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Full text of "Is your health the nations business?"

APft 1 9 ,9^g 




Is Your Health 

the Nation's 

Business? 

LIBRARY 
UNIVERSITY OF ftlCHMOHD 






Prc|Piirrd for 

Tjie [3waT£n StATt^ Aawti) FnHtts 

by 

THE AMER[CAN HISTORICAL ASSOCIATION 

This parciiiMpi \^ one al ii series iiiailt* avaiiiililr li>- ilii? Wjir l)fparirrirrii under 
ihii SfriL'ft lillr CI RfriimilnUi: A^ l!ii- p-ruraJ t'il\r inrlini-lcr^, Gl Ruunibabtc 
|iijiii|ihli't;^ ^^ruviil-c iiiulrrial wliicli ijjfi^riiEatkrJij-eiJiK.jitiiari ollicer:^ Tiiny usi- in 
vmiiiu^rLlii;; ^r-[Ri|r ilIs^Tu^L^iuiif^ ur ftixuiu^ L.h |r-iirL cif an nlT-iliily educuLlciii pro- 
prafti, and which njn^Fiitur.-- of ^niieil turcus Rfl^lio Service ouilcis may use 
la |prL'|rjr!jj>: irl HluJjo HoLinJliiMc; dii^tii^'jifiii bruudcabLs. 

Thp conU'ni of ihis imiiiplilei liiis Wi'ii j>repared by ihc tiisLiiriciil Sf-nii-R 
B<>iird al lJhi Amt^rit^mi lliL-ttrfirjJ AL^soi-JLitimi. Ejt^li j>Jm|pli]i-L in ih-i: t^rirt^ hj» 
f'jiJy <»nff piirpi)^; In [tm^iilr fmitiicil iEifitrTiiLiliiHi iukI biiliiwci:?^ arpuiit'iiilh Hfi a 
Jmhs for iJistiii^^ion of all siifi^ji o\ lh<r qi«;i.linn. li is ntti lo tc infi-rrfil lliai 
ibif Witr D^" par In lent cridurpes iiny mw of ih?^ j>jrtkiiliir vi".'Wb prewnlcd. 

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DtMrilminl Tot n^ie in thf^ <^bir<iri{k[fiil anil infcrfmattcrtiiiil firofzrani^ nf iht; Naiy. 
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TH^TM^t Division, OpRrE at- PKH!*f5T«'vn-, Ccij*!4T Cuatii> IkAngiMRTtq^i. 
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sitiunrd Jrom ihc CommaEidanl U'T). U. S* Co-a.'.l Cuard lliiadnuarltra, 



Is Your Health 

the Nation's 

Business? 



CONTENTS 

Is heallli your avn huifin-e^M ur lli«> nalioti^K li*" 1 

What 4J0 [wopif' prn|H>i^ lo flo ahoiit ihe i^iluationV . - . . 7 

What arr ihc pillars of h niiliuniil lirallh pra^am?. . . , 18 

Has II iialional lienllli proEfram been piil before Coii^reiih ? Jtl 

Whal h Ihe A.M. A* program? 40 

What are llie mam i&KiiesV 41 

To the disciisaion leader 4)1 

F"r fiirlbor j^diJin^ tft 

OtKpr r-l KnMndMt>l<' >?|il>J4M*ls 51 



WHY WERE DRAFTEES REJECTED? 



(SehcfiYG S^ryic^ ExQmirrafiofMj 1941} 



NERVOUS i HFHTAt UISIASES 3 



DEFECTIVE TEETrt.. 8.3 






EVE DISEASES. .5" 



EAR, KOSE & THliOAT DISEASES 2.i 



RESPIRATORS DISEASES. ,1.8', 



CARQlOVASCULdR DISEASES 3.8:; 



s 






VENEffEAL DISEASES. .1.5, 






-Vrr ----- ' •/--—-• 



^M 



MUSCULO-SKELETAL DISEASES 3.3!, 



FOOT DISEASES 1.5 









OVERWEIGHT £ UNDERWEIGHT 1.3". 

OBVIOUS DEFECTS i% 

OTHER MUSES 4^ 



IS HEALTH YOUR OWN BUSINESS 
OK THE NATION'S? 



WHAT ARE the flchicvcnicnts o£ American mcdicitie? 
III. it? Fervkes rtflch the pe^»[>le whc; need Ihem? Is the 
h:iJ:tlc af>:Linb;t sickness ;i pulilic f|uc-stii.n Iik<^ ihc ^aUle agaLnsl 
illiteracy? Wh^it rolo [^houl<t lf>cal, i^lsite, and naLioiia.1 gcivcrn- 
menl ;igt?ncies play in !iup[kl(.'ni(?iuiiig private cftV>rt? 

A widely accepted ansiwer tn the first two (jue^ticns wa^ 
given by the Senate Suricotiimitlee ou Waninie Health anfl 
PMucatinn (tlie Pc]>per Cninniittcc) when it sa.id in its report : 
^■^Thc ijuality i>i American medicine at its best \s very high. 
UnEorlunalcly, AmcrkaTi medicine at its best reaches only a 
■r-elatively small part of the psipulaticin." 

The other f|ucstiinis — <Mi the ^lake (if the g^cnernl pubhc in 
preventing' ill health and the rule uf gi>vcrrmen1 in the strug^j^lc 
against disease — are not ne^v ones. Community responsibility 
for public health has long been recfif^niKcd in laws and ordi- 
nances for sa.nitaCion, food mspeetion» and the prevention of 
communicable diseases. Docft public interest also extend to 
briiig^in^ better medical C^rt of iill kinds to nlore people at 
less cost? This piiinphlet presentt^ some of Ihe most widely 
discussed ^>rognim:^ fnr national liealth and the arg-um^nls 
pro and con looeJiiiig ihem. 



What ^irf^ some of tlie facts and figures lhn.t have made the 
issues scciii tsKi impurtanl to bu Itfl u.r privale etiort or to 
piihlii' litiiUK a^cnties aa they now enlst? 

Jti 1935, more thmi 23 million people in the country had 3. 
rhroiiic disease i>r a physical impainnont. In spite of tr^fmen- 
ilniis advaiK'Ci; in medkal scicnc-tj iht death rate amonj^ low- 
inoomt ^runpri iti our large L'ities is still as. high as ihe national 
rate fifty years ago. Deaths among" mother&and l>abies could 
be out atjout one-third if all gol grsfd medical care. 

The £aot Ihat struck hardest and startled the pub^c most 
was the revelation from the Selective Service figures ihat 30 
percent of the men of military agrc were unfit for general 
military duly, 

The gap hctwccn "what modern medicine has to offer and 
the kind of medical care peoi>lc acHially receive is usually 
blamed on tAvo things: people's inability to pay for j^i^od 
medical care under present arrangemcnls, and the way health 
services are org-anizei!. 

Modern mvdicine contes high 

Modern firsl-class mcdica.1 care is necessarily an expensive 
comiiKidilv- Many pc'f)ple cannot meet its lu!l co^t reg^ardless 
of the method of payment. The cheapest medical and dental 
service conijiutible with good tjuality and high standards 
would probably cost about $150 a year for the average-sized 
family. FmjI studies of family .^j^cnilLng ir-how that most fiLmilie:i 
under the- 3i2,()()0 Icvef — or about half our population — simtjlv 
cantiot pay a full if 150 a year for this purpose, If their medical 
ncedf; are t^i- be fully me-t, silch people need as.sis-tftnCC. As >t 
slaTids today, people in low-income ifroupi=, though they have 
twice as many day^i of sickne^j; as the well to do, receive only 
about half ai^ much pliysician-^* care. 

Not only does good medical eare cost a Tot, T>ut the need for 
it cannot be predicted. If you can't foretell when illness wiH 
strike ur how serious it will be, how can you prepare to meet 



its costs? Many a famUy able lobudgel $]50a yearformcdlcal 
expenses is sta^'^gcred or finaneially crushed for years to come 
by the cost of a sirgle serious illness. Moreover, having to pay 
a fee for the (luclor's services is a frighlening^ prf^3pect to 
people whcise incomes barely cover hving expenses — so they 
often put off goings to the (loctor. Thu5 they lose the benefits 
of JjrevCntivG mcaslircti, early diagnosis and treatment, and 
perhaps have to pay m^re in the ^^nd, 

Fortuiialely, though jk^ one Cian predict when or how seri- 
ously an ir^dtt^t'dual "win he sick c>r injured, the frequericy of 
such i\\b can be figured in ndva.nce with reasnnal>lc accuracy 
for grjmps of people. These facl,^ led the Pepper Committee 
to conclude: 

'■'TIlc 'pay-as-you-'go'* or fcc-for-scrvicc systcnt, wbicli ts now 
the pr(!(lonniiant inctlaod of payuiciU for medical scrvict^s. is nut 
well suitecl lu Ihe iiee(.!s (.>f iitcisi prypli^ or to tliy wide.sl ;)i>s- 
BtbJi! distTibution of hif!li-(jualiLy mei^icaF c-are. ]t Ietu^s tii keep 

peOf>l« away fw^lil the ■di>f:t<>l' UdliT llhli:'^*! li^5 1"c^kf:li(c| ij dlrtj-u 
V'herc Ir-L'alnicnt is Iil^cly lei lie jirolonpcd anil medical bilts 
large, U lictcrs [>^iiciitH from Mcckiii^ services 'v^liich a.rL- sojni:- 
times essL-ntiirii, svich as s]ftLtirilisi cart, Iftlwraiory and X-ray 
cxaniina.1ions, anti tiospilalizalion. TnilLviJuald with low income:^, 
whose nccil is greatest, are. more likely to postpone or forego 
diagnosis and treatment." 

Healthy ueahh^ and geography 

Cost is widely rect agnized iiis a barrier between individual 
people and the niedieal services they need. Another <liffieulty 
is that people in some parts of the country don't have enough 
cnedieal services nt hand — regardless nf price or abilily to 
pay. The extent of health Kcrviees actually available in dif- 
ferent parts of the country "varies according to the wealth 
of whole communities. Counties, cities, and states ^which are 
well ofif have enough doctors, niirses, and htispitals, and 
aderjuate public health facilities; those which are poor have 
desperate iy few. 

]n New York State before the war, for example, there was 
one doctor in practice for every 500 people, while in Mississippi 



Five states and the Diilrtct of Columbia , whose 
overage percapilo income in 1940 was $814.^ had, 
per 10,000 pofivhtion: 

15.7 DOCTORS 
6.9 DENTISTS 
32.6 NURSES 
45 HOSPITAL BEDS 

Seven poorer siatei , wJtose overage per coprfa iir- 
<:omelnl940wQs$303..h<i<},perW,000popitlaUon: 

7 DOCTORS 

2.3 DENTISTS 
10.4 NURSES 
24 HOSPITAL BEDS 

1 Rhode J(/ond, Dittrici of CttSvmbitt, New Yoik, N*w J*f»/, iSiinois, 
1 Ktntvcky, W*ti Virgini-a^ Ncifh Candina, SotOh DtAoiOj £auffi 



lher€ was otie for 1,500 — e^caciLy three times the number of 
petjplc to bo KGrvcd by each physician, Mureaver^ ihe density 
u( population in Missist^ippi is about one-Lenlh that of New 
York, so that not only does each physician have more persons 
to serve, but on the average, he has to travel farther to 
serve them. 

In New York there was one general hospital bed lor every 
200 people, biit in Mississippi nne to every 650. Variations 
between counties are even more striking — 17 milli^ni people 
live in l,i^OO counties that have no recog"Tii/-etI general hos- 
pital at all. Thus, where cummuuitiea are too poor to attract 



sufifirient ilnclors or lo Ijiiilil ;in«l ntainlaiti uiIilt lieiillh fiicili- 
lieSj noL only do the Tiecdy Iklvp in gn wilh^ut i^eccssary 
mc<ikaL services, bat ro do thu&c who can afford to pay but 
cannot seek care elscAvhere. 

Health services are unorganized 

Even the best g-<;nernl praothioner cannot aikqualcly cope 
with emergi?iiciej; ur with baflling and cnmplicfiied t-nses if 
he does iint have lhe resiMirre^ of :i vvell-ef|nip]ied hiis;iiiKi3 
within reach ntu\ does not b^ve ro!lc;igucs in surgery and the 
other s]K'ci:ihies. avail:ii»l-c wdion needcil. Iwen where ihere 
lire ftrst-niie hospitals, the general pni-ctitiontfr may not liiive 
the right lu lI^;e iTiem. In lialiiniore, for ex:iin]>1e, alnKisi balf 
the general practitioners cannot care for their patients in 
hitspitals. 

