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

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Is Your Health 
the Nation's 



B 



usiness/ 

LIBRARY 
UNIVERSITY OF ftlCHMOSD 



^' 




Pri"[Mri'il Jnr 
Toe UniTEti SiAita Arued Fouces 

bv 

THE AMERICAN HISTORICAL ASSOCIATION 

Thifi pamjihlpt ie, one of a uptIcf; made availdhlc by ihe ^ar Dppart[nr?ni under 
the. scrifn lillc CI Rmiiu!(ah!v. A^^ llir (:i-m'rjl lillr inrlic;ile?i, GI Rvundlabfc 
|ijiiii|iIi]l'U prn\i[lo nmlETiiil wliJi:Fi i]irtrrniu[ii>ii-i'iJiic[i|iijn ollicers TJidy u^-t' in 
cDiidui^^iiij; [■roij|i liisrii^^iiiii^ iir rnriiii]^ as |iiLr| of aw nfT-ihily <?duculi{tik pro- 
profii. anrj which "|ppr;i[nr>v of Arineil Kurres Kflilio Service outFcls may nse 
u\ |in.-|i:krii]r- CI El:idi(i Koumlliibl<i discu^-sinn bruiidcasl^. 

The conlcnl of l!ii»i puinphlel hag iie^'ii prepared hy llic Hislorieul Sfrvii-R 
lluurd f>r llii- Am4-rir'ui] Hlshirif^j] A!%rToHaTioii. Y.acM [tumjiliW in ihf- ^rie^ h:i4 
imly nnp [nirpo^e: lo iirnviili^ facluul irLfitrTiiuliikn ;md babrjced arpiim'-iilh a,-- a 
Itjipis for iJi^iis^ion of j[l sideh of iht nur^lion. It is nnl lo be infern^d ihal 
ihi- War Deprirliiient pndorpes any one of Lhi; pjrliciilar views prefcriled. 

Spi-iific ---iinfff.sti'Uis f'lr ihi: iii\<u.i..%''in ur foiiiin it-udiT it/iu plim-\ lu ii.m- l/ti\ 
ftimplih-l uiti hv f'liiiid tin pufif -l-'t. 



WAK DKr^Ain'MKNT 

Wasiiim.jmn -Z^, D- C, Ifi i.m V)\b 

\Ml .■Min.7 flfi j.in Ui)| 

EM 2*K CI Rimnihnhb-t Is Vunr Ih-iiith ihc Nalinn's ffwwne?.*? 

Oirn'iU W;ir DT'imrliiieiU iris[rijr-|in[f>: niLlhnriTf iTie rei^ni^rlinn "f 

uddilJrtMJtl «'opi<-s i>f l]ii> ji.imphli't on llif Im-i-- nf "lu^ rfhpy for fiirli 

2S militury ptT-tmiii-L wilhlii bjiiil'- of tlie ji^jiilalde :^ii|i|dyr Addilionjil 

eo|ii{'^ ^hoolil \n- ri'qiii^ilLoiii^d fnriii ibi- lliiilc-d Slaleb Ariiird Ftxcc-M 

IT1^'liTu[e, Miiilison '.]. Wi><"<kOsiii, or the m'jr'"'-t flv*'rM:i[ Mrjru'h. 



Dtslril>iUed for iif^ in ihi' f^diiriiTii>rral :tTid iiifumLJlJiJOjl [irojirjots "i ihf Niii>, 
Mtifinc Corpfe, and toast Cnard- Thi-= di>LrihiiLiEHi 1^ nuL to lit iroiisLrut-d ii^- au 
etidorteuient by the Nflvy D^iioriiuciii of iln: biateiiieiiLs toniiiinecJ ibcreiii. 



FjMirATmwAL Services Stirrmis. STANo^Bfjs apjjj Qiaincruiu Division, Train- 
isr„ Bureau ok Naval PKttMiNNt.i-, Wamiincihin 25, D. (1 (tlopies for Novy 
liurtioiiiivl ure to be requi^ilioncd from Kduca-lional Services Section.) 



tlmicATinN SErTiuH, Wkifare Divisihn, Srt:i:tAi. Skhviiks ilftANni, Uni ri.n 
STATf:s MAKmF. CoHF-s, WASlMP^m^l^ 25. II. {'.. (I^ijilTibiilei] Ut MoHiie Corps 
pflrsaiinri by Spitfal Services UrJifirh. AiMilirmul c^pte■^, or inJorm;iliunT miy 
jie ubtaJi|ud from unit Special b^rvii:es Ulliccr^J 



Til A ITS J Nt Pi VIS I ON, Office of Person nm-. Coast Guaho HzAnQi'ARTEHS, 
WA>iiiNC'ro> 25, 0, t'. ffjipies fur Coa^ Guard persorinel "^hnMld be requi- 
silioned from Ihr Cum ni and ant (PTJ, Lf, S. Coast Gunrd lleadrpjjirlers, 
Wasblngion 25. LX L.) 



Is Your Health 

the Nation's 

Business? 



C O IN r E N T S 

Is hpiillh your own hiir^iiie»ih or tlie tialion^e? 1 

What ilo [k4'0|»le profio^e |o <h» about ihe siliidlinn? . ... 7 

A\'liul itrv iht' pilljir>< irf n njiliiinjil lieallh program?. ... 18 

Has a iialional lienllli program bprn put hefore Coii^reiis? 31 

What ie tlif A.M.A, pro^ani? -W 

What arr llip main i^^iiifh? M 

To ihe HiH4'iiB8ion leader. , - . . - t3 

For further reading , , - -MS 

OUirr Gl Koiindlnhle t^uhjeel;^ 51 



WHY WERE DRAFTEES REJECTED? 



(Sehctive Service Examinafions, I94IJ 



Jfc^r^iA^j^j^.^to:-:^:;-:. . . 



NERVOUS & MENTAL DISEASES 3 



DEFECTIVE TEETH.. 8 3 



RESPIRATORY DISEASES. .1.8 




--yr^''^/r'A^-^"yr^^^ 



EYE DISEASES... 5' 



EAR. NOSE & THROAT DISEASES 2.S 



fc 



CARDIOVASCULAR DISEASES 3.8:: 






.'^ 



vmiIERLDiSEAS£S,.1.5' 



fe:-:: 



FOOT DISEASES 1.5 



/V^' t^t^ ^ 









MUSCULOSKELETAL DISEASES 3 3 



. .IvH 



::sk 



•Si;^i^.-AV.-!l 



OVERWEIGHTS UNDERWEIGHT. . 

OeViOUS DEFECTS 

OTHER CAUSES 



IS HEALTH YOUR OWN BUSINESS 
OR THE NATION'S? 



WHAT ARE the achievements n( American medicine? 
JJo its services reach ihe iiftiple who noed Ihem? Is ihc 
battle afjainsl sickness a public question like ibe battle against 
illiteracy? What r(»le should local, state, and natiunal govem- 
Tiient agencies play in supjjleint:nlin|( private elYort ? 

A widely accepted answer Ut the first two questions was 
given by the Senate Suhconiniitiee on Wartime Health and 
Education (the Pe]>per Committee) when it said in its rejuirt : 
"The quality of American medicine at its best is very high. 
UnfortHnately, American medicine at its best reaches only a 
relatively small ]>arl of the jKjpnlatirm," 

The other qncstinns— on the intake of the general public in 
preventing ill health and the rule of giwernment in the struggle 
against disease — are not new unes. Community responsibility 
for public health has long been recngnized in laws and ordi- 
nances for sanitation, fo<id inspection, and the prevention of 
communicable diseases. Docs public interest also extend to 
bring'ing better medical care of all kinds to more people at 
less cost? This pamjihiet presents some <if Ihe most widely 
discussed programs for national health and lhe arguments 
pro and con touching tbem. 



\\'hai arp some of the facts und figures that h:ivc made the 
issues seem Um important to be left lu private effort or in 
public health agencies as they now exist? 

Jn 1935, more than 23 milhuu pciipic in the country had a 
chronic disease or a physical impairment. In spite of tremen- 
lious advances in inedka! science, the death rate among low- 
income gn.mps in our lar^c citi-es is still as high as the national 
rate fifty years ago. Deaths among mothers and babies could 
be cut about one-third if ail g<il gtntd medical care. 

The fact that struck hardest and startled the public most 
was the revelation from the i>elective Service figures that 30 
percent of the n^en of military n^c were unfit for general 
military duty. 

The gap between what modern medicine has to offer and 
ibe kind of medical cnre people actually receive is usually 
blamed on two things: jx'oplc's inability to pay for gooil 
medical care under present arrangements, and the way health 
services are organized. 

Modern medicine conies high 

Modern firsl-class medical care is necessarily an expensive 
commodity'. Many petiple cannot meet its full cost regardless 
of the method of payment. The cheapest medical and dental 
service compatible with guod <|ua!ity and hi^h standards 
would probably cost about $150 a year for the average-sized 
family. But studies of family spending show that most families 
under the $3,000 level — or about half <iur populatitm — simjdy 
cannot pay a full ^ISO a year Utv this purpose, ff their medical 
needs are to be fully met, such people need assistance. As it 
stands tcday, pe(>]>le in low-income groups, though they have 
twice as many days of sickness as the well to do, receive only 
about half as much physicians' care. 

N<Jt only does good medical care cost a lot, but the need for 
it cannot be predicted. If yi>u can't foretell when illness will 
strike or how serious it will be, how can you prepare to meet 



its costs? Many a family able lo budget $1 SO a year for medical 
expenses is staggered or financially crushed fr>r years to come 
by the cost of a single serious illn-ess. Moreover, having to pay 
a fee for the doctor's services is a frightening prospect to 
people whose incomes harely cover living expenses — so ihey 
often put off going to the doctor. Thus they lose the henefits 
of preventive measures, early diagnosis and treatment, and 
perhaps have to pay more in the end. 

Fortunately, though no one can predict when or how seri- 
ously an individual will he sick or injured, the frequency of 
such ills can he figured in advance with reasnnahle accuracy 
for groups of people. These fads led the Pepper Committee 
Ut cimclude : 

"The 'p.iy-a^-yoii-go' or fee -for-scr vice sysleni, whicli is now 
llie prediiminant inclbod of pa>incn| for nieihcal *iorvircs. is not 
well suileil lo the nce<Ts uf ri"t*»l people or lo llm widesi pas- 
<viEilL' dislribulion of higli-tjuality medical care. ]l lends Eti keep 
peojjlt! iiwiiy from tlic doctor uniil ilhiess lias rtaclii'd a sUn"^ 
where Irca Intent is likely lo be prolonp'^d and medical bilts 
large. It ili^lers piiliciils from Sncekin;;^ services ^liich are ■some- 
times esstnlial. such as speci^Hsl c^re. lahoralori' und X-ray 
exam inal ions, and hoEpilalizalion. TndLviduah witli low incomes, 
whose neeil is greatest, are more likely lo postpone or forego 
diagnosis and I realm en I/* 

Healthy wealth f and geography 

Cost is widely recognized as a harrier between individual 
pecjple and the medical services they need. Another difficulty 
is that people in some parts of the country don't have enough 
medical services at hand — regardless of price or ability lo 
pay. The extent of health services actually available in dif- 
ferent partsS of the country varies according to the wealth 
of whole communities. Counties, cities, and states which are 
well off have enough doctors, nurses, and hnspilals, and 
adequate puhlic health facilities; those which are poor have 
desperately few. 

