Committee on Economic Security (CES)
Volume VII. Health in Relation to Economic Security
MEDICAL ADVISORY BOARD--MINUTES OF MEETINGS
Part 2- Tuesday Afternoon Session, January 29, 1935
COMMITTEE ON ECONOMIC SECURITY
Medical Advisory Board
Tuesday Afternoon, January 29, 1935
The meeting convened at two o'clock, Mr. SYDENSTRICKER presiding.
CHAIRMAN SYDENSTRICKER: Gentlemen, I should like you to read over pages 11 and 12 of the interim report. These matters on page 11 were discussed by the Medical Advisory Board and the Hospital Advisory Committee and laid over for further consideration.
First is the question of payment of physicians for services in clinics. I would like you to look at the wording of that: "Physicians have traditionally given their services without any direct financial compensation in most general hospitals and out-patient departments maintained by local governments. Physicians also give service without pay in many of the clinics maintained by health departments. The recently increased burdens of clinic service, and the reductions in medical income also due to the depression, have created a widespread demand for the payment of physicians for their clinic work. Not the least of the reasons for so doing is the need for placing these important preventative and curative services upon a basis of effectiveness which often cannot be maintained with an unpaid staff, however full of good will its members may be."
That is the reason for it. It is not an emergency reason, however. It carries out the general principle which the board approved at the last meeting, that the physician should be adequately paid.
"Federal legislation and administrative regulations concerning public medical services should provide for the payment of physicians for services in clinics. To a considerable extent, as stated in the preceding text, these services are rendered in out-patient departments of hospitals, while others are rendered in clinics maintained by public health departments.
"Federal policies for providing medical care to persons for whom the federal government assumes a share of responsibility should include provision for payment of physicians for services rendered such persons in clinics as well as for services otherwise rendered by physicians to such persons.
"Federal agencies which furnish subsides for the support or extension of public health services should require that physicians be compensated for their services in clinics maintained or financially assisted by health departments, such compensation to be determined in accordance with local services and conditions."
Dr. Davis, have you anything to say on that?
DR. DAVIS: No, except a few facts in the clinic service of the country, which has increased since 1930 about fifty per cent. It is, of course, mostly in the cities, relatively smaller in towns and rural areas. The bulk of that work is conducted in the out-patient departments of hospitals. The number of physicians involved we don't know, except that in a few large cities like New York and Philadelphia probably there would be a third of the local profession giving some time to one or another clinic service. The problem in the cities is a very large scale problem because of the number of people involved. It is not a problem to any extent in the small places.
CHAIRMAN SYDENSTRICKER: I gather that it is proposed that the Federal Government should complement local funds for the payment of physicians.
DR. DAVIS: It is exactly the same principle as involved in the Federal contribution for the payment of a share of the hospital care; it is simply a payment for a share of the professional services, the point being that the physicians, if they are to be paid by local or state funds or combination of the two, may fairly expect the Federal Government to take a share in contributing toward that.
DR. PIERSOL: Does this contemplate the men in the clinics only or also patients in wards?
DR. DAVIS: This is with particular reference to clinics.
DR. CUSHING: Just what do you mean by clinics? Outpatient departments?
DR. DAVIS: Ambulatory.
DR. CUSHING: The difference between an indoor an outdoor clinic.
DR. DAVIS: This means ambulatory patients, whether connected with a hospital or unconnected with a hospital except those maintained by health departments, which are generally unconnected with a hospital.
DR. CUSHING: Shouldn't that express more clearly what you mean by clinic? Dr. Crile conducts a clinic, for example. You are talking here of out-patient departments?
DR. DAVIS: Some descriptive statement might be advisable to be added to make clear what is implied.
DR. CUSHING: Of course the doctor gets something out of this; that is why most doctors serve. Altruistic reasons, yes, but also because of the experience. It would be too bad to destroy that opportunity and desire by making these places open for somebody who would get a small pay, because the man who is competing for small pay is apt to be the less desirable man. It is one of those age-long professional conditions. I think you would gradually tend to get poorer people.
CHAIRMAN SYDENSTRICKER: In a way, Dr. Cushing, this covers for the cities what is done for the part pay rural physicians. There seems to be a demand on the part of physicians who give clinic service for some pay.
DR. CUSHING: From hospitals?
CHAIRMAN SYDENSTRICKER: From somewhere.
DR. CUSHING: I think most men compete greatly for the opportunity.
DR. PIERSOL: That might be true in Boston, but I know it is becoming increasingly difficult in cities like Philadelphia and I think in New York to ger competent men to work in clinics, for the reason that they won't work for nothing. That age is gone.
DR. ROBERTS: That age is gone!
DR. PIERSOL: They have to be paid. They absolutely can't run without compensation. They are no longer lured by the idea of clinical experience, distinction, and all that; they have got to pay bills and they can't pay them with experience and distinction. Nowadays young men simply won't come unless you offer them some financial return, and they resent relief for which somebody else gets paid something and they don't get paid anything. I think it is very important. I believe if some way could be arranged by which men who work in the out-patient clinics possibly could receive some sort of compensation, at Philadelphia at least it would be very much easier to get good young men.
DR. DAVIS: I can add just a word to the point Dr. Cushing raised, the incentive offered by the clinic. A good may years ago there were relatively very few out-patient departments in the hospitals excepting in the teaching hospitals. At the present time there are approximately three hundred general hospitals directly affiliated with medical schools throughout the country, all of which maintain out-patient departments. The last A.M.A. census showed a little over 2,000 general hospitals throughout the country maintain out-patient departments. That is, within the last fifteen or twenty years the number of out-patient departments has grown rapidly among the hospitals, so that a large proportion of the hospitals not confining themselves solely to pay patients, maintain out-patient departments, and the picture as to the incentive for the physician is very different in the teaching out-patient department from the non-teaching.
DR. GREENOUGH: Would that distinction be recognized in this paragraph in such a way as to indicate that there is a definite advantage in the way of service in teaching hospitals?
DR. DAVIS: I think it might be rather difficult to carry out in practice, because there are borderline cases. Even in Boston at the Massachusetts General Hospital Clinic, if the physicians go to some other place, like the Boston Dispensary, they are paid. It might be difficult, I don't know. I think there is a very real remuneration that the younger men get on a purely professional basis in the best of our teaching hospitals. Whether you could make that distinction practical or not I don't know.
DR. BROWN: Mr. Chairman, in Santa Barbara County, which is reputedly one of the wealthiest counties in the State of California, a large number of the doctors at Santa Barbara want to be members of the county hospital staff. Why do they wish it? In years gone by they wished it because they thought that it gave them prestige, that indefinable thing, and they went to the supervisor, who has control of the hospital, to get an appointment on the staff, which, if he liked the fellow who wanted the appointment, he gave to him. That is the method of procedure used on Santa Barbara County still.
Now all the doctors who are on the staff say; "We want to be paid, we are getting tired of working for nothing, we are unable to get any teaching facilities, we have none, we want to pay for the work we do."
That same state of mind exists among the doctors all over the State of California. There is a great feeling of despair in their hearts that they are not being paid for the services that they render the patient in the way the nurses are being paid and the way the hospital superintendents are being paid, in the way the grocers and the clothiers are being paid who furnish food and clothing to the patients.
Why wouldn't it be desirable for us to recommend to the Economic Security Committee that in order to provide competent, efficient service, enabling the doctors to have reasonably fair compensation, a plan be set up which would compel each doctor who wanted to be a member of the county hospital staff in any county in the United States to pass a professional examination? If he measures up to those standards he is appointed; if he doesn't he is just eliminated. I believe in systems of examination, and I think we could incorporate that into some of our suggestions. Is that a good idea?
DR. CUSHING: We've been working at that for years.
DR. BROWN: I realize that. Let's continue to work at it. I think it can be developed if we have the will power to do it. We have no standards at the present time to determine whether a doctor is a good doctor or a bad doctor that I know of. We have two standards which are set up by the state. One is the standard of being a graduate of a medical school; the other standard is the license to participate medicine in the state in which the man desires to practice. What standards have we set up as doctors? Membership only in the county medical society. That is the only standard that we have set up to the present day. Am I correct about that or not? I believe we have no other standard.
CHAIRMAN SYDENSTRICKER: You lay down the general principle, then, Dr. Brown, that before a physician gets paid from a public fund, I mean as applies to this, he has to stand an examination?
DR. BROWN: Yes, that would be my idea.
DR. CUSHING: Who is going to give it to him?
DR. BIERRING: A qualifying test. I suppose if a man wanted to be on the medical service of a hospital staff he would be especially trained in that; if he wanted to be an ophthalmologist on the service he could stand a test in ophthalmology; if he passed some of these speciality qualification examinations they might take that certificate in lieu of it.
CHAIRMAN SYDENSTRICKER: I would suggest that that point be laid over for consideration. It doesn't apply only to this; it applies to the whole thing.
DR. ROBERTS: This all comes down to one thing, it seems to me. Are we going to pay physicians for services in clinics who work for the indigent, or not? Is that the question? That is all there is to it. Now we are in a new time. Sympathetically I am with Dr. Cushing, it is the obligation and education of the physician to take part in it, but my friend there from Philadelphia is absolutely correct. The University of Georgia had so much trouble at Augusta that they finally paid the young fellows $15 and had the best year they ever had. These fellows must be paid. Furthermore (and I would like Dr. Parran to hear this ) in the South a good deal of friction and feeling has come about because the doctors who do the FERA work in the cities for the FERA relief people are not paid.
CHAIRMAN SYDENSTRICKER: I think Dr. Brown has raised a very interesting question, and if you wish to discuss it later on we would like to do it and probably make some recommendation.
On this point, though, I would like to get your opinion. In this statement we have not said anything about any recommendation as to Federal subsidies. How could that be worked? Has a hospital in New York City the right to apply for money to pay physicians, and can we go that far?
