INSURANCE AND HEALTH[11]
So far as a majority of the population are concerned, it is necessary
to realize that they are never far removed from the line dividing
destitution from adequacy, using the word destitution to mean
insufficiency or lack of some provision essential for health and
continued welfare.
It may be urged that this is owing in large measure to the
improvidence or thriftlessness of the wage-earners who are chiefly
concerned; but such a statement fails to appreciate the higher
standard of conduct and the greater self-denial which is demanded
from weekly wage-earners than from ourselves, if out of their
wages provision is to be made for a “rainy day,” without affecting
unfavourably the present health of the worker or his family.
The general appreciation of the above considerations has led to the
provision of non-contributory old-age pensions in the United Kingdom;
and similar sentiments have led in many countries to compensation
for accidents at the expense of employers; and to the various
national systems of insurance against sickness. With the principle of
sickness insurance there can be no quarrel. It is the substitution of
coöperative for individual provision, thereby distributing some of
the loss and eliminating some of the risk of suffering from illness.
The value of any system of sickness insurance, however, must
necessarily be judged by several criteria.
_Criteria of Value of Insurance_
Is the adopted system one which is equitable in its incidence and
economical in its administration; and does it supply maintenance
during sickness adequate for the needs of the patient and his family,
while at the same time offering no temptation to the patient to
continue on the sick funds, when his condition no longer necessitates
this?
In the case of the English National Insurance Act, these questions
unfortunately cannot be answered completely in the affirmative.
The finance of the Act arranges for the uniform contributions
(differing for each sex) from some thirteen million persons, living
under most diverse conditions, to furnish equal benefits (differing
for each sex) to all insured persons, irrespective of age, locality,
or occupations; while at the same time some 23,000 independent
insurance societies continue to administer the distribution of money
benefits, each with its own segregated experience, some prosperous,
others owing to excessive sickness almost bankrupt. There is the
remote possibility for each society to pay additional benefits if
justified on the quinquennial valuation.
Substantially men and women have been placed on a similar financial
basis. The sickness of pregnancy apparently was overlooked; and for
this and other reasons the insurance funds for women are financially
inadequate for the benefits promised.
On the point of equity, it must be admitted that any system of
so-called insurance which, like that of the English Act, excludes
a large proportion of the population who, while paying in taxes in
aid of the insured, require but do not receive their benefits, is
contrary to the principle that any expenditure of Government funds
should enure to the whole community in need of the provision in
question.
The provision of 10 shillings a week for incapacity lasting 26 weeks
(7s. 6d for women), followed by 5s. a week disablement benefit,
although inadequate provision for family maintenance during sickness
undoubtedly is helpful. It is mischievous when in consequence of
this provision, the patient is tempted to remain at home under
unsatisfactory domiciliary treatment, instead of receiving the
shorter and more successful institutional treatment, which should
have been given.
As to economy of administration, I can speak only with reserve; but
it requires little imagination to appreciate that the numerous
migrations of wage-earners imply great difficulties in book-keeping
as well as in securing insurance medical attendance, and that a very
high percentage of the total insurance funds is swallowed up in
elaborate and meticulous account keeping.
The point as to malingering can best be considered in connection with
a discussion of the
_Medical Benefit_
This consists of such medical treatment, at home or at the office of
the panel doctor,[12] as “can consistently with the best interests
of the patient be properly undertaken by a practitioner of ordinary
professional competence and skill.”
The Act itself promised “adequate medical attendance and treatment,”
but under regulations this has been limited, so that in practice it
means chiefly the treatment only of minor ailments. Thus (_a_) there
is no provision for hospital treatment of patients needing this,
except the Sanatorium provision for tuberculosis; (_b_) with the
same exception, there is no provision for expert services. A patient
requiring operative treatment for fractures, for an amputation, or an
operation for appendicitis, or needing treatment for some affection
of the eyes, or nose, or throat, or ears, or the intravenous
treatment of syphilis is excluded from medical benefit. So likewise
are dental requirements. (_c_) There is no provision for pathological
diagnosis, except such as is common to the entire population, and no
X-ray diagnosis, except possibly for tuberculosis. (_d_) There is no
provision for nursing assistance.
In view of the unequal distribution and insufficient provision of
hospitals for the general population, of their inaccessibility to
large masses of patients, and of the insufficiency of the present
provision for the scientific aid to treatment which modern medicine
demands for insured and non-insured alike, it is evident that the
provision for medical treatment under the Act is unsatisfactory
and inadequate, and that it conduces to prolonged illness, which
treatment provided on more satisfactory lines would avoid.