In New York State before the war, for example, there was 
one doctor in practice for every SOU people, while in Mississippi 



Five stales and ihe Dislricl of Columbia , whose 
overage per copj7o income in 1940 was $814.. had, 
per 10,000 populolion: 

15.7 DOCTORS 
6.9 DENTISTS 
32.6 NURSES 
45 HOSPITAL BEDS 

Seven poorer slofes , whose average per capita in- 
come in J 940 was $303., Itod, per 1 0,000 popu/oJion: 

7 DOCTORS 

2.3 DENTISTS 
10.4 NURSES 
24 HOSPITAL BEDS 

1 Rhoth iiland, Dittriit of Cotvmbin, New forii. New lerwy, {Uinois, 

Colifoiytio. 
3 Kfnivdcy. Wejf Virginia, Norlh Curoiina, South Daiala. Soolh 

Corolino. Norlh Dakota, Miivaippi. 



there was one for 1,500 — exactly three time?; the number of 
people to be served by each physician. Moreover, the density 
of popnl^lion in Missisr^ippi is about onc-Lenth 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. 

Tn New York there was one general hospital bed for every 
200 people, bnl in Mississippi one to every fiSO. Variations 
between counties are even more striking — 17 million people 
live in 1 pi^OO ctmntics that have no recognii'-ed general hos- 
pital at alL Thus, where communities are too poor to attract 



siilVicieiU ;l(icior,^ or lo build ami maintain oiIkt huallh facili- 
ties, nut only do the needy h;ive I*' go willnuit necessary 
medical i^ervices, but so do those who can afford Ui pay l>ut 
cannot seek care elsewhere. 

Health services are unorganized 

Even the best general ]ir;j.ctitioner eannot adequately cope 
with emergencies nr with baffling and complicMed cases if 
he does not have the resources of a well-ef|nip|>ed hospital 
within reach and tloes not have coUejigucs in surgery and the 
ijther specialties available when nccdei[. Even where there 
are first-raic hospitals, the ^'Cneral practitioner may not have 
the right li." use them. In Tpaltimore, for csample, almost half 
the general practitioners cannot care for their patients in 
hospitals. 

Specialists nsnally set up offices in cities of some size. They 
are not easily aecessible to cnnntry doctors or country patients. 
Moreover, specialists are not as a rule organized t<» work in 
combination with general jihysicians. Such teamwiirk can be 
fonnd, however, in many of the leaditjg hospitals and clinics 
where medicine is taught and in the fiutstanding group practice 
clinics such as, for example, the Mayo Clinic. 

In today's medical schools students are trained under a 
system of group medical practice, centered about a hospital 
where the best available e<iuipmcnt and tech n if j lies can be 
emjfloycd and where the combined skills of a variety of 
specialists can be brought to bear on a pii/.z!ing case. Yet 
when they gradiiale, they go out into a kinfl of isolated 
practice similar to that of their grandfathers' day. That this 
is professional ly unsatisfactory to physicians is shown by ihe 
fact that over half the doctors in the Arniy slated that they 
would like to go into group practice nn returning to civilian life. 

To Slim up the problems of American medicine, then ■ 
Americans receive the benefits of medical science in a very 
uneven manner, partly because of the high cost of modern 



motliL-ine, pa.rtly because medical services are not organised 
In serve everyone e<iiially — regardless of where he happens in 
live <jr how much ho can pay. 

Clearly^ then, the problem of paying for health services is 
very complex. Can some way be found for families lo budget 
these costs and to assist those families which cannot reason- 
ably afford the total costs? And can facilities for rendering 
health services be made more equally available in all parts 
of the country? 

Whales to be done? 

President Roosevelt, in his "economic bill of rights" put before 
the nation early in 1944, included "the right to adequate 
medical care and the opportunity to achieve and enjoy good 
health." Wendell VVillkie declared in 1944, "Complete medical 
care should be available to alL" Secretary Wallace recently 
said, "Your federal and state governments bave just as much 
responsibility for the heahh of their people as they have for 
providing them with education and police and fire protection." 
Governor Thomas 1'-. J^ewey appointed in 1944 a commission 
on medical care "in order to devise programs for medical care 
for persons of all groups and classes in New York Slate.*' 
Jn his special message of No%'emher \9, 1945 asking Con- 
gress to adopt a five-point national health |>rngram, President 
Truman said, "We should resolve now Ihal the health <if this 
Nation is a national concern ; that financial barriers in the way 
of attaining health shall be removed : that the health of all its 
cili/,ens deserves the help of all the Nation," 

Thus leaders of both political parties have followed the de- 
mand of farm, labor, and business organisations and of the 
public at large, as shown in various opinion polls, for an 
improvement in the way medical care is distributed. 

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



hcallh work, atJ<"pIcd in Ihc fall nf 1944 an official policy which 
slates that "a natiuiial program for nn^dical care shcjulii make 
;ivailablo lo thu cnliU" pojmlaliOTi, ri'gnrd/css oj the jiimiicitrf 
tufaiiH tfj the indiriiiind. the jtimily^ or tfte cinnmuaily, ;ill c^sscntial 
|)rcvcnlivc, (ha;^noslic and curative services." The American 
J )enlal Assticiatimi has declared that "dental care should be 
;Lvailable lo all, regardless of income <ir ^cofjrnphic locati<in." 
J'he American Medical Association, represcnlinj^ ihe majority 
of jirivale jiraclilioners an<i rm the reenril as a eoifservalivc 
profcssicmal organi^aiii^n, now reco^iiccs the fact ihat there 
is a problem in ihe ifislrdjiili'^n uf medical care. Up to a few 
years Ji^n, it nflcn asserted thai, cNccy>t in isolated Tiislances, 
everyone needinj^ me(ncaf care was able to yet it^ hy |i:iyiny 
fur it or through charity. 

WHAT DO PEOPLE PROPOSE TO DO 
ABOUT THE SITLIATIOIN? 

Ai.riioiKiir a j;real many pe<i]>le kntnv that ways mnsl be found 
so that everyone can secme ^-ood meifical care more rapidly 
and pay for il mnre easily, ihere is no snch a*^recmenl mi 
just how this shotdd be done. In ]>arlicular, ojiiuions varv a 
good cleal cjn Ihc ^overnmenl's role in the fulurc of mc"die;il 
cure, Stime Ihink n<> further j^uvernmeni activity is nccess;irv. 
i dhcrs tliiTik thai the g(>vemmenl must play a part, but ditTer 
;is lo how hij^f ihal pari should be. I'rnjjosals ran^o from 
\-.ix su]i|n>r| for such liTiiiied |mr|i<ises as school heallh |)n)- 
;^'rams, h> a complete nnlic-n;d heallh jirogram paid for through 
Tialiona! he;dlh insurance and general tax furnls. 

iimids off^ (wovvrnment! 

Trrsenl j^overnmenlal aclivilies in providing health services 
are generally ;iceepled. I'Lach American citizen spends about 
a dollar a year far cciiirol oi" cuntagimis diseases, iiislallation 



oi puro milk n^nd wiiter siii"]ili4.'s, yiid ulhcr ]iul>lic htalih 
servicts. That ^Inilnr is i-fmsidereil a gi.n.>d invcstnieni. Thnugli 
st^lc-sii|tiMjrlC(l ht'^jJiirils for mental iJliicss ami liiherailosis 
:irc s<»mclimcs cnlii;i/-t'd ris insuJfick'nt, mi one \v:iiUs ihcm 
t']m:inalc(l. Rather^ ]ml>lic pressure is for their impruvcmeut 
icnil C'Njiaiisiiin. Sd on ihmtijjh the lung lisl I'i ktcal, slaio, ami 
federally supported hcallli services. 

Yet, ^l iirsl, almost all lax -supported services met violeiii 
n]>iiositi<in from small ^rini]>s whose interests were temiinrarily 
itlTeeleil. When, fur example, the testin*^ of ilairy cailk fur 
tiilicr* niosis as a means of keeping i"<m!aminaieil milk from 
ihe markets wys pmjxfsed, <lairymen hitterly opjiosed it. They 
said thai any such measure wonld mean political control and 
re^'imenUMion. 

Similar pr^OesIs have frequently come from represenlatlvcs 
oi the medical ]^rofession, who usually (»jjpr>se the extensi<in 
of lax-supportc'l health services. In 1*344, for example, the 
^^iivernin^ l*odv of ihe American Medical .Assncialion, while 
recognizing the need for im]>roved eariy diagnosis and treat- 

SICKNESS COSTS FALL UNEVENLY 






OF FAMILIES 
BEAR ^]% 
OF COSTS 



BEAR 41% 



BEAR ONLY IS% 



menl of 111 1.1 cr miosis, <lid not favi^r increased feilcral rt^i^ponsi- 
bility in this field, and refused lu supjuirl a. bill in Congress 
extending federal financi:d ai<l to the slates for the conlrol <if 
luliereiilosis. Aware th^l under present eondjlions over half 
the patients :uimilled to lulierculosis hospitals are already in 
an advanced slage of the disease, most jmblic health es|jer|s 
considered ibis bill a vital measure toward the ulliiiiale wi]>inf; 
out of lubereulrisis. Jn sj>ile of the position taken by llie 
American Medical Association, Congress passed the 1:y\v with- 
out a dissenting volt one week later. 

The A,M,A. today is strongly opposed to any form of 
govemmcnl'Sponsiirei! health iiisurimce on the jjround that 
it would brinpj political co;Urul of medicine and interfere with 
the personal relalionshij^ between patient and physician. For 
s<ime years, the A.M. A. has held thai the intimate bond 
between ]ialicnt and jdiysician is threatened or destroyed wheii 
the y>alleMl himself does not pay his doctor on a fec-for- service 
basis. Yet. the A,IV1,A,, yielding to public pressure fi)r an 
easier way f>f meetinfjj sickness cr>sls, now supjiorls voluntary 
health insurance run by cimimercial companies or by medical 
societies. This is a reversal of its position fd teu years ago 
when the A.M. A. cdiloriali/.ed against proposals for vokmlary 
health insurance as measures i>f ^'socialism and communism 
inciting; to revolution," Tn July 1945 the A.M. A. <lcclared 
its position in a program, sumniarizcil in a later section of 
this pam]>hlet, 

Voliinliiry insurance 

Voluntary insurance against the eosts nf hospitalization and 
physicians' services has, however, had a considerable <Ievelo|i- 
menl in the United States. The oldest of these insurance plans 
are those tjrpfanized in certain industries especially in mines 
and railniads, which often o]ierale in rcmtde refjions where 
medical services are scanty. Usually, a monthly deduction id 
a dollar or two is made from employees' wages and a like 



amiiuni is often timtribiited by employers. These funds are 
then ponied and :ire used to pay for the medical rare which 
may Lie needed liy the employee. Employees' families are 
sometimes ]>ui not generally included. Few new plans of this 
type have been started in recent years, although one has 
received wide aitciuion^lhai organized at the Kaiser ship- 
yards on the West Coast. 