DR. CUSHING: It brings up an immense number of things because the whole question is: Is the Government going to be the differentiater of people getting into an out-patient department to get care? It is a very difficult thing to do now. Are people higher up, the indoor people, who are also working on the poor, to be paid ? Why should just the outdoor people be paid? Poor people get into public wards and have to be treated. It becomes a very tangled question.
CHAIRMAN SYDENSTRICKER: The idea was thrown at us. I would like to get some more comment. Should we recommend it at all? If so, in fact what form? I think we ought to be more specific in our recommendation than this is right now.
DR. ROBERTS: In Augusta they are paid $15 a month and it is perfectly satisfactory to all the younger men. Of course that is a low income state. Twenty-five dollars a month probably would be a fair figure.
DR. DAVIS: For how much time?
DR. ROBERTS: Two to three periods a week.
DR. HORSLEY: How much time a period?
DR. ROBERTS: About two hours.
CHAIRMAN SYDENSTRICKER: In the public health clinics in New York City they are paid $5 per session.
DR. PIERSOL: Would this apply to anyone who came to the out-patient departments except those on Federal relief?
CHAIRMAN SYDENSTRICKER: I think so.
DR. DAVIS: Would be very difficult to make a distinction unless you prorated the number coming in.
DR. PIERSOL: In the last analyst it depends on the administration of each separate hospital. There are some hospitals that already have accepted the principle that people should be paid for treating patients in the public wards. There are other hospitals that don't allow it. Such a conservative institution as the Pennsylvania Hospital in Philadelphia has recently taken the position after many years that their physicians are allowed to charge a nominal sum for taking care of patients in the wards, and any ward patient is a pay ward patient, in order to allow these men to get some return for the time spent in the wards. These people on Federal relief, doctors who take care of them outside the clinics are able to get a certain sum of money. But the moment they come into the hospital clinic it is a different matter. That is the discrepancy and that is the kick. Those fellows say, "Why work in a clinic three hours when I can sit around the corner and see these same people and get a dollar a visit or something of the sort, and send a voucher to the state?"
DR. CRILE: I am wondering what would happen if we considered the care of the low income group all the way down. It would seem to me that under one set of conditions there you might have an enormous reduction in the work of the outdoor clinics, because these people could be cared for inside. If these people had care under another plan that we will be discussing, probably, could there be an enormous reduction in the number of out-patient patients?
CHAIRMAN SYDENSTRICKER: Quite true, only this morning we rather agreed that we would consider public medical services as a separate and distinct proposition.
DR. CRILE: I mean the rural areas.
CHAIRMAN SYDENSTRICKER: That is a very delicate and important question if the Public Health Department are going to allow a whole lot of doctors --
DR. CRILE (Interposing) : I didn't mean public health; I mean subsistence or subsidiary or supplementary budgets to take care of the indigent poor.
DR. BROWN: I move that this matter be left to the Medical Advisory Committee's advisory or technical staff, you and Dr. Falk and Dr. Leland, Mr. Simons, and others, to make recommendations or suggestions covering this matter to be reported on at some future date, possibly tomorrow.
CHAIRMAN SYDENSTRICKER: If that is your wish we will try it.
DR. ROBERTS: Dr. Cushing raises a valuable point. Would it be fair to pay the out-patient attendants and not pay the in-patient attendants who work on the same economic level patients without pay?
DR. CUSHING: It seems to me that on this basis we have got to distinguish between the indigent who pay nothing and the people whom the hospital charges something, out-patient as well as in-patient. It would mean the hospital organizing two groups of people, one who are on Federal relief, those working on the purely indigent, and others on the part-pay patients. That would avoid this feeling of irritation among these men who are working in hospitals on the same kind of people that are being paid for by the Federal Government outside.
DR. DAVIS: Mr. Chairman, there is very little problem as far as in-patient service is concerned in a large part of this country, because except in the teaching hospitals and on the Atlantic Seaboard in cities, most of the hospitals accept patients from private physicians in their wards, paying ward patients are common, whereas in the older established Eastern hospitals those going into the wards the physician is not allowed to get any remuneration for. So in a large part of the country, except for those patients who are legally indigent in the sense that they are sent there either by a public authority or by publicly recognized private social agencies, the great majority of patients both in the single room and in the wards are the patients of physicians who may take a nominal fee, but they make their fees with the patients so that they are private patients, whereas in the out-patient department of course nobody is a private patient.
DR. CUSHING: There is a great distinction between the patients in the wards, because no attendant in charge of those patients is paid.
DR. DAVIS: In the Middle West a large part of those patients pay a stated ward fee. Under those conditions the problem of payment of the physician for the in-patient service reduces itself to the group that Dr. Cushing is referring to, namely, those who are more or less certified legally or other wise regarded as indigent, and it is a group that can be discriminated fairly definitely on the in-patient services, so that it would be practical to make that distinction fairly easily. The problem in some of the Eastern hospitals, the teaching hospitals, would require some readjustment of their services. But in the large part of the country it would be easy enough to handle on the in-patient services by merely agreeing as you have in the workmen's compensation schedules and in the FERA scheme, on a certain fee schedule which the local medical society accepts and which physicians are paid on the in-patient service. Of course in the out-patient service you have to pay on a time basis rather than on a service basis.
MR. SIMMONS: I would like to ask, if this is to be referred to the technical staff, whether there would be any safeguards thrown around the method of appointment. If you are going to have a method of paying you ought to have control of the purse, and will you not reach a condition such as Dr. Brown spoke of and which exists in Cook County and other places where the people who want positions on there will apply not to the staff of the hospital or whoever the proper persons are now but to the political control that has the money in its hands? Is that a question which should be entered into?
CHAIRMAN SYDENSTRICKER: I assume that the money would be handled by the clinic management.
MR. SIMONS: I just raise the question if that ought to be a proper subject to come up.
DR. CUSHING: I wonder if we could ever limit it. In Boston in the City Hospital a member of the staff has been appointed by the Governor.
DR. ROBERTS: I am not going to ask too much even of the angels. Here is one additional point. In the City of Atlanta all the city employees are given group insurance at very minimum rates, and the doctors giving their services free to the city hospital by day or by night were not even permitted to come in on the group insurance. They are human beings. No wonder that their resentment somewhat flared. I am beginning to feel that our profession has somewhat imposed upon under the guise of our philanthropy and that here is a great and facile opportunity to call a very desirable halt to it in a very nice and plausible and gentlemanly way, as they say in Virginia.
CHAIRMAN SYDENSTRICKER: I wonder what that would cost, to pay them for their service.
DR. ROBERTS: In that school they gave two periods per week of two hours each, and they were called together and asked for their suggestions, and they said that their gasoline averaged $15 per month and if they were paid that they would be satisfied and would do better work.
DR. DAVIS: I think I can answer that question roughly. In most out-patient departments other than the stronger teaching departments which use a certain number of men for a large amount of time, physicians give two or three sessions per week; the sessions usually run from two to three hours, generally nearer two than three. For the bottom level, men doing the routine work, in places that are paying physicians, it runs $4 and $5 a session, that runs at the rate of $2 and $3 per hour of you figure it up on an hourly basis. That is the actual level.
CHAIRMAN SYDENSTRICKER: We will do the best we can with that and probably put it in more definite terms.
"b. Public attention should be called to the need of more adequate local tax appropriations and arrangements with physicians, medical societies, hospitals, or clinics to supply effective care to persons who are legally dependant, but who do not come within the scope of the relief system, and to other persons who, while self-sustaining during health, are not able to pay fees for professional or for hospital care during sickness, and who would not be able to contribute to any sickness insurance plan."
I would be very glad to get any further suggestion.
DR. GREENOUGH: Mr. Chairman, in the paragraph above (b), second line, "the support or extension of public health services." That should also be public medical services.
CHAIRMAN SYDENSTRICKER: It refers specifically to the clinics being maintained by Public Health Departments. That is taken care of in the balance.
Do you want to speak on this, Dr. Parran?
DR. PARRAN: With your permission, I have several points I would like to bring out. In the first place, it seems to me this Committee has upon it an obligation to recommend to the President means by which the economic insecurities arising out of illness can be minimized to the best possible extent. I judge from the tenor of discussion this morning that there was the thought within the group here that that might be accomplished, not only by health insurance, but by an extension of our present systems of public medical care. If we accept that point of view, I think that we should assure ourselves that such extensions and improvements in public medical care will in fact be as effective in safeguarding these low income groups against the hazards occasioned by illness as would a system of health insurance. If we were to propose medical care rather than health insurance, we would be obligated, it seems to me, to see that that extension goes far enough to give to the same low income groups a comparable security against the cost of illness.
I was very much impressed by the paragraphs in this report of Dr. Leland's in which he differentiates between the catastrophic type of illness and the usual routine types of illness, and have attempted to explore the possibilities of actually seeing to it that public assistance is given to people normally self-supporting because of catastrophic illness. I am convinced that public medical care can be accomplished.
I. Fundamental Considerations.
(a) Popular concepts of health insurance.
1. The Medical Profession. In spite of the theoretical advantages of an inclusive plan for health insurance, the attention of great proportion of practicing physicians of this country has been repeatedly called to the faults and defects of health insurance as utilized in other countries. They have slight knowledge of its merits or advantages. In consequence, health insurance in many parts of the country would not have the guidance and cooperation necessary to insure its success in any plan adopted here on any nationwide basis.
2. The Public. Though the demands for more and better medical care grow daily more insistent from that section of the public in greatest need of it, there is in general a distinct apathy toward health insurance as a method of obtaining relief from the present situation. This may be due to lack of information as to its operation and the fact that immediate, tangible returns from health insurance seem slight in comparison with the other forms of social security more widely discussed of late.
