Medical Insurance Plans
WHICH SYSTEM WILL GUARANTEE THE BEST MEDICAL CARE?
By Dr. MORRIS FISHBEIN, Editor of the Journal of the American Medical Association, Chicago, Ill.
Delivered before the National Physicians Committee for the Extension of Medical Care, New York City, November 27, 1944
Vital Speeches of the Day, Vol. XI, pp. 162, 190-192.
EVERYBODY talks about trends nowadays. People began talking about trends long, long ago. One of the very earliest of physicians, back in the time of Hippocrates, had a very interesting statement to make about trends. He said; "Observe well the trend of the disease and if it be upward and toward health, then shall the physician do everything possible to encourage that trend. But if it be downward and toward death, then shall the physician interfere and do everything possible that he can to prevent the coming of death."
The American medical profession observed a good many years ago—I suppose now at least thirty-five or forty years ago—the beginning of what was estimated to be a trend toward collectivism in medical practice. They observed the desire of a great many people to take all of the people of the United States and put them under a single system as far as concerned the provision of medical care, to take all of the physicians of the United States and get out a standardized doctor to provide that medical care.
This, of course, they did without any regard whatever for the nature of the human being or for the nature of what constitutes a good, scientific doctor. It was the idea, in other words, to place upon the medical profession, the burden of a system of dictation of medical practice, which the medical profession of this country has never seen fit to adopt.
The Scientific Method
The trend of medical practice in the United States has been guided in the past forty years by what we call, in the practice of medicine and in medical research, the scientific method. The scientific method is a technic by which one experiments in the laboratory or elsewhere on a small scale, with the idea of determining, first of all, the fundamental facts that are necessary for progress, that are necessary to make certain first that one follows the doctrine of the Hippocratian philosophy: primum non nocere—in the first place, do no harm. That is a motto of medicine that has gone back many thousands of years.
But the social experimenter has never been guided by a similar motto. He has never realized the importance of that doctrine that one should, in the first place, do no harm.
You have heard here today some of the results of the preliminary experimentation that has been going on in the United States for a matter of forty years in an endeavor to discover a plan or, if need be, a hundred plans for the provision of good medical service to the American people. I have no doubt that we are beginning now to determine some of the basic facts necessary to supply medical service to the vast majority of the American people, medical service of a high quality, not dependent on a deterioration of medical education, not dependent on the abolition of progress and of medical research—that we are endeavoring to develop a technic for meeting the costs of medical service, without breaking down the quality of medical service. It is the quality of medical service that has been the number one concern of the medical profession in their consideration of various plans.
Certain things about which you hear a great deal are said, by the vast majority of physicians who are presumed to know something about medical practice, to be basic to a high quality of medical care. One of these is mutual responsibility between doctor and patient. Another of these is said to be free choice of physician.
In the advance of scientific medicine, particularly in the past ten years, we are gradually departing, in the progress of medicine, from that concept that a human being was a collection of organs and tissues and fluids, with which one could deal wholly in the laboratory and come out with a satisfactory result. Probably the greatest step in recent progress in medicine has to do with that phase which is now being tentatively called psychosomatic medicine: the idea that every human being is an individual, composed of both a mind and a body, not just a collection of organs and tissues and fluids, about which I could say that reflex was positive and this test was negative and, therefore, this was all I had to do to get the patient well.
You have to have mutual responsibility between doctor and patient, understanding of the patient as a human being by his physician. And that means the very apotheosis of individualism. It is that type of individual relationship between doctor and patient that is bound to suffer in any plan for meeting the costs of medical care that is based wholly on collective payment and collective delivery of medical service.
Many of the plans that are being developed in the United States are experimental to the extent that they deal principally with collective payment for medical service. What you have heard of here today are the plans developed by industry to enable the worker to meet the hazards of the costs of medical care.
Propaganda Versus Facts
You will hear from the opponents of what the medical profession and the National Physicians Committee and similar groups are trying to do, that the medical profession of the United States is opposed to insurance against the costs of sickness, that the medical profession is opposed to group payment for hospitalization and is opposed to group payment for medical care. But you must bear in mind that these people are not at all concerned with facts; they are concerned primarily with making propaganda against the medical profession as the chief agency with which they are contesting for the administration of medical service to the American people.