To state adequately the defects of the medical provisions of the
Insurance Act a long address would be required. They are, however,
generally well known, and their existence and seriousness is admitted
by all. (See also page 90.)
It is necessary, however, to say more on the
_General Practitioner Treatment_
provided under the Act. Every insured person is allowed to choose his
own doctor within a given distance. In practice very few patients
change their doctor at a fixed time each year as they are allowed
to do; and a considerable proportion of insured persons do not
trouble to choose a doctor at all. The free choice of doctors is
rather a sentimental than a real demand. The panel doctor is paid
an annual capitation fee, and hitherto no limit has been placed on
the number who may place themselves on his roll. The domiciliary
treatment given by some doctors is entirely satisfactory within the
limits stated above. Commonly, however, it is as unsatisfactory as
the “club practice” which preceded it, and against which the British
Medical Association inveighed. It involves a continuance of the
mischievous ideal of medical practice of the past, a conception still
held by a large portion of the public to its own detriment, that a
hasty inquiry, a perfunctory examination, and a bottle of medicine,
represent the best that scientific medicine can offer a patient. Had
there been organized a chain of medical services for all needing it,
including consultations and expert assistance when needed, every
patient having the right to call for these when dissatisfied with
his panel doctor, including also hospital provision and nursing as
required, what a different story could now be told!
It is probable that some at least of these additional services will
be added gradually; but it must be noted that the present payments of
the insured will not suffice to pay for them; and that if they are to
be provided,—as they will probably need to be,—out of public funds,
the general public are in equity entitled to these services even
though they are not insured.
If these complete services were provided, the medical treatment now
provided largely at the expense of the community could be made a
means for advancing the public health. This it can not at present
claim to be. For nothing is more certain than that the prompt and
adequate treatment of disease curtails its duration, diminishes its
severity, and prevents its spread to others.
But even such a service would not fulfil its complete possibilities
for good unless it were joined to a system of hygienic supervision of
each insured person and of each insured person’s family, this system
being organically linked up with the wider public health work of the
larger Public Health Authorities.
The chief justification of a national system of insurance against
sickness is that it shall be an active auxiliary in the prevention
of disease. At present it is doubtful whether any national system of
sickness insurance has been so. It has only been so, to the extent to
which the medical treatment of the masses of the population has been
improved by it; and no such improvement can be claimed for British
insurance. The wider possibilities of prevention of illness and
elevation of the general standard of health, by making each medical
practitioner a family adviser on health more than a practitioner in
medicine, have not been realised or even brought within sight.
_Evils of the Present Medical Benefit_
The inadequacy and unscientific character of the medical treatment
given to insured persons are associated with a large amount of lax
certification of illness, which is injurious to the character of
doctor and patient, besides being unfair to the insurance funds.
Those interested in this point should read paragraphs 118, 119, 120,
121, 123, 125 of the Report of the Departmental Committee on Sickness
Benefit Claims (Official Report Cd 7687).
There is almost universal testimony of the belief (of
representatives of friendly societies) that medical certificates are
granted recklessly (par. 119).
Doctors ... feel a difficulty in refusing certificates owing to the
possible effect upon their practice.... If a doctor falls out with
his patient he loses the entire family (par. 120).
These statements ... are representative of an enormous volume of
dissatisfaction with the action of the medical profession.
The Committee state:
We are of opinion that in many cases doctors have given certificates
for sickness benefit in circumstances in which these certificates
were not justified.
From the standpoint of the conscientious practitioner the present
position is profoundly unsatisfactory. He has no official access to
arrangements for consultative and expert advice, he has no hospital
beds, no skilled nurses. For the patient the position is anomalous
and leaves him with but a fragment of what he could reasonably expect
under the terms of the Act.
Of the other medical benefit, i.e., the Sanatorium benefit and of
the Maternity benefit, I can say only a few words here. The former
gives the insured patient little more than in the more enlightened
sanitary districts is being provided, independently of insurance, by
Public Health Authorities. It would have been practicable to make
it obligatory on all Public Health Authorities to provide adequate
treatment for all consumptive patients. They are already authorized
to do this under Public Health Acts, and the duty could have been,
and can still be made, obligatory by regulation. And in that case
the connection of the Sanatorium Benefit with the National (Health)
Insurance Act would happily cease, and one great obstacle to a really
national organization against tuberculosis would disappear.
