the entire population benefits therefrom. Preventive medicine reduces illness and deprives the profession of income. Yet medicine rejoices in the accomplishment of lowered morbidity and mortality rates –equivalent to a merchant rejoicing over a contracting market.
Preventive medicine is a social and economic, a civilizing force, of great power. It makes people healthier and enables them to accomplish more and live longer. It has increased the mean age of man in the United States by fifteen years since the beginning of the century. It has vast implications for industry and commerce. It reduces the severity of epidemics, rids nations of preventable diseases, and aids in the enlightenment of backward peoples, bringing them into the world markets, first as consumers, and later as self-supporting producers.
Public Health has played a most important role in the success of modern nations. It has checked the ravages of such pestilences as smallpox, malaria, yellow fever, plague, cholera, typhus and typhoid fever. In the United States deaths from all causes fell between 1900 and 1938 from 1755 to 1060 per 100,000 population; diphtheria from 43.3 to 2; typhoid fever from 35,9 to 1.9; influenza and pneumonia from 205.4 to 80.2; and tuberculosis from 201 in 1900 to 45.9 in 1940. Public Health services are not only provided by government, but in case of the recalcitrants are forced upon the people.
The Public Health program is not under criticism by the laity, but its encroachment on private practice is noted with alarm by some members of the medical professions.
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In the opportunity to contribute to the efficiency and happiness of the human race medicine has no competitor. But the increasing value of its services to the people, its idealism, and its phenomenal progress during the recent past, are now bringing it into conflict with the needs of the people. Its benefits are so great that it is indispensable, a fact to be reckoned with when its cost puts it beyond the reach of so many people.
Since the usual method of supplying medical care has been attacked, it is necessary to examine carefully to see if the complaints against it have a just basis, and if the new proposals offer an adequate solution.
The question is not whether the medical profession shall surrender its rights because a group of politicians are demanding it, as is so often repeated. This shows a total misconception of the problem. Rather, the problem may be stated thus: “Can the American people, with incomes such as they may reasonably expect to receive under postwar economic and social conditions and existing methods of medical practice, obtain the benefits of modern medical knowledge to the extent that they should for their own and the nation’s good? If not, wherein lies the fault, and how may it be remedied? How can medical progress be fostered, the rights of the profession be preserved, and the needs of the people be satisfied? The matter can not be brushed aside by saying there is no problem. This has been attempted for too long now. There is a problem, and it should receive full and free discussion, for every citizen requires and is entitled to the benefits of modern medical discovery, including medical, dental and nursing care, hospitalization, and necessary medical supplies. Unless medicine supplies these needs, it fails in its purpose.
Numerous factors enter into the problem of providing medical care for the people, some of which are definitely of medical origin, while others belong neither to the medical profession nor to the people who are demanding better medical care; but to society.
Medicine has been caught in the maelstrom of inadequate adjustment to the changes demanded by the industrial era. Neither social thinking nor politics has kept pace with technological progress. We are living in a highly industrial age and thinking in terms of a rural society. We have not severed our methods of thought from those held in the prepower age of the eighteenth century. We must “adjust unchanging thinking to a rapidly changing scene.” The individual has been swallowed up by organization, yet we talk of individual enterprise the same as we did then. Today our nation is ruled and our course is largely determined by anarchic pressure groups which have developed a privately dominated collectivism to supplant individuals, thus having learned that a collective force is more successful than individual effort. They are fighting for special privilege and for their own security, regardless of what happens to other groups or society as a whole. But personal and national security are suffering neglect.
Not realizing the problems which our rapid development has engendered, we have not attempted to solve them. The conditions of society are not healthy when in this era of great industrial accomplishment no successful attempt has been made to lift our political and social systems to a similarly efficient plane. Our rapidly developing mechanization and collectivization of industry, with its concurrent rapid concentration of workers in the cities, causes many acute problems. There is much unemployment and dependency as soon as employment ceases. So there has been progressive distress as our productiveness has increased. One-half of our American families in the late twenties, our most prosperous peacetime years, received less income than is necessary to give them respectable standing in the community. The fact that machines are able to produce everything needed by the people, with a diminishing number of workers, has not been adjusted to the advantage of the worker or society.
