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.
1.

Many Americans do not receive adequate medical care. The figures presented by the Selective Service Examiners in 1942 and 1943 showed that throughout the United States 39.2 per cent of the registrants examined by the Local Boards and at the Induction Centers were rejected. This high percentage of our boys found unfit to fight was not evenly distributed throughout the country. For instance, in Oregon there were only 24.4 per cent rejected and in Kansas 25.4 per cent. On the other hand, in North Carolina 56.8 per cent were rejected and in Arkansas 55.9 per cent. Between these two extremes, Massachusetts and New York had 37.7 per cent rejected. Usually the poorer the state, the more neglect of health.

Good medical care includes the activities of the public health services—Federal, state, and local—and the preventive medical procedures, diagnosis, and treatment for the sick provided by practicing physicians. Public health services vary not only from state to state, but also in different communities within a state. In recent years the Federal government has been contributing more and more towards the public health programs of the states, the size of the appropriation varying, with a higher percentage of assistance offered to the less wealthy states. In the fiscal year 1946, Massachusetts, for instance, paid $3,930,399 for its Department of Public Health, and to the Commonwealth in the same year the Federal government contributed $3,158,842; in addition, the Department of Mental Health in Massachusetts, which cares for the mentally ill, had a budget of $14,053,672 drawn from state funds.

The activities of the Massachusetts Department of Public Health include diagnosis and treatment of the sick as well as an extensive program for the prevention of disease. The Department runs biological and diagnostic laboratories. It has food and drug laboratories with inspection service. It has a Division of Sanitary Engineering involved in the control of water supply and sewage disposal. It also is closely allied with the Department of Labor and Industries in the study of occupational hygiene. It is active in dental health and in the study and control of communicable diseases. It has responsibility for various hospitals and out-patient clinics for the control and treatment of tuberculosis. It has clinics for the control and treatment of venereal diseases. It also has responsibility for the Emergency Maternal and Infant Care Program. The Department not only deals with general health problems but participates in the care of the sick. This emphasizes a point which is not always appreciated: namely, that you cannot separate the health of the individual from the public health. In addition to what the state does, the individual cities and towns in Massachusetts support their own public health agencies.

In the years to come there will be continued expansion of the activities of the Departments of Public Health in the different states. The diagnosis and care of more and more patients will undoubtedly come under the control of these departments, if one can judge by the steady growth of these services in the past. Even in those communities already well supplied, the demand for the extension of health services exists, as is shown by requests for more legislation and for increased appropriations.

The problem of developing satisfactory public health services in a good medical program is complicated by the lack of well-trained public health officers. It is further complicated by the opposition of some practicing physicians. Such hostility often develops when the state encroaches upon the field of the private practitioner or laboratory expert, even if the patient's advantage is served. To develop satisfactory public health services in a National Health Program, therefore, further education of both laymen and physicians is essential. Physicians must be attracted into the service by satisfactory financial reward. Public health services are expensive, and it is obvious that more Federal aid will be necessary for some states if the advantages of such services is to be evenly distributed. As disease does not recognize state lines, measures to protect us from preventable illness should be uniform throughout the country.

All the studies show that physicians, laboratories, and hospitals are very unevenly distributed through out the United States. For example, in New York City there is one physician to every five hundred inhabitants, while in the United States as a whole there is one physician to every seventeen hundred. Clearly, many areas do not have the hoped-for percentage of one physician for every thousand of the population.

Good medicine cannot be practiced without laboratories, hospitals, and well-trained specialists. The lack of these facilities and specialists leaves many areas unable to attract well-trained practicing physicians. Furthermore, the resulting overcrowding of physicians in our urban centers where these facilities exist produces another problem, because even in these areas there are not enough hospitals to provide all the physicians with hospital privileges. Many communities are unable to raise the funds necessary to supply suitable hospitals and laboratories and to guarantee proper financial return to the physicians. Therefore, some plan must be developed to aid the poorer communities in the states.

The most serious obstacle in making good medical care available to the people is its cost. The following table shows the usual charges for certain operations in a hospital in which different types of accommodations exist for the comfort of the patients. These are actual figures supplied by reliable and conscientious surgeons.

Removal of thyroid
Moderate-price accommodations: $200
Full-price accommodations: $350-500

Resection of stomach
Moderate-price accommodations: $200
Full-price accommodations: $500-750

Hernia
Moderate-price accommodations: $100
Full-price accommodations: $200

Removal of gall bladder
Moderate-price accommodations: $200
Full-price accommodations: $500-750

Acute appendicitis
Moderate-price accommodations: $150
Full-price accommodations: $250-500

Removal of prostate
Moderate-price accommodations: $200
Full-price accommodations: $500-750

Compound fracture of humerus
Moderate-price accommodations: $200
Full-price accommodations: $300-500

Fracture of hip
Moderate-price accommodations: $200
Full-price accommodations: $300-500

It is estimated that more than half the families in the United States have incomes of less than $2000 a year. How can such families meet these charges? Some distribution of the justifiable costs for specialists' services must be arranged for the majority of our population.

Furthermore, in a well-organized medical program the family physician who gives the preventive inoculations and the periodic examinations, and makes the early diagnosis, and who will take care of all conditions which do not need specialists' services, should receive an adequate income. Many people cannot afford complete care on the present fee-for-service basis and therefore do without these preventive and other important medical procedures. Some program must be devised to provide to a vast number of our people a family physician of their own choice.

Another troublesome factor is that this method of paying for medical care by individual fees tempts many to gamble on avoiding preventable diseases by self medication, drug-clerk diagnosis, and the employment of cultists, all in the hope that they will be less expensive than a good doctor.

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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