The largest recent dcvehipnient in voluntary insurance has 
been ftir bc)S]>i tallica lion, especially ihe "Ulue Cn^s.s" plans 
approved by the American Itnspilal Association, Blue Cross 
subscribers arc enlisted voluntarily from anion^ employee 
griJU|jf> iu ihe community. Subscribers usu;illy pay about $24 
a year for insurance that covers ho.spilali/ation for employees 
and lhcir families for a jjcnod of three Ui four weeks a year. 
The i'luc C ross jilans have expanded in the jmsl ten years 
frcmi less than a million subscribers to more than IK million. 

Plans have also been organi/.ed to in.^urc the costs of idiysi- 
cians' services. These have not been s<^ successful as the 
hospiialixalioii insurance plans but have nevertheless gmwn 
so that they now cover about 4 or 5 million peo|>le, chieHy for 
services limited to surgical operations and obstetrics. 

Vc»luntary insurance plans have also been developed for biw- 
incoinc fanners, untler the sponsorship of Ihe Farm Security 
Administration, and about 3(K).000 rural inh;diiiarils arc now 
included in them. Farm families generally pay about $25 to 
$50 a year in these plans and receive limited medical, surgical, 
anil hospital care. 

Commercial insurance companies have made some progress 
in selling ]>olicies In cover the costs of hospitali/alion, surgical 
and obstetrical care. I'sually these policies rirc taken out by 
employers for their employees and their families, both em- 
ployer and employee making monthly C(*ntnbulions to the 
fund, .\pproximatclv 8 million ]>ers(*ns are now insured under 
such policies. 

The success of voluntary efforts in providinj; insurance 

J0 



agatnsl the costs of medical and hospital care has encouraged 
some groups to hope that all the major problems of health 
and medical care can be solved by voluntary measures^ without 
the participation of government. As mentioned above, the 
American Medical Association takes this point of view. The 
United States Chamber of Commerce a3so advocates further 
trial of voluntary methods. 

Others feel that voluntary insurance, whether it is under 
the auspices of nonprofit organi/.ationa of physicians and 
hospitals ar of commercial insurance companies is too Hmited 
to solve the problem. They point to the fact that, despite the 
rapid growth of some plans, not more than 20 or 30 million 
persons are subscribers to such plans in the United States 
up to the present time ajid that the insurance coverage of even 
these persons is largely confined to surgical, obstetrical, and 
hospital care. 

furthermore they olYer the objcciiim that most existing 
voluntary insurance schemes include no general medical ex- 
penses, no preventive care, and little family cart. They feel 
that such insurance provides no incentives for improving the 
quality of medical practice and that its cost limits its sale 
to a rather narrow section of the population. In the case of 
commercial policies, they say that it is no great bargain — 
companies on the average pay out in benefits only about half 
of what ihcy receive in premiums. 

Those who believe that voluntary efforts cannot fully solve 
ihc problem emphasise two difficulties encountered by such 
insurance. In the tiist place, voluntary plans, by their very 
nature, face the j)n]blcm of securing and retaining subscribers. 
There is an inevitable tendency for healthy families to stay 
out of the plans and for those inclineil toward illness to enter 
and remain in them. This fact is apt to bring about financial 
difficulties. Because of the spotty, uneven coverage of the 
population, the healthier families do n<»t bear a full share of 
the costs. The second difficulty is that, if voluntary plans 

II 



charge hiyli i^nou^'h premiums lo cover Ihc ctisis oi complete 

medical iiiid hospital care, they are so expensive that the 

lawer-income groups, who need this care the most, cannot 
aJTord lo suliscribe. 

Government aid for special programs 

Cicorj^e \\'ashlnf;;lon was still alive when the Marine lltispiial 
Service f<ir sick merchant seamen (tiow the United Slates Pub- 
lic Health Service) was established. Since thai day a variety of 
tax-suppurled heallh services have one by one been added to 
the functions af government. Local and slate governments 
and, to a minor f!c;;rcc, the ferlcral government provide funds 
for a larg^e number of h<.)si>ilals, public health services, and 
medical care pritgrams. These funds may be used cither to 
combat particular disea.scs, such as malaria, tuberculosis, or 
syphilis, or Ui give all types of care to certain groups of the 
population, for instance, veterans, men and women in the Army 
and Navy. Indians, or the needy. 

That such government programs can he successful in de- 
livering medical service of high quality is attested by the 
lirilliani record of Anny and Navy medicine in World War II. 
Oflicial recitrds of the War Department show, for example, 
that whereas ^.3 t>erccnt of the hospitalized wounded, exclud- 
ing gas casualties, died in World War I, only about 4 percent 
died in this war. vVJlhough warfare in the fever-ridden tropics 
meant an increase in the number of men hospitalized overseas 
for disease, the annual deaths from overseas hospitalized illness 
amounted to only 6 per 10,000 men, as compared with 12S in 
W^orld W'ar I. Deaths from hospttali/ed illness in the conti- 
nental United States accounted f<ir another 6 per 10,000 men 
in contrast to 156 in World War I. 

Such results are to be explained, in part, by recent scientific 
developments like penicillin, the sulfa drugs, use of plasma, 
i )l >T, and airborne evacuation of the wcmnded. But even these 
dificoveries cuuld not have been made elTeciive witliuut good 

12 




13 



organization, good direction, gtH>d eqiiipnienl, good doctors 
and nurses, and good use of doctors and nurses. 

Not all governmenl-aided medical programs have the en- 
viable record of the Army and Navy, but they have met 
important special needs. Nevertheless, for the total civilian 
population, these special programs do not meet other equally 
pressing needs. There arc, and will continue to bc» all sorts 
of proposals to fill in the gaps between existing tax-suppnrled 
services. 

The new tuberculosis control law is a good illustration of 
how an established state program can be expanded hy the use 
of additional federal funds. An ail-inclusive service of early 
diagnosis, hospital care, and rehabilitation is being developed 
from a meager program of treatment. 

Venereal diseasti 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 who might 
otherwise end up in mental institutions twenty years later. 

Other diseases might be attacked in the same way Ihnmgh 
use of tax funds. Rheumatic fever, for one, which every 
year kills more children than all other childhood infectious 
diseases combined, might be much reduced in amount and 
severity by a concentrated program of attack. 

Government aid will undoubtedly be requested for other 
special groups of the population. For example, tax funds mighl 
be sought to help needy parents provide their children with 
the medical and dental care recommended hy school doctors 
or to help care for the needy in nong<tvernmental hospitals. 

The necessity for many such special programs is generally 
recognized. Few attack them as undesirable, yet it is fre- 
quently fell 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 13 said, has led in the past to a piling up of agencies havint: 
to do with medical care — some local, some state, some federal, 

14 



Each has ^liffcrcnt standards anil tliflcrin^ procedures for 
ihe paiiL'iils to i^ti thnmgh before seciirinj; tart" and which the 
(iucKir.s must follow before gcltinp paid. Many, such as public 
ciiy hospitals, are still run as oharilies which moat people use 
only as a last resirirl. 

Tax-supjioricd services are sii scallcrcd an^l uoeven thai 
most people d<m't even know which ones ihey are entitled 
1(1 use or how to K" about fi^etlinjf Ihem. Under most fHucb 
programs, iKc patient must in effect prove that he is enlitletl 
to care not just because he is sick, but because he is eligible 
to become a beneficiann'^ umlcr some p;irtii"ular law. 

As T^ew health ]irograms are added, critics of the ]>iecemcal 
approach maintain, it is increasingly important Ihat Ihey fit 
Tiilo an or^ani/,ed system anti n<tl brinj^ alonj^ their own 
particular brands ni red ta]>e. " ['here is no tunctitmal or 
administrative justification," says the American Public Health 
Associalion, "fc»r <lividing humati )»cin^s or illnesses into 
many catc^^iiries to be dealt with by numerous independent 
administrati<m,s," 

The A,M,A. has lon^' maintained that all federal activities 
in the fjcld of health should he brought together in a single 
government agency, headed by a cabinet member, instead of 
being scattered among^ diJIerenl departments and agencies. 
Such a move might be beneficial in tying together i^ome of the 
federally supi>ortcd services, which, except for Ihe Army and 
Navv, form a relatively small part of all la\-sup]iorled activi- 
ties. iJut many feel that iu» fundamental change w<iuld be 
achieved by such a move alone. Confusion in the administra- 
tion of existing health services is the inevitable result of a 
variety cjf laws and allocations for strictly limited purposes, 
ihey say. Until a pcrs<in is entitled lo medical care just 
because hi? is sick, and not because he is a sick soldier, or a 
tiick Indian, or a sick orphan — until then there is bound to 
be a variety of standards and procedures to fit the needs of 
each separate program. 

J5 



Sa. while some groups want no further government a.ction 
and others see the role of government Ivniiled to special pro- 
grams where Ihere yrc certain dramatic health needs, still 
iilhers feel that an over-all national health program is the only 
satisfactory way to assure good medical care to all who need it. 

A nation-wide health program 

What do those who want an over-all health service plan 
have in mind? Two reports have recently been published 
outlining the principles under which the respective backers 
believe progress in national health can best he achieved. One 
is a statement of the American Public Health Association 
(A.P.H.A.), a second is a report of the Health Program 
Conference, a group of physicians, economists, and others 
interested in progressive health planning. These are not, of 
course, the only documents ever brought out in favor of a 
national health program. The demand goes back many years 
and has taken many forms. The^^e two reports are used to 
represent the all-out program here because they are recent, 
comprehensive, and authoritative. 

Neither report came out with a mt}del law, in fact neither 
group supposed that a single law would cover all its recom- 
mendations. The reports were designed instead as guides to 
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 national in scope, accord- 
ing to the views expressed in both these reports. Health 
programs organized on a state-by-slate basis, with no federal 
aid, tbey maintain, would fall into the same uneifual pattern 
as at prc-scnt. The same economic factors which niake some 
wealthy states able to maintain good ])rivate and public health 
facilities would also lead to successful health plans in these 

16 



iircas. And Ihc rclalive poveny ui other slates, which is niiw 
rcllcctcd in ihfir scaTtJI^ of iJoclors ami h<jspitals, would like- 
wise mean very inadeqvialc heallh plans aniun^ them. 

The A.J'.J^i.A, ;ind Health l^rogram Conference reports also 
maintain that ccrtai;i national standards arc necessary to make 
sure that the qnality tif niedieal service everywhere mccLs at 
least minimum rei^uiremenls. Because people in our c<juntry 
arc ;ilways moving from i)lacc lo place, national standards lor 
the amtnmls and methods of payment Ut hospitals anil iJoclors, 
conditions of service, and adjustment of complaints \v<iuld also 
be desirable, they say. These, however, should be adminis- 
tered in a way that would take account of the dilVerences in 
re(|nircmenls between varic^us parts of the nation, they agree, 
liecausc a health program in the hills of KculUi'ky, for instance, 
would present vastly dillerent pr^ildems from a health pro- 
gram in Seattle. 

tVitics of a national i*ro^'ram say that it woulii mean regi- 
mentation. In their view, it wouhl be liclter to have state 
pr<fgnims, even g!"anlin*f thai the people in some states would 
be far betler ^iervcd than in others, rather thati to run the risk 
tif rigid governniCTU control. 

