Social phases of the group health association movement in the United States

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SOCIAL PHASES OF THE GROUP HEALTH ASSOCIATION MOVEMENT IN THE UNITED STATES

A Dissertation Presented to the Faculty of the Department of Sociology University of Southern California

In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

By Edward C. McDonagh May 1942

UMI Number: DP31689

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T h is d is s e rta tio n , w r it t e n by

EDWARD MCDONAGH u n d e r the g u id a n c e o f h%$.. F a c u lt y C o m m itte e on S tu d ie s , a n d a p p r o v e d by a l l its m em b ers, has been pre se n te d to a n d accep ted by the C o u n c il on G ra d u a te S tu d y a n d R e search, in p a r t i a l f u l ­ f i l l m e n t o f re q u ire m e n ts f o r the degree o f D O C T O R O F P H IL O S O P H Y

Secretary D a te ..

Com m ittee on Studies

C hairm an

*-9

TABLE OP CONTENTS CHAPTER I*

PAGE

-THE PROBLEM'AND DEFINITIONS OP TERMS USED . . . .

1

The problem

2

Statement of p r o b l e m ......................

2

Methodology of the study

3

..................

Definitions of terms u s e d ................. . Group health association

. 7

..................

Social phases ..........

7

Social movement

*

Rochdale principles • • • • . .

7

• 7

............

8

Cooperative group health association

....

Proprietary group health association

• • • • 10

Quasi group health association

9

............

10

Public, state, or socialized medicine . . . .

10

Wealthy income group

......................

11

Middle income group ........................

11

Low income group .

12

Relief income group ............

* . . . . . .

12

Forecast of c h a p t e r s .......................... 13 II.

SOCIAL ORIGINS OF THE GROUP HEALTH ASSOCIATION MOVEMENT IN THE UNITED STATES

.......... 14

Cost of medical care to middle c l a s s .......... 14 Search for low cost methods of obtaining medical services

.........................

CHAPTER

PAGE Origins in health insurance procedures and legislation....................... .

25

Workmen*s compensation laws and procedures

..

.............. . . . . . . .

33

Industrial clinics and welfare services • • • •

38

Committee on the Costs of Medical Care

47

....

Abstract of chapter . • • • • • • .......... 56' III. COOPERATIVE GROUP HEALTH ASSOCIATIONS ..........

62

Farmers1 Union Community Hospital Elk City, Oklahoma

. . . . . . . . . . . . .

64

Group Health Association, Inc. at Washington D.C.

.................

84

Greenbelt Health Association at Greenbelt, Maryland...........

99

Group Health Cooperative at Chicago I l l i n o i s .......................

117

Group Health Cooperative at New York City . .. . 133 Wage Earners* Health Association at St. Louis, Missouri . . . . . . . . . . . . . Chapter summary........... IV.

PROPRIETARY GROUP HEALTH ASSOCIATIONS . . . . . .

140 159 163

Ross-Loos Medical Group at Los Angeles, C a l i f o r n i a .................

164

CHAPTER

PAGE Trinity Hospital at Little Rock, Arkansas............... . Review of chapter

. ............ 191

. . . . .................. 196

V. QUASI GROUP HEALTH ASSOCIATIONS

. ..........

199

California Physicians* Service.. ...........

201

King County Medical Service Corporation at Seattle, Washington . . ................ 214 Medical Service Bureau at Atlanta, G e o r g i a .............

218

Summary of chapter.......................... 225 VI. CORRELATIVE DEVELOPMENTS ASSOCIATED WITH THE GROUP HEALTH ASSOCIATION MOVEMENT

.....

228

Group hospitalization.................... 228 Group dental p l a n s ........................ 242 Chapter abstract

........................ 257

VII. A COMPARATIVE ANALYSIS OP THE ADMINI3TRATIVE STRUCTURE, MANAGEMENT, AND CONTROL OP POLICY OP THE THREE TYPES OP GROUP HEALTH ASSOCIATIONS OPERATING IN THE UNITED STATES

............................ 268

Structure and management.................. 263 Control of policy.

...................... 281

Chapter recapitulation.............

290

CHAPTER VIII.

PAGE COMPARISON OP HEALTH PLANS IN FOREIGN COUNTRIES WITH HEALTH GROUPS IN THE UNITED STATES

......... '.......... 295

Great Britain

...................... 296

Scandinvian countries • • • ......... . . . 308 Germany

. . . . . .