It is the desire of a considerable number of these propagandists that the control and administration of medical service shall be wholly in the hands of lay political governmental directors. It is the desire of the medical profession to show, in its understanding of the needs of medical care, that a medical service that is not guided in its administration and controlled in its administration by the medical profession is bound to suffer from all of those difficulties whichany governmental, politically-administered machine undergoes.
To show that they have not even kept their statistics up to date, this independent and only partial survey now conducted by the National Physicians Committee indicates that there are in the United States at least 17 million people covered by the Blue Cross hospital plan, which is a partial insurance against the costs of medical care. It shows further that there are in the United States some 18,000 industries which have insured their employes, in whole or in part, against various portions of the cost of medical care, and that the number of people covered is approximately 18 million.
The Bureaucratic Way
It is, of course, to the interest of those who are endeavoring to claim that private initiative and industry are incapable of doing this task to show that very few people want to be cared for in that particular manner. It is to the interest of those who are opposing medical society plans, which are now being carried on definitely in twelve states and in course of development in perhaps ten others—it is to their interest to show that state medical society plans do not really reach the people. It is to their interest to show that the only way to reach the people is something compulsory, administered from Washington. And if you cannot have that, they say you might just as well not have anything. That is not the scientific method.
Types of Insurance Needed
A study of the development of the various plans indicates that we are now in process of very active evolution. Of more than 1,300 firms reporting in this survey on specific plans. Sixty per cent included specific sickness benefits, 77 per cent hospitalization, and 58 per cent included the costs of surgical care.
This question as to just how much a medical-care plan shall cover is one of the most important of the undetermined questions in the field. Every survey that has been thus far conducted indicates that something between four and five per cent of the persons who are offered complete coverage say that they want insurance against ordinary medical costs.
Illinois County Experiment
A plan now in process of development in Winnebago County, Illinois, which is an endeavor to insure every person in one county against all of the ordinary costs of sickness, has found it necessary to introduce that principle which arose in motor car insurance under an experimental basis—the principle of the motor car insurance of the first twenty-five dollars being deductible or the first fifty dollars being deductible, in order to arrive at a premium that people could afford.
First Two Visits Deductible
They have found it necessary to introduce into their policy, the idea of the first two visits being deductible. In other words, for the ordinary cough or cold or headache or pain in the back or sore toe that somebody gets, it is the idea that that will not come under the insurance cost, but anything requiring more than two visits would then require payment of the physicians through the insurance funds.
Nobody knows how well that is going to work or whether or not the vast majority of the people will be interested in that particular feature. It is quite certain, however, as shown particularly by Dr. Robinson's surveys, that tremendous numbers of Americans do want group protection against catastrophic illness and against the costs of hospitalization and surgery.
Sound Basis Necessary
You might have said that we should have established these things thirty years ago or forty years ago, but I can assure you that forty years ago and thirty years ago and twenty years ago, insurance companies, the medical profession, economists, and many other people were trying to get together the necessary scientific and factual data on which they would be able to calculate costs so as to develop policies that would mean something from a scientific, financial standpoint.
It is very easy to set up certain costs with the idea that you are going to meet a certain premium but, obviously, if the service offered does not meet the need, the insurance will not be successful. If the costs are beyond the ability of the purchaser to pay, that type of insurance cannot meet the needs successfully. And all of you who are insured in any way at all know how difficult that is.
New Legislation Considered
The evolution of American plans, as I say, goes on apace and I have no doubt from a scientific point of view, that the growth of private industrial group insurance is going to be a tremendous and potent force against the threat of any governmental compulsory sickness insurance program.
There seems to be no question but what labor, as represented by the Congress of Industrial Organizations and the American Federation of Labor, has more or less committed itself to the idea of expansion of Social Security to include a nationwide compulsory sickness insurance program.
Senator Claude Pepper, who has recently been conducting a series of interesting hearings on the state of the health of the nation, has announced publicly that he is especially interested in medical progress and he proposes to introduce legislation to further the advancement of medical science in the United States. I have heard, and I have no doubt, that he is conferring at great length with many members of the medical profession, in an effort to determine just what he might offer in the way of constructive legislation in this field. I may be ignorant personally, but I have never yet heard that Senator Wagner, Senator Murray or Congressman Dingell made the slightest possible effort to confer with any representative physician in the introduction of their legislation to control completely medical practice in the United States. I believe that that may have some effect on the reception that kind of legislation gets from the medical profession.