J'lOlh reporls assume that government regimentation is by 
no means inevitable if, in the framing of laws, Hcxiblc adminis- 
Iration is recognised as all important. They agree that actual 
operatioij of a health program must be directed largely in each 
individual community and stale, and the ]irogram should be 
responsive lo local needs. vSlnclly metUcal matters must be 
kept in the hands of the medical profession, which alone is 
competent to set medical standards, they say, and {questions 
of public c^niccrn, such as financing and distribution of services, 
must be in the hands <if the |»nblic. 

C(mc!uding that a wholly satisfactory heallh x>rfigram must 
tie nation-wiile in scope, the A.I\H..'\. and the Heallh Program 
Conference reporls go on to tiutline what seem to them the 
essentials of any such plan. 

17 




DI&TRIBOTIOW OF 
MEDICAL COSTS 



WHAT ARE THE PILLARS OF A 
NATIONAL HEALTH PROGRAM? 

Five key pillars are necessary to support nalional health, 
accordinfr la these reports. They are: (1) (iisiribution of the 
rusls "i health services, (2) esialtlifihmcnt of hospital and 
[itiblic health facilities, (3) organization of medical services 
lo pnimotc iL high quality of care, {4) administration satis- 
factory to patients and the professions, and (5) promotion of 
continued scienlific research and education. 

Distribution of costs 

Starting out with the twin assumptions that the present indi- 
vidual pay-as-you-go tneihod <tf meeting medical costs has 
proved itself unsuited to the needs of the population and that 
voluntary insurance is too limited in scope, advocates of a 
nalional health program rec<igni/e two alternative ways of 
meeting medical costs. Both methods of payment are based 
on the fact that while individuals can never predict when they 
will be sick or how expensive their illnesses will be, the 
expected incidence of illness for large groups of people and 
its cfjsts can be fairly well determined. By chipping in 
regularly to a common pool amoLints which are fair in pro- 

IS 



portion to his income, each member of the large group can 
be sure that there will be funds to pay for his own health 
needs, whether large or small, whether ihey occur next year 
or tomorrow. 

The first alternative is a system of national health insurance, 
combined with support from general tax funds. This method 
is advocated in both reports. National health insurance is no 
new thin*^, in fact it is in operation in thirty-one nations. Tn 
S')me it is over fifty years old. It works like this: Employed 
people turn Jii a certain part of Iheir wages each month, 
through payroll taxes. In a government-administered health 
insurance fund. Employers match the amounts each worker 
puts in, as under Social Security in the United Stales. When 
sickness strikes the wage earner or his family, doctor and 
hospital bills are paid <»u( of ihe insurance fund. 

Insurance of this type was desij^ned orig^inally for the wage 
earner, whose premiums can be easily collected through pay- 
roll deductions and for whom employers can also make iheir 
contributions easily. Such health insurance in other countries 
has seldom been available tn farmers, people who run their 
own small businesses, domestic servants, and other similar 
occupation groups. Health insurance on this plan docs not 
touch the sickness costs of nonworking people — the unem- 
ployed, the aged, the chronically JIU For this reason both the 
A-IMI.A. and the Health Program Conference reports recom- 
mend thai, if national hcahh insurance is adopted, it be supple- 
mented by general tax funds to include all groups of the 
population. 

The second alternative method of financingj suggested by 
the A.P.H.A,, Is that the insurance features be forgotten and 
public health services be paid hw simply and solely out of 
taxes— just like public schools. This, it is argued, would in- 
volve far less red tape. AH ^'roujis of the population would 
pay for their health services by the same kind of (axes. The 

19 



amtniTil would vary according to the particular circumstaoces 
ul the individual. Great Britain, which has had national health 
insurance since 1911, is planning a system in which two-thirds 
of the costs will be financed through general taxation along 
these lines. 

Whichever may he the hctter way of enabling people to 
l>ay for medical care — whether by health insurance combined 
with laxation or by taxation alone — the reports of the A.P.H.A, 
and Ihe Health Program Conference a^rce that as long as 
payment is made in the manner of today, the "right to achieve 
and enjoy go<itl health" will not be truly available to all, and 
ihat some such nation-wide solution must be found for the 
J mil *l cm. 

I>ui a method of paying for medical care is only part of the 
story. With a thousand dollars in his pocket, a man on a 
desert island with no ductor or hospital cimld still not g^et his 
broken arm set. Both the A.P.H.A. and Health Program Con- 
ference plans emj}ha5i/e the need for construction of facilities 
in areas which lack tbeni and improvement and enlargement 
of facilities where they are inadequate. 

facilities and personnel 

The keystone here, according to both reports, is the hospital, 
A hundred years ago the hospital was mainly a place for the 
i^ick poor lit 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 practice to the provision 
of good medical care — yet 40 percent of the counties of the 
United Stales have no recognized hospital facilities. This situ- 
ation would be bad enough in ilself ; yet it is also reflected in 
the number and kind of physicians such counties can attract. 
Younger physicians whose education and training is centered 
in well -equipped and well-organized hospitals cannot practice 

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 half as many doctors per thousand inhabitants as counties 
of the same income level which are generously supplied with 
hospitals. Since counties lack hospitals directly in proportion 
to their inability to support them, those who favor a national 
health program think that federal funds should be used to con- 
struct, enlarge, and modernize hospitals in the poorer counties. 

The A.IMl.A. report, in addition to urging hospital con- 
struction, stresses the need for public health departments to 
serve all areas of the country. At present, 1,223 of the nation*s 
3,000 counties lack any organi^-ed health department. 

The need has long been generally recognized for health 
departments to insure safe water and milk supplies, sewage 
disposal, and control of communicable diseases, and for health 
centers where special clinics can be conducted, such as those 
for maternal and infant care or diagnosis and treatment of 
venereal disease. The A.P.H.A, report again emphasizes this 
need and concludes that it should be woven into a national 
health program. 

Both reports assume that modern hospital and public health 
facilities, 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 now greatly nndersupplied- 

Organisation of services 

With a fairer way of paying the health bill and with hospitals 
and medical personnel distributed according to where they are 
needed, many of the obicctives of a national health program 
would be realized- What about the 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, pertain methods 

S2 



of organizing professional services tend more than others to 
encourage advances in quality. 

The report of the A,P.H.A. and, more particularly, that 
oi the Health Program ConfcrcnL-e, stress encouragement of 
better professional organization as another essential of a 
national health profi^ram. The focns here, ugain, is the hospital 
but a hosjtital that funcikms in a new anil dilVerent way. It is 
to become not ooly a place where illncs.s is treated, but also 
a center li>r jtrevenling^ disease and for improving the wbcile 
practice uf niedicxne in the surrtnmding area. It is supi^gestcd 
thai .such a truly modern hospital conkl, in addition to its usual 
facilities, house public health clinics, the oflices (*f phyjiicians 
and dentists, and eijuipment for the common use of all. In 
such a group-prdctice unit, doctors would be encouraged to 
work more as a team, pooling their knowledge and skills. 

Croup practice 

'i*he general physician, it is assumed, would he the patient's 
main source of medical care. But at his elbow wcjuld be the 
hosintal and the specialists whi>se service.^ are neccssiiry if he 
is Ui ]>raclice modern medicine. Freed through health insur- 
ance from ihc rcs]ioMsibiliUes <if fee setting and bill collectings 
the family doelor might, for example, imd mure time to act as 
guide and counsehir in the cmolicmal problems of his patients 
as well as ]>r("vjding ihcm with other tyi>es of medical care. 
His role in the prcventiim of mental illnesses, tme of our 
biggest unmet hcabh needs^ might be strengthened through 
The a<lvice and leaching of his colleagoacs in p.sychiatry. 

Working in groups, doctors are to some extent supervised 
by each other in the kind of services ihey render. For example, 
a young surgeon in a gnmp is usually assisted liy a more 
txperieoced colleague when undertaking an especially ticklish 
operation. The story leading up ti) the dcalh of any patient 
is reviewed at stafT meetings. These supervisory practices arc 
nut a new idea: they have been used for years in good hospitals 

V -■ ■ 23 




Gn>lip tncdii'ul f>rac-li(-v brings your dorliir inlo irUnc ^^cirkintf dsr^ocialion 
tvilh otiicr doctor;* of difTcreul inlcremH aud skills. 



24 



lo safeguard the quality of niedkal service, especially for 
\vard cases. 

Such supervision docs not require an outside government 
lnsi>ccIor. Under any health program it could he carrieil out, 
as at present, by groujis of physicians themselves. Indeed, 
as mentioned hclore, group medical practice is no new idea, 
])Ut a familiar ]ihenomcnon in the private group clinics scat- 
tered lliroiighout the Unite<l Stifles, particularly the middle 
ueslern ami western states. What is new in the Health 
Pro^-^ram Conference report is the idea i>f encourapinp; this 
lype of organization thnmghout the nation, and combining 
il with a more favtired ]>lacc for ihe family dctclor than exisls 
now either in individual or in certain types of gnmp practice. 

A neiworh of hospitals 

Towns and cities of dilYerent lypcs, sizes, and locations natu- 
rally reijuire diiferent sized hosi*itals and dilYerenlly e(|uipped 
hospitals, llie country hospital, for example, could never make 
enough use of radium lo justify ihe cx]>cnsc <i( owning it. 
A thinly populated area may need a highly trained brain 
surgeon only once or twice a year. Nevertheless, when these 
and other unusual services are needed, they must be accessible. 
\\'hat is the answer? 

llolh reports endorse a plan of organization somewhat 
similar lo that of Army hosptlals. They would encourage 
future construction of hospitals according lo an integrated 
scheme of health ccnier.s (corresponding lo the Army field 
statiim'J' — rural hiispitals, district hosjiitals, and base hospitals. 

To illustrate; A state might have one or more base hospitals, 
preferably connected with medical schools, where all types of 
medical service would be available and where the more unusual 
types of treatment wtmid be carried out. Here, where they 
cmild answer any need in the state, w<ndd be the brain 
surgeons and the radium. I'ase hospitals would also be centers 
i»f leaching anil medical research. 

25 



The many dhtricl hospitafs. lutalcd in large towns or cities, 
would be l:irgc. and equipped to handle the more usual medical 
and surgical cases. Smaller rural hospitals would be far more 
numerous than at present and would 1)C designed to take care 
of ordinary diagnosis and treatment, minor surgery, obstetrics, 
and so forth. They would refer complicated conditions to the 
district or 1iasc hospilals. Health centers, spotted about hos- 
pitals of all types, woidd huusc the ollicts of public health 
nurses, laboratories, pubhc health clinics, di»c|ors' offices, and 
some cmerf^'ency beds. 