The Maternity Benefit provides a money payment for each insured
woman and for the wife of each insured man on the birth of a
child. The money payment is made through the Insurance Societies
unconditionally, instead of being made a means of securing that
the birth takes place under circumstances favourable to mother and
infant. During recent years public health authorities (aided by
grants from the Government of one half of the total approved local
expenditure) have been making medical and nursing provision for the
care of women in pregnancy, in parturition, and during the nursing
period, on a rapidly increasing scale, the grants including not only
skilled assistance but also domestic aid (home helps) in suitable
cases. There can be no question that increased provision in these
directions will have a more generally beneficial influence than money
payments, and should at least supplement the latter.
To sum up, if the national English system of insurance is to
continue, it ought in my view to be shorn of its medical functions
and to be limited to money payments during sickness, in return for
the weekly contribution made by employees and employers. If it be
thought inadvisable to limit the State’s contribution, as in Germany,
to what is spent in administration, then in equity the present system
of insurance cannot continue to be limited to those now participating
in it.
I hold strongly that the State should embark on a much larger scale
than at present on
_The State Treatment of Disease_
The great and fundamental mistake made in the initiation of the
English Insurance Act was that in effect it ignored the entire
history of the relation of preventive and curative medicine to
the State. This history cannot be detailed now: but, briefly, for
long years the destitute had been entitled to domiciliary and
institutional treatment at the public expense. This medical aid was
given by Poor Law Authorities, and their method of doing this work
had rendered the benefaction commonly unacceptable. Then Public
Health Authorities on a steadily increasing scale found it necessary
to treat disease in order the more effectively to prevent it. And so
fevers and smallpox, and chronic infective diseases like tuberculosis
and syphilis came under treatment, practically for all comers, at
the public expense. As already mentioned the fundamental importance
of maternity and childhood has also been realised, and the State is
now taking an increasing share in ensuring health at these periods
of life. And while Public Health Authorities were increasing their
activities, Education Authorities began to subject school children
to medical inspection, and to treat them for the detected defects,
the treatment of which they could not otherwise secure. And so, not
to make this sketch too complex, three great central government
departments or sub-departments and three sets of local authorities
were engaged in medically treating the people at the public expense.
This sketch does not include the smaller (nevertheless enormous)
amount of treatment of disease by voluntary hospitals. It is safe to
state that at any one time one-half of the total treatment of disease
is being carried out at the public expense. If the domiciliary
treatment of insured persons is worthy to come into the same category
as the skilled services mentioned above, the proportion of disease
already treated at the public expense greatly exceeds 50 per cent.
(Note.—Less than four-ninths of the cost of medical treatment of
insured persons comes from the contributions of the insured.)
The complexity of local authorities concerned in the treatment of
disease was wilfully increased under the National (Health) Insurance
Act; and, contrary to the advice of public health workers and of the
Royal Commission on the Poor Laws a golden opportunity for securing
the merging of poor law into public health work and for initiating a
unified system of State Medicine for all who need it was lost.
Poverty to a preponderant extent is due to sickness. Two statements
have recently been made by the Medical Society of the State of New
York, viz., that “evidence is against the fact that any considerable
amount of impoverishment is caused by illness,” and that they can
find no “available evidence that ... in the main, medical attendance
in this State is grossly deficient in quantity or grossly defective
in quality.” (_Monthly Labor Review_, January, 1920, p. 256.)
One can admire the optimism, while denying the accuracy of the first
statement: of the second statement, as it refers to the State of
New York, I can say nothing, except that a statement identical with
the one denied above would be literally true for England. In 1907
I wrote, “the coexistent but uncoördinated systems of treatment
of disease have failed lamentably to provide what the health of
the community requires—means for ensuring effectively the early
recognition and proper treatment of all disease” (_British Medical
Journal_, Sept. 14, ’07). That remains broadly true, and no remedy
will suffice which does not ensure for every member of the community
in essential particulars as good treatment as the most favored now
possess.
