How Good is Government Medical Care?
Can a high quality be maintained in our medical services if, as many believe, they must be vastly enlarged by government aid? OSLER L. PETERSON, M.D., spent six years in Europe as a staff member of the Rockefeller Foundation, studying the various government-supported health services, and is now a visiting lecturer at the Harvard Medical School.
There is a hospital bill on my desk. On October 10, Mrs. A—, a Boston resident, aged 66, fell and broke her hip. Her hip was operated upon and nailed, and she left the hospital on November 18. Excellent care contributed to her recovery. The hospital bill was $2949.38. The surgeon’s fee is not known. It is this problem of paying the cost of medical care that the Forand Bill and its many rivals, including a reluctant Administration’s proposal, have been attempting to solve. And yet there is more, much more, to the problem than the question of how, and how much, the government will pay.
The issues that the Forand Bill sought to deal with seem fairly clear: Man is mortal, a fact which is remorselessly driven home to the age group of over sixty-five years. They have more diseases and higher death rates than younger age groups. They visit their doctor’s each year half again as often as younger people, and they require about twice as much hospitalization. These fat medical bills must be paid from a thin purse. The Census Bureau reports that almost 60 per cent of persons over sixty-five years of age had cash incomes of less than $1000 in 1958, while about 70 per cent of couples had incomes of less than $3000. Some have cash, some own homes. Some live with children, and their expenses are probably small. But not many are on Easy Street.
This is a difficult situation that many people would be happy to turn over to the government. Some of the public opponents of governmental health insurance for the aged, in fact, privately support it, and with reason. While the voluntary health insurance organizations are pointing with pride to the progress they have made in enrolling the aged, progress has brought them problems. The Blue Cross organizations have repeatedly raised premiums to keep pace with hospital charges and increased hospital use; the public complains, and there are threats of investigation. Successfully insuring the sick old people would be a Pyrrhic victory. Commercial insurance is based upon “experience ratings”—the likelihoods that the insured will have to make claims—and the experience of the aged is such that the companies probably are not eager to compete for their premiums.
Even so, almost 45 per cent of our older citizens have some health insurance now. Does this mean protection against the costs of illness? A publication of the Health Insurance Institute points out that the hospital benefits which older persons receive may range from $5 to $25 per day. Most hospital charges run $25 per day and up. The person over sixty-five who goes to the hospital will stay there an average of almost fifteen days, compared with just under eight days for the general population. An average old person going to the hospital can thus expect a bill of about $375. Some of those who are “insured” will get back as little as $75. Medical costs are therefore a common cause of indigence in this age group.
Somewhere between organized labor, picturing the aged as victims of universally besetting misery, and organized conservatism, dwelling glowingly on the joys of the sunset years, is the uncomfortable liberal. He appreciates that the problem is real and that political action is almost certain. Why, then, is he concerned? Because the Forand Bill was not very good, and its rivals are no better. These bills assume that paying the medical expense is the only issue—in short, that this is just another welfare problem—when actually the problem deeply involves the practice of medicine, the quality of care, and the organization of medical care services. Inevitably, any legislation providing government health insurance will have consequences in these areas, too. There has been a great deal of experience with government support of medical care, much of it in Europe, which should help us to understand why this is so.
For example, a great weakness of the Forand Bill was that it provided only for hospitalization and medical care in the hospitals. People who have health insurance are hospitalized more than noninsured persons, in part, at least, because they know that their hospital care will be paid for. The demand that would have been created by the Forand Bill would have been even more serious. Old people tend to live alone or in easily broken homes, and once hospitalized they might have nowhere else to go. This is particularly true when there is some residual disability.
In England, where virtually all medical services are now provided through the National Health Service, this problem was pressing during the early years of the service. There was much “silting up” of the hospital beds by old patients with chronic diseases. The Forand Bill could not have been better designed to silt up our hospital beds and to keep them silted up.
Later bills have included provision for payment for home care and nursing-home care, which are cheaper and often more appropriate for the patient. Care in a doctor’s office is the most economical and sometimes the best form of treatment, but it was conspicuously absent from most of the proposals advanced earlier. Thus, a patient who has to pay for an X ray in the doctor’s office, but who is insured against the cost of that X ray in the hospital, has a good chance of ending up in the hospital.