(b) Types of established tax-supported medical services. In addition to preventive health services, we now have important tax-supported medical services, such as,
1. Medical care for all public charges, including 23,000,000 now supported in whole or in part by the FERA.
2. Medical care for almost all mental diseases.
3. Public use of nearly one-half of all beds in general hospitals; payments from tax moneys to private hospitals; public maintenance of hospitals for the acute communicable diseases.
4. Medical care of the larger part of the tuberculous.
5. Medical care of one-half the syphilitics.
6. Medical care of crippled children.
(c) Value of experience and precedent.
A body of experience has been accumulated through the conduct of existing services which shows the directions in which improvements are needed and extensions would prove profitable. In many of the foregoing types of tax-supported medical service, a satisfactory technique of cooperation has been worked out with the practicing physician.
(d) Limitations of health insurance.
1. Participants. No system of compulsory health insurance can be devised at this time to embrace contributions from public charges, including the unemployed; the self employed, employees of small establishments and agricultural workers; the total of whom comprise an estimated ____ persons.
Even though we were to put in a system of health insurance in which all industrial employees were included having incomes of less than $2500, but at the same time having some income from which they could contribute towards such a system, it would not by any means cover the whole situation; it wouldn't cover the rural problem, self-employed, etc.
2. Funds. Many persons of small income are able to negotiate the cost of private care for minor illnesses, routine dentistry and nursing, but are unable to meet the cost of occasional "catastrophic" illness, or long-continued chronic illness, such as cancer, tuberculosis, or arthritis. Health insurance funds, according to the most-discussed proposals, are not large enough to provide through contributions for such contingencies, the largest proportion of the expenditure being for general medical care in the home and office.
3. Costs. Again, medical care does not lend itself to the application of the insurance principle so readily as does the payment of old-age pensions. It is very simple to accumulate a reserve on an actuarial basis to pay a flat monthly pension to persons when they reach sixty-five or seventy years of age. It is only one very simple operation that is involved, while in rendering medical care under health insurance the operations are so diverse and so much discretion is needed as to what type of service a person needs in a given instance that the costs of administration inevitably are higher. For example, to be inclusive, health insurance need not only compensate for wage loss, which is relatively simple, but for general medical care, surgical and specialist care, hospitalization, nursing service, dental service, maternity care, and perhaps cash benefits. Because of these sundry complicating factors the costs of administration in health insurance are almost invariably higher than administration of other forms of insurance, and , secondly, in certifying illness we are faced with one or the other horn of a dilemma, namely, that the doctor who treats the patient must certify as to his disability, with the inevitable pressure upon him to certify for disability when disability doesn't exist, or we need to set up a dual and therefore a more expensive system of certifying salaried doctors and attending physicians, which is the plan embraced in the report.
Again, we have had a very wide experience in this country in furnishing public medical services. It has grown up gratuitously. It is unevenly distributed geographically. Many medical public services and dispensaries are poorly operated, many hospitals are politically dominated and the character of care, I grant, is not so good, and yet we do have a background of experience in providing for all the indigent so far as they are provided for at all, either from public funds or charity. We have a background of experience on providing for certain expensive illnesses, tuberculosis and mental diseases, crippled children, upon which it seems to me we might readily extend the system to include persons who are in the low income group but not paupers. I will not repeat the kinds of experience we have had. We took that up a little earlier this morning.
II. What extension of public tax-supported medical service might be visualized which would meet this problem as well of health insurance? In the first place, federal funds and standards are necessary to promote provision by the states and communities of satisfactory medical care to public charges and the income groups for which such care is now admittedly inadequate. These funds should be available to states on a basis of population and need, under restrictions to insure (a) adequate standards of service; (b) the continuation of existing state and local support of such services. In other words, federal funds are needed; they merely dry up existing local expenditures for these purposes.
Such federal funds should be granted either for an approved system of health insurance for any state which elects to adopt it. In general this will be done only when the medical profession and a majority of the citizens to be benefited are in accord as to the installation of such a system. Or federal funds also should be granted for an approved system of tax-paid direct medical services and indirect services such as the maintenance of laboratories and other diagnostic services to the private physician, public participation in hospital use and maintenance, public provision of nursing services, and direct payments to physicians, dentist, or other professional personnel required to render needed medical services to the low income and indigent groups.
What should be the scope, then, of such a system? First, an extension of medical care on a tax-supported basis should provide the following services, meeting reasonable standards of efficiency in order to secure federal assistance.
1. For all public charges, including the unemployed, those employed on work relief at less than industrial wages, the indigent, and dependent children, the following, namely all kinds of service:
General medical care
Minimum of dental care
They have no money. If they are to get service tax funds must provide it. It seems to me there can be no argument on that. We are seeking to render that kind of service now and doing it in a haphazard and not very well organized way.
2. For those persons who are contributors to the proposed federal old-age pension fund, namely, those persons of, let us say, $2500 income as an upper limit, more or less service, depending upon its nature. For the more costly illnesses, perhaps public payment for the whole cost; for less costly service, less public payment.
I have tried to list them, not with the idea that they represent a final conclusion, but merely as a basis for discussion and to indicate the scope of such a plan.
1. Diagnostic service for obscure disease, furnished to persons earning less than $2500 a year and their dependents upon request of the family physician, the general physician. There are many cases in which the doctor is uncertain as to the cause of illness, in which expensive laboratory and x-ray and consultation service is necessary, for which the patient cannot pay and for which no service now is available. We already have a beginning in the principle of furnishing such diagnostic service from public funds upon request of the physician.
2. Public treatment for the disabling chronic diseases, again for this low income group; cancer, syphilis, tuberculosis, arthritis are examples. Perhaps you will subtract from or add to that group, but it illustrates the principle of a costly, highly skilled, long continued medical service for the person with small income for whom such disease is a catastrophe, who cannot meet it out of his current income.
3. Major surgery and pneumonia, and that type of acute condition, including hospital and nursing charges in excess of some specified amount. For example, a man earning $125 a month has pneumonia with complication, emphysema, and so forth, requiring several hundred dollars expense. Such a person might be required to pay one month's income. Over and above that public funds would share, say half the added cost; a higher maximum, perhaps we would need to pay from public funds all of the added cost. In other words, I am trying to introduce here the principle of having the person who has a catastrophic illness pay a certain amount, over and above which not all of the cost but at least some of the cost would be shared from public funds, either paying part or all of the hospital bill or all of the surgical aid or part.
4. Obstetrical care. While that ordinarily is not a catastrophe or major surgical operation, at least we know that the economic hazard to good obstetrical care is a very great one. I think it is a major factor. This plan proposes a cash benefit for employed women at childbirth. The same principle might be introduced without health insurance. And also the payment of a part of such costs if the patient registered early with the physician and thereby was able to secure prenatal care and care all through confinement.
Of course, such a system might conceivably be extended in a socialist state to include the whole population. I personally would oppose in my own philosophy any such extension. On the other hand, it does seem to me that this group has laid upon it the obligation either to recommend to the President a plan of health insurance which will minimize the economic hazard of illness, or some system which will do as much, or both, as an alternative.
My suggestion as I have outlined it here is an option be left with the state either to elect health insurance if it chooses -- there is some discussion about California and Michigan -- or to extend to present systems of present medical care to accomplish approximately the same thing.
I have endeavored to show in here some of the ways in which it could be done. What sort of requirements should be set up by the Federal Government for a system of medical care?
1. A specified minimum percentage of the cost must be borne by state and local authorities to prevent drying up of the present expenditures.
2. Adequate facilities for the use of the general medical practitioner, the private physician, in this income group, such as diagnostic laboratories, specialist or consulting service such as we now supply, I may say parenthetically, for tuberculosis and cancer and other things; also facilities for the direct care of those unable to pay, rural hospitals we have discussed, visiting nurse service we have not discussed but it is quite important. Standards obviously should be varied to fit local conditions.
3. (Perhaps this should have been first.) The eleven principles laid down on pages 14 and 15 of the interim report which were published in the Journal of the American Medical Association are applicable, should be applicable, and should be part of the requirements set up by the Federal Government.
4. Private hospitals which meet standards as to service should be eligible to receive tax support as well as publicly supported and maintained hospitals. You know the problem there. Not more than sixty-five per cent utilization of private hospital beds exists, chiefly because of the economic barrier of illness at the moment.
5. Physicians of course should be compensated for all services, whether in the home, office, clinic, or hospital ward. The basis of compensation to be determined locally within certain federal and state standards.
6. All preventative, diagnostic and treatment services, that is in so far as public funds are spent for such a system, should have their administration integrated and under medical and not lay direction.
We come finally to the question of wage loss, which is cared for under the system of health insurance. I would suggest first that amendments and supplements to the old-age pension plan that is now before Congress be made so that benefits on account of invalidism through disease be included no less than invalidism due to old age. In the British health insurance system, and others, a separate category of invalidity insurance, I think is the term, provides a long-time or permanent pension for the permanently disabled. It should be possible to include that under the pending old-age pension plan, conceivably unemployment, but I think the old-age pension.
At the present time we have cash payments to employees under state employees compensation laws, all of which would of course apply to persons who are injured in industry, who have permanent pensions as the result of permanent disability in industry.
Through those two methods it would seem to me the bulk of the problem of long-continued wage loss could be taken care of under existing or proposed methods.
CHAIRMAN SYDENSTRICKER: I suggest that we discuss the relative merits of this. That goes a long way in the extension of public medical service, especially in the low income groups. I would like to get your reactions to these suggestions. We have not gone nearly as far as this in our proposals or tentative proposals.
DR. CRILE: I had the advantage of a chat with Dr. Parran on the railroad train sometime ago. Ever since that time I have thought this might come in as a most important subject for discussion. This has several very interesting factors in it that wouldn't interfere with the thing Dr. Cushing was speaking of this morning, that is, the most fundamental thing of all is to continue to attract to the medical profession very desirable students from the ranks of well qualified men, and this kind of plan I think would work in very well because it would employ the young doctor and would allow hin to get the full advantage of medical practice, and it would solve almost complete, I think, the question we have been discussing about the dispensaries and the outdoor group, because they would be cared for very largely in this plan, as I take it. It seems to me it would not dislodge or disturb seriously the long-time tradition and feeling of the medical profession itself especially on the education and training of men and men in their practice.