Patients would, as a rule, go to the hosi>ital nearest home, 
but [or particularly dilficuU types <'f diagnosis or treat- 
ment might go to a base h<ts])ital, much in the same way 
that lhi>se who can manage it now go to a well-known clinic 
or medical center. 

This scheme of integraieil hospitals would make constant 
.exchange of information, Iraining, and personnel am<jng them 
possible. On this foundation, a cim-sultalion serx'iee could be 
built so that at rc^lar inlorvnU fipci-ialisis fioin iht^ larger 
hospitals would visit rural hospilals and health centers. At 
the same time, rural physicians mighl g<i up ti> the base hos- 
pital for special postgraduate training, reluming to Ihcir 
praetice stimulated and belter prepared. 

ProjKjnenls of a natiim-wide health program see in hospital 
organization along these linc^ a tremendous inducement to 
phj'sicians to organize themselves into strong professional 
groups. Whether or not doctors wouM wish to lake advantage 
of these opportunities would of course remain to be seen. 
There are indications ihal vounger members of the pn>fession. 
in particular, would welcome the chance, 

A dm in isl ration 

How could such a program be carried out so that both the 
patients who receive the services and the docti>rs, dentists, 
nurses, hospital people, and others who render the services 

26 



would be satisfied? Here, the guiding principle, both reyorls 
agree, is tbat while the health prognim should be national iu 
scope aud while certain national standards arc necessary to 
insure that public funds are used to best advantage, neverthe- 
less the responsibility for the detailed planning and working 
of the program must rest with local areas. 

For example, the federal government might refuse to allot 
national health funds to hospitals without laboratories. Few 
would question that siich minimum standards should he set. 
On the other band, the government would not be similarly 
justified in tryinf^ lo tell doctors when to use a particular kind 
of laboratory lest. Such judgments must <if course be made 
by the doctor himself, subject to the slalT regulatiims of his 
fellow physiciatis In the particular hospital. 

Except fur profcssictnal questions, the lay pubhc, which 
receives it, should have a strong say on h*iw the service is 
c^mductcd, b<ilh in their <iwn c<immunitics and at the state 
and national levels. 

Certain freedoms are considered basic: 

1. l*alifitLs should be free either to make use id services 
provided under the national program or tci continue to secure 
medical services in the traditional manner, as they prefer, 

2. I'utifrUs should he entitled t(» choose among individual 
physicians, organized groups of physicians, hiispitals. and so 
forth. Likewise, they should be free to change their sources 
of service without difliculty. 

3- Phydcmii^ should be free, as ihey now are, to accept or 
reject patients; to participate or not to participate in a national 
program ; to furnish services as ii^dividuals or lik associate with 
other physicians in groups. 

4. Voluntary agencies (such as hospitals) should be encour- 
aged lt> participate in the national ]>rogram, maintaining their 
status as independent agencies iiml retaining full responsi- 
bility for their own admini.stration, <ir not to participate in 
the natiiinal pnigram if lh;it is their j^reference. 

27 



■>■-' 



Incomes of physicians 

Neither the A.P,[-LA, nnr the Health Program Conference 
repcjrl oiYcrs a pat solution to the thorny question of how 
doctors should be paid. They agree that medical services 
should be provided as economically as is consistent with high 
(juality. At the same time they feel that remuneration to 
doctors should be Jaufficienl to attract and hold good men and 
should be scaled so that there are financial rewards for pro- 
fessional excellence. 

There are three principal ways doctors could receive pay- 
ment under a national health program. The health fund could 
pay doctors in individual practice: (l) a fee for each service 
rendered to patients, in the same way that most doctors now 
collect fees from their private patients, or (2) a set amount 
per year, called a ^'capitation fee" for each person choosing the 
doctor's services. Doctors working together in group practice 
could he paid by salaries from their groups. Jn such cases the 
health fund could pay (3) a lump sum to the organized group, 
determined by the extent of medical service the group provided 
or the number of patients using it 

Although fce-for-service is most used in private practice 
today^ there are also many physicians in the United States 
who are paid by the other methods and apparently find 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 number of years after graduation before doctors 
begin to earn a living by their practice. It is natural for doc- 
tors to wonder whether a government system would offer a 
reasonable income. The example of poorly paid schoolteach- 
ers, government clerks, public health nurses, and "city physi- 
cians" does not reassure them. Many people feel that the 
question of paymeni to physicians lies ai the heart of doctors' 
opposition to a national beahh program. 

28 



Holh ihc A, ]\ H. A. aiul tlii.- llc^illh ]'r<i^q:rain Ctinference 
reports JigTUL" lh;il IhtTc is roi>ni for cxporinicnlation with 
methods ijf piiying physiciriiis, but argue ihal a jthysirijin's 
yearly intonic must he rvilc<|U^[to, as jiieasiircd by the iin:(imes 
usual anumg' other jihysitians of tlie same 'i^e ami traiTiini; 
anrt in the same \yjiv tif coinnmnity, ami hy the iiic<imes of 
other professional j^ronps. 

Research and education 

Under any type of health program, tlic quality and the oon- 
tiimed improvement of medical serviees lean heavily on rc- 
seareh and nic(lieal education. 'I'he half billion dtillars invested 
in these heltis hy xjrivale pli]laoihro|iy oyer the last fifty 
years are held to ]>e largely resiKinsihle for the hij^^h jdaec 
of American medical ,snence today. Advocates of ;i national 
health pro^^ram say that government funds ninst he fortheom- 
in;;^ where ]>riva1e funds leave ojf if knowle'Ig^e is to march 
steadily forward. Iji fad, during the war, the federal ^'overn- 
tnenl Sjjonsored and in many eases subsidized both mediial 
and nursinfi^ education and a variety of scientific rcscarch. 
The results— fi>r example, discoveries as lo the ]>rocessinjjj and 
uses of stored blood — iire familiar enoiij^h lo those in the 
armed forces, 

Jn adiiiticm Ui funds for research, the Health Proj^ram Con- 
ference report emphasizes the need for more opportunities 
for |iostgradiiate tr;iiiiin^ for ])hysicians. Medical scieme 
advances so ra]>idly ihal the pliysician who ^'raduales from 
medical school this year will iind it necessary next year In 
brinj; himself uj) to date. Too often the busy practitioner has 
no time lo keep up with advances throiiJijh study and readiuj;: 
rarely is he in a position Avhere lie can alTord to take a month 
off for pos1j:ra<luale study. This is parliculailv true of tlie 
country doctor. Opportunities for doctors Ui ^'et i>r>st gradual e 
nieflieal education couhl he prcatly furlheruil by Ihe use of 
public funds, advocates claim, althou^jh even more important 




The charily clinir and die vi-^iling nurse are uftcn ilie only Noiircea of 
niedicnl «rvice |o (lie poor and llic JNolnfed. 




3Q 



<!ny-l>yMl;iy ro^iiills would he oI>tmned through improved or 
^'.in'vAAiujn of medical servicer. 

The OSRD report 

The use of federal funds In sii|)]Mirt a program of scientific 
research Avris recommended 1o President IViiman in July 
1945 in a rej^iTl of T>r. Yiinnevar Tinshn clirector of the Office 
of ScK'niiric Kescarch and \ >cvelii]}mont — -I he ;^nvernment 
agency res]>onsilde for ihe use of federal funds for such re- 
search <lnrin^ the war. 

In this rci}ort the war aji^ainsl disease is given iirst con- 
sidennictn- Dr. Bush strongly advocates government support 
of medical research as hasic to siny naiiimal program of ex- 
pandc'l medical training and research and to the promotion 
of publk' health. 

The reporl, which recommends the estahlishment of ^ 
national scientific research fourjdaUun rrsjjnnsildc to the presi 
dent and Congress, was rec(?ived wilh widespread public 
interest. 



HAS A NATIONAL HEALTH PROGRAM 
BEEN PUT BEFORE CONGRESS? 

Ilo TJIERK r'KiM'ii'i.KS ol a national health jtrofrram appear in 
y>raclical fonii in the legislative juiiposals brought before 
Tongress? A\'hal manner of luitional health program is it any 
way ihat has hcen advanced for [ftiblic discussion and eventual 
Congressional ilecision? 

Heginning in 1*^43 with the original Wagner-Murray-Dingell 
Bill In add health insurance t<i the Social Security system, 
several bills Inive been ]iro]n>seil embodying the principles. 
They incbide ihe Mill llurtun Hospital Construction Bill, a 
new version id" the ^^'agner'Mu^^ay-l)ingell Bill introduced 
in May 1945, ;ind n still later revision of NovcmbeF 1945. 



The first Wngner-Murray^Dingell Bill 

National he:ilth insurance was l>ut :>nc of several |»nkvlsions 
of this bill- Other provisions, such as extensiiin of ^^ocial Se- 
en rity^ the nalionalizatiim fii uncniploymont compensation, 
and federal aid for jjeneral relief, are beyond the iicope of 
ihis discussion, 

The bill providcil llial liealih insurance would be cstaldisheil 
by the creation of iv national medical care and hospil^di^a- 
tiun funcl, to which employers ^nd employees would each con- 
Iribute 1.5 i)e!-ccnt of the firsl $3,000 of jinnnal waj;;es, making 
3 percent in all. Self-employed would contribute the entire 3 
percent themselves, Omtribultcfns amountinjj to an adiii- 
ti<inal 4.5 percent of wages would be made by empli)ycrs and 
employees, 9 percent in all, to pjcy for ihe other benefits of 
the hill. Two of these latter provisions have an important 
bearing on healtli, namely, those providing; for cash payments 
during temporary and permanent disaliility. 

Fur every insured pers<ui and his family, the medical care 
and hospitali/atictu fund would pay for unlimited cloetors' 
care iTicludinjj specialists, fi.r hospitali>^ation up to 30 days, 
X rays, and laboratory tests. Dental care, nursing, medicines 
and drugs would not be paid for. 

i'alients would be free to choose their physicians from 
among those particijiating in the program, whether engaged 
in individual or jijroup practice. Standards of c<ini|>clence f<>r 
specialists and hospitals would be established by the Surgeon 
General of the United States Public Health Service. Any 
licenseil physician could parlidpate in the program as a gen- 
eral praciiiionen 

The national fund would pay physicians for the services 
rendered ti» patients covered by the system through any of 
several methods — fee-for-service, capitation, part-time or full- 
lime salaries, or by a combination of these methods. The 
physicians of each area would choose by majority vote the 



methiul of pjiymcnl U* he itUuiJltU in that iirca. I If jspiuls 
wiiul<1 lie paid up Lu $0 yn^v day kn each day of c^re they 
furnished. 

Reaction to the hill 

I'he 1^43 \Vaf:jner-Miirray-T)inp:ell Hill never came to a vote 
in Congress. Ncvcrthelej^s il laused a sliimi of comment 
Backed enthusiastically by organized labor and some fann 
or^ani/aliims, it was tonsidereil hy them '*so cnonmms an 
improvement over our present social security pnwiKions that 
no respimsible person, deeply concerned with the welfare of 
our country, can fail to support it." 