A second frequently overlooked consideration in the Forand debate was the fact that a payment mechanism alone may have inflationary effects. Since the aged have low incomes and much illness, the advent of social security or other payments for their medical care would probably produce a sharp rise in the amount of medical care they receive, and therefore in the total cost. The history of fees and charges, furthermore, shows that they rise more easily when paid by insurance than when they have to be pried out of individual pockets. However, any attempt to control the cost and use of health service by fiscal means alone will not he more than partly successful. This would be like trying to control automobile accidents by manipulation of insurance premiums, when we are well aware that safe driving is a function of road construction, traffic cops, stop-and-go lights, licensing practices, driver training, and many other things. The problem of controlling the cost of health services is one of the considerations that will inevitably push the government more deeply into the field of medical services, once it has entered. It is equally certain that before long the government would become preoccupied with the problems of the quality and distribution of the care it purchases. We have already seen this in the Hill-Burton Bill. The government granted money for hospital construction only after each state had formulated a regional hospital plan. A plan was essential, the Public Health Service knew, simply to make sure that the government dollars would build the right kind of hospital in the right place. Pleasant Farm County needs general medical and surgical beds; the city can use one specialized neurosurgical ward that may serve patients from most of the state. Without a plan, hospitals might build the medical equivalent of a Yankee Stadium in Cokato, Minnesota.
A third consideration is quality, in the United States, the most enthusiastic backers of voluntary health insurance and government medical care have coupled their hopes for a solution to economic problems with brave talk of comprehensive medicine, high quality of medical care, primary and secondary disease prevention, and other wishful arguments. Instituting some form of prepayment for medical care does not solve the problem of poor or unskilled care. When the British Health Services were nationalized in 1948, there was widespread expectation that general practitioners would practice better preventive medicine in their own interests. Since they were paid according to the number of patients on their lists, whether they saw each patient a dozen times, once, or not at all, it was reasoned that the doctors would try to reduce their work by preventing disease. The new health service had not been functioning long before it was generally realized that the good doctors remained good and the others plodded along in their characteristic ruts.
If the government pays the piper, it is likely to demand that the musicians be qualified. Government support of health services has been undertaken primarily to eliminate financial barriers between patients and medical care, but attempts to set standards usually follow. For example, in our own country, much surgery is done by doctors with minimal training. It is most unlikely that the government would pay the well-trained and the partly trained doctor the same amount for an operation. Indeed, government subsidies of medical care would probably result in the limiting of surgical privileges to the fully trained and certified specialists.
It is often said that the United States has the best medical care in the world. Some aspects of American medicine are indeed outstanding, but the Scot or the Norwegian who enters a hospital in his country can do so with the assurance that the surgeon or physician who cares for him is well trained and well selected for his post. The American who enters a hospital must depend upon his own imperfect judgment of a doctor’s qualifications.
The editor of the British medical journal Lancet, Dr. T. F. Fox, commented recently: “The lack of fully specialized staff means that at present one’s chances of dying quietly in a hospital bed with a wrong diagnosis are higher in America than in Britain.” For this and other reasons, the government, when it loots the bill, may set standards of training for the doctor who gives the service. The sharpness of Dr. Fox’s comment is a case of tit for tat; the British have smarted under our criticism of their National Health Service.
The government may be forced to dabble with the quality of medical care for another reason: the need to have a brake on the use of hospitals. The practice of medicine presents many situations in which choices between action and inaction, surgery or medical treatment, hospital or ambulatory care must be made. The pressure is usually on the doctor to “do something.” The decision runs the risk of being biased when “doing something,” such as surgery, means a larger fee.
The very acrimonious fight between the United Mine Workers Welfare and Retirement Fund and the medical profession in the coal mine areas arose over this issue. The fund at first paid fees to local doctors. This question of unnecessary and incompetent surgery was soon raised publicly, and it was not long before the fund decided to build its own hospitals and staff them with salaried specialists. Dr. Warren F. Draper, the fund’s medical director, says bluntly; “We will never return to free choice of physicians; we have found that as long as the fund would pay any physician for any service which he saw fit to render, surgical diagnoses were often poor and the amount of surgery in beneficiaries was far in excess of that performed in others.” The government is not likely to be as cantankerous as labor about paying medical bills, but it is likely to scrutinize them carefully.