This appeals to me very greatly. I don't know how it will work out as a practicial measure, but I can see how it equalizes the existing professional feeling, supplementing the income of a great many men all over the country, in the cities and in the rural communities, and it seems to me to have a very broad application. In principle I like it.
DR. CUSHING: There is one thing I wanted to ask Dr. Parran, whether you had thought of any provision to prevent the desire for sickness and prolonged sickness.
DR. PARRAN: Full payment on our present basis would be made for the ordinary illness treated in the home or the doctor's office for that group of persons between work relief and $2500 a year; there would be a continuation of our present system of general medical practice for that group with these additions. By general medical practice I mean the uncomplicated illness as treated in the home and the office, the buying of glasses, routine dentistry, routine home and office service. Dr. Leland has outlined that. That would be left as at present.
DR. CUSHING: Psychologically the most important thing which the doctor has to do with the patient is to inculcate a desire to get well; the will to get well and to get back to work is perhaps the most important thing that you can secure with your patient. If he is too well provided for permanently he isn't interested and very soon he prefers that existence to getting back to work.
CHAIRMAN SYDENSTRICKER: I assume that Dr. Parran has in mind cash benefits in medical care. There are ways of taking care of that, of course. You couldn't pay too much, certainly.
DR. HORSLEY: Would it not be well to provide for loss of wages the actual cost of medical care? What I mean is this: When an individual is ill he naturally falls in the class of unemployed, that would possibly be a subdivision of the unemployable, but he is unemployed just the same, and his compensation or dole or whatever it can be called cannot be reasonably differentiated from that of the unemployed. It seems to me one of the most puzzling problems and one of the most difficult ones in this cost of medical care for those in the lower brackets is just that thing, to separate entirely the actual cost of medical care from the loss of wages, and if that feature can be entirely separated and placed, for instance, in the unemployment, it might simplify the situation a little bit.
DR. FALK: Without giving you the basic question to which Dr. Parran's remarks were directed, namely, the value of developing in as great detail as is possible the considerations of an entirely alternative system, leaving the states the privilege of choosing public medical services and receiving Federal aid therefore as a means of reducing risk to economic security, there are one or two points which I think may clear the discussion.
I would take exception to some of the preliminary remarks which Dr. Parran made, but which do not prejudice the discussion which we have to face in respect to the alternative scopes of a health insurance plan that will come up later, but I do think we should be clear on one or two points which I think are not clear. In the first place, we have not recommended in this memorandum which is before you a provision of cash benefits for wage loss, and I think it is worth while calling to your attention what may have been insufficiently emphasized here. There is a difference of wording which was deliberate and intentional in respect to the recommendations for medical services and the statements in respect to cash benefits. You will find if you look at them (it appears once in page 6 and a number of other places in the brief memorandum) where we deal with partial replacement if wage loss, we say, not that we recommend or propose, but that if furnished as an insurance benefit would cost about so much should be defined in such a way. I think you should carry in mind that we have never, I think, we have not yet certainly, taken the stand that we are convinced from a strictly technical study of the problem that we are prepared to give any unqualified or strong endorsement or recommendation for cash benefits. Secondly on that matter of cash benefits, our studies have convinced us that if furnished there shall be an independent medical officer to certify. Thirdly, we have already proposed that whatever the system of administration of an insurance procedure which gives cash as benefit, it shall be linked to unemployment insurance or some other. In other words, I think it should be perfectly clear that on this point in the first place we have not taken any definitive stand in recommending that; secondly, we have taken a definitive stand that if there is such a benefit the certification for it shall not be by the physician who furnishes the medical care; and thirdly, if there is any system of insurance which furnished such benefits, whether you have health insurance as a general alternative for public medical service or not, it shall in any case not be linked to any system which furnishes medical care. I think that point applies equally in our plans for health insurance or such a plan as Dr. Parran has elaborated over what we have done in respect to public medical service.
I think we would all agree upon the sharp separation of the administration of cash benefits from either health insurance or public medical service. Our memorandum on that point could be applied in toto to what Dr. Parran proposes.
There is one other point I should like to mention, though it will come up for more detailed consideration, a point which Dr. Parran has made and I think I cannot follow him on. He has made two points. First, if I understood him correctly, that because of the complexity of problems and of the nature of the benefits involved in furnishing medical service, the complexity of itself introduces special difficulties in applying the insurance principle to the risks involved. I think experience will not support Dr. Parran on that. If there is any form of social insurance which has always been actuarially sound, which has always stood up in the face of the most extraordinary emergencies the world has known in recent years, the one form which has met those is health insurance and not old-age pensions or invalidity or any other form. They have all been more or less bankrupt in the face of the emergency, of unemployment, of inflation of currency, and other things, but health insurance has stood out as one which has always been able to live on a balanced budget, for this simple reason, that all these other forms of social insurance are capitalized risks and must be build up reserves in savings in years when the individual has a low risk against the years when he has a great risk, as in life insurance, but sickness or health insurance is a distributive risk, to use the insurance parlance, namely, that you merely require in each fiscal year contributions sufficient to pay the costs for that year, and at the end of each fiscal year you balance your budget and start again. You build up enough operating reserve so as to make unnecessary frequent changes of your premiums or of returning reserves.
I don't want to go into that as a discussion of a problem which we must face in connection with health insurance, but we must recognize this point, that when we come to consider proposals 1 and 2 on health insurance, I think we will find -- I may be wrong -- that one of the basic differences between proposals 1 and 2 is in respect to the matter Dr. Parran emphasized, namely, the administration costs. I think I am right in this, but we shall face it later, that one of the important objections which must be considered against any form of insurance or any form of providing medical service to the public which is restricted to the catastrophic risks as distinguished from the total risks, is that it at once vastly changes your administration costs. It is a fact, I think, that an issue as between public medical service and medical service as an insurance benefit does not rest on the question as to which is more expensive to administer. The cost of administration enters as an issue only as between whether you undertake to cover a blanket risk or whether you undertake or attempt to delimit the risk, set up the administrative machinery to define how much the patient has to pay first before he becomes eligible to receive the benefit either as a public medical service or as an insurance benefit.
If I am right about those points (and I think we must keep them in mind) indicate that the merits of Dr. Parran's proposal rest upon other considerations than the validity of applying the insurance principle or the administration costs. I think those are not arguments that enter here. The arguments that do enter are of the other kinds to which Dr. Parran referred.
CHAIRMAN SYDENSTRICKER: I think Dr. Falk is quite right. I think, however, that the fundamental thing which we have got to face is what this all means. That is what we want your advice on. What are the implications?
DR. FALK: The point is to clear the record. I think Dr. Parran didn't mean that the principles referred to on the page which is cited here had been published in the J.A.M.A. I think he said that. The principles which have been published in the J.A.M.A. are those which were cited by the Committee on Economic Security to the President. It isn't a matter of moment, but I think we ought to be clear on the record. I meant merely that there be no misapprehension that anything in these confidential documents has been published in the J.A.M.A. or elsewhere.
DR. PARRAN: I thought they were the same as to adequate compensation of the doctor, no profit making agency, etc.
DR. FALK: There are certain similarities, but what was published was the statement of the Committee on Economic Security.
Dr. Parran touched upon invalidism and the problem of cash benefits for invalidity. You should know, I think, that when we were first charged by the Committee on Economic Security the subject of invalidity insurance was in a very vague way within our field of study, but when we found that it would not be practicable for us to deal with the problem of invalidity insurance and when we came to the conclusion that even if it were practicable within the time limits we did not have a sufficient body of data upon which to measure the risks and to design any program which could stand up under actuarial examination, the matter was laid over by the Committee on Economic Security, though another staff undertook a supplementary study, reviewed the evidence, and came to the same conclusion that we had come to from our knowledge of the subject, namely, that there was not an actuarial basis available at this time with which to deal with that problem. So while Dr. Parran is perfectly justified, I think, in raising the question on the need for protection of the kind ordinarily called invalidity insurance, we have had to decide that we could not at this time deal with it and we have had to make such a report to the Committee on Economic Security.
CHAIRMAN SYDENSTRICKER: That does clear the ground. I would like to know how you all feel about the underlying principle, which I conceive to be a considerable extension of public medical care.
DR. BROWN: My impression is, Mr. Chairman, that the suggestions made by Dr. Parran would put the whole matter under the control of politicians, which is what we do not wish to have occur. I may be wrong, but that is my interpretation of it.
CHAIRMAN SYDENSTRICKER: My impression, Dr. Brown, is that this simply goes further than we have gone, considerably further.
DR. BROWN: And links it up with what we are all opposed to, state medicine. I think it does.
CHAIRMAN SYDENSTRICKER: I raise that question myself. I want you to be perfectly frank in talking about that point.
DR. ROBERTS: Mr. Chairman, I have been trying all day to agree with my friend from California, and I have at last succeeded. I think that he is correct. I have been trying not to agree with my friend Falk down there, but I think he is fairly correct when he says that some of Dr. Parran's premises are rather inclusive (I will put it that way).
For example, you stated that they could pay for the routine dentistry, but I find that that is one of the greatest arguments that appealed to me in favor of health insurance, they cannot pay for the routine dentistry, at least in the lower groups that I am associated with. As a matter of fact, I have come to feel, after more recent study of the dental part of the problem, that we are about twenty years behind in dentistry, as was stated in one of the reports.
Then I notice this ever recurring thing: cash benefits for employed women at childbirth. Now somebody here has got to take up for the farmer. We have 12,000,000 families, and if anybody ever did need cash benefits it is the farmer's wife, without any domestic servants at all, except so rare as to be an exception, at least in the country that I know, and I see no reason why we should limit that to employed women in industry; they are getting money from month to month, and it is the farmer's wife who seems to me should be included in this program.