Herein lies the basis for much of the people’s demands made upon the medical profession. The cause for the people’s inability to pay for the medical care which they need is put upon the medical profession when it belongs to society. If our economic and social organizations were working harmoniously and were efficiently geared to our industrial structure, there would be no more pressure on medicine than on other groups such as industry, banking, agriculture, and labor. All of these groups would be obliged to adjust if we had a well organized society. But a society which has failed to give its people security through work must furnish security in other ways; and because of the great importance of health to the worker and his family, security against illness has been singled out as being not only essential but a thing that is attainable, especially since it has been established by most other enlightened nations. The argument that American medicine is the best in the world is beside the point. America has the highest living standard in the world and should have the best medicine. The nature of our people, our rapid scientific and technological advances since War I enabled us to advance while Europe, with the exception of Russia, stagnated. The best in the world is not enough. The best for all the people alone will satisfy. The best when beyond the reach of most is unsatisfying.
In our democracy the past fifty years has been an era of intense specialization in which first one group, then another, has come into prominence, each striving for its own improvement and success. The interest in every subject which calls for group organization has been so keen, the advances in knowledge have been so rapid, and the attainments –whether in manufacture, transportation, finance, agriculture, la, medicine, teaching, or labor– have been so outstanding that society has proceeded with the assumption that these warring groups, if let alone, would not only satisfactorily solve their own problems but the problems of our economic, social and political life as well. On the contrary, because of their special interest and strength, they have worked for their own benefit; the national interests have been submerged; and society’s problems have become greater –not less. The security of the individual has suffered greatly. While we have transferred the balance of power to the city, we have not preserved the independence and security, the individual opportunity, which we enjoyed as a rural people, hence this must be compensated in other ways.
There are a number of well recognized security measures which are proposed to meet the situation. Such are insurance against unemployment, old age, illness, accident, and industrial hazards. The necessity of these protective measures is an admission that our social institutions are not meeting the requirements of our era. Our political and social maladjustment has left no other course but the establishment of security through taxation.
The special purpose of these measures is to provide families of medium and low incomes with a security which they otherwise would not have, a security which is enjoyed by those who have larger incomes because of their ability to provide for themselves. Such security measures provide protection for the beneficiaries against some of the hazards, inconveniences, and catastrophes to which they are subject, which, if unprovided for, would lower their plane of living. While opposition to social security taxes is expressed by certain groups, the objection is mitigated somewhat by the fact that the money paid for such security is not lost to society. It is spent and becomes an important factor in the support of business by increasing the purchasing power of the people. Whether it should be provided by a payroll tax or from general taxation is subject to discussion. The necessity for a security program –except for the severely handicapped and aged– could be obviated to a great degree by an expanded program of production with large sales and small profits, a program sufficient to give full employment at an ample wage.
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The cost of medical care has increased in recent years; and along with increased cost has come improvement in the services which medicine is able to render. Prior to fifty years ago medicine had scarcely entered the stage of scientific development. A physician could start to practise after three short terms in a medical school. Not even a high school diploma was necessary. Today the combined college and medical course requires a minimum of six years, but because of the wide nature of the new trends in medicine many take the full four years of university work. After the medical course is completed, one year of hospital internship is required, and often two or more years of residency are added. Thus seven years is the shortest term of preparation, and this is frequently extended to ten or eleven. This means not only from seven to eleven years of expense but also from seven to eleven years without earning power. After training has been finished offices and equipment, with assistants and technicians, must be provided before the physician has an earning power, and thereafter expense of books and journals, medical societies, new equipment, and postgraduate study make their steady demands.
Unless we make the necessary adjustments in our economic and political systems to provide adequate incomes for the people, some different method of payment for medical care must be provided. Group practice, which avoids the cost of consulting multiple specialists, and community hospitals by the common use of equipment and technicians will reduce the cost somewhat to those who can take advantage of these methods; but this still leaves much needed care for which provision is not made. Middle and low income families will still be insufficiently provided for, and sparsely settled country districts will find themselves far from the protection of physicians and hospitals.
While the cost of medical care has been steadily increasing, so have the demands made upon the incomes of the people. The cost of living in America’s highly industrialized world is high. The small percentage of our people who have incomes above $4,000 or $5,000 can afford to pay the bills charged for private practice, yet a large proportion of these protect themselves by insurance. Those who are not financially able to pay for their medical care and are not protected by insurance must in case of serious illness (1) expend the savings which represent their future security if they are so fortunate as to have any; (2) depend upon the charitable nature of physicians; (3) be treated as indigents; or (4) suffer from lack of care.