Specifdists usually set up offices in cities of 5;onne si?:c. They 
:ire not easily ncccssihlc to cmintry do* tors or country pnticnts. 
Moreover, .sjiccinlists are not as a rule organized lo wiirk in 
cumbinatiiin wilh i;eneral ]>hy^i:cians- Such teamwork can be 
found, however, in many of the leading; hospitals and clinics 
where medicine is tanghl and in the outslandini*- ^mup Jarftctice 
uUnics snch as, for example, the May* Clini-C. 

In today's medical schooU Students are traine<t under a 
f^Y'^lf^rn oi" ^roiip medical prjiclice, ccutercd about a hoy]>ital 
ivhere th<; bef^t available e*[ui.pmcTit and teehnUjuei^ can he 
eiTi|iIoytd and Avhere the combined skills of a varielv of 
KpecialislSi can be brous^ht to bear on a pu^.i'-ling case. Yet 
when they graduate, they go out into n hind of isolated 
|ir:ictice similar to tb:^t of iheir grandfather^;* tlay. That this 
is ]>Tnfessio]icLlly nnsatisfattdry to jdiysicians is ^bown by the 
fact that over half the doctors in the Army Klated that ibcy 
vt'OTild like to go into group practice on returning to civilian life. 

To sum up lbc problems nf American medicine,, then : 
Americans receive the benefits of medical science In a very 
uneven manner, partly because of the high cost of modern 



nicdicme, partly because medical services are in>t org"aniKed 
to serve everyone e<£ually — rc^'ardlcas i^f ^vhere he happens t<i 
live or hr>w niinrh hc can {yay. 

Clearly, then, ihe pnvblem of paying [or health servkea is 
very <:c:>mpleji. C^n some way be lom^d for families lo budget 
ihcse costs aifi-d to assist those families which ca.nnf>t reason- 
ably afford th-c total costs? And can facilities for rendering- 
he^ihh services be mafle more efiually available in all pans 
uf llie country? 

What^s to be done? 

Prc.sidcnt RoOiScvck, in his "economic bill of rights" put before 
the nation tSrly in 1944, inCinded "the right to adequate 
niedicfll care and the opportunity to acJiieve atid enjoy good 
liealth," Wendell \Vi]llci<_^ <lcclarcd in 1944, *'Com;)let<.^ medical 
care should be available to all." Secretary Wallace recently 
said^ ''Your federal and stale govern tJients have just as much 
respnnsibiHty for ihe heaUh of their people as they have for 
providing tbcni with edncatiun and police and fire protection." 
Goveriior Thomas l.*^. Dewey appoinied in 1^44 a coinmission 
on medical care '^in order to devise programs for medical care 
for persons of all j^roups and classes an New York Slate/' 
Jn his special message nf Novemher \^, 1945 asking Con- 
gress to adopt a five-point national health proi^'ram, President 
Tnin^an said, "We shuuld resolve now that ihe health of this 
Nation is a national concern; that financial harriers in the way 
<jf attaining- health ^hall be removed ; that the health of all its 
cilii'.ens desc^rves the help of all the Nation." 

Thus leaders of both political parties have followed the de- 
mand oi farm, labor^ and business or^ani/^ations and of the 
[iiiblic at large, aa -shown in various opinion polls, for art 
improvement in the i-vay medical care is distributerf. 

Some professional medical organizations echo the cry. The 
American Public Health Association, an organization of physi- 
cians, nurses, saiiilary engineers, and others engaged in public 



l^caUh work^ n^loplcd in Ihc fjil! fjf J944 an official poliuv ^vlli^:h 
.^t;ilc^ Lhill ";i iiLiliuniil pro^ra.ni lor nictlitiil care nSht^ulii inak\; 
avuiliil.^lc l^> th^ ciilire iW']>ukUitJTi, reganiJe^.^ oj the fiimuvinl 
int'iir).^ i>j the indivUif^d. ihc ftimity^ i>r lf*e- oomnmnity, ;lIJ csftcnti:il 
prfVL'iilivc, (iiiiyiinslic uiu] curalive servicer." Tlic American! 
Dontiil ^VsscK'iatiiiii has dccl;ircd lliat "clcnt;!! czirv t;lif>iilrl l>i? 
iLviiihiblc lo all^ rc^iirdlcsa of incoTJic or ^cu^'raiiliic localiini." 
'J'hc Anierifan Medical Assofiation^ r*?pn?st?fil^ng the niiijorily 
■f'f ^irivalc jiniclilinrnfrs and <iii llie rccnrd rts :t vnusiMVuUMr 
lirofcssiiiiial nrfi^tnixnlinn, imw rrcnj^ji/t?; thu faci thai llit^n- 
is a jjrnlilcni in ilic liislrilmlinii iii" medical cart-. L'p l<i :i fi^w 
vcars ;ij;u, it riflcn asserted llial. cxLC]>t in iyolali^d instances, 
evervnnc ncciliiii^ medical care was alvk U' ^ci it, liy paying 
fL^^ it OT ihruuj^h cliuriiy. 

WHAT DO PEOPLE PROPOSE TO DO 
ABOUT THE SITUATION? 

AmiiiJU<;ir a great many jicujdc kjiovv thai ^.v^^ys must l>c fuuird 
s'l Ihat everyone can sern/v ^iiod medical care more ra]ij(lly 
and i^aj ior il nsorc easily, there is t)\> siidi afifreeincnj imi 
just h*>w this shijuld Ik: dtme. Jn ]jartieu]a.r, opinions vary a 
^o*>d di^al on the ij^iJvernmeni's role in the fnUire of nurdicri3 
tare. Some think no further ^-^nvcrnnu-ni aclivily is necessary. 
Others thiTik UiUI UiO government mual play a l>arl, hul ddTcr 
:i!i to h->\v hi^ that part t-hniili3 Ik:, l*n>i>osals ran^c fmni 
\:iK siqipurt for .such limitt'd imrpoi^es ils school licallh fro- 
;i^rams, t-^ a com]>k'lc naliuind he^iTth |>n>^--riirii j'airl fur ihrou^di 
nali(>ri:i] hu:dlh iiisnranee :im] ji^-'t^nc-ral tu;< ftJii'ls^. 

iffmda off^ Go}pvrnmentl 

\'\-i:^i.-\\\ j^nvernniental activities in providing; hcalili s^Tvices 
are j^fciitruHy JicCe|ited. JCaih -Am^Tivan cili:^en .-^i^ends ahoni 
a dollar a y^;ur for c«>iili"ul o£ c<»ijt[Lf^i^>ii;H diseases^ insUiIlatiiin 



of pure milk nnil water snjiiilits, Jintl other pnblii' lu'Jilili 
services. J hat <!">li;ir is eonsi^lered a giK>d iiive?hneTil. Thi>u^h 
stalc-;>iipi!urlc<l hn^|>il:ils for aiicjitaJ illjicss aisil tiil^crculosis 
jirc iiomctinics triti4;i/.ed fts iTisxifiicitriU, iio i>iic wTtnts ihem 
cliiniii;ilc"]H Kathcr, ]nil*ii^^ prcsL^itrc \^ for tlicir impn^vtm-Cnt 
;tTi<l i-'^pansifni. S" t>ii ihn-ti.i^^h ihe Itm^ ]isi of I^hmI, staio, ;iinl 
fofleraliy Jiiipjirirled hesiKli i^crvicts. 

Yet. :it fir<iX, alinr>!^[ all liix-suyjported scTvkes met violcni 
r»p]>TisilioT3 fnsm sLmall f;"riiu]w whnse interests were temiioriinlv 
rtrkcU'il. Wli^n, fnr example, Ihe leslin^ "^jf 'lairy cattle for 
Uil'*!r< iilusfcs as a mean*; of keejiiitj^ c-rmlaiiiiiialeii milk from 
the mark-els "vv:ts pnjposc<f, dairymen hittcrly opposed it. They 
said thai any such measure wotild mean politicaT control and 
regimen la lion. 

Siniilar prolc^ls have frcqticntly cnmc from representatives 
uf the medical proft^s.sinn, ^vll(a usually t>iipose the extension 
of taK-suppnrtecl health -seTvi<.xs, Jn 1^44. for exaiiip!e, ihr 
j;^ovcrnTnj:: hi^>dv of ihc Amenran Medical As^orlaliun, while 
reC'K'ijii'.iil;^ iho nt-cd Ist iniprovtd early diagiiOi^iti anJ treat- 

SICKNESS COSTS FALL UNEVENLY 




S 



nierl of lubcrciilopis, dkl not fav-i>r inCre;idt<] fedcrill r<^spOTtsi'- 
bility in this field, :\m\ rclLiscd lu KiipiK^rL u l^ill in Cu7igreys 
extending fcJ(?riil fin;iiiLi:il :»i<l tu the ,^laLe*^ ft>r the conlrul of 
lubcrculo^iy. Aware U^at under prcseiU coiullliotis over ha.lf 
lli<? piitkvity rulmilK^d io liibcrc^nliiyif^ hospitiila iirc ;ilrf:u3y in 
:in advanced slugc i^l ihe diticaso, iiioi^t public htaKli (;;<|n?rts 
cnjisjdcri?<l Uii-i bill a vilal mcar^uro tow^trd the ullimalc u'i]>in^ 
oiit of tuliL^rculosiK, Jii F;[>ilc tif the position taken by IIk: 
American Medka! AssncKillon, Congress passed the htw wUli- 
cjiit a dissenting vote one week letter. 

The A,M,A_ today is slrnn.i^ly opprwcd to any form of 
jfnvernniciit-Kpnnsorctl hcaiili inMiniruc fni the ground that 
it vvoidd brin^ ]>Qlitkal cnnLrol of nicdieiiic and inicrfirre with 
the personal re]atioii,ship helvvccn patient and physician, b^^r 
^onie years, tht A.M.A. has heUl thfit the intimate bond 
between patient and ■i>hy,skian is threatened or dcsin^ycd when 
the [jatient himself docs nrd pay his doctor <^n £i fet:-k>r-j:ervire 
lii^fsid. Yet. ihe A.M_A., yielding io public iTO^stirc U^r an 
■Cii^ii^r way f>f J^icctiiig sjcknei^s costs, now snpjinrls voluntary 
health insurance run l>y eommereial coTVipaine!^ or by mcdLeal 
Scscjctjej;. This is :i reversal of it^ position of ten years ago 
when the A_M_A. cditoriali:'-i?d a,i;ainsl proposals for voluntary 
Jicallh insurance as measure!^ of ^'stteiaJism and conimiinisni 
iiteiliiig to revotution." Tn July 1945 the A_M_A. <k'ciare<I 
hs position in a pnigrani, sum3na.rized in a later seclion of 
this pamj^hlcl- 

Voluntary insurance against Ihe eosls nf hnspit:dixa1ion anJ 
physicians'" s.ervkcs has, however, had a crmsiik'ridjle ik'vebip- 
nienl in Ihe Uniled States. The oldest of these insurance plans 
are those or^ani^^ed in certain industries, especially in mines 
and railroads, which often ojserale in reniolc rejjions where 
medical services are scanty. Usually, a nnjothly deduction nf 
a dollar or two is made from employees' wa^es and a like 



amount is oftCM oyniribnted by employers, ThtSt funds art- 
then ponied anrf are ^scd to pay for the medical care which 
may he neeiied ]>y the cmplf^yee. Employees' fairillies ar-t 
sometimes bui not generally included, i-^ew new plans of this 
type have been started in recent years, although one has 
received \vide alieniion^ — thai organized at the Kaiser ship- 
yards on the West Coast_ 

The largtrfiit recent tlevelopment in voluntary insurance has 
l>een tnr hnspilali/anun, esiiecially ihe "'Blue Cnjs:^" plans 
apprnved by the American llo.spilal Assr)cia.tifjn. IjIuc Crnss 
subscribers arc enlisted vf ilunlarily frcm amonf,'" empluytc 
5,'^roups in the eomniuiiity. Snb^crill■c^s usually pay about $24 
a year lor insiirance ihai ctiverti h<>sf>itabi'.aii<in fur CTiijjbiyees 
and their families for a period oi three to fiiur weeks a yeiu. 
The Blue Cross plans have expanded in ihe ]^asl ten years 
iTiiTti less Ihan a rnilli{m subscribers to JUorC IhsiM IS tnillioii. 

Plans hiive aUu betn urganiiitU U» ii^-^ure the eosts of pliysi- 
ciaiis"" &;ta"vi<:es. These have not been so succej?sful as the 
hoypilalizaliitti insui"ailCC plarij? ]>ut have neverlhele^^^; fjrnwii 
*nt Ihat they no\v enver ahont 4 or 5 million people^ chieH}' for 
services limited tij surgical <jperalions and obsletrics. 

Volunirtry in^uranee plans have also been developed for b^v 
KUinne lanucr.^, under Ihe sponsorship nf the Farm Security 
A<lmiTiistr:iti^m, and about 3(30,000 rnral inh;ibitanls :ire now 
iniluded in them. Farm families generally pay about $2,"> to 
$50 a year in these plans and receive limited medical, -surgical, 
and hospital care. 