.................... 312

Union of Soviet SocialistRepublics . . . . India

314

..................... ........... 317

South America............................ 318 Chapter review IX.

...

. 320

MAJOR CONTEMPORARY PROBLEMS AND VALUES OP COOPERATIVE AND PROPRIETARY GROUP HEALTH ASSOCIATIONS

. . . . . . . . .

Major problems Major values X.

525

• - • • • • ' ................ 325 .

.................... 342

SUMMARY OP FINDINGS, RECOMMENDATIONS, SUGGESTIONS FOR FURTHER STUDIES, AND SOCIOLOGICAL IMPLICATIONS. OF THIS

BIBLIOGRAPHY APPENDIX .

STUDY . . . 349

............................. . . . . . . .

361 377

LIST OF TABLES TABLE

PAGE

I* Membership Dues Payable to Group Health Association of Washington D.C. II.

.......... 88

Membership Dues Payable to Greenbelt Health Association of Greenbelt, Maryland . . . .

III.

102

Comparative Cpst of Medical Services to Members and fton-members of Greenbelt Health Association

IV.

.................... 104

The Comparative Cost of Medical Service to Group Members of Group Health Co­ operative at Chicago, Illinois

......... 120

V. Comparative Cost of Medical Services to Group Members and Individual ^embers of Group Health Cooperative Kew York City * # 135

LIST OF CHARTS CHART I.

PAGE Administrative Structure of the Ross-Loos Medical Group at Los Angeles, California .

II.

Administrative Structure of California Physicians* Service................. . •

III.

264

267

Administrative Structure of Farmers* Union Community Hospital at Elk City, Oklahoma

IV.

. . . . .....................

Administrative Structure of Group Health Association at Washington D.C.

V.

271

.. .. .

273

Administrative Structure of Group Health Cooperative, Inc. and Civic Medical Center at Chicago, Illinois...........

VI.

276

Administrative Structure of Wage Earners* Health Association at St. Louis, Missouri

VII.

...........................

Model Administrative Structure of a Group Health Association

VIII.

278

..............

280

Comparison of Group Health Associations in the United States with Health Insurance in Great Britain and State Medicine in Soviet R u s s i a ...........

294

CHART IX*

PAGE Socio-Medical Comparison and Summary of Health Groups Analyzed. . .............. 552

CHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED The problem of how best to dispense medical care to the American people has been the subject of much social con­ troversy and conflict for the past several decades in the United States.

The clash of deep-seated attitudes rooted in

custom and tradition with modern medical innovations which threaten the security and status of the established institution of medical private practice has succeeded in focusing this problem in the public consciousness.

Arguments both for and

against various medical plans, as expressed by their proponents and opponents, have heightened public interest on the subject, and tangible evidence of newer methods of distributing medical care, in the form of group health associations, have crystal­ lized areas of attitudes and opinions of diverse groups of people.

Lay and professional groups throughout the country

have sought some means to meet their health needs and have been instrumental in fostering and developing organizations offering group health services through a system of periodic or pre-payment plan.

They met with opposition, primarily, from

the medical doctors through their professional organization, the American Medical Association.

2 Inasmuch as many group health associations have

been

in existence less than two decades, it has been possible in certain cases to observe with considerable clarity and accuracy the particular steps in their formation and their ensuing prob­ lems at each stage of their growth and development to date. The scholarly literature on this important subject is meager and scattered, a fact

which constituted one of the academic

hurdles of this study.

However, sufficient primary sources

and pamphlets came to the attention of the writer to circum­ vent this

difficulty at least partially* I.

THE PROBLEM

Statement of problem.

The primary aim of this disser­

tation is to trace the underlying factors in

the development

and functioning of the group health association movement in the United States.

Basic to :a thorough analysis and under­

standing of this central problem-are the following questions, which constitute sub-purposes of the study: origins of group health associations?

(1) what are the

(2) what features

characterize cooperative group health'associations?

(3) what

features typify proprietary group health associations?

(4)

what hallmarks designate quasi group health associations? (5) what related developments correlate the group health assoc­ iation movement?

(6) how do group health associations contrast

with health insurance schemes and plans of state medicine?

(7)

what do the attitudes of group health association members reveal and disclose about the group health association movement and the medical set-up in the United States today?

(8) what seem to be

the significant social values and major problems of group health associations? Methodology of the study*

A careful analysis has been

made of the available literature pertaining to group health associations and related organizations in order to ascertain lay and professional thought on

this topic.