At ihe same time, it was vigorously opposed l>y repre- 
sentatives of organized ]>hysicians, in whose minds it w^s 
"snci^ilizei! medicine," The op]>osilion ^'n>u|'K said that thu 
bill implied that sick people would have to dt]>enil <»n a 
doctor p.iid by the government to work only eipjht hours 
<l;d!y — emert,'ency cases would have to wail until the docit^r 
chucked in. i^atients would have to go to the doclor assigned 
to them Iiy political bureaucrats, and doclt>rs would becmic 
incompetent Ijccaiise methods and remedies would be fixcil 
by bureaucratic superiors, l^arj^cly to uttpose this bill, physi- 
cians and drug h<iuses raised an<l spent over a (|uarlcr of a 
million dollars in jjivin^ out "iiifomiatidn" of this nainre. 
Extremes were reached with statements like, '*lt is diniiMfol 
if even Nazidom confers on its j^^aoleiters the powers which 
ibis measure would confer on the Surgeon- General of ihe 
U, S. Public Health Service." 

One group of physicians attempted to jiromotc a national 
movement to boycott any Icjri.sl.-Ltive pmgrain stich as the 
^Vagner-Mtl^^ay-iMngcll Jlill, g^iving physicians this advice: 
*']f such Icfi^islation as the Wagner-Murray-Dinj^'ell Hill passes 
and yimr t>atients come to you for services unck-r the plan, 
tell them you don^t serve the ]>oliticians, ytiu serve them. If 
they want to know what they are going to get for the money 



deducted inim ihcir pay checks for health insurance, vrni 
diHi't know." 

It IS of course deb:itable whether an insiir;uu'e scheme such 
ns tha.t prupijsed in Uic bill wnmld in fact have the disastrous 
effects predicted by its opponents. Certainly the l>ill itself 
had no provisions for assigninj^ patients to doctors, for 
repulating^ physicians' hours (jf work, income, or methods of 
practice, except £i>r the elementary re(juirement that specialists 
meet national standards ni competenie in their parlicidar fielils. 

Many perscms in favor of federal legislation fur health nnd 
medical care felt, however, that the first Wa^ner-Murray- 
Oingell Hill fell far short of prnviding a truly ade<|uate health 
program for the nation. They pointed nut that it included, for 
example, no provision for the construction of hospitals and 
health centers. It contained iioihiuf; to cncourag^e the expan- 
sion of preventive health services. It offered mithin^ to 
induce physicians to modernize their methods of practice by 
joininij to^'ether in gnnips instead of continuing in the tradi- 
tional solo i^raetice of the old-lime family physician. 

Some felt, too, that ihe whole population should he protectc<l 
under the plan^ rather than merely employed persims anil their 
families. For this reason, and to promote preventive health 
services, support from general taxes as well as from the pay- 
roll fonlribulifms of emplovcr and employee was ur^cd. 

Finally, disinterested critics generally felt that the hill per- 
mitted too centralized an administration of ihe program. They 
said that the program did not require sufficient participation 
hy state and h'cal t^ovcrnments nor by local representatives 
of the professions and Ihe public. The American Bar Associa- 
tion made the adililional point that it failed lo provide for 
court review of administrative decisions. 

The new Wagitcr-Mnrray-Oingel! bills 

A revised ^Vagner-Murray-Din^'cll Bill, intrf>duccd intit Con- 
gress in May 1*^45, proposes a ]*attern essentially similar to 

34 



the earlier oTie, hut has added features wliirli meet some of ihe 
criticisms made of llic i>nginaK It had not been acted upon 
when President Truman sent to Congress his special message 
oi November 19 asking national health legishnion. 

The President sirnngly advocated a pm^rain .tf five related 
pHJposals for action by the federal goveniment: 

1. Financial and other assistance for the cunstniclinn 
of hospitals and other health faiililies Avhi're lliev are 
most needed, 

2. Increased grants to the slates for public health 
services and maternal and child health tare pmgrams. 

3- Support of medical education and research, 

4. K-xpansion of comptilsory insurance under the So- 
cial Security system \o cover medical, hospital, nursing^, 
laboratory, and dental care, 

5. Cash benefits to cover some of the wage h>sses 
during jicriods of sickness and disability. 

In order to meet, at least in part, the President's request, 
Senators \\'agner and Murray and Representative Dingell 
proni]itly lifted, rewrote, and introduced as a separate bill the 
health provisions of their earlier measure. 

These health provisions include, besides medical care insur- 
ance, increased federal grants to the slates for public health 
work and for Ihe care of mothers and children, but no funds 
for construction of hospitals and health centers. Benefits of the 
medical care insurance have been increased by adding limited 
home nursing and dental care. .An altempt has been made, 
too, to increase ihe responsibility of slates and communities 
through advisory commiliees, allhough the final administra- 
tive control remains in the federal government. Court review 
of administrative decisions is, however, s])ecifically authorized. 

Groups of physicians, as well as indiviilual praciilioners, 
may particiy>ate in the plan but they are not expressly en- 
couraged. The physicians of an area may still decide by vote 



liow Ihfy wish to In* paiil, lull -sm"b a vf\c is no lon^^cr liiniliii^ 
nimn ;ill Uio tliiilors nf the arc;i. tlcntriil lase?^ aru lc» be nsc^I 
more generously to supplement Ihe funds ctmlribulcd by 
cmplnyers nnd em]*liiyees, I)i3l llie ]0:iii <l(Pes mil yel niver Ihe 
enliri." i">pul;iU()ii. 

Summary of opinioit 

iJisi iissiun of iialiim-it le(:^isl:iti< m fur health wi!l chmhlless be 
foiused ahoni ihe 'iViiiiiaii |inijiosuls and ihc iaiesl Wa/jnur- 
Murnty-lHii^ell I'.il! for some lime In lome. It wilJ be useful, 
therefore, lo rejual Ihe |>niuii>al arjinriU'Ols for .im] a^';iiiis1 
the orifjiiiai liill. i'hc ^ronjis sniipDrlJnti the 19-13 measure 
om]jhasi/,ed Ihe necessity for iiali<in-\vitle action in onlcr to 
e<fnali;^e the o]f]iorlnnily fur heaUh services aiiicjn^ all ^nin]>s 
of [he jio|jnlaliiiii in whatever ]mr\ of the conTilry Ihey lia]}iien 
to live. 'I'hey also siresscd the need for a inelhod of jiavin^ 
for medical serviie liy whiih ]ie<t|>le can pay in known, ref^nl;ir 
rimnunls, month liy month, in jtecMrdame wilh llicir eaniin;;s. 

Those (ipjiofted to the first bill, on the other hand, made ni\ 
issue of ihc dan^'(.T of poliliial ronirol over medical niatleis, 
of a ]M>Ksiljle threjil lo [he individual freedi>m of jialients and 
doctors, and iif the limitations thai it mif-ht impose uptm 
]}hysicians in |)nfk'ssional slatns and — hy inijdication — incinne. 

■J*he iialioii-wiiie discussion \]v\{ loi»k place as a result oi the 
inlroduelion of the bill hivd liro;i(l ^'ducationrd value, li stimu- 
lated peo]i!e everywhere lo greater awareness of ihe issues. 
It provoked |jainslakin^ in(|uiry by numerous ]ion])r<>fessioi]al 
orfi-ani?.ali<ms nnd groups as lo ihc true frtcts of medical care 
in their own communities and in Ihc nalion as a whole. All 
this served in some de^ee to clear the air, to dispel false 
ni>tions and Kr^undless fears, and to aid the country in facinjp 
rcalilies. \\ilh this increased interest and knowled^'e as a 
backfjround, the ]niblic is belier |ircpar(."d, wilh the ijiln^- 
ductiou of the November ]94^ bill, tr) res4ilvc diHercnces 
of "ly^inion and to focus its utlcnlion ui>on specific jjoints 
for action. 

36 




AtHivtf: Arlit^L^ skolrli unil fluur ptkin for 'i niCHl^rn lirMth renler in a 

i^Ommiiriilj at 30.V0O. Hclim : Skclili for iip-Ut-ibikp IiJ'Iv-Ih'J liospilal 

in a cuniiiiuiiiij oi' 10,000 Lo 20,000. — U. S. riiblir. Healih Hervicc. 




The Hiil-Bnrton Hospital Construction Bill 

This mc.isurc, inirodiicetl in the spring of 1945, wr>uM provide 
federal grants lo slates fur the cnnstrucliijn of hospitals and 
health centers. Designed to encourage over-all planning by 
the stales of an ordered network of health facilities, the bill 
calls for each state to study its existing hospital resources 
and unmet needs, in order to develop a master plan of cnnstnic- 
tion. The federal treasury, after slate plans had been approved 
by the Suri^eoii General of the United Slates Public Health 
Service, would sn^ipiemenl funds for construction raised within 
ihc stales, payinj*^ a larger share of federal funds in poorer 
stales, and a smaller share in richer ones. 

Besides i>ri»viding for Ihe conslaiclion and improvement of 
slate, city, anil cimnly hospitals fi>r general care, mental illness, 
and tuberculosis, ibis liill w*puld also aid in the construction 
uf those nongijvernmental community hospitals which are not 
operated for pn»fit. 

Suj>porTcd by the American Tlosinlal Association, organized 
labor, farm grout^s, and the American Medical Associaliim, 
this bill has aroused little <ippf>sition. It fits into the principles 
of a national program in the following ways: 

1. DifffTDuces l>cl"wccn slates m :iv:iilahihiy of hospital 
Eacililics nii^lit he grtally Icsseiacil hi't"iusL- ii:ilioii:d lax fund^ 
winlld shilrc ihf costs nf construclion. 

2. Tniprovcd orj:,'aiii -Million itf ficrviccs ccnlcrtd nroiiml hos- 
t"lii!s is made possihlc if hospil^d ;id]niiiistralors, |»hy,siciiins, 
and I lie pufjlic \sislj lo avail lIlitmscTv<^s of The o^>pnrliinily, 
bctiitisi.' couslrmlioi! would lie U;iSi<l on Htalc-widt ]i]aiii|j|i^, 

3. Decent rali/c-d :idini nisi ration within Ihe slates, tiubji'ct 
only to Reneral nalicmal slamf^iriT^, would Tcflecl llii; parlicular 
needs ^nd circnmslanccs of the various shilcii iind eonmuinilie!:. 

A. Tlie principle Ihal ]frivale, nonprofit agencies can main- 
tain individuality wilhin a national, li*x-sided ]>Tui;ram is recop- 
nii^ei! I»y llie mcluMfm of improvements and new conslmction 
tor tliiii type ai huspiiaL 

The bill, however, is criticized to some extent by farm and 
labor ^n*ui>s because the general jmblic, who would use ihe 

38 



hosjiitals, would not hnve A grcnt deal to sny aliout where they 
are to be locateiJ. As provided in llie l>ill at present, the 
committees who determine the location of the hospitals would 
he compof^ed larfjeiy tif hospital adminisiratnrs and physicians. 