The demand for change in the plan for providing medical services is not intended as an attack on medicine as a profession, nor on the services which it is capable of rendering. It represents rather a belief on the part of the people that one of the prime necessities to their welfare and happiness is beyond their ability to obtain. Furthermore, if the cause were thoroughly investigated, it would be seen that the inability of the people to have adequate medical care is more a lack on the part of society than an intent on the part of physicians. In spite of this the probabilities are that the people would still feel that the chances of success are greater by making demands on the medical profession than by attempting to amend our malfunctioning political and social institutions. The one can be changed quickly by legislation; the other requires the political and social education of the American people and will be a process of gradual evolution unless precipitated by some such catastrophe as the present war. In case unemployment is not solved and a condition of greater social security is not brought about following the peace, there will be a stronger demand than ever before for planned security. While economic progress has brought economic abundance within the grasp of all, we have not devised the institutions to distribute it, and this can not wait much longer.
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The arguments used by the organized profession against socialized medicine center about the individual rights of both the physician and the patient –the right of the physician to practise his profession according to the established traditions of medicine and live his life as an individual; and the right of the sick man to choose the physician whom he wishes to have care for him.
There may possibly be sufficient elasticity in governmental schemes to partly overcome this last objection, for it is important to note that under present conditions of practice the staffs of federal, state, and county hospitals, and the physicians employed by industrial organizations, fraternal and insurance groups, are readily accepted by those who enjoy their benefits, the chief complaint being against the limited service which some of them render. Freedom of choice is freely exchanged by the patients for care within their means to purchase. In no instance is this shown with greater clarity than in the many public tuberculosis sanatoria scattered throughout the United States. While the death rate from this disease in 1900 was 200 per 100,000 population, with the aid of these governmentally staffed institutions it was reduced to 45.9 deaths per 100,000 in 1940. The fact that more than two-thirds of the hospital service rendered in the United States is governmentally provided by fixed staff bears heavily upon the validity of the argument for the necessity of free choice of physicians. What chaos would be wrought in our medical schools if the patients used for teaching would refuse to be examined or treated by physicians other than those whom they designated as a result of free choice.
That the profession is convinced of the necessity and committed to the idea of insurance is shown by the many plans for medical service and hospital care which the physicians themselves have instituted. These attempts are praiseworthy, but too often they are too limited in their scope to satisfy either patients or physicians. A satisfactory plan requires wide coverage which is made possible only by the participation of a very large proportion of the people. Laymen look upon limited plans as stopgaps to prevent them from getting what they want. The plan must not be a makeshift but be based on comprehensive studies of the conditions to be met and a determination to solve the problems justly and efficiently.
One reason for the medical profession desiring to follow its traditional practices is based on the fact that it is a very conservative body and finds little time for the study of political and social problems. It has been successful by following present methods, and sees no reason for wanting to change. It has given good service and has enjoyed a satisfactory position in society, both of which are worthy objectives. Stripped of all verbiage the chief reason probably is that living in the present industrial era, in which economic reward is considered to be of such great importance in measuring success, it is a stimulating fact that physicians may attain a high economic as well as high professional standing. This they are unwilling to forego, especially when other groups are permitted to continue enjoying their usual course undisturbed. In other words, the profession of medicine fears that changes which are suggested may make it less successful and lower its standing in society. No fault can be found with this attitude provided at the same time the people can be provided with the medical care they need.
Competition is put forward as necessary to the development of the best practice of medicine. Who knows this to be true? It is not true in research. It is not true except to a limited degree in our public schools and great state universities. Competition has been largely destroyed in industry. The great corporations are no longer governed by laissez faire but by control of price and elimination of competition. Pride in work is a far greater stimulus to any physician who loves his profession than competition.
The profession naturally resents what it terms “being regimented” by a compulsory governmental plan. Regimentation is the ‘big bad wolf’ which they wish to avoid. But in reality it is what every group seems to desire for itself if it can control the regimentation. Every physician, every member of a labor union, every business organization, is regimented by his own organization, and in turn is anxious to regiment the rest of society. The enormous corporations which destroy competition are regimenting not only the property of their stockholders but the lives of every citizen; and the international cartels are reaching out to regiment the citizens of the world.
Private regimentation is accepted by members of groups; but governmental regimentation which offers the only protection which the masses of the people have against powerful organizations is called “bureaucracy” and thought to be wholly bad. Governmental regimentation is bound to increase as business becomes more powerful and can be avoided only by the operation of a high social conscience on the part of businessmen. Neither bureaucracy nor totalitarianism should frighten those who live in a democracy, for they have the power to prevent both. But we can lose our freedom and democracy while bickering over such terms as “regimentation,” “individualism,” and “Free enterprise,”
Trends of opinion on many phases of medical care were recently published by the National Physicians Committee for the Extension of Medical service, based on a three-months’ investigation by the Opinion Research Corporation, Inc., of Princeton, New Jersey. This report should be studied carefully by all who are interested in the problem of medical care for the American people. The questions asked in obtaining the information would require far more knowledge of the subject than most people possess; nevertheless, the report indicates that the people are thinking about the medical care which they need and the best way of providing it.