I still feel that I am open to argument that this is a better plan than health insurance, but "Bear ye one another's burdens" has pretty well educated the race to insurance in all lines, and it is the one great economic procedure to which the American people are committed. I am open-minded; if it is a better plan I am willing to favor it, but I am also not far from Missouri.
DR. DAVIS: On the relative scope of this scheme as it would apply to the population of the country as compared with the existing scope of public medical service, that is something of the quantitative bearing of this program, in the first place the first category apparently applies to the indigent, those without any incomes. The chief change which it would bring about would be merely in the quantitative and actual application of an already accepted principle. While of course different states vary in the way in which they have actually cared for their indigent, under law there is a general public acceptation of public responsibility extension of the service, meaning more money from taxes, federal or local, and the carrying through of the principle that the physician shall be paid for his services, which of course the Federal Government in the FERA scheme has recognized and has been putting into effect to a certain degree, that is in so far as applies to the indigent.
As to what indigent means, under present conditions I am told that the Federal relief and the work relief groups are estimated to include at the present time about 23,000,000 people. There are a considerable number of additional people who are practically in the same category, although they are supported by relatives in other ways, but they have no means of their own, so we have to add something to that.
When one comes to the list of services for those with some income, Dr. Parran proposes diagnostic services, chronic illness, and services in catastrophic illness. If you want to say something about catastrophic illnesses, major surgery, pneumonia, and similar acute expensive illnesses, as I understand it you are making a separation there between the expensive chronic illnesses and the expensive acute illnesses; they fall in two different categories.
In the main, a larger part of major surgery and a considerable portion of the other acute illnesses, in the cities at least, are cared for in hospitals. At the present time, even before the depression, about thirty per cent of all acute general hospital cases were cared for in governmental hospitals, practically without charge; a few governmental hospitals charged nominal sums, the medical service in these cases again being mostly free. This type of illness to a large extent has been already recognized and provided for, and there is a considerable and active move on the part of the people interested in hospitals of course to extend and broaden the scope of services by getting government funds to pay for the hospital care of patients of similar means, small means, but unable to afford a hospital bill, in non-governmental hospitals. It seems to me that it raises an extremely difficult question. If it is proposed to pay a portion of the cost for these expensive illnesses of those who are able to pay something to their private physician and surgeon and for hospital care and it involves the principle of individual appraisal of means to pay, individual investigation, I think there is very great doubt whether any scheme which involves individual investigation of the ability of people to pay will work on any large scale.
We are already applying the principle of giving this care to thirty-five per cent at the present time, considerably more under the depression, of all general hospital cases.
If it is proposed that people just above this level shall have these illnesses cared for in part out of tax funds, and requiring individual investigation, which is not at all a popular move in the first place, and in the second place is extremely difficult to administer without charges of favoritism it seems to me that it is very unlikely that it will work satisfactorily or be sufficiently popular to allow its continuance. I doubt very much whether the principle of paying for a portion of services out of tax funds for people of this middle income group could be carried on a large scale. You propose investigating an individual case, how much a person can pay, and then paying a portion of that.
CHAIRMAN SYDENSTRICKER: We do that now in hospitals and clinics.
DR. PARRAN: That is the way the public hospitals in New York now operate.
DR. BROWN: For the past year in Santa Barbara, a small city relatively speaking, we have adopted a part pay plan for people in low income brackets. The people appear before a welfare worker who investigates their financial circumstances. This has been approved by the Santa Barbara County Medical Society unanimously. Practically all the doctors in the medical society are party to the plan and are operating under the direction of three members of the society. When we tell people, "You can have an operation for appendicitis or for gall bladder disability or any major surgical operation for approximately $17, $15 or $23, your hospital bill will cost you, instead of the regular rate of $4.50 a day, $2.50," only sixty per cent of those part pay patients pay either the doctor or the hospital. Those are actual statistics which we have found out by experiment. I rather feel the plan that Dr. Parran has suggested to us will not be operative in general in America.
DR. ROBERTS: Dr. Brown, may I ask you this question for the benefit of all? Suppose all the people in this country who live more or less in contact with hospitals took out hospital insurance which gave them a thirty-one day limit for each calendar year, how much would that solve this whole problem of curative medicine, and how much would it add to the chances of each physician getting a reasonable fee from the patient?
DR. BROWN: I think it would not solve it at all.
CHAIRMAN SYDENSTRICKER: I would like to get your reactions. Let's go around the table on this plan. Dr. Leland, what do you think about it?
DR. LELAND: If this matter is referred to the technical staff I would like to have the text of Dr. Parran's proposal to study before making any very definite suggestion.
CHAIRMAN SYDENSTRICKER: I mean in a general way.
DR. LELAND: I think I should have to disagree with Dr. Davis and Dr. Brown in that there are a number of places in the United States where this thing is working. They have found that as high as fourteen to seventeen per cent of people so investigated are not only able but willing to pay full fees for medical and hospital service. Those figures can be produced.
DR. BROWN: I grant you that, Doctor. But I am speaking about the part pay plan. They do not pay their bills because they can't afford to pay them, they haven't the money to pay them, neither their hospital bills nor their doctor bills.
MR. SIMONS: That is something that the social service agency has to determine.
DR. BROWN: No, I think not, because the economics committee of the county medical society investigates all those cases.
MR. SIMONS: They may be incompetent.
DR. BROWN: That is possible.
CHAIRMAN SYDENSTRICKER: We probably will discuss this thing in more detail when we get a chance to read it, but as regards the general principle of extension, Dr. Piersol, what have you to suggest?
DR. PIERSOL: It is such a big thing that it is pretty hard to get your thoughts well ordered. It seems to me that extension to that extent will open up a lot of dangers that have been referred to and perhaps will lessen the control.
DR. PARRAN: May I say that I don't insist at all on any minimum of service except the general principle that such a system should provide an equivalent amount of security to these people as a system of health insurance. As to the details and as to how far the treatment of one category of disease shall go, it is quite open and those things can be decided on their merits.
DR. GREENOUGH: In Massachusetts we have had the experience of establishing facilities under the Department of Public Health for cancer service. That was not at the request of the medical profession, but it was initiated in the legislature by laymen, and we succeeded in guiding the activity of the legislature in such a way that they finally accepted the bill that we thought was safest and established a state cancer hospital and some diagnostic clinics. Those have been regarded as serious steps toward state medicine by the medical profession of Massachusetts, and that largely, I think, under a very serious misapprehension, because as a matter of fact the facilities provided by the legislature make it possible for any physician in the state undoubtedly to give better service to the suspected cancer patient than he ever could before, and those patients do not remain the patients of the state cancer hospital or these clinics, but they are sent back to the physician who first referred them after they have had treatment, and his cooperation is sought in the follow-up of the case. Yet it has been a red rag to the bull from the point of view of the attitude of the medical profession toward that facility, and I fear, for instance, that our own lives would be somewhat at stake if we voted for Dr. Parran's plan of extension of the public medical services when we returned to our homes and came in contact with our colleagues.
I think the medical profession is far more ready to accept a limited health insurance plan than they would be that plan, although as far as the welfare of the medical profession is concerned, purely from that standpoint, I think that their welfare can be protected under either plan, but we must recognize the attitude of the medical profession toward these problems at present if we are going to accomplish anything, because we cannot put any method through without their cooperation.
I would myself hesitate to put the burden of this intermediate group of income class under Dr. Parran's plan without very much more serious consideration of those implications.
DR. HORSLEY: I believe that Dr. Parran's plan is certainly idealistic, but if we are having difficulty in putting through a comparatively simple insurance plan, it seems to me Dr. Parran's plan, however excellent it may be, would be almost impossible to execute. I rather think that some form of insurance, not necessarily the form outlined here, perhaps some modification of it, had better be tried first, and if you can do that we might get into Dr. Parran's plan later on.
DR. BIERRING: Taken in its general principles, this appeals to me very strongly and I believe that if it is regarded purely as an extension of public medical services, that it furnishes a solution. I believe it is practical and can be carried out. It is being done now. In a sense we have had some experience with public medical services, particularly during the depression period, and I believe that this will meet with more favor and accomplish more than will the special system of insurance. I believe it is very worthy of our consideration. I feel that there is no more state medicine in this proposed extension than there would be in health insurance, and I believe it will meet with more favor in the organized profession than a definite plan of national health insurance, which I do not believe medical men of this country are prepared for at this time.
MR. SIMONS: I have nothing to add to this. It is a question of largely professional opinion, on which I don't presume to speak. I might suggest one thing, that this is largely a proposal to install what has been found necessary to add to the British health insurance system, a system of extension and care to meet catastrophic diseases and to set up laboratory facilities for diagnosis, and it may be possible that approaching the problem from that end we would be meeting what Dr. Davis calls problem cases.
It has one other point. It is a fairer distribution of this burden by putting it on taxation through the entire public rather than distributing the burden entirely among the class that is least able to bear any additional burdens. At the same time I don't want to say I am for or against it until I have taken a good thorough study of it.
CHAIRMAN SYDENSTRICKER: Dr. Sinai?
DR. SINAI: Mr. Chairman, I will have something to say in connection with proposals 1 and 2.
DR. CUSHING: I think this is a very important proposition. It appeals to me tremendously. Will you tell me what is the apprehension about state medicine over this rather than over insurance?
DR. PARRAN: Of course any plan can be damned by the label that is given to it. I have had the employment of two school nurses in the City of Quincy, Illinois, labeled as bolshevism.
I think we might consider the broad question as to the difference between contribution and taxes. Viewing it broadly, all taxes are contributions levied presumably in proportion to ability to pay for one or another service to the whole people. Similarly, contributions are taxes, and the Federal plan for unemployment insurance taxes all of us, whether we are partakers of it or not, in higher costs of living, and so on. Again, certain of the low income groups who pay very little in direct taxes except cigarette taxes and gasoline taxes and such like, actually pay in real estate taxes added to their rent as unlabeled increments to it, so all of us pay in any event.
