The Health of the Nation: A Plea for Public Medicine

A Boston physician of leading and liberal opinion, CHANNING FROTHINGHAM was physician to the Peter Bent Brigham Hospital from 1912 to 1933, and has been consultant physician since 1933. He was a member of the faculty of the Harvard Medical School from 1908 to 1933, when he became physician-in-chief of the Faulkner Hospital.
2.

The amount of money spent annually on medical care for individuals in the United States is estimated at about $4,000,000,000. Those who have studied the possibilities believe that this sum is sufficient to provide good individual care for all the people and to reimburse the physicians adequately.

The problem, therefore, is to develop a plan to collect this sum in a manner consistent with the individual's ability to pay and then to spend it so that good medical care will be available to all the contributors. Obviously there will always be some who cannot contribute and must accept charity, and of course provision will be made for them.

Two methods of collecting funds from large numbers of our people to provide medical services for all have been in operation: namely, taxation and insurance. Because tax-supported medical care is usually associated with charity, and because the reception of charity is repugnant to most Americans, the trend is to develop the needed funds by the insurance principle. Radical changes in the insurance programs are necessary if we are to extend coverage to that more than 75 per cent of the population which for one reason or another does not have medical insurance. Yet only a few years ago it was contended by some—especially those in control of organized medicine—that prepayment plans to raise money to distribute the costs of medical care were unnecessary.

Insurance plans already in existence cover the costs of medical care in varying degrees. Some are voluntary, some compulsory; some operate on a nonprofit basis, others for profit. Most of them, if properly managed, are successful, but unfortunately they include less than a quarter of our population, and the benefits in most instances fall far short of complete medical care. How shall we extend this insurance program so that it will be available to all but the really indigent? And how shall we provide comprehensive high-quality medical care, including preventive medical procedures, early diagnosis, and treatment for all?

The evidence is conclusive that voluntary prepayment insurance plans will not be able to provide medical care for the great majority of our citizens. It cannot rescue from medical indigency the great mass of people who now frequent our charity or tax-supported clinics. It will not provide complete service to the tremendous number of people who for one reason or another do not get good medical care today. Its cost is too high. For under a voluntary insurance system the rich will stay out and continue to receive their medical care as they do today on a fee-for-service basis, thus reducing the number of subscribers. Those who gamble on their health will also stay out, as will the cultists who believe that disease rests upon a theory and that its cure does not depend upon elaborate diagnosis and expensive treatment. The omission of these groups will further limit the number of subscribers. With the subscribers limited, the rates must be raised or the benefits from the funds diminished. The premium rate for comprehensive voluntary insurance—profit or nonprofit—is too high for the majority of American families.

3.

The existing voluntary plans controlled by the physicians cover unusual emergencies in medicine rather than preventive medical procedures and early diagnosis, both of which are so important for the health and welfare of the individual. Compulsory insurance, on the other hand, based on a percentage of one's income, with certain necessary restrictions, offers medical care to its contributors and will include all but the really indigent. In the Wagner-Murray Dingell bill, which was presented to the Seventy-ninth Congress, provision was also made to include the really indigent if their local communities, which must assume responsibility for them, wish to have them included.

One might still hesitate to urge a program to be financed by compulsory prepayment through an extension of the Social Security system, and to be administered under its supervision in conjunction with the Surgeon General of the Public Health Service, if such a program would in any way lower the quality of medical care provided. A study of the proposed legislation, however, shows that the quality of medical care would be better safeguarded under such a system than it is at present or is likely to be under voluntary insurance plans.

Organized medicine has always claimed—and on this point I agree—that two important factors that have elevated American medicine to its present high position are free choice of physician by the patient and absence of interference with the intimate physician-patient relationship. Both of these factors, instead of being hindered by a National Health Program, will actually be more extensively developed. Through inclusion in the program, the families with the smallest incomes, who now go to tax- or charity-supported clinics, will be able to choose their own physicians as the well-to-do choose them. Furthermore, that ugly reminder of the cost of care—namely, the fee—will no longer come between doctor and patient. All too often the conscientious physician, in trying to save his patient expense, omits a consultation or a test whose value is questionable, only to wish eventually that it had not been omitted.

The family physician will continue to play the most important role in medical care. It is he who is first consulted on all problems by the family, who knows the environmental problems of the family, and who guides the individual to the proper specialist. The solo practitioner who tries to tackle all the medical problems of an individual is long out-of-date. In his place, and after considerable controversy, we have what is known as the group practice—that is, the family physician, the pediatrician, and the specialist in partnership. This group practice has been increasingly successful in providing better service.

In the proposed National Health Program the practicing physician will have available all needed laboratory aid and consultations without having the question of cost arise. He will be freed from the too frequently justified worry that he will lose his patient to the specialist. For the proposed National Health Program calls for all subscribers to see to the family practitioner or pediatrician first. This point alone will improve the quality of medical care because poor results can develop when a patient goes directly to a specialist or one who poses as a specialist. All medical care for the individual should be guided by a physician who is familiar with the patient.

We need more doctors. We need more money for medical education and medical research. And while profit insurance companies contribute generously to medical research, the records show little if any money allocated to medical education and medical research by voluntary nonprofit prepayment insurance plans for hospitalization and medical care.

The proposed legislation for a National Health Program provides for contributions to expand medical education and to further medical research. It also provides:—

1. A family physician for each subscriber, to care for him in the office, home, and hospital.

2. Laboratory and hospital facilities for the Physician and the patient.

3. Specialists of guaranteed quality as needed—namely, group practice.

4. Equal division of control in the administration of the care between qualified laymen (the recipients of the care) and the medical profession.

The term "socialized medicine" has been carelessly tossed about in discussions of the Wagner-Murray-Dingell bill. There is nothing in the program similar to the type of socialized medicine which exists in Russia. If, however, by socialized medicine one means medical care paid for by taxation and administered under governmental supervision,—Federal, state, or local,—then the beginning of such socialized medicine already exists in the United States and has been found satisfactory, if one can judge by the fact that it is steadily expanding.

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