THE RELATION OF MEDICAL BENEFITS OF HEALTH

INSURANCE TO EXISTING HEALTH AGENCIES.

By B. S. WARREN, M.D., Washington, D. C., Surgeon, U. S. Public Health Service.

Without an adequate medical service clinical and preventiv-health insurance will fail of its best results. By providing a substantial part of the wages and medical treatment during sickness it will no doubt, as a relief measure, prove satisfactory to the welfare workers, the employers, and the employes, but without adequate provision for the prevention of disease it will not prove to be a public health measure. Each of the groups of people mentioned see, at close range, the damage done by disease and that the damage is greatest among the group of low paid workers who are least able to bear the burden.

The welfare workers' field lies mainly among the group of low paid wage earners and, in their feeling of helplessness among so much suffering, the idea of health insurance has come like a ray of hope for the solution of problems that appeared wellnigh hopeless.

The employer has found from experience of idle machines or from machines running at lessened output by inexperienced operators, that sickness is expensiv and whether he has sought to remedy this as a matter of economy or filanthropy he will find in health insurance a business-like method of meeting this situation.

The employes may not be afraid of death, they may not be much concerned about accidents, "but they dread the thought of illness," and will find that "the only way this matter can be handled properly so that the most necessitous will be provided for is thru universal compulsory state health insurance."

That group, who are interested in bringing about industrial peace, will doubtless find in health insurance, a common ground on which employer and employe can meet in agreement and thru 1 Royal Meeker, Commissioner of Labor Statistics, U. S. Department of Labor, Address before International Association of Industrial Accidents Boards and Commissions, Columbus, Ohio. The Survey, May 20, 1916, p. 205.

these agreements they have reason to believe that peace in other fields will be promoted.

In this way health insurance will have wonderful results as a relief measure, and will no doubt measure up to the expectations of those who advocate it on this account. But as stated above, it will fail of its best results if an adequate medical service-clinical and preventiv-is not provided. On the other hand, with proper provision for such a service, health insurance will be a public health measure farther reaching than any that has ever yet been enacted into law. It is on this account that it attracts the attention of health authorities. At present the fight for better health is one which is carried on at a great disadvantage. Health departments, national, state, and local, and volunteer health organizations are all suffering from the lack of men and money. Men trained in disease-prevention are too few, but if health agencies had regular and sufficient appropriations the men would soon be at hand.

In this connection it is of importance to present some estimate of the sum of money that the contributions to a complete health insurance system would amount to each year. There were approximately 30,000,000 wage earners in the United States according to the census of 1910. It has been tentatively stated that the contributions to the insurance funds would not have to exceed 50 cents per week per employe. According to these estimates the total sum contributed annually would be more than three-quarters of a billion dollars. It therefore becomes a problem as to the best method to cut down sickness and save a large proportion of this enormous sum. All health agencies realize that much sickness can and should be prevented. It will be to these preventiv agencies that the people contributing these millions will sooner or later turn for relief.

Experience with workmen's compensation laws has clearly demonstrated that the "safety first" movement is one of the best results of these laws. Just as the laws which fixt the price and responsibility for industrial accidents resulted in "safety first," just so surely will health insurance laws, which make similar provisions with respect to sickness, result in a movement for disease

prevention. Furthermore, the demand for disease-prevention will probably be as much greater than the "safety first" movement as the loss from sickness is greater than that from accident.

Why then provide a health insurance system without adequate machinery for disease-prevention? If one of the principle arguments for the measure is its effects in promoting health, surely then every effort should be made to bring into its operation the aid of the health agencies of the country.

Up to the present time there is no experience in this or foreign countries which has been satisfactory as to the provision for proper co-ordination of the administration of the medical benefits with other health agencies. In Germany there was so much friction between health insurance administrativ bodies and the doctors that a "doctors' strike" resulted; this strike was only temporarily settled by a compromise known as the "Berlin Agreement." This agreement was made early in 1914; the war began soon afterward and interrupted further action. In Great Britain the health insurance act provides for governmental administration of medical benefits and the free choice by insured persons of doctors registered on "the panels." This provision and the acceptance of disability certificates signed by physicians of the insured persons, choice has, however, resulted in an improper drain upon the funds and it is freely admitted that doctors have been entirely too complaisant in signing certificates of disability.