The most scriims eriiicism of the Hill-Burton Bill is that 
it can meet only limited needs. It does nut attack the problem 
of paying dijctors' and hospital bills. A modern, well-equipped 
hospital is of liiile value to a cononuniiy if ihc pc*f]ile in that 
I'imimunily cannot alVord In use it. At present, it is the sad 
iruth that areas which h;i.ve ihc least hos}»ital liicilitiea in 
]fr(j|n triKiu Ut jufpulation arc also the areas where such hos- 
jnlals n^ do exisl are the least used. In other words, where 
cum muni lies arc loo poor to build adc<|uale hospitals, the 
]>eo|jlu liviiif,'' iht-rc are loo j>oor lo ]»ay fi*r hi*s|iiia] care under 
present arrangements. Tu guard against the possibility of 
putting u|) white cle]jh;inls, Mi the sh^jic <if hos]>itals which 
wnulil Tiot he use<l. this bill pro\i<les that coniniunilics want- 
ing' \^L■^\ hns|»ita]s niusi show ability to su|i|»ort them after 
ihey are btnll. If this cannot lie shown, no federal money 
wouhl be forthcoming. 

Were ihi: Hill-Hurton Bill passed in this form — and in the 
absence of any measure to meet the patient's prohlcm of paying 
hospital charges- — sonae critics think that most new Imspitals 
would Ijc built in wealthy areas which need them less than 
iilher lotalities but which can afford to siippi^rl them after 
they are built. 

The THli-llurton hospital construction bill is of great sig- 
nificance because it is the first national measure related to 
medical care which has received support fnmi all major profes- 
sional groups as well as major farm and labor groups. Yet 
even its most ardent sponsors recogni^^e thai at best it can 
meet only limited necils as ionj^ as the problems of paying 
diiclors' and hospital hills are still unsolved and that at worst 
it might result in an even less e(|uital>lc distribution of general 
hos^ntal beds than at present. 

39 



WHAT rS THE A.M.A. PROGRAM? 

In July 1945 Ihe American Medical Assi^ciaiion announced its 
program to meet the admittedly unsalisfactory health situation 
in America, This program emphasizes the need for intensifica- 
tion of voluntary efTorts to solve the problem of paying the 
medical hill. Sustained industrial and agricultural production 
is urged lo iin]>rove living conditions and therefore health 
condilions. State surveys are suggested to determine the need 
for additional medical care and to appraise the adequacy of 
voluntary insurance plans in meeting such needs and in im- 
proving the quality of medical service. Extension of preventive 
ptihlic health services to all parts of the country is advocated. 
The expansion of voluntary insurance against the costs of 
hospitaliiiation an<l physicians' services, so as to s^rve all 
communities, is proposed. 

The A.M.A. report further suggests that the medical care 
of the needy be met from locnl tax funds paid as premiums 
to voluntary sickness insurance plans directed by doctors. 
Supplementing state and local funds by national lax funds 
is proposed where definite neefl for such aid is demonstrated. 
Emphasis is placed upnn llic importance of informing the 
pitblic about the nature of voluntary insurance plans, with 
recogTfilion that they need not involve any increase in 
taxation. 

Finally, the report urges postponement of the consideration 
of "revctluliiinary changes" while large numbers of men and 
women, including medical officers, remain in the armed 
services, and proposes measures for rectifying the present and 
future shortage of medical personnel, particularly in rural 
areas. The questiim of the organization of medical services 
around a network iii hospitals, or in group practice, is not 
totiched in this report. 

40 



WHAT ARE THE MAIN ISSUES? 

Pcblk: iiiscussinN in rcient years indicates widespread con- 
cern about the quality and distributiuii (if health services in 
the United States. Five principal problems are generally 
recognized: 

L How to arrange payment so Ihat all the people can 
regularly pay specified amounts in accordance with their earn- 
ings rather than be burdened irrcfjularly and unexpectedly 
with the large costs of unpredictable illness, 

2. How to pay f<jr medical services and facilities so that 
they can be available more evenly throughout the country. 

3. How to organize America's health services to use our 
medical resources most elTeclively and furnish service of high 
professional quabty. 

4. How to make necessary changes and yet preserve the 
best of our present medical practice, avoid undesirable and 
arbitrary ^'cjvcrn mental cnntrols, and guarantee freedom within 
Ihe program f<»r both patients and yihysicians. 

5. How at the same time to stimulate continued and im- 
pnived medical eclucaii'm and research. 

Although there is much disagreement as to how it should be 
done^ most groups of the professions and the public appear to 
agree on the basic principles that people can more easily pay 
for medical service by s<»me type of insurance than by the 
traditional fee-for-service methctd; that federal funds from 
general taxation will be nce<!ed if hnspitals and other facilities 
are to be built in needy areas; that medical services can he 
supplied more economically and with better guarantee of 
cjualily by the use of group medical ]>raclice Ihan by in<lividnal 
practice; that local representatives <»f the prufessJons and the 
public must control the distribution of services on the basis 
of broad nali^mal standards: an<l ihat national funds will be 
needed to support improved and extended medical education 
and research. 

41 



Controversy has been most pointed about the proper role 
of government in any changed organiiation of health services. 
Opinions range from those who would limit government aid 
to specific problems — such as sanitation, communicable dis- 
ease control, the care of the needy, institutional care for mental 
illness and tuberculosis — to those who vvould have govern- 
ment, particularly the federal government, take steps to assure 
adequate hcaUh and medical services (o all. 



4t 



TO THE DISCUSSION LEADER 



Every imwAN beini^ is faced with thtr problem of his own 
pt-rsiinal health. The head of a family has the added rcsponsi- 
liilily f'f locking alter the health of his wife and children. 
Civic-minded indivifluals recognize ihal health \^ alsi} a com- 
munily concern — thai good health for the individual often 
depends on ini]»roving health coniJitions and health standards 
for the eommunily. 

This pamphlet presents major points of view on the impor- 
tant ijiicstion of improving- health. It docs not try to j^ive an 
answer. That is soniclhin^ for iJie individual to think through 
for himself. 

Jt is donfjtful whether any reai7er of this pamphlet or any 
member of a discussion i^roup would argue against the im^ 
provement of health. IJiscussion leaders will encounter plenty 
of conllieljng opini<jns, however, when they raise the <|uestion 
of how health can best lie iinprnved. This question of hoiv it 
should be done is something to talk over at your discussion 
meeting on the basis of the soundest information available. 

Hoi€ fan you plan a discussion meeting? 

Discussions are ideas in action. You cannot have a lively 
voluntary discussion unless you brinj^ together individuals 
who are interested in a subject. Therefore, you need two 
things: a subjeet that will interest some jieople very much, 
and a means of letting people know that a discussion meeting 
is to be held on that subjeet. 

'*Is Your Health the Nali<in's Business?" is a subject that 
will prohaiily interest many pei.ipk". 

Your first major task as a discussion leader, therefore, is to 
let i}eopk- in your area know thai you are planning a discussion 
meeting on health. 

43 



How can you do this? There arc several possibilities. Vou 
can show i\ copy of this pamphlet to the editor of your local 
newspaper and explain to him the type of program you are 
planning- "^'ou can prepare notices lo be placed un Iiulletin 
boards. Y(m can prepare posters for readiTtg rooms where 
you have placed copies of this pamphlc(. You can suggest 
that local librarians arrange reading table displays of this 
pamphlei and other suggested reading material an public 
health. Finally, ynn can "talk it np*' to certain individuals 
who will pass the wonl along to their friends that a discussion 
meeting is going lij be held on this subject. This proredurc 
on your part will give people who are interested an opportunity 
to plan to attend your meeting. 

W^hat kind of discussion icarks best? 

Earh discussion leader is pn^bably his own best judge as to 
what type of discus-slon will be 3Ti<ist satisfactory for his group. 
If you are in doubt you might discuss this matter with c|ualificd 
advisers. In making this decisinn you ,shouId consider several 
important factors. How large will the lUscussion group pruh- 
ably be? What kind of facilities are available at the meeting 
place? What lype of discussion has proved most popular with 
local discussion groups in the t>ast? What good speakers 
might be obtained for this parlicular subject? 

You should be certain that you understand the general ad- 
vantages and disadvantages <if various types of discussion. 
Forums, panel discussiims, symposiums, and. general group 
discussions are the forms most frequently used. EM 1^ Guide 
for Discussion t^eaders. tells just how they differ from one 
another lielow arc some specihc suggestions. 

Forum: A competent doctor who is a good speaker might 
iriake an eNcellent forum spealver on hcallh. One who has ha<l 
both civilian and military experience in dealing with health 
problems might be particularly well <palified. After his pre- 

44 



liniinary lalk on health, members <jf your group could question 
ihc speaker on poiiils of parliciilar inlerL-st lo them. 

Panel Discussion: Health is a subject that would lend itself 
partkularly well to a panel discussion if you can get four or 
five qnali^ed speakers. A gn>up i>f yuung; doctors, or a com- 
hinalion of doctors, dentists, and psychologists, might make 
a panel that would keep the discussion ball rolling in a lively 
manner. Time should be allowed for members of your group 
to question the panel participants. 

Symposiuni: Two or more doctors, particularly those with 
diverse ideas about kovj lo improve health, would make gin)d 
symposiuni Hi»cakers. You shouki limit each to about ten 
minutes so that members of yiinr gnmp will have an oppor- 
tunity to question all ihc speakers. 

injonnal Discussion: Since health directly concerns every 
individual and each has his own ideas about maintaining 
health, your entire program could he c<jiiducted as an informal 
discussion- It will be necessary for you, as discussion leader, 
to be familiar with the contents of this pamphlet and to be 
])ri,'pared with well-<»rganized (questions lo bring out major 
health issues for discussion. 

Can tUm'iission handbooks he helpful? 

Discussion leaders will find many helpful suggestions on plan- 
niiig and conducting discussions in EM I, Guide jor Discussion 
Leaders. This Guide discusses in detail the various types of 
discussion possible. It gives helpful hints on handling difficult 
personalities at discussion meetings. It emphasizes the im- 
portance of careful planning and outlining a program of 
discussion. Study of this handbook will enable a discussion 
leader to improve his program; it challenges him to use his 
tfwn ingenuity to make his program interesting and worth 
'while. 

Some discussion leaders face the problem of planning and 
conducting programs to be broadcast over the radio or on a 



loud-speaker system of Armed Forces Radio Service. They 
will find EM 90, Cf Radio Roundutble, full of sound advice 
and usable suggestions. 

Questions for discussion 

You should jot down your ov\^n questions as you read this 
pamphlet and outline your discussion program- You should 
encourage members of your group to ask questions. Some- 
times the most helpful questions grow out of the discussion 
itself. It is well, however, to be prepared. Below are some 
questions which you may find helpful. 

1 
Has civilian medical care heen accessible and satisfactory 
to members of the discussion group and their families? Has 
the problem of payment for physicians' care or hospitalisation 
been difficult? Have doctors and hospitals been located 
reasonably near at hand? Has it been easy or difficult to obtain 
tlie services of necessary 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 problem of payment throughout the country? 
In urban communities? In rural areas? In all geographical 
areas? 