The following

libraries were utilized for purposes of research and for the gathering of bibliographical materials:

The Edward L. Doheny

Jr. Memorial Library of the University of Southern California, The Los Angeles Public Library, Stanford University Library, University of California Library, Southern Illinois Normal University Library, and the Library of Congress.

The librar­

ians in these institutions were helpful and courteous in locating literature and information pertinent to this problem* A second method used in this dissertation was to make a comparative study of the constitutions, by-laws, and espec­ ially the contracts of important group health associations. Most of these documents were obtained by requesting specimen copies from each health group from the managers of each particular group, who were,

in nearly all cases, eager and

willing to cooperate in supplying the requested information. For the reader, a few representative copies of group health association contracts have been placed in the appendix of this study. A third method of gathering data

was through correspond

ence with the managers and leaders of group health associations Specific information was obtained from administrators which would not otherwise have been available in group health liter­ ature.

Questions asked were specific,

on the whole, and

thus did not involve a too extensive answer from the receiver. Cooperation from professional and lay

members of the health

groups studied, in so far as correspondence was concerned, was excellent. The utilization of the objective observer technique was a fourth type of methodology used to gather information for the study.

Considerable factual information was collected

on each of the contemporary group health

associations before

an attempt was made to interview and evaluate any health group.

Thus, an unbiased and detached attitude in intern-

viewing these group health members^ whether they were medical doctors, managers, or subscribers, was possible.

An apper­

ceptive mass of factual information concerning each one of these group health associations was

an important aid in

making interviews and observations more objective than would otherwise have been true.

Several hundred interviews conducted

by the writer, have thrown some light on the attitudes and reactions of subscribers, administrators, and physicians.

(; It

was noticed that physicians frequently showed more reticence than others in discussing* the nature of group health associations.

However, the reserved nature of physicians, in a

number of instances, may have been due in part either to the pressure which the American Medical Association has brought to bear on almost every medical doctor practicing in this country, or to an occupational attitude of medical doctors. Caste- data of a representative nature were made avail­ able through the cooperation of

persons who interviewed

members of the three different group health associations studied intensively.

These interviews were conducted along certain

specific lines to insure greater validity of the findings. A written account of each interview was sent to the writer, and

each case was scrutinized and evaluated, and the analysis

incorporated in the dissertation.

Hearly one hundred inter­

views with members of Farmers* Union Community Hospital were gathered by field interviewers.

Approximately one hundred

and fifty interviews and about one hundred tfexpressionnairestf were collected from subscribers *to Ross-Loos Medical Group. Interviewees represented the following occupations served by

6 ROss-Loos Medical Group:

Southern California Gas Company,

The University of Southern California, Los Angeles City School Teachers, Southern California Telephone Company, and the Los Angeles Police Department*

Wage Earners* Health Association

of St. Louis, Missouri was studied intensively by the writer* The collection of case materials disclosing the attitudes of members of group health associations constituted a fifth method of procedure* In order to attain a realistic understanding of the at­ titude of the American Medical Association toward the inception and development of the group health association movement, the writer attended a phase of the trial between the Government and the American Medical. Association which was held in Judge Procter* s court in Washington, D.C*, during the month of March, 1941*

The Journal of the American Medical Association has

published a complete report of the statements and proceedings of the historic trial.

A brief review of the outcome and

findings of this trial has been undertaken in a later section of this work. A sixth type of methodology was to present the location of group health associations in the United States not only in terms of spatial concentration, but also in terms of temporal sequence*

Such a graphic method indicates both the points of

concentration of health groups and the date of origin of the

health, associations which are in operation at the present time.

Again, this spatial-temporal map makes possible a

more complete comprehension of the relationship which may exist between regionalism and the distribution of group health associations. II.

DEFINITIONS OF TEEMS USED

Group health association.