Now, those are apparently the things that are on the tapis in Washington having to do with the progress of medical care.
Medicine's Amazing Progress
In the meantime, medicine goes forward. The advance of medicine has not been halted in the United States in the war period but rather has proceeded with an intensity that is the amazement of all of the other nations of the world. I can assure you, on a well-informed basis, that no other nation in the world, during the course of this war, has carried on and made medical progress, as has been made in the United States, and that our greatest task in the next five years is going to be some attempt to bring the rest of the world up to the point which we now occupy in medical achievement. Nowhere else in the world have they available the type of industry that has produced forthe United States, the great leadership in the production of the new remedies that mean so much for the promulgation of human life.
I have often wondered how these insurance actuaries as they look at their statistics today with a view of calculating rates suitable to meet the hazards of illness—to meet the hazard of the threat of death—can determine for themselves the effects of the introduction of new remedies of the type of the sulfonamides and penicillin, of new technics for anesthesia, of new methods for the control of shock, and what steps they take to meet the tremendous advance that medical science makes today in controlling mortality.
I can conceive of a period in the practice of medicine in the very near future in the United States when a patient will approach the operating room, thoroughly prepared against the danger of shock by preliminary narcotization or sedation, thoroughly prepared against the hazards of hemorrhage and of shock by preliminary blood transfusion and blood plasma, thoroughly prepared against the hazard of secondary infection or peritonitis by preliminary treatment with several doses of penicillin administered either by intramuscular injection or intravenous drip or in some other manner. And I can assure you that when the facilities become available and that when the material becomes available, we may anticipate a reduction in the hazard of mortality from practically all surgery that is beyond the possibility of calculation at this time.
These are advances that come out of war. We have seen the death rate for pneumonia among American troops drop from twenty-eight per cent in World War I to a fraction of 1 per cent in this war. We have seen the death rate from meningitis drop from something like eighty per cent thirty-five years ago to three to five per cent at this time. And recently a physician at the Great Lakes Naval Training Station reported seventy-five consecutive recoveries from meningitis—not one death until the seventy-sixth case! These things are unheard of.
Of Greatest Importance
And the advancement of medical science in the United States, with sufficient encouragement to research, with sufficient encouragement to maintaining the high standards of medical education that have been established by the medical profession on its own initiative and often under opposition from those who endeavor to deteriorate medical education in order to get a far greater number of less-educated physicians, the advancement of the science of pharmacology, the advancement of the new technics of tremendous mass production of remedies, bringing down costs, for instance, of a product like penicillin of what might have been $400 for a million units to a matter of 68 or 70 cents if you need an awful lot or maybe $3.20 if you are just buying a million; the development of our atabrine to the point where we can say to the world that we are capable of producing two or three billion tablets per year, which may mean eventually the complete disappearance of malaria as public enemy number one of all mankind throughout the world; the nationwide proposal for universal examination of the chest of every human being, using the 4x5 film, for the early detection of tuberculosis, to be carried out again without breaking down the system, the technic of medical practice now carried on in this country—these things mean far more for the American people than any attempt to make a wider distribution of a low grade of medical care that will, in the vast majority of cases, not even be accepted by the people to whom you are offering.
Do Things "Better in America"
There came from Great Britain just within the past week an editorial in the British Medical Journal, pointing out that with the development of national health insurance in Great Britain there occurred the most rapid rise in the sale of patent medicine directly to the public that had ever occurred in the history of that nation. And at the very time when in the United States we are proceeding even further toward the development of high-grade medicinal products that will do what the manufacturers claim they do and that will be what the manufacturers say they are, the British Medical Journal says, as a conclusion in its editorial, "They do these things much better in America."
I hope that our experience of the past will give all of the respect for American medicine that it deserves and make us more determined than ever to find our own American way, on the basis of private initiative and private responsibility, for meeting these problems that mean so much to the health and lives of all of us.