Commercial insurance companies have m;^dc some progress 
in scllinfj jiolicies lo cover the costs of hospitaUi'-ahon. sur^^ical 
and obstetrtcal care. Usually these policies ;vre taken out by 
employers for iheir employees and their families, l>i>th em- 
ployer and emplovce making; monthly ■conlributions tn the 
fund. Approximn-Iely 8 millirm persons are nnw insured under 
such policies. 

The success of voluntary elTorts in i>rn^Ldinjc insurance 



again?3t the costs of medical and hospital care has encoiaraged 
snnic groups to Elope that all the major problems of health 
mid madical care can be solved by voluntary measures, without 
Che participation of government- As mention<;d above, the 
American Medical Association takes this point of view. The 
United Slates Chnnihcr of Commerce also advocates further 
trial of voluntary methods. 

Others leel that voluntary insurance, whether it is under 
the auspices of nunprutit organizations ui physicians and 
hospitals ur of commerciikl insurance companies is too limited 
to solve tlie problem. They poinl to the fiict that, despite the 
rapid growth of some p3ans, not more than 20 or 30 milHon 
j>er5ons are subscribers to such plans in the United Stales 
up to the present time and thai the insurance coverage of even 
these persons is largely confined to surgical, obslelrical, and 
hospital cart- 

yiiTlhermore they olTer Ihe objeeli^m that most existing 
vtjluntary insurance schemes include no general mtdical e>:- 
peiiseSf no preventive ^:are, and little fLimily tare. They feel 
that such insurance provides no incentives for improving the 
(|uality of medical practice and that its cost limits its sale 
to a rather nnrrow section of the population. In the case of 
ccjmmercial policies, they say that it is no great bargain — 
companies on the a\cra^e pay out in benefits only about half 
of Avhat they receive in premiums. 

Those who believe that voluntary efforts cannot fully solve 
ihc problem emphasi>:e two difhcullies encountered by such 
Tusurancc. In the fira^t place, voluntary plans, Ifv their very 
nature, face the problem of securing and retaining subscribers. 
There is an inevitable tendency lor heahhy faniihes to stay 
out of the plans and for those inclined toward illness in enter 
and remain in them. This fact is ai>l to bring ahout fmaiKi^l 
difficuhies. Because '^f thc spotty, uneven coverage of ihe 
]>o]>u1atio!i, Ihe healthier familicj^ do not bear a full share of 
the costs. The second rfifFicullv is that, it voluntarv plan^ 

n 



cha.rgc tiigh citim^'-h premiums lo cover ihc costs of complete 
incdicul aiul liu^|>it;il care, they arc so cxjieiisivc tliat the 
luwer-ijictmie groups, who need this care ihc mi>st, cannot 
aJTord lo subscribe. 

Government aid for sp&ciat programs 

George AVashington was Kiill alive when ihc M;ir]nc Hospital 
Service for sick merchant seamen (now the United Slates ] Pub- 
lic Hciihh Service) was esiabHshed, Since that djty a variety of 
lax-suppurlcd health services have one by one been added to 
the fuiK-lis^ns <jf government. Local and stale ^nverrmenls 
and, to a jninor diegrec, the fef!cral E«verniiienl provide funds 
ftir a large number of ho^t>itals, jmblic hcailh servicer, and 
nitdical care [iro^rams. Thetie fundi may be uscfl cither to 
\;umbat particular disesi^es, such ;is malaria, tuberculosis^ or 
syphilis, or to give all types of carC to certain ^"^roupi of the 
population, for in^Umce, vcK-r^ns, ruen and woruen in the Army 
and Navy, Indians, tjr the needy. 

Thnt such government programs can be succcysfui in de- 
livering medical service of higJi cjucility is attested by the 
hrilltaiit record of Army and Navy medicine in \Vt>rld War IL 
Oflicial recur<l:> (ft the War iJepLirtmt;rt t^ho^w, for example, 
that whereai S.3 percent <»t the hospitalised wnundtid, exclud- 
ing gas ca^ualliea^ died in World War I, only about 4 percent 
died in this war. Althtmgh warfare in the fever-ridden tropics 
meant an iiicreast! in the number of men huspitalized overseas 
for disca.fie, the annual deaths from overseas hospitalized illncs.'; 
amounted to only 6 per 10,000 men, as compared with 12S in 
\V%>rld War L Deaths from hospitalized illness in the conti- 
nental United Stales accounted fnr another {> per 10,000 men 
in contrast to 156 in World War I. 

Such results are to be explained, in part, by recent scicniific 
developments like penicillin, the sulfa drugs, use of phisnirt. 
) M >T, and airborne evacuation of the wnuuded. But even ihc^c 
discuvcrici could not have been made effective withoul Ji^ood 

12 







jd 



organizaiion, good direction, g<Mjd e^inipmcni, goot! cEoctors 
and nurses, and good use of doctors and nurses. 

Not alE govcrnmenl-ajded medical jjrograms have the en- 
viable record uf the Army and Navy^ but they have met 
important special ncedi. Nevertheless, for the total civilian 
population, these special programs do not meet other equally 
pressing needs. There itre^ and ,will continue to b*, all sorts 
of proposals to fill in th^ gaps between existing lax- supported 
services. 

The new tuberculosis control law is a good illustration of 
how an established state program can be expanded by the use 
of additional federal fnntk. An all-inclusive service oi early 
diagnosis, hospital care, ;ind rehabilitation is being developed 
froni a meager program of treatment- 
Venereal disease clinics in a way fit into state mental hos- 
pital programs. Early discovery and treatment of syphilis, 
at a clinic can free from this disease vast numbers "whn mipht 
otherwise end up in menial instiiution:^ twenty years later. 
Other diseases might be attacked in the same way through 
use of tax funds. Rheumatic fever, for one, which every 
year kills more children than all either childhood infectiouji 
disea&es combined, might be much reduced in amotiot and 
severity by a concentrated program of attack. 

Government aid -will utidoubtedly be requested for other 
special groups fjf the pojHilaiion. For example, tax funds might 
be sought to help Tieedy parems provide their children with 
the medical and dental care recommended by school doctors 
or to help care for the needy in nongovernmental hospitals. 
The necessity fi)r many siich ^^pecial programs is general5y 
recognized. Few attack them as undesirable, yet 5t js fre- 
quently felt that approaching the problem of medical care in 
this piecemeal fashion, disease by disease or by one special 
population group after another, is unsound. This approach, 
it is said, has led in the past to a piling up of ageiicies having 
to do whh medical care — some local, some state, some federal* 

14 



Each has (liiTcrcnt standards anil (liffcriniej prnccdiircs ittr 
the pnlii^iUs Uj 3^11 thrtjugli before 5c-curin|^ tiirc" and which the 
doctorii must follow Ijcforc gelling \m\(\. Many, such as puh^ir 
city hospilals. are siitl run ei,s charilies whith most iK-npSc usli 
only ^rt a l^^l resort. 

'J as-sni>;KJTlcrf services are so scattered and Uneven that 
niOiSt people don't fvcti kiKj-w whuh ont:S ihcy ar<; cntillc-rl 
to \t^Q .If hf>w I" K" ^d^nui gcilLnj^- ih^m. L."nHcr most j^uch 
programs, ihe paticiU mti-^l \if effect jn-nvc that h<: is entitled 
to care not just l>c-L'a.uwe he ts j^ick, but hccatisc he is eligible 
to beenme a heneficiarv unvlcr fi'^me prirlirnlar l;iw_ 

As new health jin)granis are added, critics of the ])iccemcal 
ap]»rn:ich maitiLain, it \^ iiicrcasin^'ly itn]>iirlanl that they fit 
int(t an evrgnnizcd system and not brinj^ ahmj^ their own 
|uirtit'iilar brands of red ta]>e. '"There is nn functional or 
administniUve justification/' says the American rublie TleaUh 
Asst)cialiun, "for dividiiijj human hcin^s i>r ilhies»ves into 
many categories to be dealt ivith by numerous independenl 
administrations," 

The A,M,A, has h'nj^ maintiiinetl that all federal aclSvllies 
in the field tif health should be hroughi tugeihcr in a single 
government agency, headed by 3 cabinet member, insteati of 
being scaltercil amonj^ tliflcrent departments and a^CTicies. 
Such a miive mif^ht be betjclicial in lying tn^ether .some <if the 
federally supported services, -vvhich, except fnr the Army and 
Navy, fonn a relatively small part of all laK-sup5>(>rted aetivi- 
lics. r^ut many feel that nn fundamental thanj^e would he 
a<:hicvc-cl by such a move ah>ne- L\i-nfu^ion in the administra- 
lion of exi^Tting' htEtUh servJCti^ is- the iiievitahle residt of tl 
variety of laws an<t allocations for strictly limited purposes, 
Ihey say- I'jitiS u perwan la entitled to medical care just 
hecaus-e he is sick, and mil because he is a ^ick sol-dier, or a 
asck Indian, nr a sick orphan — until then there is bound to 
be a variety of standards and procedures lo fit the needs of 
each separate program. 

15 



So, while RDinc gJ"OUps want no further g-ovcrnment action 
and others see the role of government limited tu special pro- 
grams where there iirc certain dramatic health needs, still 
olhers feel that an over-all national health program is the only 
satisfactory way to assure good medical care to all who need it. 

A nalion-iride fiealih program 

What do ihoic who want an ov^^r-Eili health service plan 
have in mind? Two reports have recently been published 
outlining- the principles under which the respective backers 
believe progress in natio^ial health can best be achieved. One 
is a slatemcnl: of the Ameri-^'Clfi I'ubhe Health Asso-eiation 
(A.P.H.A.), a secorid is a rep<->rt of the Health rrograni 
C-anferem!e, a group of physicians, economists, and others 
interested in progressive health ;iJaTining-. These are not^ of 
course, the only dcK'uniejiti^ ever Lirought cnit in favor of a 
national health program. The demand goes back many years 
and has taken many forms. These two reports are used to 
represent the all-out program here because they arc recent, 
eomprehensive, and authoritatU'C. 

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

Why national? 

A comprehensive health plan must be rational in scope, accord- 
ing to the views expressed in both these reports. Health 
programs organized on a state43y-state basis, with no federal 
aid, they mainlain, would fall into ihe same unequal pattern 
as at present. The same economic factors which make some 
wealthy states able to maintain good jirivate and public health 
facilities would also lead to successful health plans in these 

J6 



iLrcas. And the relative poverty u( uiIilt stales, which is in^v 
rcilccted in iheir scarcity u3 doctors and hospitals, would like- 
wLsf mean very iTKnIc(|iiatc health plans aniung ihera. 

The A_1\H-A, and ilculth I'rograin t'ciiifcrence reports iilsih 
maintain that certain iiaiional slandanis arc necessary to make 
sure that the quality ni mcdicEil service everywhere meets at 
lejLSi minimum reffuiremeiits, liecause people in our country 
are alvvay,^ mi^vin^' from i»lace t<i [ilacc, iiaii«Mial :stafidards lor 
ihc amoitnis and methtida af payment to ho^spitiils and doclurs, 
c(jnditioTis of .service, and adjuslinent of complaints would also 
be desintble, they say. These, however, should be adniini^s- 
lircd \i) a wiiy t}iat wnuid tiikc account of the dill-ereijtes in 
r<^(|ij]rtiuciil^ btlW<^tn varic^tlS |>artd of the niitian, they agree, 
because a health program in the? hiHs fif KeiUiicky» for iriiilartce, 
would present vastly difierent proMcms from ^ health pro- 
gram 111 S(;allle. 

Critics of a nalional pro^-ram say that it would mean regi- 
mentation. Jn iheir vicWi it wijulil he better li> have stale 
programs^ even granting thai the people in some states would 
be far better served than in niher.s, rather than lo run the risl 
of rigid government nmlrol. 

Both reports assume that goveritment regimentation is by 
ni> means incvitalile if, in the framing^uf laws, flexible adminis- 
Iration \s reco]t,nii/.etl as all iinporEanl. They a^^ree that actual 
(il)eraliou of :l health program must be directed larg:ely in each 
individual community and state, and the program should be 
responsive In h^cal ii«eds- Strictly medical matters must be 
kept in the hands of the niedical y>rofession, which alone is- 
vinnpctcnt lo ^et medical standards, they say, and t|uestions 
i>f public r<»necrn, such as financing;" and distribulitm t.jf services, 
must be in the hands of the pultlic. 

C'cncludinfj ihaf a wholly satisfactory health prof^ram musl 
be nation-wide in scope, the A.P.ll.A. and the Health Program 
C'onferenee reports go oti lo oirtline what seem to them the 
essentials of any sueh pliiti_ 

17 




Scientific RfSfARc+i 



WHAT ARE THE PILLARS OF A 
NATIONAL HEALTH PROGRAM? 

