AS TEXAS DOCTORS ORGANIZE Some Probing Questions on Medical Care The news this week is that Texas doctors are organizing politically to endorse candidates In various races and to get their position across more effectively. We welcome rebuttals to the following article.Ed. AUSTIN Since my son is one of those undesirable socialized babies and I’ve still managed to find him delightful, and since in one of those socialized English hospitals I was treated like the Duchess of Marlborough down from Blenheim, I’m afraid I find the statements of the American Medical Association frequently hard to take. That august group sponsors some of the most incredible propaganda in the history of American public relations; it becomes particularly offensive when terms like “freedom” and “socialized medicine” are used so sweepingly. Because the area of freedom I most cherish is that of thought and expression, I find it difficult not to become incensed at the idea that people should cherish the right to rot of disease in the richest country in the world. A great deal more calmness and sanity and a considerably more responsible use of the language are necessary in future discussions of the problem of medical care in the United States today. ANYONE who wishes to discuss that usual AMA whippingboy, the British national health service, with informed objectivity should read Dr. Paul Gemmill’s Britain’s Search for Health, published recently by the University of Pennsylvania PI’ 2SS. Dr. Gemmill, professor emeritus of economics at the University of Pennsylvania, spent almost four years on this study, seven months of them in Britain. The study is by no means a propaganda piece, although the author’s basically sympathetic position is implicit. His investigation is fair, balanced. and informative. The British National Health Service, he points out, is the product of an evolutionary process begun in 1912 with the National Health Insurance Act, the country’s first compulsory health measure, and it has been a co-operative venture of Britain’s three major political parties. When the Labor Party came to power in 1945, the Conservatives found themselves in the position of attacking politically a program which they had publicly favored for some time. “Thus it came about that on this theoretically most radical piece of Labor legislation, there was, in effect, no real opposition at all.” The operation of the NHS has been “marked by frequent argument over details. But the general principle of the Serviceready access for all to every kind of medical care–has been accepted by all political parties in Britain and by an overwhelming majority of the British people.” NO ONE CLAIMS perfection for the NHS, and few insist that its form would be appropriate in any country’ other than Britain. But the AMA’s contention that the British people are miserably unhappy and poorly cared for tinder National Health is absurd. 97 percent the British people have joined the Health Service and an estimated 97 percent of doctors and dentists have joined on either a full-time or a parttime basis. Since 1948, membership in the NHS has been open to all who wished to join, but doctors and patients alike were free to take it or leave it. “Under the NHS,” Gemmill writes, “it has always been easy for a patient to change to a now doctor, or for a doctor to get an objectionable pa tient off his hands.” The program provides free access to a general practitioner, specialist care, hospitalization, dental and opthalmic care, and free medicine. Since the early days, several financial obligations have been placed upon patients, including an annual contribution amounting to about $13.50 and relatively small charges for designated services such as prescriptions, all of which are refundable to anyone who convinces the proper authorities that payment would entail undue hardship. Salaries for the general practitioners are based on the number of patients they have, and it has been claimed that the capitation fee stimulates the doctors to give the best service and care of which they are capable. “The assumption is that the unquestioned right of patients to change doctors will be exercised whenever a patient gets the notion that another practitioner is better than the one he already hasand that the fear -of losing patients or the desire to attract, additional ones, will supply the economic incentive needed to induce NHS doctors to compete with one another in trying to render the best service.” The NHS specialist, who is a salaried hospital staff officer, dces his work at his hospital unless the patients he examines or treats are too ill to be moved from their homes. Unlike the practitioner, the specialist is paid a salary, the amount of which depends on his rank and the length of his NHS service. The Service is supported chiefly from public funds, from national and local taxes, and has never taken more than 4 percent of the gross national product. To remedy a geographical maldistribution of doctors, a central committee, compared mainly of doctors, classified the country into three categories, and began regulating the movement of doctors into these areas. In a six-year period the doctor-patient ratio has changed substantially for the bette: “The proportion of the population living in underdoctored areas fell from 51.3 percent in 1952 to 18.5 percent in 1958, while the proportion that lived in ade-quately doctored areas rose from 48.7 percent to 81.5 percent of all the people.” The presence of good specialist care and hospital facilities in even the poorest provincial areas is one of the major triumphs of the British system. Gemmill was, of course, curious to know how the people as a whole felt about the NHS, and he sent elaborate questionnaies to what seemed a reasonable crosssection of the population. He found them overwhelmingly pleased at the wide scope of the NHS program, the right to have high-quality medical care, and the immunity from catastrophic medical costs. THE FEELINGS of doctors were similarly consulted. Gemmill writes: “It seems fair to say that, en the whole, the gains brought to patients by the NHS were more obvious than those enjoyed by the doctors.” Doctors would find particularly interesting his sketch of the important role played by the British Medical Association in the evolution of the Health Service. In 1911 it opposed the LloydGeoge Bill for National Health Insurance. But in 1930 and again in ’38 it urged that health insurance coverage be extended to dependents, and that its benefits be expanded to include specialists, opthalmic, dental, and full maternity care. In 1930 the BMA stated a desire for a health service “which may be necessary for the prevention and care of disease and for the promotion of full mental and