The socialization of medicine has gone too far, its beneficent
effects are becoming too well appreciated, to render it possible,
even were it not undesirable and mischievous, to hinder its further
extension. We have travelled more than half the road towards the goal
of general provision of skilled medical assistance by coöperative
means, i.e., out of the communal purse. If this is desirable for
elementary general education, it is even more important when the aim
is the restoration and the maintenance of the highest attainable
level of health for each member of the community, who is willing
to share in the offered benefits. If we include the third of the
total population who now receive in Great Britain the unsatisfactory
medical benefit under the National (Health) Insurance Act, and
remember the rapidly increasing scope of voluntary and official
institutional treatment of disease, hesitation in accepting the
inevitable should be replaced by a determination to guide future
developments and to render them efficient and economical. What is
good for the public is good also for the members of the medical
profession.
If asked to advise on the steps which it is advisable to take in
regard to Sickness Insurance in a community which has not adopted
a scheme, I should emphasise the prior necessity for the State to
secure a completely satisfactory system of public medical care before
engaging in the more difficult task of providing monetary payments
in sickness. It is well to bear in mind that medical attendance is
a form of communal assistance the demand for which does not tend
to increase with the supply; whereas monetary benefits have always
shown this trend, as demonstrated by the experience of both Friendly
Societies and charitable agencies. As satisfactory administration
of monetary benefits during sickness depends on securing medical
certification which is above suspicion, it is fundamentally important
that under any method of public medical attendance the certification
(for incapacity to work) should be completely independent of any
coexistent system of sickness insurance.
A completely efficient public medical service, if preventive as well
as curative, will diminish greatly the monetary calls on sickness
insurance and lower its expense. Let me briefly enumerate the
conditions which such a medical service must fulfil:
1. It must possess facilities for consultations with physicians and
surgeons having special knowledge, equalling in efficiency those
possessed by the well-to-do.
2. All modern pathological and physical aids to diagnosis and
treatment must be available.
3. Hospital treatment must be secured for all whose illness cannot be
satisfactorily treated at home.
4. In the ordinary treatment of patients by medical practitioners
there must be provision for team work, as for instance at local
dispensaries, so that a patient may, where this is desirable be
conveniently examined by several doctors. (Group medicine.)
5. Skilled nursing must be obtainable for patients needing to be
treated at home, though the extent to which this is required will be
greatly reduced by increased use of hospital beds.
6. In every district the patient might have the choice between
several doctors; but unnecessary change of doctors should be
discouraged. Subject to general regulations, however, he should
be entitled to demand a consultation when not satisfied as to his
treatment.
7. The doctor chosen by the head of the family should be held
responsible for supervising the health of the whole family; and
should be required at least once in three months to arrange to
see each member of it, to ascertain any existing disease, or any
habits, manner of life or work tending to cause disease, and to make
a concise statement to the medical officer of health or health
commissioner embodying his recommendations as to any public health
action which may be needed.
8. The scheme at first might be limited to one section of the
population, but there is no reason why ultimately it should not
embrace all willing to join it.
9. The remuneration of doctors engaging in this public work should
be adequate at once to attract junior members of the profession. The
remuneration should not be on a capitation basis, but by salary,
modified according to the success achieved. The scheme would enable
doctors to have ample leisure and holidays and to take part in
post-graduate courses. Every inducement should be given to physicians
to undertake along with their family work special work in connection
with one of the following activities:
Pathological laboratories,
Hospitals,
Health centres for infants and mothers,
Prenatal and post-natal clinics,
Consultant obstetric work,
Pre-school clinics,
School medical inspection and clinics,
Industrial inspections and clinics, etc.
10. Medical schemes on the above general lines can only be completely
satisfactory to the extent to which every physician taking part in
them becomes imbued with an appreciation of the _almost unlimited
preventive possibilities opened up by the opportunity to treat
disease_, and by the realization likewise that an essential part
of his family work should consist in detecting the _beginnings of
disease_ and in detecting and securing the removal of domestic,
dietetic, housing, industrial or other factors liable to cause
disease.
If these ideals can be even partially realised, we shall have
approached the time when every practising physician will become a
hygienist, and when any sickness insurance still demanded or required
will be on a scale much lower than is necessary at the present time.
In short, compulsory sickness insurance under present conditions is
a measure of relief. It has almost as little prevention involved in
it, as has insurance against the risk of fire. Relief must be given,
by insurance or otherwise. How much preferable, however, it would be
to precede it by a far-reaching scheme of effective preventive and
curative work, or at the least to place it in a strictly subsidiary
position to such a scheme in actual operation!
FOOTNOTES:
[11] An address given to the Quiz Medical Society, New York, Feb. 14,
1920.
[12] _I. e._, any doctor in a given area who is willing to treat
patients under the conditions of the Insurance Act.