Five key pillars are necessary to siipptirt nalional heaUh^ 
according to these reports. Tht^y are: (1) distribution of the 
iMSls nf health services, (2) eslalili&hrneiit of hospital and 
liublii: hcrilth f:icilitie&, (3) organisation tif medical services 
Hi promote a high quality nf carL% [4) :i(hiiinislraiion .satis- 
factory lo patients and the profovsions, and (5) promotion o£ 
continued scientific research and education. 

Distrtbuiion of cosis 

.Starting out with the twin assumptions that the present indi- 
ridiiai ]iav-as-vou-go method of meeting medical eosts hrks 
proved itself unsuited to the needs i>l the p(.»puhition a.iid that 
-vohintary insurance is too limited in scope^ advotites of a 
national health program recognize two a.lternative ways of 
meeting; mcdicEd costs. Both methods oi payment iire bastJ 
on the fact that while individuals can never predict when they 
will l>c r^ick or how expensive their illnesses will be, the 
expected 3ncidenc<: of illness for large groups of people and 
its costs can be fairly well determined. By chipping in 
rej^ularly to ti common pool Jimountfi which are fair in pro- 

J8 



portion to his inconK, e^ch member of the large group can 
be sure that there will be funds to ^my for his own health 
needs, whether large or small, whether ihey occur next year 
or tomorrow. 

The first alternative is a system of national hcallh insurance, 
■combined ^vith support frnni general tax funds. This methnd 
as advocated in hoth reports. National health insurance is no 
new thing, in fact it is in operation in thirty-one nations. In 
fiotiie it is <>ver fifty years old- It works like this: Employed 
peopl"? turji in a certain part of their wages each nKi:ith. 
thrciu^h payroll taxes, %n a grovcmment-administered health 
insirnincc fund. Empl-f:iyers match the ^mounts- each worker 
put^ in, a.< nnder Sot^ial Security in the Vnited States. When 
sickness slrikes the wage earner or bis family, doctor and 
hospital hills are paid out of ihe ius-uraiice t'uud. 

Insurance of this type was designed orij^inally for the wage 
earner^ whfise preniitims can be easily collected through pay- 
roll dednctirms ^nd for whom employers can also make their 
contriJiutiojis easily. Such health insurance m other countries 
has seldom been a-vailable to farmers^ people "who run their 
own small businesses, domestic servants, and other similar 
occupation ^o^roups. Health insurance on this plan docs not 
touch the sickness costs of nonworking" people — the unem- 
ployed, the aged, the chronically ilL Fur this reason both the 
A,P_H.A, and the Health Program Conference reports re eom- 
meiul llial, if national health insurance i^ atlnptedj it be supple- 
mented by general tax funds to include all groups of the 
population, 

Th« seeond alternative method of financingj suggested by 
the A.P.H.A-, is that the insurance features be forgotten and 
public health services be paid fur simply and solely out of 
taxes^ust like public schouls. This, it is argued, would in- 
volve far less red tape. All groups of the population would 
pay for their health senices by the same kind of taxes. The 

IP 



amoiinl w*^uld vary accor^ting to ^he particular cir^ittistances 
of the jndividyaL, Great Brimin, which hay had naliunal health 
jtisgrance yince 1911, \s planning a system in which two-thirda 
of the costs will be financed through general taxation along 
Ihei^e lines. 

Whichever may be the better v/ny of enabling people to 
pay for nicfiieal care — whether by health insurance combinerf 
with taxation or by taxation alone — the reports of the A.P.H.A. 
and Ihe Health Program Conference agree that as hing a*i 
payment is made in the manner of loday^ the ""right Lo achieve 
and enjoy g<iod health" will not be truly available to all, and 
that some such nation-wide solution must be found for the 
protilcni. 

lUu a method of paying for medical care is only part of the 
story. With a ihousand dollars In his pocket, a man on a 
desert island with no doctor or hospital could still not get his 
broken arm set. Both the A.P.H.A. and Health Program Con* 
fcrence plans emphasize the need for const ruction of facilities 
in areas which lack iJicm and improvement and cnlarg^ement 
of facdilics Avhere they arc inadequate. 

Fficilitiei^ and personnel 

The keystone here, according- to both reports, is the hospital. 
A hundred years ago the hospital was mainly a place for the 
sick poor to go^ often only to die, Today^ the hospital is a 
place to which any sick person goes to get modern treatment, 
and it is a place where he expects to get welL 

The hospital is indispensable in pracLice to the provision 
of good medical care — ^yet 40 percent of the counties of the 
United Stales have no recognized hospital facilities- This situ- 
atioTt "would be bad enough in itself; yet it is also reflected in 
the number and kind ol physicians such counties can attract. 
Young-er physicians whose eilucation and training is cetilered 
in well-ef|llipf"ed and well-org-anized hospitals cannot praetiec 

20 




21 



the kind of medicine they have so painstakingly learned in 
school unless there is a hospital to work in. 

The result is that counties with no general hospitals have 
only hali as many doctors per thousand inhabitants as counties 
of the same incoine level which are generously supplitd with 
hospitals. Since counties lack hospitals directly in proportion 
to their inalnlity to support them, those wlio favor a national 
health program think that federal funds should be used to con- 
struct, enlarge, and niodeniize hnspitaLs in the poorer counties. 

The AJ*.H.A_ report, in addition to urging hospital con- 
struction, stresses (he need for public health departments to 
serve all areas of the country. At present, 1,223 of the nation's 
3|000 cc^untics lack any organized hcallh department. 

The need has long been generally recogiiizcfi for health 
departments to insure safe water and milk supplies, sewage 
disposal, and control of communicable diseases, and for health 
centers where special cUiiics can be conducted, such a^ those 
f^^t maternal and infant care or diagnosis and treatment uf 
venereal disea*so. The A_P.H.A, report again emphasises this 
need and concludes that it should be woven inlo a national 
health prn^ram. 

Both reports assume that modern hospital and public health 
faeilities, combined with improved methods of paying for 
needed medical services, would, to a certain extent, auto- 
matically attract doctors, dentists, and nurses to areas which 
are innv greatly imdersuppHed. 

Organization of fien^ices 

With a fairer way oi paying the health bill and with hospitals 
and medical personnel distributed according to where they are 
needed, maay of the objectives of a national health program 
would he realized- What about t^e quality of this care? 
Obviously, quality under any system of financing is, in the 
last analysis, what the individual doctor, nurse, dentist, or 
laboratory technician makes it. Nevertheless, certain methods 

22 



of organizing prufcssional services lend more than others to 
encourage advances in quality. 

The report of ihe A.P-H.A. and, more particularly, that 
of the Health Program Conference, stress cncourageaneTit oj 
better profcsi^iona-l organ i:^a.titin ^s another essential of a 
natJf^nat hcnlth prf»f^r-Tiii, The tocns here, again, is tht hospital 
but a. hori|nt;il that funetioiis in a ticw aii<f dtlferent way, II is 
to beeome not only :i pl;ii'e \vEi<ire illncs.^^ i^ Iresledj but als*:i 
;i eeiiter for jirfvenlin^ disciisii ynd for iinproving Ih-e whr>lt? 
Israelite A>i medicine in llic' turromiiling areu. It is suggci^tcd 
that such a truly modern liospiial could, in addilion to its tisu:i1 
f;iLi.lilieSj. house pnlilic hcn^llh clinics, the ollice:^ of phyt;ieikns 
:ind d*.'ntiits, untl etjuipnicnt for the common tise of all. In 
such a group-pniciice unit, doctors would be enccjuraged to 
work more as a leani. pooling their knowledge and skills. 

Group practice 

The genend physician, it is assuiti<!d, would be the paHenl's 
main source of niedic;il cure, liut ai hi?; elbow AUi>uhi be the 
hii^pttal :md the speiialislsi whoM; services are necess:iry if he 
is l«j ]»raclice modern n:n'dicinc- Freed throii^di health insur^ 
aiice fnim ihc rcspcjnsibililici iti fee scilinjj and bill collecting, 
the family doctor might, for example, find more time to iict as 
tjuide and counselor in ihc eniolitjnal problems of his 7>aiieTiis 
as well as pmvidmg them with other tyi>ea uf medical care. 
Hi-^ role in the prevention of mental iUnesscs, one of uur 
baj^pcst unmet health needs, mij^ht be strenj^lheued thnmgh 
the ^idvicc and teaching nf his colleagues in psychiatry. 

Working m grotips, doctors are to some e>EteiU supervised 
l>y cn.ch other in the kind of s;crvices they render For example, 
a voiinfT .^iirpeon in a gro^n]) ]^ usually assisted hy a more 
experieneed collcajr-iie \vh<.'n undertaking an ej;peeially ticklish 
operation- The ^tory lending np to the death of Jmy palienl 
is reviewed at staff meetings. These supervisory prncticps are 
nl^l a new idea ; they have been used for years in good hos]>ilalK 




GlWp iiicilJc-jil j>rji{:ki(:e brings jour d<fct*ir jnl^^ln^e WOrkins a?id^«li(>n 

ivfth other doctors of difTcrenl inlcre^la and skiUe. 



24 



to salegiiarri th*^ qoalily <>f niedkal servii:^, especially fnr 
ward cases. 

Such, supervision does !i<>I require an nutside government 
inspector. Lender miy hfalth program it could he carried out, 
;iw Hi present, by groups of ]>hysici;ins themselves- Indeed, 
lis mentioned Ijcforc^ group medical practice is nn new idea, 
l>iiL n familiar pjienumciion in the private group clinics scat- 
tered IhrimghcRit the L'nitcd Slates, particularly the middle 
western and western states. What is new in the Health 
rnj^'ram C'tnifcrence report is the idea of encnuraging this 
lyt^^ of <^rf;anii:atioTi thrrmghout the nati^m, and comliininfj 
it with a more fav^>^eil place for the famiiy doctor than csiisis 
now cither itl iildividiiltl t»r in Cfirtiiin tyi^cb t.>£ g^roup pruCtitc- 

A network of hospitals 

Town.s and cities of dillercnt lypcs^ siscs^ and iDcatinns natu- 
r;*Lly require dilferent sised ho.spitals and differently equipi>eii 
hospitals. The cfmntry hospitrd, for example, ccmld never make 
enough use of nidjuni to justify thti exi>ciisc of owning' it. 
A ihinly p<-tpiil:tted area may need a highly trained hrain 
Hnrf^con ^*nly once or twice a yean Nevertheless, -when these 
and other unusual services are needed^ they must be accessible. 
What is the answer? 

Jjdth reports endorse a plan of organization somewhat 
similar Id that oi' Army hospitals. ^Hiey would encourage 
future constructirm ni hospitals according to an integrated 
scheme of health centers £cnrres]>fmding to the Army field 
station)- — rural hiispitals, district hospitals, and base hospitals. 

To illustrate : A state might have one or more base ho.tpiiah, 
l)referably connected with medical schnuls, where all types of 
niedicaS service w<iiild be available and where tlic more iinusual 
types (jf trcainien! would he carried out_ Merc, where they 
cimUl answer any need in the state, wonid be the brain 
snri^ieDns and the radium. Base hospitals would also be centers 
of leaching and medical research. 

2S 



The many district hospitafs. luiratcd in large tow^ns or cities, 
would be lar^c, and ecjuipped to handle ihe more usual incdiciaL 
and surgkal cases. Smaller rural ho^piials would be far nion; 
numerous ihau at present and would be designed to tnkc care 
of Ordinary dingnosis and trcatmcnt» minor 5iirg:ery» obstetrics, 
an<I so forlh. They would refer complicated comiitiona to the 
district or bai^E liospila3s. Health centeri^, spotted nbout hos- 
pitals of all types, would hmisc llie ojlire^ ■i.>f ptibli<: health 
nursps, laboratories, public hoallh tlinics, ili>clors' <^ffices, and 
some cmcrgeuey bcds. 

pjitients would, h^ a ndc, go to ihe hn.^piiEd nearest liome, 
but lor pari i-cul art v {lijUeull lype^ <»f din^glio-^i^ **r treat- 
ment might go to a base hospital, much iu the Ranie w^ay 
that those who can manage it now ^-r^ to a well-known clinic 
or medical center. 

This Kchetne of inEefifrated hu^ipitals would make constant 
.exchange of information, draining, and personnel among them 
pOKsiMe, On this foundation, a consnltaliun service could be 
built so that at regular ititcrvak j;]3Cii;ih!st^ frimi the larger 
hospitals woLild visit rnral liospil^ds and health centers. At 
the same time, rural physicians mi^j^^hl ^"^o up tit the base hos- 
pital for sj>ecial postgraduate IrainiuK. returnhi^ In llicir 
]jractice stimulated antl better prepared. 