In the bills introduced into the several state legislatures in this country the German plan of administration of medical benefits has been followed and no provision has been made for correlating the system with health agencies.

The public and those framing health insurance laws should realize the necessity of making proper provision for the administration of the medical benefits so that the best results may be obtained for the prevention as well as for the relief of diseases. They should profit by the mistakes made in the German and English acts. One reason for the mistakes made, is the lack of understanding on the part of those framing the laws. They treat the whole matter as the doctor's problem, taking it for granted that all doctors of medicine are doctors of public health and have

made no provision for utilizing health agencies except possibly in the matter of the prevention of tuberculosis.

To write into the law adequate provisions for the relief and prevention of sickness, the law makers should advise with doctors of public health and doctors of medicine as well as employers, employes, and welfare-workers. Surely some plan can be workt out by which adequate medical and surgical relief in home or hospital can be provided, one by which the doctors will receive every inducement to render his best services in the relief and prevention of sickness, and by which all health agencies can be brought into the system and use made of their specialists in disease-prevention.

The following outline of a plan for bringing about proper coordination between health insurance systems and other health agencies was adopted by the Fourteenth Annual Conference of State and Territorial Health Officers with the United States Public Health Service, May 13-15, 1916:

There must be a close connection of the administration of any health insurance system with the health agencies of the country and with the medical profession. It is believed that this can be done along three lines: (1) By providing efficient staffs of medical officers in the federal and state health departments, to carry into effect the regulations issued by the central governing boards or commissions; (2) by providing a fair and sufficient incentiv for the activ co-operation of the medical profession; and (3) by providing for a close co-operation of the health insurance system with state, municipal, and local health departments and boards.

Corps of Full-time Medical Officers.-In view of the experience in both Europe and America, it would seem best to place the administration of the medical benefits directly under governmental agencies and to insert a provision that no cash benefits be paid except on the certificate of medical officers of the national and state health departments acting as medical referes under the regulations of the central governing board or commission. Such medical officers should be selected according to civil service methods. Since these officers are the representatives of the health departments in the funds, their selection and appointment should also be based upon their knowledge of preventiv as well as of clinical medicine. After a probationary period of service satisfactory to the health administration they should be given permanent appointment, subject to removal only for inefficiency or immoral conduct. One of their duties should be to examine each disabled beneficiary and keep themselves informed as to the progress of his recovery. It is need

less to say that the referes should not be permitted to engage in private practice.

Free Choice of Registered Physicians.—With such a check on the payment of cash benefits, the medical and surgical treatment provided for beneficiaries could safely be left to the physician of the patient's choice, and payment made on a capitation basis regardless of whether the patient was sick or well, after the manner of the English national insurance act. This method of selection and payment of physicians for the medical and surgical relief would offer every incentiv to them to keep their patients well and to endeavor to please by rendering their most efficient service.

Hospitals and Dispensaries.—In addition to the provision for home treatment by the physician of the patient's choice, provision should be made for hospital and dispensary treatment and to this end hospital and dispensary units should be establisht or contracted with, where the very best medical and surgical service would be available for all insured persons.

Value of Such Plan in Disease-Prevention.-The greatest value of such a system of administration of the medical benefits would be in the splendid opportunity it would offer for preventing disease among the insured persons and their families, by the organized corps of medical officers, and the improved medical and surgical treatment. It would be thru the corps of full time medical officers of the health department acting as referes, that the health insurance system would be linkt up with other health agencies. It is not necessary to relate here the advantages which would arise from the visits of such specially trained men into the homes of all sick persons. Nor is it necessary to tell how these officers, acting as health officers, could further lower the sick rate. The objection could not be raised that such a corps would be too expensiv. It would not require more than one such medical officer to approximately every 4,000 insured persons and at that rate they could more than save their salaries by relieving insurance funds from paying unjust claims. Furthermore, while an estimate cannot be made of the amount to be saved by their efforts in the way of lowering the sick rate, it is safe to say that it would amount to many times more than the sum of their salaries.1

With such a system funds would be provided and every existing health agency and newly created agencies could be utilized and fitted into its proper place and all work together without duplication of effort. Above all there would be a financial incentiv given to each interested group to prevent sickness.

The employer, who found that he was contributing more per

1 This description of plan for administration of medical benefits is taken from the report of the Standing Committee of the Conference of State and Territorial Health Officers with the United States Public Health Service.