This system of individual contributions, it seems to me, has been devised by the Administration as another name for taxes, and levied, as Mr. Simons very properly points out, upon the group least able to pay, and also inherent in any contributory plan of health insurance is the necessity for tax funds to supplement the contributions of the employer and the employee, so that the rest of the body politic pays in general taxes, pays in higher costs; as the result of the contributions which the worker and the employee have paid into it, by and large, it seems to me, there is no essential basic difference between contributions and taxes.
Again, such a plan as this might be implemented by an employer's pay roll tax of one per cent, if you wish. Under the definition of terms that we have been using up to now, this is state medicine as contrasted to a contributory health insurance system which is outlined here in the documents before us. What we now are doing is state medicine for the unemployed, the FERA, etc., the clinics, and so on, amounting in normal times to how much?
DR. DAVIS: Six hundred million dollars a year.
DR. PARRAN: Exclusive of mental disease?
DR. DAVIS: No, that covers it.
DR. PARRAN: In New York State, with one-tenth of the population, exclusive of mental disease, public payments on account of preventive and curative medicine last year were $48,000,000, and you can add another fifty for mental hygiene. That is general hospitals, crippled children, tuberculosis, the whole thing.
We now have a large measure of state medicine. Of course some of it is political. I have no illusions that one or the other system in itself means necessarily political control or the other means non-political control. It gets back to some of the basic questions that Dr. Cushing and Dr. Bierring raised this morning concerning medical direction rather than lay direction.
DR. CUSHING: If I understand you correctly, you merely propose a broadening of existing facilities.
DR. PARRAN: To an extent which will secure to the low income groups and the public charges a degree of security against illness comparable to what would be security by a system of contributory health insurance. I assume that is an obligation that is laid upon us, to recommend a system which will as far as possible secure these low income groups against the hazard of illness.
DR. CUSHING: I feel as almost everyone else feels, that they would like to study this more, but my impression of it is, if it means a broadening of the existing conditions, that this is not going to be so great a dislocation as if we introduced an entirely new system. I may be wrong, but my whole feeling about the insurance system is that under that system the practitioner gets squeezed above and squeezed below and finally deteriorates, and I should think that from his standpoint this is a safer thing for him to bank upon and that he would look upon this with more favor than the other system, but that is about as far as I can go on it.
CHAIRMAN SYDENSTRICKER: Gentlemen, this is a very interesting suggestion by Dr. Parran. If you wish we can have copies of it this evening.
DR. CRILE: I think this point that Dr. Cushing raises is exactly the key to the situation, that is to protect the physician. I am wondering whether it would be at all feasible (I was thinking of what was said this morning about these large rural districts) at the present time in some way to introduce the Saskatchewan principle of supplementing the local care for the indigent to the United States very generally.
DR. BIERRING: You could do it with his plan.
DR. CRILE: But I was thinking of going on up, the question of taking the indigent poor, for instance, and covering as low a margin as can be done, which would take away a great deal of objection from the profession as a whole.
This certainly requires a lot of thought. My first thought is that that principle could be worked, and then limit it as far down as we can in the income groups.
CHAIRMAN SYDENSTRICKER: Dr. Parran, what you have done essentially in your plan is simply to provide, in addition to what we now recognize as perfectly proper and acceptable, certain types of medical care in serious illnesses, prolonged cases, etc., to all the people under certain income levels.
DR. PARRAN: And Federal subsidy for that.
CHAIRMAN SYDENSTRICKER: The rest of it is all in the picture anyway.
DR. CRILE: May I suggest one other thing, and that is as completely as possible keep the element of political control out of it.
DR. PARRAN: May I state one further word, Mr. Chairman? Certainly I do not wish to appear as a protagonist of this plan. I am just an interested student of this whole problem and have considered what seem to be both professional and political shortcomings of the system of health insurance. This was gotten up very hastily in a period of two hours after conversation with Mr. Sydenstricker, merely as a basis for discussion. I hesitate very much to advance it because it is easy enough to consider what needs to be done, it can be shot full of holes, so I hope that the fact that I have proposed it doesn't indicate that I consider that the only way of meeting the problem or necessarily a desirable way. I just throw it on the table as a basis for discussion, without any commitment as to details.
CHAIRMAN SYDENSTRICKER: The real difference from the other things we are talking about is that it offers medical care of certain kinds to people who theoretically can pay something.
DR. PARRAN: In whole or in part.
DR. CUSHING: Here at least is a new proposal. We can call it the American plan versus what so many people have gradually come to believe is a very undesirable foreign plan which we must introduce just because a lot of other countries have already done it, and we see the evils of it. There may be evils develop in this, but at least it is a new proposition. I should think this could tie in perfectly well with all these experiments that are now being made, which can be made further sources of study. This can be our recommendation for further development -- certain parts of it; probably the public health part of it, and all, could be acted upon right away with our full agreement. This enables us to get somewhere without too disastrous a dislocation.
DR. CRILE: Don't you feel that this sort of plan if it can be worked out will to a large extent obviate the very thing you were talking about this morning?
DR. CUSHING: I hope so very much.
CHAIRMAN SYDENSTRICKER: I think you will find, Dr. Cushing, that the outline of the health insurance plan which we have has very little element of the foreign in it.
DR. ROBERTS: Do we not have to discuss health insurance anyhow?
CHAIRMAN SYDENSTRICKER: Yes.
DR. ROBERTS: Wouldn't it be a good idea to proceed with that the rest of the afternoon and do all the work we can and be in a better position to take up Dr. Parran's plan in the morning?
CHAIRMAN SYDENSTRICKER: I think we might start on health insurance this afternoon. I would suggest that you turn to our interim report on page 13. The general statements there simply set forth the goals. If you want to modify or change the verbiage or phraseology I shall be very glad to have you do it.
First is the provision of adequate health and medical services to the insured population and their families; b, the development of a system whereby people are enabled to budget the costs of wage loss and of medical costs; c, the assurance of reasonably adequate remuneration to medical practitioners and institutions; d, the development under professional auspices of new incentives for improvement in the quality of medical services.
DR. CUSHING: "Adequate medical service" of course is an indefinable term. No two people would agree upon what was adequate care of any patient, even between doctors.
CHAIRMAN SYDENSTRICKER: Shall we leave it out? It conveys certain ideas, maybe a different idea in your mind from someone else's.
DR. CUSHING: It is a platitude.
DR. ROBERTS: "Adequate" has come to be the accepted descriptive adjective.
DR. CRILE: As a matter of fact, it is a universal opinion it should be adequate.
CHAIRMAN SYDENSTRICKER: I will run through these things and I think it would be a good idea to ask Dr. Falk to answer any questions. This is our last chance at this. We want your advice.
We bring in a point there that is important in view of our report to the Committee on Economic Security.
"From a financial point of view, social insurance against unemployment and old age are quite different from health insurance. Unemployment and old age insurance, on the one hand, require the accumulation over a period of years of large reserves which will be drawn upon as periods of unemployment or old age require. The risks in these forms of social insurance must be capitalized. In health insurance, on the other hand, the finances are substantially on a pay-as-you-go basis, no reserve being required except a reasonable working capital. Moreover, unemployment insurance and old age pensions will require large sums of new money, since the potential beneficiaries are not at present spending or putting aside these sums for these purposes; whereas in health insurance most of the funds needed are already included among the items of family expenditure."
It isn't a question of enormous appropriation at all. The money is there, except in so far as the type of person Dr. Parran has mentioned, where when you get down to the lower income groups the state has to come in and be a part. We put that in for the education of the Committee on Economic Security.
"The benefits which may be provided fall into two broad classes and should be considered separately:
"a. Cash payments in partial replacement of wage loss due to illness and for maternity cases; and
"b. Medical services of various kinds."
Dr. Falk has already pointed out, I think, what is contained in paragraph 12, and Dr. Parran has somewhat covered that. "The program of insurance to provide cash payments should be designed along the same general lines as for unemployment insurance, whether conceived on a national or a state basis, and administration should be linked, so far as may be practical, with the administration of unemployment benefits. The medical certification of disability entitling an insured person to cash benefit should be the responsibility of salaried physicians. The physician treating the patient should not be responsible for recommending or certifying disability."
DR. CUSHING: That has been the cause of the chief trouble.
CHAIRMAN SYDENSTRICKER: Yes. The responsibility of signing the certificate is the responsibility of the official, not the doctor.
DR. CUSHING: Not the practitioner, but he may be a doctor.
CHAIRMAN SYDENSTRICKER: Oh yes, he may be a doctor, must be a doctor.
"13. In respect to medical care through health insurance, the role of the Federal Government is conceived to be primarily:
"a. To lay down certain minimum standards with which the several states must comply by their own laws in order that these states should qualify for federal subsidies, grants-in-aid, remission of tax, or otherwise;
"b. To provide financial incentives to states which establish plans meeting such federal standards;
"c. The Federal Government also has responsibility similar to that of a state for its own employees, wards, etc." The Federal Government has 600,000 employees all told.
"14. In the further consideration of the subject, three points must be covered;
"a. Description or definition of proposed federal standards;
"b. Such description of the elements of a state law and administrative system as would illustrate the working processes to which the federal law and the standards are intended to apply; and
"c. Estimates of cost and indication of sources of funds.
"15. In designing a system of medical care and health insurance, the following eleven principles are fundamental in indicating the intentions of all other proposals bearing directly or indirectly upon medical services and upon professional problems and relations."
Those are not the ones that appear in the Committee on Economic Security report; these are the ones that the board here adopted with certain suggestions as to changes in phraseology. We would be very happy if you would run over those and see whether you have any further suggestions.
"a. The availability of good health services and medical care to all of the population is essential to the public welfare."