PnijHincnls of a nation-wide health program see in hctspital 
urganizatinn along" these lines a tremendous inducement to 
physicians to organize themselves into strong professional 
groups. Whether or not doctors would wish if tnke advantage 
of these opportunities wrmld nf course remain tii !jc seen. 
There are indications that younger members of the profession, 
in particular, would ^velcomc the chAnce. 

A dn t in ist ration 

How could such a program be carried out so that both the 
patients wlio receive the services and the dr>ctors. dentists, 
muses, hospital people, and others who render the services 



would be satisfied? Here, the guiding principle, L)Oth rCi^otls 
agree, is that while the htaltJi program should be national in 
scope and while ceriain niitioii^al stiLnda.r<Jj5 are Jiecessary to 
insure thai public fundy are usc^d to best advantage, neverthe- 
less the responsibility for the detailed planning an-<J working 
of the program mu&t rest with local areas. 

For esamplCj llie federal government might refuse to allot 
national healili funds to hospitals wiiliout laboratories. Few 
would queSilion that such minimum staiidards slinuld he i^et, 
On the nlher hand, the government would not be similarly 
justified 111 trying Uf tell dcjclcjrs when Lo use a particular kind 
o£ labt>rat(jry test. Sueh jiicfjjmcuts must tif course be made 
by the doctor himself, subject to the staff regiibiiiiMis of his 
fellow physicians in the particular hiispiiaU 

Except for professional (|iiestions, the lay public, which 
reteives itj shoiikl have a strong^ say on lin%v ihe s*;rvice is 
conduet-od, bf^Mh i:n ihi^ir i>wai cummunilie.s and at the state 
und national levels. 

Certain frtcd^mis are coni^idcred biisic: 

1. I^uttj^rtls v;h<nild he free either tiy make u.se of weryieej^ 
jirf)vided under the national pro^nim nr In enntinue to secure 
niedieal serviees in the traditional manner, as they prefer 

2. Puiifttts .should iie entitled to chooi^e ain<mg individual 
[Thysicians, organized groups of physicians, hc^spitals, and so 
forth- Likewise, they shonid Ije free to change their sources 
of service without difficulty. 

3- Phy.'iicmnji should he free, as they now are, to accept or 
reject patients ; to participate <ir not to participate in a national 
progran: ; to furnish services as individuals ii-r to associate with 
other physicians in groups. 

4- Volunlary a^cricttrs (,sucli as hospitals) should he encour- 
aged to participate in Ihe national i>ro^ram, maintaining their 
statu-^ as iutlependeni ajc^ncies auiE relai3iiiig full responsi- 
bility for their *Hvn ;id mi ni.st ration, or not to participate iu 
the national program if that ij^ their preference, 

27 






Incomes of physicians 

Neither the A-P-H-A. nor the Heallh Program Conference 
report offers a pat solution to the thorny question of how 
(Joctors should be paid. They agree that medical services 
sh(iul<l be prLivided as economically as is consis-Lcnt with high 
quality. At. the same timt: they feci that rcniuneriticn to 
doctors should be auffidenl to attract and hold goad men and 
sJiOitld be scaled so that there are financial rewards for pro- 
f^saj(^^al excellence. 

There are three principal ways doctors could receive pay- 
ment under a nalionaJ hcaUh program. The health fund could 
pay doctors in individual practice: (i) a fee for each service 
rendered to patients, in the same way that mosL ductors nuw 
collect fees from Ihcir private patients, or C^) a sel amount 
per year, called a "capitation fee" tor each person choosing the 
doctor's services- Doctors working together in group practice 
could Le paid by salaries froni their groups. In such casts the 
health fund could pay (3) a lump sum 10 the or^ani^ed group, 
determined by the extent of medical se^^vice the group provided 
or the nutnber of paliefils using it 

Althoujjh fee "for- service is mast used in private practice 
today, there are also many physicians in Ihe United States 
whtJ are paid by the niher metEiods and apparently fmd them 
satisfactory. When faced with the prospect of payment by 
the government, however, doctors are naturally concerned 
lest they be underpaid. Medical education is expensive, and 
it takes a iiuniber of years after graduation before doctors 
begin to earn a living" by their practice. It is natural ior doc- 
tors to wonder v^hether a government system would offer a 
reasonable income. The example of poorly paid schoolteach- 
ers, government cJerks, public health nurses, and "ciiy physi- 
cians'' does not rea>^aurc them. Many people feel that the 
question of paymetat to physicians lies at the heart of doctors' 
opposition to a national health program, 

28 



Bdlh tliL- A. ]'. M. A. aiul ihi- ilcnith ]*rc\q;rain Omft?reiii:e 
repurls agrte lh:il lht.Te is roimi fur expenmeittati nn with 
mcthiJclA nf Inlying physid:ins, btil argxie ihal a jjhysirian's 
je:irly iiitdnic must !>c ^itlciiiialo-, a;; measured liv llic i^icoints 
usual anicni^ nlhcr jihysaLiaiis dl the siiint: iigc ami Iniiiiiii^ 
and i]i the: sn:mc type nf cummiinily, aint by the incumcs of 
other profiASsiuiiEil groups, 

K^$v4irrh <tml education 

Under any lyj>c ot hcJiUli pro^rnin, llie fiuality and Ihe con- 
linucd iTiiprovenit.'nt {^f incdiial .s^Tvitca It-an heavily nn rc- 
BLMrcIi ^ym] ivic^lical t'^diKMli^^u Tlu' half hiltvn^ dollars invt'^l^'d 
ill ihids^i iiL'l^b hy privaiL- philiiruhrnpy (.vvr thi- ia^l i'lfiy 
years arc held tii I>c larfjf<?ly rcsponiiiMi.' (nr llit: h"i|^li place 
of American medical s<:ienL'e today. Advocalct; of .1 nnTlional 
hcallli prn;^i"am say lliiil ^(Jvc-rnint?nl funds: iiinsi In- ffirtlicinn- 
ini^"^ uhcrc" ]>riv:itt." jiini!-'^ leave tt\i if kncnvlcdge is io inarcl] 
sicadily fcirward. In f;icl, during llic war, ih*.- ftdcnd ^ovcm- 
nienl sisnnsored Eind in many nisfs siiL^'iidiyc*? lK>th mi'ilkid 
and Ttnisinj:^ riUicalijin and a varicly nf scienlirfic TCSi.anli. 
The resnll:^ — ^for exanipSc. di^mverics as iu Ihc jsrotcssinfj and 
uses nf sliJred hloud — jirc familiar -enoiij^h tu the^t in the 
armed fi^rccs, 

Jn I'uldilinn 1^« fiind^ f^^r rff!cari:h, llic TTcalth rrn^r^m C(ni- 
fcrctifc rc'jxirl cni}tb;L!ii/.cs ihe need fur more -t^pporlnnities 
for poslgniihialo Irainitiff ftir pbys^K-ianK- IMedii-al .sttcncc 
advances sn rajadly thai thp ]diy>iician who gradnaR-s fmm 
mcdital srhnol ihis yi'ar \vi]l find il ncressary iie>;:t year tn 
hrin^ hiitisclf np lo dale. Ton tiflen the busy piac litinner has 
no time to keep up with advances ihroujj-li sttidy ami rcadiiij^: 
rarely is he in a ]j[isui(m where he can alTnrd to take a mimlh 
off fnr poslj^radiiak" sUidy. This is jKirlicnlarly Inie ol" ihe 
country ditctur. Op]^ni1mnlie.s lor dncturs In j^e! i)ostj|radiiale 
medical educ;ition eonid he ^really fwrthcrcf! by ihe use nf 
publie fundrt, iidvocateH claJin, althoui^li even more important 




The charily cliitir and ihe vi-^iling mii-Fae m* ufh^n xlie only sourcca of 
iiicJiraJ ecrvke U> tlic |io«r and iJie i«o7mcd. 




M 



rlay-by-day r-csiitts woiilrf he ohtained llirotigh improved nr 
gimizatujii of medical jscrviccs. 

rft*> OSRD report 

The use of federal fiimls tu siip]Mirt a j^rogram ui scientific 
re^canrh \v:is rerniiiniende-il In l'ri?,»;iiloTi1 'J'rijinmi in July 
1045 ITT ;i rciJiirl nf I >r. V;injicv;ir liiish. director of the Office 
uf ScieiilJIic Kcsciircli ;ind Devclnpmenl — the guvernmcnl 
agency resprinKililc for the use of federal funds for such re- 
tie;irch diirinf( llie WJir, 

Jn Ihis report the av^tt :ig;.iitist clisga.sc is g"ivcn Jirsl COn- 
t^idcnttirvTi. J>r. F^ush stn^n^jy advocates f^fn'crnmcnl support 
of mc^lic^l resear<!h a^ hasic XO any n^tiimid pri>Knim of ex- 
panded mcih^^id tFLiiiaiiig tiYii research and to the pruiuotton 
tjf piihlic hvahh. 

The rc|iur1, whirh recommends Ihe cstid>lishnieTil of a 
n;it]ifnjil .scicnliHij rcsivirch fiiuud^ilion rcspinisihlc t(^ the presi- 
dent and Congress, was received with vvJtJcspread public 
interest. 



HAS A NATIONAL HEALTH PROGRAM 
BEEN PUT BEFORE COiNCKESS? 

J>o TiiH^sj-: rj^iPJ^rii'j.ts of :i nation;:! heallh ]>rojjr:in rtppf^ar ii^ 
prarlical form in I he Jt'/^islative jimp^sals lirotighl before 
Congress? ^\'haL niamier of iialional heiilth program is it any 
way ihat has been advanced for public discussion and eventual 
Con^rcssitjnal decision? 

Jle^innin^' in VH^ with ihe nri^iiiat Wagnef-Murray-DingeJl 
liill to add he;dth iiisuraiue lu the SiacraL Security system, 
several bdls have been jiroposed eiribodying^ the principles. 
ITiey include the Hill-Sjurtmi Hospital Construction Bill, a 
ncAv version of the ^Va^fner-Mumiy-J^ir^ell llill ititrndured 
in May 1945, jLiid a still later revision of N<*vcni]>er ll>45. 



Thi'. first Wagner-Murray-Dinge.ll Bill 

Niitional health iiisumncL' wu^ liiit one iif several [irovisions 
of this TjiII. Oilier pruvisi^mf^, such as extpnsuni uf S<»ei;i! Se- 
curity, the nation alization nf unemployment vnnipcrisation, 
and lederal aid fur £"enertLl relief, are beyond the scope of 

Tht bill pnjvidf:(l lliat health Irssurance Vb'niiUI be establisheil 
by the creation ni ii national mcdieal tare and Knspilaliza- 
tion fund, to which empb^yers and employees would each con- 
tribute 1.5 percent of (he firsi $.1,()00 «>[ nnnnal "WJiges, makinjjj 
3 percent in all. Self-empluyed would cuninbiitc ihe entire 3 
]>crcent themselves, Ctmlribulinns ami.mnlin^'- to an adiii- 
lional 4.5 percent tif wages xv'iiild be made by emplrtyers a]i<l 
employees, 9 percent in all. to pay fur (he other henefils nf 
the !>ill_ Two of these latter pnwisions hav-e an impnrtiml 
bearing on health, namely, th(jse proviilin^ for ca^h payn^e^ts 
during temporary and pcnnauent disability. 

For every in>iured person and his family, the medical care 
and hospitalization fund would pay for unlimited doctors* 
care including" spccialisls, fi:r h(jspital]i:ation np to 30 days^ 
X raysj aijd laboratory tests. Dental care, nursings, me*Eicines 
and drugs would not be paid for_ 

J'alicnls woidd he free to choose their physicians fTom 
among |h(»sc t*arLici]"itting: in ihe j^rogram, whether enj^at:^ed 
in iTidividiral or jjnuip praciice. StaiuEards of competence for 
speeialisti; and hospitals would be established by the Surgecm 
General of \hQ United States Public IkaUh Service. Any 
licensed physician could participate in the p^'^^grain as a gen- 
eral practuinner. 

The nalioiinl fund would pay ]>hytibcians for the scTvi<:es 
rendered lo prilients covered by the Kysleni tEirou^h nny jif 
several mcihods — fee-for-serv!ce, capitaiion, part-lime or full- 
time salaries, or by a combination of ihesc methods. The 
jfhyaiciana of each area would choose by majority vote the 



Tiicthoit cif iKijmcnt Ici he :tdopted in ihat ;irea. JIospilalM 
"wiiulH Ijc paid lip lo $0 pt;r ttEiy f<ir cauh day of c:irt: rhcy 
iurniahed. 