physical efficiency,” though it opposed the inclusion in such a plan of the upper 10 percent who were “willing or able” to pay. The British profesional ideal of public service is obvious in a statement from The Lancet, a leading medical journal, while the Bevan Act was under consideration: “To a profession of individualists, the whole concept of Government control is repugnant. To some it may seem that, Whatever the safeguards, such control must mean the triumph of bureaucracy over medicine, and the degeneration of much we hold dear. “Nevertheless, there is another possibilitythe triumph of medicine, in its own field, over bureaucracy . . . In any medical service the opinion of medical men and women, when adequately expressed, is bound to command attention; and if it cares to apply its energies to continuous improvement of the NHS the profession cannot fail to produce something finer than we have y t known.” This is a somewhat far call from the AMA’s opposition through the years to the National Tuberculosis Act, Red Cross blood banks, federal aid to combat infant and maternal mortality, public venereal clinics, government medical care of soldiers and sailers, free diagnostic centers for cancer and TB, school health services, compulsory vaccination for smallpox, Social Security, old age a n d unemployment insurance, Blue Cross \(“a half-boked schOf the general practitioners who took part in the survey, \(who had an average of 2,283 , patients it reasonably easy to give what they regarded as adequate medical care; 37.8 percent found it difficult; and 3.4 percent found it almost impossible. But the idea that British doctors are busier now than in pre-NHS days is definitely challenged by Professor Richard Titmuss of the University of London. Some 39 percent of the doctors said they found the volume of paper work burdensome; 61 percent did not find it so. \(The increase of certain kinds of paper work has of course been largely offset by the disappearance of the 49 percent said the patients often took up their time with very minor ailments; 30 percent, occasionally; 21 percent, almost never. Such statistics should be considered in light of the fact that “ready access to medical service sometimes leads to the prevention or early detection of serious ailments.” Only 2 1/2 percent of the doctors felt that patients who genuinely required hospital treatment were often kept out of hospital beds because they were occupied by persons with minor ailments. 98 percent of the doctors said that an emergency case could always get to the hospital promptly. ABOUT 60 percent of the doctors questioned said “the standard of living that most general practitioners could buy with the money income they were then receiving from professional services was almost certainly lower than it would have been if the NHS had not been adopted.” But in 1958 general pratitioners with the average number of patients and with no income except for capitation fees were in the highest 2.8 percent of British income-getters. “Those with 3,500 patients were in the highest 1.6 percent. as were also all full-time consultants of at least three years’ standing.” Apart from their objection to what seems to them an unfortunately low income, some doctors object to their inability to move readily from area to area, and many complain about the NHS policy which prevents private patients from having free medicine. On the other hand, many doctors do like the fact that the relationship between physician and patient is no longer a commercial one and are pleased that they can give each patient the care he needs rather than just the amount he can afford. 87 percent of the general practitioners interviewed felt that the health needs of the country were being better met under the NHS; 3 percent, less well met; 10 percent, about the same. , APART FROM whatever inade quacies can be cited in the American medical situation, two problems may encourage Americans to think of modifying their system. One concerns the ever^ dvancing costs of medical care in an increasingly technological Writes Professor Francois Lafitte, of the University of Birmingham: “The twentieth-century scientific and ‘industrial’ revolution in medicine, while greatly enhancing the potential efficacy of medical care, requires so high a ‘ rate of investment in medical facilities as to put the cost of medical care increasingly beyond the slowly changing spending-propensity of the private consumer.” The second problem concerns preventive medicine. The AMA strongly urges that everyone see his doctor regularly, and particularly when he feels at all badly, so that dangerous illnesses may be, detected in their earliest and most easily curable stages. However, even if it could be shown that most Americans can, through various means, afford the medical expenses necess-ry to deal with their obvious ailments, how can the profession expect the majority of people who must carefully apportion their incomes to regularly give a part of it to their doctors when there seems to be no immediate need? To the various problems of financing medical care, the proponents of free enterprise medicine now seem to offer two solutions: voluntary health insurance and charity. Unless there are some significant insurance schemes of which I am completely ignorant, the notion that health insurance can solve the medical payment problem of the nation is patently false. Millions of people who most need financial help in dealing with their medical expenses are quite unable to pay the monthly insurance premiums. Most insurance schemes pay only a portion of medical bills, usually concentrating on hospital expenses, and leave bills for docto visits and medicine to the individual’s ingenuity. Another significant limitation to the efficacy of health insurance is the fact that a company may insure a person with promise to pay for the majority of expenses incurred through illness but include in the contract a. “waver,” disavowing financial responsibility for illness or complications arising from a pre-existing condition of which the company is aware. Thus the companies often refuse insurance for precisely those eventualities which seem most likely. Of course some people, and especially older ones, find it impossible to qualify at all for health insurance. being deemed insurance risks. THE WORD “charity” is seldom used these days in the sense of the Christian love of our fellow men. Its use now implies patronage on the one side and failure on the other. The question, perhaps, is ultimately a philosophical one. Do people have a right to health when the finest sort of medical care is available, or should the availability of that care depend on an individual’s
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