Medical Care for All the People

THE PRESENT WAR emergency has given the problem of social security renewed significance, and the Wagner–Murray–Dingell bill endeavors to merge the existing state insurance schemes into a uniform federal system. It proposes at the same time to broaden the scope of social insurance so that it will include health insurance. The bill is violently attacked by those groups who stand for unchecked free enterprise and oppose all forms of government planning and coordination, and also by the groups who stand for unlimited states’ rights and object to any form of interference by the federal government. They overlook the fact that uncontrolled free enterprise has led the country, and not only ours, into depressions and wars, and also do not see that with the present means of transportation the country has become much more uniform than in the past. If the Wagner–Murray–Dingell bill is defeated, as it is likely to be, since our present Congress is very conservative, we may expect another similar bill in the near future because the need will remain as acute as ever. . . .

The idea of social insurance is by no means new but has a history of over sixty years. It is not a revolutionary but, on the contrary, a basically conservative issue. It does not tend to overthrow the existing economic order but provides a corrective mechanism that mitigates its hardships. We can distinguish different periods in the history of social insurance. The beginning was made in Germany when Bismarck, after a long parliamentary struggle which lasted over six years, established in 1883–1889 a national system of social insurance that included accident, sickness, invalidity, and old-age insurance. It was a great experiment that had never been tried before and created a great deal of interest all over Europe. Another period began in England when in 1911 the National Insurance Act was passed under Lloyd George and Winston Churchill which for the first time included unemployment insurance. World War I, which led to intensified industrialization and was followed by social unrest in many countries, raised the problem of social security anew, and legislation was passed in the following years in many countries. The great depression of the 1930’s, which threw millions of people out of work and created an acute relief problem, was a new stimulus for such legislation, and a number of South American Republics adopted some form of social insurance, Chile first, then Brazil, Peru, Venezuela, Costa Rica, and Ecuador. Mexico has made similar provisions. In the present war, industrialization has proceeded in an unprecedented way and the time has come when we no longer can evade the issues.

In America, we were able to get along without social insurance for a long time because conditions were totally different from those in Europe. Ours was a large, thinly populated continent with immeasurable potential wealth in agricultural land and natural resources. Industries developed relatively late, and a constant stream of immigration provided an inexhaustible reserve of manpower. In times of economic crisis, people could move west and settle down on the land. Conditions have changed today. The country is settled; we have the most highly developed industry, and immigration has stopped. Conditions are now very similar to those in European countries, and the same needs will of necessity call for similar solutions.

As a physician, I am particularly interested in health insurance. Security in matters of health is one aspect of the great general problem of social security; it is a very important one because all too well do we know the vicious circle of disease creating poverty which in turn produces more disease. Opponents of health insurance like to point out that medical care alone does not guarantee health and that what the people need first of all is a secure job, a decent home, plenty of wholesome food, fuel, and warm clothing. Nobody will deny that the standard of living is probably the most important factor in the maintenance of health, and every civilized country is striving to raise the standard of its population. The opponents of health insurance, however, should realize that, if we had to enact legislation today that would guarantee all the people a job, a decent home, plenty of wholesome food, fuel, and warm clothing, this would require infinitely more radical bills than the one of which they are afraid. As physicians, we cannot wait for the happy days when everybody will have everything. We must try to break the vicious circle wherever we can and must do it without delay. . . .

What can be done? Let us agree first on some general principles. I think we agree that all the people should have medical care, irrespective of race, creed, sex, or economic status, and irrespective of whether they live in town or country. I think we also agree that all the people should have not just some medical care but the best possible care. The whole modern technology of medicine should be available to them, including the services of the general practitioner, the specialist, the nurse, the hospital, and laboratory. We also agree that prevention is better and also cheaper than cure, and that preventive medical services should therefore be in the foreground of all activities. For 5000 years people have fallen sick and, once sick, have called upon a doctor, who endeavored to restore them to health. Today we already have the knowledge and means that would permit us to reverse this old relation. The doctor in the future must see the people before they become seriously ill and must advise them how to maintain their health. More and more he will become an educator.

The provision of medical services to the population has two aspects, one economic and one medical. Both must be considered and studied together because they are inseparable. Indeed the best economic plan defeats its own purpose if the money is used to finance a poor type of medical service, and on the other hand the best medical plan must collapse if it is not properly financed. Illness is an unpredictable risk for the individual family, but we know fairly accurately how much illness a large group of people will have, how much medical care they will require, and how many days they will have to spend in hospitals. In other words, we cannot budget the cost of illness for the individual family but we can budget it for the nation. The principle must be to spread the risk among as many people as possible and to pool the resources of as many people as possible. In other words, we must apply the principle of insurance, with which everybody in America is familiar. . . .