Of the group interviewed, omitting those who stated that they did not have any opinion, 58 per cent had consulted a physician during the past year; 18 per cent paid less than $5, and 20 per cent over $100 for their family doctors’ bills; 76 per cent would go to the same doctor again; 29 per cent put off consulting a doctor because of cost; 54 per cent bad had hospital experience, and 58 per cent thought hospital charges were reasonable and 64 per cent thought doctors’ charges reasonable; 12 per cent thought charges were too high; 63 per cent thought some plan should be devised to make costs of physicians and hospitals easier to pay; 47 per cent were in favor of insurance of some kind, but only 20 per cent carried insurance; 32 per cent of those knowing of a governmental Social Security Plan for medical care approved it, of which 29 per cent were in the upper income group, 31 per cent in the middle group, and 33 per cent in the lower group; 16 per cent were in favor of it even if it meant increasing Social Security taxes to 6 per cent; between governmentally and medically sponsored plans 37 per cent were in favor of the governmental and 43 per cent medical; 33 per cent were in favor of the government setting the fees of doctors; 29 per cent were in favor of the government paying the expense of medical students and medical schools; and 24 per cent thought it would be good for the country if the medical profession were controlled by government.
This report does not indicate so much a hostility on the part of the laity toward physicians, as a disappointment, a frustration, a belief that physicians have something which is essential to their happiness and efficiency which they are not able to buy because of lack of funds. It indicates that the people who patronized physicians and hospitals were fairly well satisfied, but that they need some better way of meeting the costs. And it must not be forgotten that 29 per cent put off consulting the doctor because of cost. It must be surprising to physicians to find that 32 per cent approved a governmental Social Security Plan, and that 29 per cent in the upper income brackets so approved. In the recent California poll it was shown that more than 50 percent of the people favored state medicine
This investigation should stimulate the medical profession to make an earnest and honest attempt to put medical services in reach of all the people before the matter is taken out of their own hands. The situation is real and urgent, and can not be satisfied by attempts on the part of the profession to prove its ability and good intentions. The time for self-compliments is past.
The development of the world is a process of evolution, punctuated now and then by an acceleration of movement or revolution which sweeps away the old with more or less violence. Our social and political systems with their many institutions, of which medicine is only one, are facing the uncertainty of present-day unrest, and their status is anything but secure. But a people which has made such scientific strides in the past fifty years should be capable of meeting the major demands of our industrial progress. If it is not, it is a sad day for democracy.
If medicine, which has come from the mists of the prescientific era to today’s accomplishments in a half century, would use the same open mindedness in its social relationships that has made its greatness in its scientific aspects, the problems connected with the distribution of its benefits to the people would be readily solved. It may not yet be too late for the profession, itself, to provide a plan for extending medical care to all the people, in accordance with their needs and economic status, and at the same time to protect the rights of the profession. However, to do so it will be necessary to resort to the government’s right to tax, for the middle and lower income groups can not carry the financial burden of adequate care alone, and it is too onerous for the profession to carry.
The following plan might be taken as a basis:
(1) Private practice for all who desire it;
(2) Voluntary insurance for those who desire to divide the risk;
(3) Compulsory insurance for all families with incomes below a certain amount, for example, $2500 or $3,000.
(4) Governmental provision for all group with medium and low income.
As an alternative, Groups 3 and 4 might be cared for through government taxation, instead of payroll deduction; and the Medical Society, through a corporation, might contract with the government to furnish the necessary medical care.
If the payroll tax is utilized, single persons and persons who are not employed could fit into the plan on a basis in which the risk is proportionate to that of the family.
The effect of such plans would be to guarantee that all people could have necessary medical care without being obliged to ask for charity. It would make the general practitioner a more important and more efficient member of the profession. It would bring more patients to the physician and so increase the actual number of primary treatments, but should reduce the number of instances of serious illness. Furthermore, each physician would become a more intimate and important part of the organization for the prevention of disease. If medicine were to initiate some such plan, it probably could secure its acceptance and retain control of the plan which it may lose if devised by nonmedical forces.
The people do not care so much who institutes the plan as they care about its adequacy to meet their needs, its sympathetic and successful interpretation and its permanency, They are interested in a plan which will meet the conditions which make planning necessary. Whoever devises it must remember that it must be a three-party plan in which the interests of the physician, the patient, and society all enter and in the management of which all must be represented.