It is an oversimplification to equate unnecessary surgery with a fee. The fact that the largely discredited operation of tonsillectomy is still being done does not necessarily mean that it is performed because of the fee it brings. The doctor may decide on this operation because of his frustration in dealing with a child’s repeated respiratory infections. In Europe, the family doctor may send the child to a hospital, but it is the specialist who decides whether he is admitted for surgery or not. Checks and balances of this type are becoming increasingly familiar in this country, and governmental subsidies of health insurance will almost certainly extend them. But the exclusion of the general practitioners from hospitals is not without serious hazards. It divides the profession into an elite and “the others.” This division has the effect of removing some doctors from the one institution which gives promise of providing them with knowledge of the rapidly accelerating advances in medical diagnosis and treatment. It is for this reason that the real bedrock opposition to government health insurance is found among general practitioners rather than among specialists. Our country might well pioneer a new approach in which family physicians are permitted to use the hospitals under the direction or well-trained and well-selected chiefs of staff, the pattern that is now followed chiefly in our university hospitals.
The unavoidable issue of quality control has concerned physicians, and they are quite right in recognizing that the Forand Bill really involved it. These deeply conservative physicians also recognize that medical care for old people is only the beginning. They are right, because government-supported medicine for one problem group will be extended and broadened to include others—ultimately, all of us.
The Health Insurance Institute estimates that “getting sick and getting well” will cost the average American $105 in 1960. This sum will be distributed about as follows: $34 for the hospital, $26 for the doctor, $28 for medicines, $11.50 for the dentist, and $5.50 for other costs. The average United States family in 1957-1958 spent a little over $300 for medical care. These averages are influenced by many factors. Those with hospital insurance received more care than those without, and families with higher incomes spent more than those with smaller ones.
Medical costs also vary with age, sex, and amount of sickness. Persons or families alike in other respects often have different habits of use of doctors and hospitals. Medical bills are not constant, as rent is. In any given year, about two thirds of the population will visit a doctor, while the other one third will not. Admission to hospitals is even more skewed: about one in eight persons suffers this misfortune. The child who has a tonsillectomy usually is in a hospital for twenty-four to thirty-six hours, and the whole bill may be $75 to $150, depending upon the institution and the surgeon. The average hospital bill, which is somewhat more than $200, is compounded of many tonsillectomies and a very few operations on the heart. A typical example of the latter was a New England lady of about sixty years who entered a hospital on November 5 for heart surgery. She was discharged thirty-six days later. The bill, exclusive of surgical fee, was $1734.41.
Hospital charges, which usually produce the catastrophic bill, are increasing more rapidly than the cost of other types of medical care. Although the hospital bill is the most dramatic example of the unequal distribution of the sickness costs, there are diseases that push other charges into the catastrophic class. A few patients must make very frequent visits to their family doctor, and the total cost may be great. The unfortunate parents who have a child with cystic fibrotic disease may find that they are spending $40 or more a month on essential medications, as well as paying for frequent hospitalizations and visits to the doctor. Since the disease is familial, more than one member may be affected. Again, when the breadwinner of a family is ill, hospital or medical bills are often compounded by loss of pay. In any case, it is clear that the elderly are not the only ones with medical care problems and that the problems of the whole population differ in degree but not in kind from those of people over sixty-five.
If Congress passes a law to help old people pay their hospital bills, it had better prepare for another to pay for the doctors’ services. Some of the later bills have included this. The doctors can be bulldozed into a new system of medical care, but the bulldozer cannot make them like it. A recent survey published in Medical Economics indicated that doctors were more worried about what they called “socialistic trends in the United States” than about their personal finances or their children. It would be dangerous and unjust to think that the doctor’s opposition is based merely upon fear for his income or his right to charge whatever he pleases, as opposed to a fixed fee. Experiments such as prohibition should warn us that it is important that the solution to any problem should have the respect of those whom it will affect. Like justice, any provision of medical care must not only be well done but must appear to be well done in the eyes of both the doctors and the patients.
The respect and satisfaction with which different peoples view their government-supported health services vary. After long and thoughtful trial and error, the Scandinavians evolved a system which they feel has the proper mixture of state support and individual responsibility. Though the individual purchases state-subsidized health insurance, he must also pay part of the costs of each visit to his doctor out of his own pocket, and he must make a small payment for each day of hospitalization. To both patient and doctor, this fee appears to represent an assurance that the problem of the moment is an important one. This dual system of government and personal payment is more complicated and costly, but the Scandinavians seem to think it is worth the extra cost.