3 
Would there be professiona.1 advantages in a scheme in 
which physicians practiced in groups? Economic advantages? 
From the patient's point of view? From the doctor's point 
of view? ■ ' ' 

4 
How do the advantages 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 normal peacetime dislnbulJon of civilian physicians 
and hospitals satisfactory? What factors ioflncnce this dis- 
tribution the most? Cotjid Ibey be modified by physicians? 
By the piiblie? How? 

6 

What measures have recently been proposed by the Ameri- 
can Medical Association to meet the nation's health needs? 
What etYect do you think these proposals, if carried out, would 
have upon (a) the ability of people generally 1o pay the costs 
of sickness? (b) the distribulion of ilociors' and hospital 
services? (c) the quality of medical and hospital services? 

7 

Da you think the United States government should (a) do 
nothing further in the health field? (1>) support only special 
health programs such as those to benefit mothers and children 
or comfiat venereal disease, lubcrculosis, and mental illness? 
or (c) sponsor national ;iction for health care im a bri)ader 
basis by insurance or tJix support? Would action by the federal 
government tend t<j impnwe <ir lower the <|uahty of medical 
care received by people generally? Why? Would most doctors 
benefit or sutler economically and professionally as a result of 
federal action? Why? 

S 

Should the federal government aid in the construction of 
hospitals where they are needed? How should such hcjspitals 
be supported if built? Who should own Ihem? Who should 
delemiine their location? What d(?ctors should be eligible to 
use them? What patients should be eligible for admission to 
them? Would hospitals built without federal government aid 
serve the public better? 



«r 



FOR FURTHER READING 



TuESK BOOKS arc su^gcstctl for suiJ]>lomt'nl:iry' reading- if you 
have access lc» them or wish Uf ]>iiii:hasL' llieTii frtiwi ihe piil>- 
lishens. They are nol ;iiJiiniveil imr iiHii'ially supplied liy the 
War Dqiarlmenl. They have been selccicd because Ihey give 
adililicm;]! iiifurmatiini ;viid represenl dilVerenl juHiits t>f view. 

AMKkKA Om;AM>:K*i Mkhkink. liy Miehael M, Uavis. Puli- 
lisheil l)y J larper and Urolhers, 4'J T^st AMi Si,, New York 
lU, N. Y. (1941), ^.^W. 

Oui\.\>iVAv.n Pav.mknts Kok Mi:i>r'al Skuvicks. liy I'ureau ttf 
Meiiiial J'Aononiies of Aiuerieau Medieal .\ssi»eiiili(in, 535 
Norlh l)e:irln»rn S\., (."hieaj^^M, UK (1941). Copies no longer 
available from pidilisher. 

U. S. Mkotdnk in TKAN-siTiuN. Ariicle iri t'orutm: Detember 
1*M4. Reprints available on rc*|uest from foiUiiw. Kmpirc 
Slate r*uil<linf.^ 350 Kiflh Ave.. New York I, N. Y. 

liTSTin-: AfJt> TiTK b'uTifKK OF MmTtiNT':. Arlide by Wendell 
lU-r^e 111 PuUiv Ut'tihli Ri^fttfrLs. Vol. (lO, Nit. 1^ January S. 
I^M5. May be cibiained frnm tiovcrnmeiU Printing ( Mlieu. 
^\':ishioglim 25, HX'. 10 rents. 

lh:Ai.Tii l\suKAN(-K [\ Amkui^a. Publishe*! by IJniled S(;ilci> 
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O, DA". (Pi45b Addresses delivereiT ai ihe Semml N^i- 
Jional limk-reme uii Soiial Seeurity. J-'iec on reijuesl Ut 
scrvieemen. 

Wahtihi: TTealtu anu KoircATioN. Ke]H»rl Ni», 3 i»f the Senate 
Snbeomniillee on Wjirliuie lleallb ami I'dtu alioii, Senale 
Offiee Ihnldiiig. Washtnglon 25. D.C. (January 1945). f^Yee 
nil re<|uisl. 

IIkai-IU Caki-: roi; .\^:T.r^lc'A\s. \\\ {\-K. A. Win.slosv. No. HM 
of t'ubfic Affitir.-i I'limffhfvts. |iublished liy ruhlie AlTairs 

tn 



l."c»Miminci\ .*t) Kiiikcfcllcr IM:ii'.;i, Nfw ^ <irk 20, \. \. 
09451. 10 icnts. 
PRiNcm.KS OK A Natkjn-W'iuh IlKM/rri PkockAM. Kcporl of 
ihc I le;illli IVofjram L tmlcTciioc, |nil>lishftl l>v Omimillcr 
Of) Kese:iR-h in Mfdiriil Iximnmios, l/'H) l'^ni;iihv;i_v, Now 
\<*rk 10, N- ^'- (VM4). 10 cents. 

1'(INTK\T ANU AllMlSlSTKATION df" A MKnU'Al. C'AUK rH(li;KAM. 

An ;irlirlc \'V |"Si']»li W. Mimiiliii in AiiiprUnn Ji'uniitl I'j 
Puhfiv Ueiiffh i l>cc(rmltcr PH^V Kt'ijrinls aviiilulilo fmni 
Amcrit"in Tnlilic Hcallh Assm-ialioii, ]7'N) llrn;nlwav, Sew 

York VK N. ^'- 2^ t^"l^^- 

Voluntary MKniCAT. IvsiTKANrK in tiek U>jrn:i> Sta'j>;s: 
Major Tkksjis am> t'lkf^KNT rKiJiii.KMs, Hv 1 It'lon I k'rsh- 
ficlci Aviifl. I'tiljltslit^fl liy Mi'iliiJil Ailniinislnilinn Strvict', 
J790 Brnadway, Now Vurk 1^, N. V. (1944), $L00. 

Medical Skgvhk T'LA^s. Uci>*irl nf P.nroan i>f Mt'dic:*l Km- 
nomics of Amorican Mctlu al Ass<k iafiun ( 1943^ (.dixies 
no lonj^cr availaMi- from |nil>lislicr. 

A Cdnstkitc TivK rk()i;KAiM Kok M Kim AL L'AiiK. 'IIk' nfhiial 
proj^rani of Ainfruan MfilUal A^socialiuii, in Jirurimf of thr 
Amerlntii Mi'diciil Assiirinliim, July -I, 1''45. Sif also t'iiiloriai 
am! ;iriiclc tailctl "Ueallh Insumincc" in the sanu' is.sm^. 

Nationae. IIkaltii Skkvkk. i^y Brili^ili Ministry iff lU-allli 
an(l Dcparlnicnt of IlcaUli f<ir .Sc()llan(t. ('uhlisht^il by Mai- 
millan t'o., rrf) Infill Ave, New York 11, N. Y, (1944)- 
7S cents. 

T\tv. \\ac;nkr-Murkav-Dini^ell Hill — ^S.1050 y\v I 'MS. An 
ar^lysis by l-iurt'an yi i.cgal Medicine of AmencaTt Meilical 
AssocialioTi, "^ Joui-nat uj the. American Mt^Jiviti Asstiviutlon, 
June 2, I'MS. See also an crliliirial on ihe Tiill in the saii;c 
jiutnhcr, Rc]>rinls available on re<]ucst. Mnch material on 
the I*H3 and VMS Waj^ner-Mnrray-Din^cll liills a[>]>eaTs in 
oilier issues of ihe Jimnud. See especially an analysis by tlie 

49 



Boreal c»f Legal Meditinc and ati c<lit<>ri;il (June Zti, n*43), 
and cotnments by Senator \\'agncr Qunc 30, 1945). 

AmEKILJ\N BaK ASSOCIATTON CoMMTTTKK REPORTS. In JuUrniil 

of thf American Medical Association. March 1 1, 1944. Reprinis 

available (pn reijueat. 
Fok THE I'EnpLE's Healtie. Published by Physicians Fonnn. 

/I East .S7lh St., New York, N. Y. (1945), Free *>n recjiiesi 

Ut servicemen. 
SciKNt'lC, TTIK Kwm.Es'is FiiONTTFK. By Vannevjir Hnsh. ]*ub- 

lished by Governnienl rriniing Offiie, Washington 25, 1), C 

U945). 30 cents. 



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Ihe nearest USAI-"T Oversea Branch. I,ist KM nnnil]cr. lith\ 
ami <|unnlily. New sulijects will he announced as published. 
CI Romufiiihlti subjects now available: 

KM I, r.iirni' KOK DT'^rii'iSTdN I.kaiikh-. 

FM 2, What i'^ F^HifP'AjMNHA? 

EM 10. What Stiam. Wk Hhnf aihh'T (^krvmsy aftkh iiik Wah? 

EM II. Wii^i HiiAM, l^K Tii'f^K w(rir iirK Wah TRiMirfALs? 

E\f J2, OiS Wr rKi:VF.NT EllTllKK Wai^s? 

EM ^^. Mow Sii\r.i, Li'mi-Lk^sk ArnnrMT.^ Hn ^y.T\\,K\t'f 

EM 14, 1.^ iiiK (-nrm NutiriioH Pnucv a Sih^cksiv? 

EM IS, What SuiIli. Hk Done ahmiit .Ia^-an aftf'k Vif-MiHvV 

EM 20. What IIa'^ Alaska Tn Offkk I'iistwaii I'ynfuy.vM^'- 

EM TZ. WiiJ. TiiKH^: B>i Wmmk vh All? 

EM 23, Why CiMirs? Wfixt Aiif: Thkv? How Di> Tiiet Wowk? 

EM 24» What ],ii:s Atikaii fhu tut-: I'liii.iri'iNts? 

EM 37, What Is tih: K['ti'iii: of Tkikvi^^ion? 

EM 3n. <:an Wah MARiiTArts Of. Mauk To W<»uk?* 

EM 31, Du Yin: Wa^t 'Whm Wifk Tc* Wokk A^-n^H thk War? 

EM 32, SiiAix I Brir.n a IIoit^e amkh tuk Waa? 

EM ,1,1, What Wiij, Yoith Tmwn Bt Like? 

EM 34, Shaj.i. I <;o Rack to S<:h«ol? 

EM 35, Shall I Take Ui' FA\tM\tirJ; 

EM 3A, Dhfs It I'ay Tn Boiimiw? 

EM .t7, Whj, TuFtiP Rf- a I*lahk l^ Evehy (Iarace? 

EM 40, Wn.L THE FittNCii Kepijuuc Live Again? 

EM 41, Oi H Rhttisii Ally 

EM 13, Oi'K Ounf-se Ally 

EM 43, The Balkan;* — Mahy Pkoi'lk'^, Many Pkojli.kms 

EM 44, Ai"iTRALLAi Otr Neiohuiih "hi*wN IImieii" 

EM 45, What ErTiiHK fur the Islanus <•¥ THt Raliek:? 

EM 46, flint Ri'jiSMN Ai Lv 

EM 'XJ, CI IE Mint RnliVhTACLE 
■For diilrihulmn in Ujiltrd StaTrt cnl^. 

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■ft U. S. COVERMiWENl FFIIKTING OFFICE. l?4^}— 675507