Reaction to ihc bill 

The 1943 WiLf:jner'Murrn:y-I>iiigcll 7'iill nevor came In a vole 
in Cong:ress_ Ncvcrlheleys il caused a slnrm of cnmmeni. 
Backed cnlhiisiListically l^y organised labor and ^^nic farm 
i>rgai]i^a(ii>iis, it was considered hy ihenj "so cnrirninns an 
improvement over our present sochil security proviHionjs (bat 
j]<i respimsiMc person, deeply eoncemcd with the welfare of 
our counlj-j, can fail to supjiort it/' 

At the f^UTiie time^ it was vigorously opposed by reprc- 
SentatrvcH <d or^l^iii^^ed J>liysicians, iti whuse mituls it waM 
"!>*n:\'.i]\7.Gd medicine," 'I'lvt OppuMtion g:nnipHS said that the 
hill implied that pick |>eople WOldd have to dtpend on a 
doctor i):Lid hy the K'>vc^^nmert t*- W^rli ouly ci^^ht hnurs 
daily — emergency ca.^^es wuuhr have to \v.iii until the dnct^tr 
cJiecke<l in. rntients would have tn go to the doctor ai^si^iiefl 
to them hy polilical bnreaiicrat?, and doctors would becone 
incom[ietent because methnd;:; am? remedies wmild 3ie fi.^ed 
by bureaucralic siipenors, [-arj^cTy In oppuse Ihis; Isill, physi- 
cians and dru^^ houses raised and sjicnl over a ijuarler of a 
milHon doflars m giving out "infortnatKin" of this natiirc. 
Kxtrcmes were reached with slaleinenls hke, '*Jt is doublful 
if even Kai^idom c^*nfcr,s i>n its f.'-auleilers ihc powers which 
this measure winild cuiifer on the Surg eon- General *jI the 
U. S. PuIjHc Hcahh Service." 

One j^roup of phy.sieiana attempted In promate a nrttional 
m<n'C!ncjit In hoycoM any lef^nshilive prn^ram such n^ the 
^V^lfJne^-Mls^^ay-^ingcll Mill, ^ivinj^ physicians Ihss a<ivice: 
"If such le^!f;hition ap the Waj^ntr-Murray-Din^cll Bill pasLit^ 
and your paiient^ eomc lo yi>u for i^ervice^ Under \h<' J^lan, 
tell Iheni ynu <lon't sen^c the ]io|iiici;irifl, ynu ^crvc thetii. M 
they want to know what they are going- to g*^i for the money 

33 



deducteH from their pay ch^oka for health iTlSUrancej Vf m 
don't know/' 

It is of (!ciurs<^ deb:it^ible whether an insurance scheme :iut:Ii 
as that prt>poyed in the bill wuuld in fact have the ^Hsastrou^i 
effects predicted l>y its <)ppniientH. C^LTtuirilv the hill itself 
had no provision.^ for assigning patitnts tn dociors, for 
rr^ulaling' physician*^' hour.s of workj income, or method;^ nl 
praciire, except fcir the elementary rerjuiremcnt thnt speciali,s.ts 
meet mktioniil ."Standards nf competence in their parlicijlar fieUls. 

Maiiy persons in favor of federal legislation for hcahli rmd 
medical care fell, however, ihai the first WaK'"'^r"'^^'"ray- 
J)ingcU 15iU fell far short of providing; a truly adequate health 
pro^'rnm fur the nation. They pointed <!Ut ihat il included, for 
example, no provision for the construction of hospitals and 
health centers. It contaiT^d nidhing to cntnuraK"e the expan- 
sion of preventive health Rcn'iceH. It offered nothing- to 
induce physicians to modernize their methods of practice by 
joining loj.'-ether in ^jronps iiiMCAd of continuing In ihe trrtdi- 
tional solo practice nf the old-tii^it family physician. 

Some felt, loo, that the whole population should he protected 
ondf^rthe plan, rather than merely employed pers<ins antl their 
fariiilies. Fr^r this reason, and to promote prevenlive health 
services, support from general taxes as well as from the pay- 
roll ronlribniinns of employer and emplnyec "was urged. 

Finally, disinterested critics generally felt that the bill per- 
mitted too centrali/,ed an adniinistraikm of the progratii. They 
said that the program did nol rerpiirc su(Ticicnt participation 
hy state and hjcal g^overnments nor by hical representatives 
of the professions and the public. The American Bar Associa- 
tion made the additional ptmit lliat it failed lo provide for 
court review of administrative dtci^ions. 

The new Wngnrr-Murray'Dingell bills 

A revised AVagiier-Mitrray-Din^ell T^ill, intrfKlu<:cd into Con- 
gress in Mav 1945, proposes a jmtlern essentially similar to 



ihc earlier one, but has ad<ler] features whirh meet some nf the 
criticisins made uf ihc original, it had not been acted upon 
when President Truman sent to Congress his special message 
of November 19 asking national heaJth legishniim. 

The President strongly advocaleti li pnigra-ni iri five r^-latei 
pruposal:? for aL'tiion by thfi l-eJetiil g'uvoriinit'i'il ; 

1. Financial and other assasianirc for tht- cnnstnicllnn 

oi hospitals and other health faei!ilies uhere ihey arc 

must needed, 

Z. Increased grants to lire states for public health 

services and maternal and. cJiild health care ]>njgrann^. 

3. Supp*>rl of tiicflicil cfhicatioji and research. 

4. Expansion of eotnpnlsory insiirnncc under the So- 
cial Sccnrily system lo cover medical^ hospital, nursing", 
laboratory, and dental care, 

5. Caf;h benefits to cover some ()f the wa^e hissei^ 
during j>criuds of ^ickoc?^^ and disability. 

In orrler to meet, at least in part, the President's request. 
Senators Wagner and Murray and Kepresenlaiive Dingell 
promiitly lifted, rewrote, and introduced as a separate bili the 
health provisions of their caHier measure. 

These licalih provisions inclade, hesidcs medical care insur- 
ance, increased federal j^rants to tJie states for public hcalih 
work and for llie care of mothers and children, hut no funds 
for construction of hospitals and health ceiiiers. l»enelits nf the 
medical care insurance have been increased by adding limited 
home nursing and dental care. An attempt has been matte, 
too, to incrca.sc the responsibility of states and communities 
tIiroug"h advisory committees, although the final iidniinistra- 
tivt C^nlri.4 remains in the fcd-cral government. Court revi-ew 
of adtiriini^lrative detisionsis, however, si>ecifie;d]y authorized. 

Groups of physicians^ as well ad individual practitioners, 
may partiui]>ate in the plan but they are nut expressly en- 
couraged. The physicians of an area may still decide by vote 



hnw llipy wijih to lie paiil, Init such <t. vote is nn lon^jcr IjiJidiii^ 
ujmn :ill Uic clncif^ns iif tlio .irca. (jcncra! taxes ari" l<> he usi^d 
iiinrt' ^K^ncnnisly Hj sni}]ik-nK.'n1 the funds coiitriTnitcl \ty 
LMiiiilnyer'? itiul <:mi>lf>jees, bin ihc plan dues not yet enver the 
eiitirL" i">imhj.n<*ii. 

Sitituitary uf i>i*tiiiuif 

J>i^rnsM<ni Iff ii:ihciii;il le^'isl;iEi<m fur liciillh will ilinilj^lkss Ije 
rnLu,setl ;il>oiH tin: Truman |>n»p(>sLLls and the InK'sl AVu^'iujt- 
Murniy-J Jin^^dl IJiU fur :sonie tiin^: li? <."<tiin;_ ll wifcl Ik" U^vhli, 
Iher-jf^^rC, l<^ ^f|H:i^l lli^ prinvil/ul lir^^tinH't)!^ fi.r jn^d ji^jun:^! 
the ori^insil hill, Thv groups sii^iiinrlin^"^ the 19'=13- mcsisiiro 
o?n|jh:isi/t'd llio nirt'ssily fur iiaiiun-wiilr ailiuii in orclt-r in 
cijiialiyL- the njiiuirtunily fi>r health servicrcs among all grnujts 
(j{ the p^ipiitaliuii in wha(t'ver ]>art nf the auintry they ha]j]>en 
tn live. They ;Mso stressed the need fur a inelhud of paving 
for niechial scTviie \ty wliu3i pe<t|>le ean ]"av in kiiDwn, rej^nlar 
amimnt-^, nmnlh hy iimnlh, in aeeiinlanee whU their tarnrnpj^s. 

Thiise nppnsirt] to the first hill, on the oTher huTid, made an 
i.sstie (if ilic ditn^Hir iif jinTitlral rmitrol over mediral mailers, 
of a j^ossibh: threat lu tht individnal freedom tii iialieiit.s and 
di>Cti»rs, and of the liniitatJont^ that it mi^diC iin]>(jsc up^jn 
pbysiciiLn^ in prnfcssiMna] stiiius and— l>y im]Tli^-ation — inanne. 

ThQ nati'^n-wifU' di^rti^;>iion \h:\i l^of^ phu-t- ,'ts a R-sult oi the 
inlrfuhjeilnn of Ihe U]U had hroad edniahona! valne. It slima- 
htted peo]>k' everywhere to ^rcjaler aw:trcncs-s of the issues-. 
IL provoked jjaiEi.^takin^ in<|iiiTy hv ntinieroii.s non]>r<>fejishjn:Ll 
urf^^nixaliiins :inA ^^ronps as l<> the Ifuu fsiets of n}efhe:d eare 
in their own eommunitios and in ihv. nalion as a u-hole. All 
this served in some dc^ee to elcar the rsir, to dispel false 
notions and ^rmnidless fears, and (o aid the country in facing 
rcalilics. \\'lth Ihis increased interest and knoi\ k-di^a- as a 
haek^ronnd, the inihlie is heller prejiared, uilli ihe inlici- 
dtirtiiMi of the November 194S bill, to resolve dilVerenres 
uf opinion and to forus ils atlvntion u|>un speeiiic ^loints 
for iiclion. 

3^ 




AIhiv^: Arii>^f»i i-k^lrli ^nil flour |k]im for a vnw\eTn li^nltli renier in a 

runimiiiiilT Hif 311.-0(10, ItHoH: Skcli-li for np-lii-fliiif^ lil'lv-htJ tioapilJil 

in a coiiiiniiiiilj oC 10-fiM lo 20,ft00- — V. S. I^ubiic Hi^uUh iervice. 




The Hili-Burltpri Hospital Coiuitruction BUI 

This measure^ introduced in the spring; of 1945, would provide 
federal fjranls to stales for the construction of liospitals and 
health rcnlers. Designed to cncoiirn.ge over-all planiiing by 
the slates of an ordered network: of health facilities, the biH 
calls for each yt^itc to Ktudy Us existing- hospital resources 
and unmet needs, in order to develop a master plan of cotistiiic- 
tion. The federal treasury, ;Lfter platc pla»s ha<i been approved 
by the Siirijeoii (kneral of the United States Public Health 
Service, would supplement finidi^ for conslruclioii raised, wilhin 
ihe stales^ paying a larger share of federal f«nd.s in poorer 
states -^"d ft smaller share in richtT ones. 

Besides pr<>vidinK" Uir the vonslruclit^n and improvement of 
slate, city, and ci-iinty h^i^pilals fihr^cncnil care, mental illnesj>, 
and luberriiU»tii.^, this bill ■w^■uld ali^O aid in the construction 
of those nonjrnvernmenfal eommunity hospitals ■which are not 
i>pera1ed fnr profit. 

Supported by the .American Hospital Association, org^anized 
la3>ur^ farm ^nmps^ ami the American Medical Association^ 
this bill has aroused little opposition. It fits into the principles 
of a national pn>yrani in the following ways: 

1. Di^crc-nccs 1>eiwccn shilcs wi :ivanaliilliy of hospilal 
f:icilitifs uii^hi l)c grtrally IcHsciml Ih'Cjiusl- ii^iioiul mx fiintis 
WDidd sluirt llif costs of construe lion. 

2. Improved or^^aiii/^ition ni services. cctil<?r*'(l anHiml lios- 
lutkls is Inside possible if IioSl>ilid adtniiilritrklofSr |dtyriiti;in.t;, 
auil tlic public wish to avail lljcnis<:-]vi^^ o\ the oi>pnrLiiiiitv, 
Uetansc consiniriiini w^nilii he hn^vd f>n Htiiic-wiilc iiliinniraK' 

S. Decentralized admiidstralioii within the slates, ^suljjecl 
only to Kcneral ralicinal slaniTards, would rci^cct the pailiruliar 
needs and circin]|s;ianceK of lln? varaotis siaics ^nd crniiiiunilies- 

4. Tlie principk IIiM privatt-, nonprofit afrciifies can iii:iin- 
1:iiit individuality within a national, l-sx-aidfJ ]>To|^ram is rccofj- 
tfciaC"! hy lli^ iiiclusat>ti fii imf>r^vements and new construcdon 
for this lyi>c oi liospila?. 