In contrast, when the British made the great leap into a national health service in 1948 under the optimistic banner of “fair shares for all,” the Socialist government hewed to the ideological line by deciding to pick up the whole tab, leaving nothing for the individual to pay. Rather than rejoicing, many of the British were subject to fears that the free care might be abused. Reimposition of charges for drugs, appliances, and false teeth met with some political but no popular opposition.
The British general practitioner also has complaints. Since he is not paid anything by the patient himself or paid for each visit, he is prone to feel put upon by patients who need much care, forgetting that his list of patients—which is the basis of his pay—also includes many whom he does not see from one year to the next.
The opinions which patients and doctor hold about their system of medical care may be wrong or right, but they are very human. They do demonstrate that what people think is true may he just as important as the objective truth. The British knew that, administratively, it was simpler and cheaper to collect money by taxation than through an insurance premium. Their logical decision to let the National Exchequer pay the bill was their most serious mistake. This centralization of the bill has produced a preoccupation with cost and cost alone that has hampered many needed developments. The moral: In problems as personal as the provision of health services, the logical and most efficient administrative device is not always the best. The task is to make good administration a means, not an end.
In most countries government health insurance has been financed through insurance mechanisms: partial payment for care, taxes, and voluntary effort. With funds coming from so many pockets, or from the same pocket at different times, the costs do not become the primary issue. In this respect the Administration’s proposal to provide health insurance for the aged is better than the Forand Bill, because it would distribute the cost between the federal and state governments and the consumer. But it looks as though the Administration’s proposal would pay only about $600 of a bill amounting to $1000, leaving the patient to find $400. Since, as we have seen, most old people are living on cash incomes of less than $1000 yearly, a $400 bill may be just as overwhelming as the full amount.
The first tentative government steps into medical care will uncover a chain of problems. The European experiences may have only limited applications, but ignorance of these experiences will condemn us to repeating errors. The liberal is worried because the debate has concentrated on financial problems. The American Medical Association has been a conspicuous exception; it has seen clearly that the Forand Bill involved more than the use of social security to pay medical bills. Paradoxically, its opposition is so complete that it is fair to question if its membership will lead when leadership is needed. The British Medical Association made the same mistake; it continued to resist even when the issue had been decided.
There is a peculiar assumption in the intense focus of the health bill debate on the question of how to pay for medical care. The assumption is that the only question in the minds of our sick old people, their families, and the doctors who will care for them is where and how to find the money. This attitude is dangerous because it obscures the crucial fact that we are struggling not with a fiscal problem but with a human problem; in fact, with a whole range of very human needs and problems. We had better make our plans accordingly.
What are these human expectations? First, the patient’s need for an interested doctor and the kindly care that has always been the hallmark of the good private practitioner. Second, good care, in the sense of competent care. Third, the desire to be treated with dignity as a respected individual, not as a casually handled body on a hospital assembly line.
But there is more to it than this. We need not only to take care of sick patients but to do this in such a way that we meet the needs of their families. The children of chronically ill or senile parents, or the parents of a child with cystic fibrosis or a congenital defect, are often squeezed between the almost insupportable emotional and physical burdens of their care and the fear that any alternative really will mean dumping them into the hands of a second-rate, and indifferent, outside authority.
The needs of the physician must not be overlooked. He wants to feel responsible for his patients to the limits of his competence. He wants freedom to be the boss of his own office or at the operating table and to practice as best he can. He wants to be paid a reasonable amount as reward for long and difficult training and a rigorous life. However he is paid, he should feel that he is being rewarded because of his individual skills and efforts and not merely as an entry on a payroll.
It is clear that paying for medical care for old people involves much more than paying a few hills. The legislation now under consideration touches on only part of the problem and is only a beginning. Major changes are ahead, and rational answers will not come from hastily considered legislation in an election year, though that is the way the process usually begins. If the liberal is a man who dislikes change but recognizes its necessity, then he and his legislators will need the time to plan what must be changed, the courage to leave some things unchanged, and the wisdom to tell the difference.