I don't know what Dr. Cushing would think of that.
DR. CUSHING: It's agreeable.
CHAIRMAN SYDENSTRICKER: "b. The provision of medical services for those who cannot otherwise secure them is an obligation of society."
DR. ROBERTS: You mean that is another one of Thomas Jefferson's inalienable rights, the pursuit of happiness and the right to adequate measures of medical care.
CHAIRMAN SYDENSTRICKER: "c. The provision of medical services of the highest quality is in the interest of the patient and of economy, and the improvement of the quality of medical services should be a continuous aim in any plan to furnish services;
"d. Responsibility for the quality of medical services should be borne by the professions."
MR. SIMONS: Would you add "whose members deliver the service"?
CHAIRMAN SYDENSTRICKER: Sometimes it might be the responsibility of the professors of medical schools or those who constitute organized medicine.
MR. SIMONS: They would all be included, wouldn't they?
CHAIRMAN SYDENSTRICKER: "Rendering the service"?
MR. SIMONS: I was thinking of professions as applying to those whose members delivered the service.
CHAIRMAN SYDENSTRICKER: Shall we put that in -- "whose members deliver the service"?
DR. ROBERTS: Isn't it strong enough as it is?
MR. SIMONS: That's all right.
CHAIRMAN SYDENSTRICKER: "e. All medical features of medical services should be under the control of the medical professions;
"f. The patient should have freedom to choose a legally qualified doctor of medicine from among all those who are available and willing to give service under necessary rules of procedure."
DR. BIERRING: Do you suppose "qualified doctor of medicine" would cover it?
DR. HORSLEY: "Legally qualified" means chiropractors or anyone else who practices.
CHAIRMAN SYDENSTRICKER: We could say "doctor of medicine".
DR. LELAND: In some states chiropractors have the same right.
DR. HORSLEY: And osteopaths.
CHAIRMAN SYDENSTRICKER: Do you think the Federal Government could pass upon a proposition of that kind, especially if we are talking about a permissive system in the states?
DR. HORSLEY: I think it ought to be gotten around.
DR. FALK: As a matter of fact, I think we should caution the board that this is the only place, I think, in which in our text the phrase "doctor of medicine" appears. Counsel may order us to strike that out on the grounds, I suppose legally quite properly, that who is a physician is a matter determined by the medical practice acts of the several states and not by federal jurisdiction. We are trying here deliberately to say in effect that if in a state an osteopath is a fully qualified physician, the state provisions in a health insurance bill may also permit the patient to choose him, but we are at least assuring that the patient shall have the privilege of choosing a legally qualified doctor of medicine from among all those who are willing to give service under necessary rules of procedure. We feel that at least we can make this positive statement, even though counsel may not permit us in any federal proposal to put in the converse that it must be only a qualified doctor of medicine.
DR. HORSLEY: Is not an osteopath a legally qualified doctor of medicine?
DR. FALK: I think he is in only one or two states. There are states in which he is qualified to hold himself out as a chiropractor but he is not in the language of the medical practice acts a doctor of medicine.
DR. HORSLEY: An ophthalmologist wouldn't be legally qualified to practice medicine.
CHAIRMAN SYDENSTRICKER: If you can think of a term to describe a full-fledged doctor I should be very pleased to employ it.
DR. CUSHING: May I go back and ask about the responsibility for the quality of medical services borne by the profession? Does that mean if the quality is poor the profession is responsible for it? Just what is the meaning of it?
CHAIRMAN SYDENSTRICKER: Who else is responsible for it?
DR. CUSHING: And that the appointees are made by the profession, not only the practicing doctor but the man who supervises? I am just trying to take a critical view.
DR. FALK: I think there is room for some ambiguity. I think Dr. Cushing's point is well taken. The intention here, I think, was responsibility for the supervision and maintenance the improvement of the quality of medical services, so far as it rests upon any group, shall rest collectively upon the professions, and administrative procedures when they are designed in respect to this matter shall be designed to place both responsibility and authority in the hands of the professions. If that is not clear as the intention of this statement, I think perhaps we should modify it and make it more explicit.
DR. CUSHING: What I have in mind is something I wanted to bring up later about what I felt under most of these systems that I have had a chance to review, happens to the quality of the service; it deteriorates under the system. Should the medical profession be held responsible for that?
CHAIRMAN SYDENSTRICKER: I am not prepared to agree with you on that point. However, I should be glad to hear you later in a discussion of it.
What we mean here is a general statement.
DR. CUSHING: I took this to mean that you felt the doctor is the fellow whose business it is to look out for these things. As I look at this (and I underlined it when I read it over the first and second times) it is very ambiguous and the profession might be held responsible for inadequate service even when they perhaps are not responsible for it.
Another thing, how are these doctors under these circumstances, who are really state agents in a way, going to be protected as to malpractice? Are they going to be insured?
CHAIRMAN SYDENSTRICKER: They are not state agents. They continue to practice medicine exactly the way they are doing, providing we have the right kind of plan.
MR. SIMONS: Would it clear it up to sort of combine d and e, and after the word "professions" in d add "and to assure this"?
CHAIRMAN SYDENSTRICKER: So it would read: "Responsibility for the quality of medical services should be borne by the professions, and to assure this all medical features of medical services should be under the control of the medical professions." Is that right?
MR. SIMONS: Yes.
DR. CUSHING: In think that answers it.
DR. FALK: I would like to point out, however, that while that does make much more explicit the meaning of "d", it loses something of what was intended in "e". The intention of "e" is not merely to safeguard the quality of medical practice, but also to safeguard the economic position of the physician. We must not lose sight of that merely to accomplish the other.
DR. HORSLEY: Just what does it mean by the responsibility for the quality of medical service? Suppose the quality is poor, what is the medical profession going to do about it? How can you fix that responsibility and what is going to be the penalty? Will there be punitive measures? Will it be a local society, a state society, or the American Medical? It is rather vague, necessarily so, probably.
CHAIRMAN SYDENSTRICKER: I think the idea in our minds was this, that we felt that non-medical people should not meddle with the question of the quality of medicine, that that was the concern of the medical profession.
DR. CUSHING: That is what I thought you meant; I wasn't quite sure.
DR. FALK: It becomes illustrated when we come to define what we mean by specialists. There is a proposal which places upon the medical profession of the community or communities the responsibility of listing certain men who in its opinion are competent to hold themselves out or to be qualified under an insurance system as surgeons or as neurologists or ophthalmologists, etc.
DR. CUSHING: That is another group. I am thinking of the general practitioner. He perhaps has hard luck with a case he is treating and his people say that he is incompetent. This goes up to higher authorities and they want to scrutinize this man.
DR. FALK: I think when we come to such matters as grievances, adjudications of disputes, and so forth, I think we have the proposal that matters that are of a professional nature or between physicians shall be adjudged by professional groups. For example, if a patient complains or the heirs of a patient complain that a physician has been negligent or incompetent, that would quite properly in the first instance be a matter to be judged by his professional colleagues in the community, for them to determine first whether or not he was incompetent, then perhaps to recommend what penalty should be imposed, whether he should be excluded from insurance practice, or whether he should be punished for not having answered a proper and reasonable call, by withholding a fee. If we tried to do it we should have to duplicate the hundred pages of the British regulations.
DR. CUSHING: Merely the regulations that exist today in the medical profession.
CHAIRMAN SYDENSTRICKER: I don't want it to be a statement that might be misinterpreted.
DR. HORSLEY: It certainly would imply responsibility.
DR. BIERRING: Would you take out "responsibility"?
DR. ROBERTS: If the medical profession isn't ready to take the responsibility, who is? We have always accepted responsibility. When one of us has a patient we accept responsibility for that patient to the best of our ability. I think these are just polite axioms that we have always lived under, and I think they make a good definitive front. They have been gone over and plastered and replastered and they sound like good English to me.
DR. BIERRING: Before you leave it, I am wondering if there is some way to catch those Middlesexers. How about that "legally qualified"?
CHAIRMAN SYDENSTRICKER: If I recall correctly that was your suggestion.
DR. FALK: It was. Your original phrase was, I think, "a properly qualified physician," and it was the suggestion of this board that it be changed to "legally qualified doctor of medicine".
DR. CUSHING: On that basis the medical profession is responsible for the quality of medical service from Middlesex and other places. Whether they should be is a question.
CHAIRMAN SYDENSTRICKER: To continue, "g, The method of furnishing medical services should retain a continuing, confidential relation between the patient and his physician. This relation should be the fundamental and dominating feature of any system."
DR. BROWN: I would like to read a statement from the preliminary report of the committee of five for the study of medical care in the California State Medical Association. "Hence, in so far as the medical profession regards the freedom of choice and preservation of personal relationships as fundamental its main concern should be not primarily with the question whether the existing system should continue or whether voluntary or compulsory insurance should be adopted, but rather with the question whether in any voluntary or compulsory insurance that may be proposed, the particular schemes provide or do not provide for the maintenance of freedom of choice and the personal relationship between physician and patient."
That is the same thing said here, is it not?
DR. CUSHING: Only much longer and louder. (Laughter)
DR. BROWN: I made a note here, which is: "What have we done as doctors to instruct the public how to choose a good doctor? Have we done anything? I say no."
DR. CUSHING: We never can.
DR. BROWN: Yes we can.
DR. CUSHING: The public will prefer to go to the quack first, usually.
DR. BROWN: If we would teach in our grade schools, in our high schools, and in our universities how to choose a good doctor--
DR. CUSHING: And at the mother's knee.
DR. BROWN: Surely, that's the idea -- the doctors chosen would be reasonably good doctors. We haven't done that as part of our educational system.
DR. ROBERTS: The medical societies won't do it. They sidestep it every time.