The bill, however, is criticized to some extent by farm and 
labor groups bccau-se the |];"encFal public, who would use the 

SB 



hospita.ls, \vouM not have a great deal in s^iy al>f>ut where they 
are U» be loi-aied. A^ |>rovideil in llie hill al present, the 
commiLLces whu deiemiine the location of Ihc ho&pitiils would 
be coinpnseil largely of ho5;pital adminisirator& and physicians, 

Tlic iTKj.^t serious cniicism of the Hill-Burtpii Bill is that 
it can meet only Ihnited needs. It does not attack the problem 
of paying doctors' and hospital bills. A muilern, well-equipped 
hnspilril 3S of Hlllc value lo a c<miniunity if the people in that 
ci>miminity canmit airord Iti use iL At present^ it is the sad 
I ruth I hat areas which h;L\'e the leiist hospital faci lilies in 
]fru|MrlMii tiJ i>opiilalic*n arc idso ihe areas where such hos- 
jjitals as do cxi.sl fire ihe Ic^t^t used. In mhcr words, where 
cunini unities arc too ]»onT tn build adequate hospitals, the 
]>eo|/lL" living ih^Ti; lire too ponr to ]>ay for hiJSpital care under 
presetu arrnji^einent,^, Tu ^u;ird fiit-^insl the |*ossilnlily of 
putting up while elcphii-J'it^, ill Iho sli^l>e iti honpltalj; which 
would not he use<l, thi^i hill provides that com uiuiii lies want- 
ing' UL'W hnspiUi]>; must ^J:ow ubiliiv to s-upporl ihein aft-er 
they are buill. 1 1' ihis camioi In; sluiwu, no feiieral money 
would he forlhconiing. 

Were the IlUI-llurion Tjill passed in this form — auil in the 
ahseijce of any meaMire to meet ihe ])aticnl's pnihlem of paying 
hospital charges^— some criltcs think lliat most new hospitals 
would [>e built in Avealtliy areas -rthith need them le.s^ than 
iilhcr liiLalities hut Avhieh can aflord lo support ihcni after 
they are built. 

The llill-liurton hospital construction bill is of ^reat si^^ 
nificance hecn,u,sc il is the first national measure related to 
nicditiil care which has received support irom all major profes- 
sional prroicps as well as major farm and labor groups. Yet 
even its mo^t ardent 5ponpors ref0^ni:^c Ihat at best it can 
meet only limited nee^ls as ionf^ as the problems .if priying- 
diKTtorfi' atid hosj>iiHTl lullt; are still unsolved and that at Wi>rst 
it nii^ht result in an even tess equitable distribution of general 
hospital beds than at present. 



WHAT IS THE A.M.A. PROGRAM? 

Ik July 1945 the American Metlical Aasociation announced its 
program icj meet the ac?mittcdly unsatisfactorj health situiition 
in America, Tliis program emphasises the need for intcnsifica- 
tion nf voluntary efi'orls to solve the problem nf paying llip 
medical bill. Sustained industrial and iL^riciillural productioti 
is urged lo improve living conditions and therefore hf^aUh 
conditions. State surveys are Sug^^ested to determine the need 
for additional medical care and to appraise the adequacy of 
volnrilary insurance p!aiis in meeting such needs and in im- 
pruviii^ the quality of medical service. Kxtcnsinn of prevciUive 
puMic health services to all parts of the c(juntry is advocated. 
The expansion of voluntary insurance against the costs of 
hospitalization ami physicians' services, so as to serve all 
communities, is proposed. 

The A_M-A. re]>ort further sug;;csts that the medical care 
of the needy be met from lo<:al tax funds paid as premiums 
to voluntary sickness insuninte plans dir-ected by doctors. 
Supplementing state and local funds by national lax funds 
as proposed where (3cfinitc need for such aid is demoTistratef!. 
Eniphasis is placed upon ihc importance of informing the 
public about the nature of voluntarv insurance plans, with 
recognition that they need not involve any increase in 
taxation. 

Finally, llie reporl ur^es postponement of the consideration 
nf "revolutionary changes" >%hi^e large numbers of men and 
women, including medical ofliccrs, remain in the armed 
services, and proposes measures for rectifying the present and 
future shortage of medical personnel, particularly in rural 
areas. The r]ue?iion of the organisation of tnedica! servites 
around a network nf hospitals, or in ^rOup priictice, is not 
touched in this repoTln 

40 



^■■' 



WHAT ARE THE MAIN ISSUES? 

Public discussion in recent ^ears in^licates widcsprea<i con- 
cern about the quality and distiiliuticin of health services in 
the United States. Pive principal problems are g^enerally 
recognised : 

L How to arrange payment sv> that all the people can 
regularly pay specified aini>unlK in accordance witb their earn- 
ings rather than b*: bunicned irregularly and tjnexpettedly 
Willi the large costs of unpredictable illness. 

2. How to pay for medical services and faeilities so that 
they can be available more evenly Ihronghout the country, 

3_ JIow^ to organize America's health services to u^e onr 
raedTcal rcKimrees most efleciively and fprni!>h service ot high 
professional quality. 

4. How to make necessary changes and yet preserve the 
best of our present medicaJ practice, avoid undesirable :tnd 
arbitrary gtnernmeiital controls, and ^^uarantee freedom witbin 
the program for bolh patients an<l physicians. 

5_ How at the same time to stimulate continued and im- 
tiroved medical cdvicittion and research. 

Although there i^ much dii^agreemerit a^ to how it should be 
done^ most groups of the professious ami the public appear to 
agree on the basic principles that people can more eas-ily pay 
for medical service by some type of insurance than by the 
traditional fee-for-service method; that federal funds from 
general taxation will be needed if hospitals and other facilities 
are to he built in needy areas; that medical services can be 
supplied more ecojioniicaljy :in<I with belter guarantee of 
<|uaiity by the use of group medical practice than by individual 
practice; that local reprcsenlalives tjf the professions and the 
public must control the distribution nf services on the basis 
of broad nali^mal siandnrds : :nid ihat national funds will !>e 
needed to support inipr-tpved aTid extended medical educatii^n 
and research. 

41 



Controversy fias been most pointed about the proper role 
o£ government in any changed organiiation of health services. 
Opinions mnge from those who would limit g"overnmeiit aid 
to sjjecific problems — such as sanitation, comiminicable dis- 
ease control, the fare of the needy, inSlhutional tare it>r mental 
illnesti and tiibCrtuloSiS — lO those who would have govern- 
ment, particularly the f-edcral government, take steps to assure 
aderjuatc heaUh and medical services to all. 



« 



TO THE DISCUSSION LEADER 



Every iu'wan beini; h faced with the prohleni of his own 
jK^rS{niLil health. The hcaf! of ^i family hii^s the afldciE rcrspi>n5i- 
l>ility of looking after the health of his wife and children. 
Civic-mitlded individuals recoguizc that health hs also a com- 
munity concern^that good Jieallh for ihc individual often 
dejjcnd.R on improving- health coaiditions and health standards 
f<iT the eommunity. 

This ]vim]>hlet pre^et^t-^ majfjr fxoints of view on the impor- 
tant ijne^tion of Tmprovin^ htallh. It does n^t try to give an 
i^TiJiWLT. Thai t^ rtomclhini,^ f'>r the individual lo Thiflk Ihniugh 
for himself. 

]t is doubtful whether any reafJer of this pamphlet or any 
member iif a discassion group ^vould argue against the iin- 
]>rnveincnt uf health. Di^nissinn leaders wil? enc-snnier plenty 
vi cojtlli^'iin^ opinitjns, however, when they raise ihe question 
of how lieallh can hcit l]c improved. This question of how it 
should he done 5s something to talk over at your discussion 
meeting on the basis of the soundest information available. 

Hoic can yon plan a discufision meeiirtg? 

Discussions are ideas in action. You cannot have a lively 
voluntary diRSUssion unless you briuK: together individuals 
who arc interested in a subject. Therefore, you need tw(> 
things: a Subject that will interest some people very much, 
and a tneanii of letting people know that a discussion meeting 
is to be held on that subject. 

'*la Your PJcalth the Nation',^ Business?" is a .subject that 
will prohahly interest many ptt.ipU?. 

Your first major task as a discussion leader, therefore, is to 
Itl pe^^plo in your area know that you are planning a discussion 
meeting on health, 

43 



How (Tin jQti do this? There arc Hcvcriil possibilities. You 
can dhtjw ti Copy of ihis piiniphlct lo the editor of your Inc^l 
newspaper atid e>^plaiii If hiiu the lype of prf»gr:im you are 
plannhlg", Vou can prepare notices to be placed im bulletin 
boards. You can prepare puj^ters fur reading rnonifi where 
yoTi have placed copies of ihis pamphlcL Van can suggest 
that local librarians arrange reading table dijiplayt uf this 
pamphlel and olher suggested reading material on public 
health. Finally, you can *'lalk it up'' to certain individuals 
who will pass the word along to their friends that a discussion 
mectini^ is g<.iiiig lo be h^-hl cm this subject. This pruredurc 
on your part will give people who are interested an opportunity 
to plan to attend your meeting. 

, What kind oj discu:isioit works best? 

Each diJicti-ssion leader is probably his <Jwn best judge as in 
what type of discussion will be most salisfactory for his group. 
If yt>u are in doubt you might discuss this matter with L|italifictl 
advisers. In making this decision you should consider several 
imporlant factors. How large will the discussion grouf> prob- 
ably be? What kind of facilities arc available at ihc meeting 
pEace?" What lype of discu.s&ion ha& proved most popular with 
k>eal (fiseussioii groups in the past ? What good speakers 
jiaighl be obtained for this pariicular t^ubject? 

You should be certain that you understand the general ad- 
vantages at^d di-^P-dva^tag-es of various types of discussion. 
Forumsj panel discussions, symposiums, and general group 
discussions are the forms most frequently used. EM 1^ Galde 
for Discussion I^caders. tells just hcnv they differ from one 
another. Below are some specific sug^^'estions. 

Forum: A competent doctor who is a good speaker might 
make an excellent forum speaker on health. One who has had 
both civilian and military experience ir dealing with health 
problems might be particularly well qualified. After his pre- 

44 



liminary talk un he:ilth, members, of your g^roiip could queslion 
ihci spcakffr on points of particuliir iiilcrt'Rt \o iheni, 

Panel Discussion: Health i*; a subject thrit would lentl itself 
piirticuhirly well to a panel discussion if yi>u l'^ti g<^t four or 
five qualified speakers. A group of young doctors, <>r a com- 
liination ol lioclors, dentists, and psye^oli>gifils^ might make 
a panel that would keep the discussion ball rolling in a lively 
manner. Time should l>e allowed for members of your group 
to question the pane3 participants, 

Symposiittn.: Two or more doctors, particularly tliose with 
diverse ideas about how to improve health, would make good 
aymposinm speakers. You should limit each to about ten 
minutes su that menib-ers of yuur ^wup will have an oppivr- 
ttinity U> question all llic speakers. 

fnjonnai Discussiim; Since health directly concerns every 
individual and eath has his own ideas about maintitinin^' 
heaUhj yotir entire program could be conducted as- an informal 
discnssion. It will be nec^iisary i<^r you, as discussion leader, 
tu be familiar with the ermlents of this pamphlet and tt> bt 
prepared vvith well-or^f^a-nized tjuestions tp bring out rnajor 
health issues for discussion. 

Can diaeti^sion handbooks be helpful? 

Disciissiou leader>'^ will find many helpftil suggestions on plan- 
iiirig" and Conducting" discuiisions in EAl 1, Cruide /or Discussion 
Lcadifi-.t, Ttjid Cui4e di£:cui;yes in detail the various types ^>t 
discussion possible, ft ^Wq6 helpful hints on handling difficult 
personalities at djpcussior meeiin^p. It emphaaixea the im- 
portance of careful planning^ and outlining a prc^gram of 
discussioii. Study of this handbook will enable a discussion 
leader to improve his program; it challenges him to use his 
own ing'enuity to make his program interesting and worth 
while- 
Some discussion leaders face the proWem of planning and 
conducting programs to be broadcast over the radio or on a 

45 



loud-speaker syateni of Armed Forces Radio Service. They 
will find EM 90, GJ Radio Roiindiable^ fuU of sound advice 
£ind usaljle Silggestions, 

Questions for discussion 

You sliould jot down your own questions as you read this 
pamphlet and outline your discussion prog:ram. Vou should 
encourage members oi your group to ask questions. Some- 
times the most helpful qu-estions grow out of the discussion 
itself- Jt is -well, however, to he prepared. Below are some 
questions which you may find helpfuh 

1 
Has cirilian medical care been accessible and satisfactory 
to members of the discussion group and their families? JJas 
the problem of puymerU for physicians' care or hoppitali^ation 
been difficult? Have doctors and hospitals been located 
reasonably near at hand? Has it been easy or difficult to obtain 
the services of tiecessary specialists? Why? 