The experience of the last fifteen years in the United States has, in my opinion, demonstrated that voluntary health insurance does not solve the problem of the nation. It reaches only certain groups and is always at the mercy of economic fluctuations. The Blue Cross plans were launched at the bottom of the depression and developed with an expanding economy. It is not difficult to foresee what would happen to them if the country were hit by another depression when people would be unable to pay premiums. . . . Hence, if we decide to finance medical services through insurance, the insurance system must be compulsory. It should include as large groups of the population as possible. It is a great weakness of most European systems that they are limited to the low-income groups, while we know that the provision of medical care is a serious problem for practically all brackets of the middle class. Health insurance must include not only the wage earner but his family members as well, and it should also include self-employed individuals. It must provide complete medical service, preventive, diagnostic and curative, by general practitioner, specialist, nurse, hospital, etc. People should have complete security in health matters.

Should the system be centralized or decentralized? That depends on conditions prevailing in different countries. In the United States, Senators Wagner and Murray think that the entire social insurance system should be centralized in the hands of the federal government so that the people would be guaranteed equal benefits irrespective of state lines. . . .

There is another technical question that is not easy to solve, namely, the remuneration of the physicians. There are three ways of remunerating doctors under a health insurance scheme. One, which seems to be the most popular with doctors because it comes closest to the traditional form of payment, is the so-called fee-for-service system, according to which doctors are remunerated for every individual service according to a tariff. In my opinion this is the most unsatisfactory system because it always calls for a great amount of paper work and red tape. The physician has to itemize his bills, which in turn have to be checked by the insurance fund in order to ascertain that the services were justified. Expensive services, moreover, usually have to be especially authorized by the fund. . . .

The capitation system, under which payment from the insurance fund is made not on the basis of services rendered but of the number of patients registered with the doctor, is better because it undoubtedly greatly simplifies bookkeeping. It is, however, impossible to bring the specialist into such a system. The third, and in my opinion by far the best, method is for the funds to appoint physicians on salaries graded according to experience, responsibility, and hazard. The advantages of such a system are obvious. It eliminates a great deal of unnecessary bookkeeping, permits provision of adequate remuneration to doctors in rural and far distant districts, and guarantees the physicians an income on which they can count. I am well aware that the idea of being salaried employees does not appeal to the majority of doctors, because it is not the traditional form of remuneration. They also fear that a salaried system might reduce their initiative. The experience in other countries, however, has shown that if salaries are adequate—and there is no reason why they should not be adequate—the doctors are very soon reconciled with such a system and appreciate the security and independence it gives them. Nobody will deny that the public health services in Canada as well as in the United States have given a splendid performance with salaried doctors and that excellent medical care is given in such places as the Mayo Clinic or the Johns Hopkins Hospital where doctors are salaried also. We should furthermore keep in mind that most of the progress of medicine was achieved by salaried men, such as Pasteur, Koch, Ehrlich, Walter Reed, Welch, Flexner, Banting, to mention only a few. . . .

Medical services provided under a health insurance scheme will not be enough to solve the health problems of a nation. We shall still need our public health services in addition. The sanitation of dwelling places, the protection of society against epidemics, the provision of medical services to poor minority groups, and many other tasks will remain such that they will require the full state power for their execution. The two services together will promote health, prevent disease, restore and rehabilitate the patients, once prevention has broken down. Every country will have to decide on the basis of existing conditions what public health and what insurance services it wishes to have. Personally I believe that ultimately the provision of health services and medical care will become a public service, just as education already is.

Health cannot be forced upon the people. It cannot be dispensed to the people. They must want it and must be prepared to do their share and to cooperate fully in whatever health program a country develops. No bill is perfect from the very beginning. If we had to wait until we had a perfect bill that would satisfy everybody and would solve every problem at once, we would never get anywhere. A beginning must be made and must be made soon, because in war as in peace the people’s health is one of the nation’s most valuable assets.

Figure 1.

On January 30, 1939, Time magazine published a flattering article about Henry E. Sigerist and placed his portrait on the cover. Courtesy of Time magazine, Time Inc/TimePix. Photo by Holmes I. Mettee.