DR. BROWN: We have no criteria in our medical societies or in the practice of medicine in America, except three, two of which are instituted by the state and one by the medical profession. Those two criteria instituted by the state are what? That a man must be a graduate of a medical school and he must be licensed to practice medicine in the state he selects. What standards have we established by the medical profession? Only one, that every doctor shall be a member of a county medical society. We have no other standard whatever. If he is a member of a county medical society he is a good doctor. That is erroneous, that is not true. That is one thing I think we should do in this committee, to try to establish better standards, better principles, which we are now trying to do, to help the public to determine what the choice of a good doctor really is. They don't know. We should help them to do that.
DR. CUSHING: Do you know?
DR. BROWN: No, I don't know. But I would rather have Dr. Harvey Cushing operate upon me if I had a brain tumor than I would Dr. XYZ, I'd rather have Dr. Crile operate upon me if I had a thyroid lesion than I would Dr. ABC. In other words, we have certain standards that you and I recognize as medical men. Why can't we inculcate those ideas into the minds of the public?
DR. CUSHING: I think that is beyond the province of this committee.
CHAIRMAN SYDENSTRICKER: I heartily agree with you, Doctor, in the main, not knowing what doctors to select.
DR. CUSHING: If you were a doctor you would have great difficulty knowing, too.
CHAIRMAN SYDENSTRICKER: "h. The medical features of services furnished in institutions should be under professional control;
"i. Those who furnish professional services should be adequately remunerated."
DR. CUSHING: There is the question of adequate again.
CHAIRMAN SYDENSTRICKER: Reasonably adequate, perhaps.
DR. BROWN: For five years the Committee on the Costs of Medical Care couldn't find any word to substitute for that word "adequate".
DR. ROBERTS: If you have an adequate income you know what that is, don't you?
CHAIRMAN SYDENSTRICKER: I think it conveys the idea.
"j. Health service and medical care should be furnished with due regard to economy consistent with the maintenance of adequate quality of service."
DR. GREENOUGH: You could spare that adequate and it would still mean the same.
CHAIRMAN SYDENSTRICKER: Do you want to cut that out?
DR. ROBERTS: No.
CHAIRMAN SYDENSTRICKER: "k. In the formulation of plans for medical service, the participation of both the public and the professions concerned is essential."
DR. BROWN: I think that is a splendid principle which the medical profession has never recognized up to this period.
DR. BIERRING: I would like you to elaborate that just a little.
DR. BROWN: Because the medical profession's attitude, as all other organizations who render service are concerned, is that their rights must be maintained at the expense of the rights of other people. That is one of the characteristics of the practice of medicine, that their rights are of more importance than the rights of the public.
DR. CUSHING: I would heartily beg to disagree with Dr. Brown. I think it may be true of some doctors, but I don't think it is true of the majority of them. I think public rights are put ahead of everything else.
CHAIRMAN SYDENSTRICKER: Perhaps there is a distinction between the rights of the patient and the public, which is Dr. Brown's point. Is this true, Dr. Cushing, that the ordinary doctor puts the right of the patient, the health of the patient, above everything else?
DR. CUSHING: I think that is the whole tradition of the profession.
CHAIRMAN SYDENSTRICKER: But when is comes to the question of the community, that is Dr. Brown's point.
DR. BROWN: That is exactly what I mean.
CHAIRMAN SYDENSTRICKER: Do you agree with that, Dr. Bierring?
DR. BIERRING: Oh, I guess so.
DR. ROBERTS: I think Dr. Brown has raised a very good point here. I hear doctor after doctor use the expression, "rather than affront my sense of social rights." It is very common. I hold in my pocket the charges against a young man who got $65 a week. It cost him his position, it cost him loans from his family, and it cost him some $3475 a year for two operations and an illness. That was nothing short of highway robbery. I say that with due love for my profession. That thing is going on all the time, and I think we must be frank to see where we ourselves are lacking.
Herrick said in his address in Chicago that the affairs of the medical profession would begin with the proper analyses of the profession by itself and its own weaknesses. Now I'm not preaching, but would some sentence like this be out of place (if it would criticize it and let's drop it): The public should acquaint themselves with the conditions of adequate medical care.
DR. CUSHING: That puts the burden on the public.
DR. ROBERTS: They pay for it.
DR. CUSHING: How are they going to find out when we don't know?
DR. ROBERTS: I think we know. I'd rather have you operate on me than some man I know in Florida.
DR. CUSHING: I don't think that is a just criticism of the medical profession, because I think this man wasn't considering the welfare of his patient or the welfare of the community or the welfare of his profession, and I think that the majority of better doctors have a very broad view, a social minded view of the position of their profession; no matter what happens, they take care of the poor and everybody. The doctor is interested in the patient and in doing the best he can for him.
DR. BROWN: My knowledge of doctors in California is that when they do not get paid for the services they are rendering to an indigent patient they do not go to that indigent patient.
DR. CUSHING: I think that is the kind of doctor we want to eliminate from some of these rules we have.
DR. ROBERTS: I call once more respectfully and humbly and in puny fashion for any criticism of a simple statement like that -- I don't say the personnel of the profession, but the public should acquaint themselves with the conditions of medical care. I can't see how one can object to that. If so, go ahead.
DR. BIERRING: Isn't that to a certain extent being provided now in an extensive campaign of health education that the American Medical Association put on in radio that if we had been charged for would have cost $290,000 last year? Every state society has its committee on health education and has speakers. Every state health department is endeavoring to bring to the people not only the achievements of medicine, but a distinction of what constitutes a well trained physician, and every effort is made to differentiate between the quack and the properly prepared man. We are trying to bring it to the public in a manner of publicity which we feel is in keeping with our ethical traditions.
DR. ROBERT: Is there any objection to making one more effort?
DR. BROWN: Dr. Bierring, I listen to the broadcasts of the American Medical Association, the California State Medical Association, the Los Angeles County Medical Society, and they are so extremely dry in general it is more interesting to listen to a quack.
DR. CUSHING: That is just the point, it is much more interesting to listen to them and their program. That is the kind of medicine that people get. I don't know how it can be checked.
CHAIRMAN SYDENSTRICKER: I would be very glad to hear more comments on Dr. Roberts' suggestion.
DR. ROBERTS: We haven't said a word about the public except we want to keep in personal relations with them.
DR. GREENOUGH: Don't we all admit that one of the very important things to do in connection with any such thing as this is to take on the education of the public?
DR. ROBERTS: That is my only thought. Why shouldn't we make an effort to educate as well as some other group, over the radio or in the papers? Dr. Brady is writing, Dr. Wagner is writing. I think Dr. Brown has made a good point here, and I am willing to back it up with my sentence or anybody else's sentence if it will improve on it.
DR. HORSLEY: Wouldn't it be better to make a separate heading, because it seems to me that heading rather means a different thing, it seems to me to denote something in connection with actual details of carrying out medical service as it is provided or as it exists. It seems to me it would be better to include in a separate item that the public should be acquainted with what is adequate medical service, including, of course, not only adequacy of the practitioner, but adequacy of hospital treatment.
CHAIRMAN SYDENSTRICKER: It seems to me that there is no doubt about the fact that the public ought to be educated, they ought to acquaint themselves with what is the right kind of medical care, good doctors and bad ones, that is all right, I agree heartily with what Dr. Roberts says, but this particular thing here relates to the question of medical service under health insurance.
DR. CUSHING: Isn't it covered in "k" anyway?
CHAIRMAN SYDENSTRICKER: It is covered in "k" and it is also covered in "b", "The provision of medical services for those who cannot otherwise secure them is an obligation of society." That implies public responsibility.
"k. In the formulation of plans for medical services, the participation of both the public and the profession concerned is essential."
To say out of a clear sky that the public should acquaint themselves with medical care looks a little out of place right there.
DR. ROBERTS: In the scheme of health insurance do we not as a primary pivot to the thing give the people the right to choose their practitioner?
CHAIRMAN SYDENSTRICKER: Just as they do now, yes.
DR. ROBERTS: Just as they do now. In choosing that practitioner isn't it a matter more of head than of sentiment, and of judgment, and shouldn't they know the conditions of medical care? They are not going to learn them, I know.
CHAIRMAN SYDENSTRICKER: You might say that the patients have the freedom of choosing a doctor but that the medical profession should enable them to do it.
DR. ROBERTS: I don't want to put the personal element or the personnel in it, I was trying to avoid that by saying "the conditions of adequate medical care". If it is not prudent I'll drop it.
DR. BROWN: I think not as a principle, but the technical staff should draw up some expression so that the public might learn how to choose a good doctor. What do you do when you get sick? What do I do when I get sick in Washington? Do I go to every member of the American Medical Association? By no means. Do I go to every member of the American College of Surgeons? By no means. Whom do I go to?
DR. BROWN: You get the hotel doctor.
DR. CUSHING: I don't do that, either. I find out for myself with my brain, I hope, who a good member of the American College of Surgeons is, who is a good member of the American College of Physicians, and not who is a good member of the A.M.A.
DR. BIERRING: That isn't fair.
DR. BROWN: That is fair, because a member of the American College of Physicians, a member of the American College of Surgeons, is usually a more adequately trained man than is a member of the A.M.A. If my eyes are bad I go to a member of the American Ophthalmological Society.
CHAIRMAN SYDENSTRICKER: I make the suggestion that Dr. Brown and Dr. Roberts sit down and give us something on that, or the technical staff do it.
DR. LELAND: I have tried to do it for years.
DR. CUSHING: I just want to add to Dr. Brown's statement. Of course if he went a little farther and only took the members of the American Surgical Association and the members of the American Association of Physicians, he probably would limit his choice to still a more highly selected group. How are you going to educate the public to do that?
DR. BROWN: I would educate the public in our grammar schools and in our high schools, I would teach them the difference between a qualified doctor of medicine, a chiropractor, an osteopath, a naturopath, I would teach that to them in their schools.
CHAIRMAN SYDENSTRICKER: Gentlemen, the hour of five has arrived.
...The meeting recessed at five o'clock, to reconvene at eight p.m....