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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jftifupfifi-t uili itv f'jiind tin pufii- -t.'L

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Marine: (jirpK, and <]i>iiMl (!ijjirii. This diHribiiLiuh i^ nul iv Ire; ciiii!:trLiiii<l ^^ aw
K-t\^^Taca\tii\t iiy ihe Nnvy Di:[*:irLiiL{:[iL v\ lIil- flaiLnkUiL::^ i;uJimiacJ Lli?r<:iii.

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prriniiiiiif:! jiru ti> l>e requisitioned from Kducjilioji^^ Si^c'vi^fS SecM JOD. )

KmifTArrrfiiT SECrror*, Welfare Divrsiim, Special StnvifTS ItHANrii, Uw7va>
Stati:^ Mahink 0>Rr=. ^^ASl^Nr.T■>^' ZS. 11. C (Di^ilrihiited In MariTie Oarp!;
[icr>nniim-l by Spi-ei:i1 S^rvicr^^ ]tr:trudi. Addi^irviizJLl copii^iv, or inJormnliun, may
lie uliiaiudd frum uihit Special S*?n-itf'i OlIicL-rs.)

TH^TM^t Division, OpRrE at- PKH!*f5T«'vn-, Ccij*!4T Cuatii> IkAngiMRTtq^i.
W/sLimciO.-v 25, t), r. Ujii>i»> f[ir CoaJ^l Guard per^nnel ?»h.nidd Ite ri-qui-
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