Dollars, Doctors, and Disease

"Society must look forward to providing for health on the same basis as education, or else leave the medical profession in its present unfortunate plight."
VI

In its final report, the committee lists six essentials by which the value of any proposed plan must be judged:—

1. The plan must safeguard the quality of medical service and preserve the personal relationship between patient and physician.

2. It must provide for the future development of preventive and curative services in such kinds and amounts as will meet the actual needs of all the people, not merely their effective demands.

3. It must provide services on financial terms which the people can and will meet, either through individual or through collective resources.

4. There should be a full application of existing knowledge to the prevention of disease, so that all medical practice will be permeated with the concept of prevention. The programme must include, therefore, not only medical care of the individual and the family, but also a well-organized and adequately supported public-health programme.

5. The basic plan should include provisions for assisting and guiding patients in the selection of competent practitioners and suitable facilities for medical care.

6. Adequate and assured payment must be provided to the individuals and agencies which furnish the care.

Having spent five years in factfinding, and having agreed upon these six essentials, the committee was forced to recommend, as the only ultimate solution for the great majority of our people, group practice of medicine and group payment of medical services.3

The committee recommends that medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, and other associated personnel. Such groups should be organized—and preferably around a hospital—for rendering complete borne, office, and hospital care. The form of organization should encourage the maintenance of high standards and the development or preservation of a personal relation between patient and physician.

The major recommendations envisage groups providing all the needed therapeutic and preventive medical and dental services, except care for tuberculosis, mental disease, or other conditions which have been accepted as governmental responsibilities. Thus, complete groups would contain physicians, — both general practitioners and specialists, — dentists, nurses, pharmacists, medical social workers, and all the needed technicians and assisting personnel.

It is clear that many groups in smaller cities and towns cannot afford the full-time services of specialists in each branch of medical practice. To obtain the less common specialized services, these groups should affiliate with larger centres, particularly with teaching hospitals and medical schools.

The committee recommends, further, the extension of all basic public health services, — whether provided by governmental or non-governmental agencies, — so that they will be available to the entire population. Primarily this extension requires increased financial support for official health departments and full-time trained health officers and members of their staffs, whose tenure is dependent wholly upon professional and administrative competence.

The committee also recommends that the costs of medical care be placed on a group-payment basis, through the use of insurance, through the use of taxation, or through the use of both these methods. This is not meant to preclude the continuation of medical service provided on an individual-fee basis for those who prefer the present method. Cash compensation for wage loss due to illness, if and when provided, should be separate and distinct from medical services.

It is unfortunate that the committee, having decided that some form of group payment is absolutely necessary, did not recommend compulsory health insurance; for nothing is more certain, in the whole wide range of the committee’s field of study, than that voluntary health insurance will not meet the needs of those who are in greatest need. It will not reach the unorganized, low-paid workers. It will not solve the problem of satisfactory care for all the people, which is the very problem the committee set out to solve. Already most European countries have abandoned voluntary systems in favor of compulsory systems. Yet only nine members of the committee declared themselves in favor of a compulsory system.

VII

Nine other members of the committee, all doctors of medicine, are so far committed to the present fee-for-service system that they cannot bring themselves to sign even the moderate majority recommendation for the more extensive use, on a voluntary basis, of various methods of group practice and group payment. These nine members have presented a minority report.

The minority report states—what everyone must admit—that there are dangers in the proposed plan, and that the results, at least for some time to come, may be less satisfactory than the majority report leads us to expect. The minority members advocate continuous, complete service for chronic diseases, paid for on a yearly basis; the adoption of insurance methods only when they can be kept under professional control; and a change of emphasis in medical education, with a view to developing general practitioners and improving instruction in preventive medicine. On the other hand, the minority members condemn all schemes devised by laymen to exploit, for their own profit, the medical profession and the public; all ‘contract practice’ as usually carried on; and all forms of practice which make it difficult or impossible to maintain the personal relationship of physician and patient.

With all this, the majority members of the committee agree. These minority statements would have been incorporated in the majority report if they had been received by the editing committee in time. The differences of opinion, therefore, among the members of the committee do not cover as many points as the minority report seems to indicate.

All the recommendations of the minority members put together, however, promise little progress toward the provision of satisfactory medical care for all the people and satisfactory payment for all the services. The minority members evade the main issue—as, indeed, the other members do who refuse to endorse compulsory insurance or any other adequate plan for group payment. The minority members are essentially laissez faire economists. They insist that doctors be left alone to solve, in their own way, the problem which, after centuries of trial, they have been utterly unable to solve. In other fields of human endeavor, there is painful evidence that leaving each individual and each group alone to provide commodities and services in its own way, in pursuit of its own profit, fails to provide all the people with the food, clothing, and shelter which society, in the United States at least, is fully equipped to provide.

We learned this lesson long ago, as far as education is concerned; but the analogy between education and health is like a red rag to a majority of the medical profession. The trouble seems to be that it is a remarkably sound analogy. Certainly human welfare depends on the health as well as the education of all the people. These objectives cannot be attained if each member of society is allowed to be as ignorant and as sick as he pleases, or if each member who wants the help of a teacher and a doctor is obliged to pay for such help, without the aid of any method of group payment.

Education is now provided by group practice and group payment. Measures for achieving the same results in health are advocated by a majority of the Committee on the Costs of Medical Care. The minority report falls short of advocating an adequate plan either for group practice or for group payment. The majority report, it is true, falls short of advocating the use, at present, of adequate tax support or adequate insurance. The majority report does say, however, that ‘unless the national income increases so rapidly that many of the families at the lower end of the economic scale are enabled, on a periodic payment basis, to meet such costs, some method of tapping the combined resources of the population must be found.’

This is, in effect, an admission that society must look forward to providing for health on the same basis as education, or else leave the medical profession in its present unfortunate plight. Even the chairman of the minority committee admits that ‘a tide of public opinion inimical to the profession is rising which has already become a distinct menace.’ For the sake of both the profession and the public, the Dollars should be provided by collective action; the Doctors should be professionally in command; and thus the abundant resources, human and material, which are already at hand should be mobilized for the age-old battle against Disease.

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