2 
Would, the problem of payment for medical service be eased 
by insurance against the costs? Do you think voluntary insur- 
ance against the costs of sickness can provide a satisfactory 
solution for the proSlem of payment throughout the country? 
In urban communities? In rural areas? In all geographical 
areas? ' ' . ' - ' J 

3 

Would there be professional advantages in a scheme in 

which physicians practiced in groUpd? Economic advantages? 

From the patient's point of view? From the doctor^s point 

of view? 

■ 4 ■ 

How do the advantageii and disadvantages of medical prac- 
tice in the military services compare with those of present-day 
civilian medicine? From the patient's point of view? From 
the doctor*s point of view? 

46 



5 

Is the Tiormal peacetime Ji&lribulion of civilian physicians 
and hospitals satisfactory? What factors influence this dis- 
tribution the most? CtJtild ihey be modified by physicians? 
By the public? How? 

6 

What measures have recently been propt>sed by the Ameri- 
can Medical Association to meet the nation's health needs? 
Whal crt'cct do you think these proposals, if carrieiS out, would 
have upon (a) the ability of people generally ki pay Ihe costs 
of sickness? (b) the distribulion of dociors' am! hospital 
services? (c) the quality of medical and hospital services? 

7 

Do you jhink the United Slates government should (a) do 
nothitijif fiirth^i- ii^ the health field? (h) support only ?;pecial 
health pr(>;jram>s such as those to benefit uT'lhers and children 
or combat venereal disease, tuberculosis^ and mental illnet^s? 
or (e) sponsor national action for health care on a bnmder 
basi^ by insurance or tax support ? Would action by the federal 
g"overnment lend to improve or lower the c|ualily tif medical 
care received by peo]>Ie generally ? Why? Would most dtictors 
benefit ur suffer econtitnically and professionally as a result of 
federal action? Why? 

8 

Should the federal government aid in the construction of 
hospitals where they are nee-ded ? How should such hospitals 
be supported if built? Who should own them? Who should 
determine their location? What doctors should be eligible lo 
use them? What patients shoidd be eligible ff>r admission to 
thcni? Would hospitals built without federal government aid 
serve the public better? 



.^ 



FOR FURTHER READING 



TiiiiSK ifoox.^ iwii *^u^g<^)^iC{] ioT siii^]vl<.MiH'ntriry rending If ymi 
have nct'fSi^ Uv khcm or uiwli in ]Miri'li;iK<' Ilium Lnmi the piih- 
iisher^. They are nol approved tt^l^ uJllciully supplied hy (he 
W:ir DqKiriinenl. ^Phcy hinc. hccii sclcrtal htiMuse they ^ive 
atlfliliiniiLl iiifi>rm:itiuii :Lncl rv-i^reseTil tlillert-iil puint:^ of V!t-*NV_ 

AMiLifitA Ok<;A>3ixi-:,<i Mi-:iUMNi^,. 1'y Michael M. Diivis. ]\ib- 
hf^heil by lUiqjLT ;nicl llnHhur*;, -1^) K:iM 33il Si., Nww York 

10, N. V. (]9'nj. :t^,5,(X), 

Oriianixkd Pavmknts Kiik Mkjmcak Skkvjck?;, lly Kiireau tif 
JVleilii:a1 Kconiiinics ui ATiieriraii Meclic;Ll A>isi*ci;itiuii, 535 
N()rlh I U-i\i1iiirii Si, (.■hi<."^fJ;^«, Ml. (IfMl), LVapies ihj lunger 
aviiiialjli: fnun puhiishcn 

U. S_ MKTiinwF IN Tkan-S^tion. Article in Ft^riunr^ DeceTtihcr 
]^H4. Ke|»riiils availriljK' on ri'<£iiesl fr<>m f^irriuiit% linipirc 
Slate r>uil*lin^r, .IM) Kiflh Avl.. New York 1, N. Y. 

hivn^i-: AMD TiiK iMi'nrr-^K or MkhicinI':. Arlitle by Wtiiflcll 
JJerge in J'uhJir Ifi'ufjlr RrjMinfi. Vol, (lO, No, t, JruiuriTj' 5, 
1945. M;iy be ubiaineil fmtn (lovcraniLcnt rnnlSn;^ (JtHiti.', 
AVashiaijjiuii 2S, [).f. U) L-crns_ 

lli-:AL'rn 1 wsukanci-: in Aa-ikic[('a_ I'liblished hy UnilL-d Suilcs 
Chain bcr oi" (.'iHnnicrcc, b*15 II Si., NAV., \ViisliiTigliin 
6, !).(". (1945). Atblresscs ik-livcrt:il ;li ihe SccoihI Nil-- 
liural Oinferciii-e on Sotial Security. J'Vee itn rc(|tiest in 
stTvirrmen. 

WAKrinii: TlF.AL'riL ahj> Eijucatcok. KciM>rl No. 3 of the Scniite 
Siibconimittce on WEirlime lleallh ami l*,(hicaiion, Senaie 
Office IhiiKliiif;. Washin^-'tun 25, D.C, (January 1945), E'rce 
(111 rctiiusl. 

1Ii-:a].'|[| Iaui-: fhk .^^3T.Jvl^A^.s, I'v t\-E'].. A, \Vinslovv_ Ka. HH 
of i'ublic Affair A- J'aniff/iirLt. i>nhlifihed by I 'iiblie All ill rs 

43 



l"nniniiliri\ ,^0 lic.ilvcfcllcr Vlnzii. K-fw Y^^^k 20, X. \. 
094>). 10 cciils. 
PKiNnn.KS ov A Nationt-Wmik IIkai.tii 7"'T<<K;kv\,M- Kcport of 
ihc Mfallli Trti^niin Omli'rtjruc-, pnl^lisbcd liy Oininiitlce 
on HcscEirc'li in Mtrdical ICanmcnirs, l?'>0 r.niiuKviiy, Ni'w 
York ]*^. N. V_ <1'M4")_ in ixn1s. 

t"nNTHhT AMI Al-miNl,'^'niATII>r4 ClI" A -\lKnnv\i. C^AKi: riCl)i]fCAM. 

An ;irli^'lc liy |c*,si']»li W. MiJuiiliii in Amerrcfin jfturniil vf 
f'uhfit: fh'tiUh (Dc^'cnilicr I'H^V Kt^ijrinl^ jiviiiliilik' fnim 
Amcru'Fin rulilii- llcallh Assiirialion, i7'J() iSrwadwiiy, New 
York 19. N. Y. 25 t^nls- 
VniAmTABr MKuicrtr. lNriiTKAN( i: in thk VInitmh Statics; 

field Aviiel. ViililiNhL-tl liy Mi'(iic:il Aclininiiilrntini] Serviix-, 
1790 nr<M«ln;iy, New Yurk \^K N. V. (1044). $L00. 
MKiiiCAr, Ski^vu'k T'^lan*^. Kc|nirt iif lluroan uf McHic;tl Ivco- 
ntiTnu's (if Am-o-rir;Lii Mcdioal A s^nt'iiilioii (1943). t'npius 
no InngCr iivftilaMt.' \ti>u\ |mMiJiliciv 

A t'ONSTIiPl TIVK ]^li(J<;KA^] I OK M KinTAl. C A I* I". Thf oftif-'Jill 

pniK"niui <i^ Ai]Krir;in MciiKiil A.ssniijiliuiij in Jtrnniirl t'j the 
Afnenmn Meiiiail A.\.\iii:iut.itni, \\\\y 21j l'.M5. Stt riLsu cihlt^riiLl 
anti iirlulc called "Ucallh lusiinimc" in llic Scmit i^isnc. 
Nationat. "Ukaltii SKWVitK- liy Firilisli Ministry nf IIimIiIi 
anri Deparlmciit i»f llcallh Hir Scolknui, l^ihliKhuii liy Msic- 
millaii I'o., (lO riflli Avt., Nc;w Vurk 11, N. Y. (1*>44). 
75 cents. 

T\IV\ AVA<iNh;R-MUkKAY'l:>lNl-iELL BiLL— S.1050 OV V^^. All 

aEialysis by Hurtan iif Legal Medicine uf Amcricasi Medi^:?*! 
Ass*n4filion, in Saumttl irf fhe Amrrictui Mcdicttl Assuciitllott, 
|i]iic 2. 1*^S. Sec :ils(i ail eililnrial <in the !»ill in llie smne 
number Kcprinls av^iilablc on rcijuesl. Much nuilcriEil i?ii 
lliL- t^H3 ;in<l l*J45 Waj^iicr-Murray-l )in^a41 bills appears in 
III her issues of llic Jtrurittd^ See espt'cially an analysis by ihc 

49 



Bureal of Lt?ga.l Medicine iind ;tn cditcirial (June 2h^ 194^}^ 
attd lomnients by Senator \^'ag^c^ (^June 30, 1^45). 

AmEHILAN EaK A<:S0rJATrOK COMHTTTKE RkPORT-S. In jojirnni 

i>f ffu' Aiitvricnti Medicut Association. March 11, 1944. K-eprinls 

;ivaiia]jle tni rt'quest. 
Fok THE People's Healtjl J'ublisbed by Phy^^iciaTis Fonmt, 

?1 East 87ih St., New York, N. Y. (1945)- Free on reqiiej^i 

to *;eniktfnn'n. 
Si n^NC'iC, Tiii". r^NDi-F.ss Fi^oNTrKW. I^v Variiev;ir Hiii^h. J'uli- 

li^hed l>y Gnvernnienl rrinling- Office. ^^"a&hingloIl 25, 1J_ C, 

\VH5). 30 cents. 



50 



OTHER Gl ROUNDTABLE SUBJECTS 



lNTWo^itr<"roRV copii^s of ca<_'li new CI Roumlmhle piimplilct 
art autoin^li^"Llly issued lo irfomTiiUnn-trducalinn oflicjr;^ in 
the UniLftl Statics £ind t'^versea ^roiit^. A^ldUiona-l copies arc 
authnriiicd on llic hasis of one <:opy fi>r each 2S inilitarv' pev- 
sonnch Paniphlcis may be rcquisilLoncil from lite United 
States Armed I'Virccs Instilutc, MacUsoii 3, WiscQnp;in, or frtim 
the nearest USAJ-T OvcrsL'a I»raneh. List EM^ niinilicr. litle, 
and f|iiantity_ New suhkcts will Tic announced as pubLislied. 
Gi Routidtuhlc sidijculs jiow available: 

FM 2, What is rH^j^Ac^rsaiA!:' 

K^l Ifl-, W"MT ^^IA|J. \\i- l]lHHjK A|,i(lii- HkHMAIST AFTHH I UK WaH? 

K^f J2, Ciis Wk IVjvf.pjt KutHhk WAnS? 

KM IS, WiiAt SiiAi.i. Hk Dopjc ariutt Jaj'aiv aftf:!! Vmrimv? 
KM ^, What IU't Ai>^kA To Oifkk I'ostwah pnl^K^:p^? 

EM Tl, Wi\.L TiiKUK Rk WiHiK V'li* Am? 

EM 2,^, Why Cci-ms? Wllvr Ai*k Tll^:Y? How Do Timy W.»Bk? 

EM ?1-^ What \m\^ Aiih:Au kor titj: PniLir^'iNKs;? 

EM 27. WiiAT l^ Till: Fcniiiii i'>T Ttu:vTin*N? 

KM ,^0. Can War VlARiiMrt].^ Wv. M^iiJi T() Wc^iik?" 

EM 3-1, Df> Yhu W.f_NT Yoim Wert; 1\j Wouk .*i--ieii in»: WahV 

EM .^2, SiiATL 1 RriT.n A llfH^iE ahkh tifk War? 

EM ,tt, What Will Ymnr Tmwn Bt Leke? 

EM 111, Shall 1 (In Rahk to S<;jr(joL? 

EM 3^, SiiAt.L I T.\Kt Ui- FAi^nMNi:? 

EM ,^. DdE.^ It Tw Tn B<^iciriiw? 

EM .T-T. Will Thrhp Rf. a I'i.atjl irv Evibt Carac:c? 

EM 40, Will ^iirt: FnrNni KtPuuLic Live Acae?*? 

EM -11, Oi H BKin?;ir Allv 

EM 1?, OiiB C]iiNF-=^ AiT.v 

EM 4.^. T]it B.'\LkAPJs — A1apj\ Pkopi.fs, Majjy l^itojiLFvit 

KM 44, Ai'STBAnA; 0th NtiuiiiiiiK "tJoww IInfikh" 

EM IS. WiTAT FrniTRK niH nit Fm-^nii?^ of nit PALifit? 

EM 46, Oiijt Ki's^MN Alf.v 

EM m CI Rmh.i RiiLAiifAiaE 

'Fpr diiiribution in LJnitrd StalM trrAy. 

For uk by ehe Suprrin^endrni nF I'^nfTrmmH, IJ. S. Goflpmmpnf Priniin? CWFirf 

■ft U. S_ OOVERNhlENr FRIhiriNG OFFICE^ \'?A'j — fi/S547