In general, a group health

association is an organization with the following essential elements:

(1) systematic or periodic payment of fees by sub­

scribers or potential patients for health services, usually on a monthly basis, (2) medical personnel provided on a group scheme, (3) centralization and pooling of scientific equip­ ment in one or more buildings* Social £hase*

This term is used to describe the social

or interactional aspects of group health associations, including attitudes and opinions of members, and organizational develop­ ment and problems of health groups. Social movement*

Doctor Clarence E* Rainwater has

defined the term as a nmode of collective behavior occasioned by social disorganization or contacts involving intercommunica­ tion of desires, and manifested by an organization of social activities intended to accomplish a common o b j e c t . H e noted -^Clarence E. Rainwater, The Flay Movement(Chicagos The University of Chicago Press, 1922), p. 3.

four otlier significant characteristics which were common to movements as followss

(1) a series of events involving the

adjustments to a social situation, (2) an extension of this series in time and space, (3) an object to be realized by means of the adjustments involved, and (4») a tendency toward attainment of that object, disclosed in stages in its development and transitions in its policy and activities.

p

The inability

of a large number of American people to pay for adequate medi­ cal care was largely responsible for bringing about the social movement of group health associations. Rochdale principles.

In 1844 an organization of Roch­

dale Pioneers formed a consumerfs cooperative which proved to be successful. 3 The principles which governed this weaverts cooperative have become known as the nRochdale principles.n Because these cooperative principles have stood the test of time, it has been appropriate to qualify them as the cardinal principles.

The Executive Board of the Bureau of Cooperative

Medicine has pointed out the relationship between the Rochdale principles and cooperative medicine as follows!

wFrom the

standpoint of organization, the fundamental principles of con­ sumer cooperation apply;

one member, one vote; no proxy voting,

2Ibid., p. 3. 3 Emory S. Bogardus, The Development of Social Thought (Hew York: Longmans, Green and Company, 1940), p. 383.

9 no political,, racial, or religious discrimination; membership#

open

These principles are the basis of democracy#1

Xt has not been possible for group health associations to return to subscribers a ffpatronage dividend' because of the nature and structure of health groups#

Excess capital over

operating expenses at the end of the year is turned generally into medical research or used for the purchase of medical equipment for the group health association, or the premium rate is lowered# Cooperative group health association#

The essential

principles of cooperative group health associations are; group medical practice, preventive medicine, periodic payment, and consumer control# In these health groups the lay members democratically control administrative policies and the physicians direct and supervise all medical problems and practices.

It

has been found advantageous to have a functioning division of labor and control between lay subscribers and. professional personnel#

f,No agency except an association of patients seems

to be so motivated as to provide the proper relationship be­ tween the doctors and the purchasers of medical service#

Let

it be said, however* that under the cooperative plan, lay control

^Cooperative Health Association (New York: of Cooperative Medicine, 1937), p# 23#

The Bureau

10 does not extend into the field of medical matters.

These are

exclusively in the province of the doctor.*1 Proprietary group health association.

In this type

of health group a number of physicians pool medical equipment into a centrally located suite of offices and offer medical services on a periodic payment basis to a group of subscribers# Physicians in these health groups are owners, operators, and administrators.

Thus, subscribers to a proprietary group

health association do not have a voice in the formation of administrative policy. Quasi group health association.

The American Medical

Association has encouraged the formation within counties of a form of quasi group health association which incorporates periodic payments and a panel of names of all physicians in good standing in the local county medical society.

Such

health groups have been quasi because there is no pooling of medical equipment or medical personnel in centrally located offices.

Some of these health groups have been created to

prevent the spread of more thorough plans of distributing medical services. Public, state, or socialized medicine.

Medical services

that are financed by government funds are known as either

5Ibid., p* 25.

11 public, state, or socialized medicine.^

Medicine so dispensed

has been more prominent in European countries than in the United States.

The poor and relief classes even in

States, however, have

the United

been recipients of a system of almost

mass health, as practiced by public medical agents.

The

American Medical Association has waged a vigorous campaign for several years against the development and organization of state medicine away with

on the grounds that such medical care did

the ,rpatient-physieian relationship.”

Wealthy income group.

Families with an annual income

in excess of $10,000 have been designated as belonging to the wealthy income group.

In 1928 during the period of

^economic normalcy” there were only 2*7 per cent of the families in the United States with an annual income of more than $10,000, or about 783,000 families that might have been considered as constituting this aggregation# 7 Middle income group#

This term does not necessarily mean

the average income, but rather what the lay person defines

Some writers have attempted to make a distinction between socialized and state medicine# For them, any form of group •medicine is socialized and thus group medicine that is financed by government funds is state medicine# Therefore, to them socialized medicine is the more inclusive terms. 7 Statistics compiled from The Ability to Pay for Medical Care, By Louis S. Reed. Abstract of Publication No# 25 of the Committee on the Costs of Medical Care, January, 1933, p. 4#

12 popularly as the ’’middle class*”

Annual incomes between §2,000

and $10,000 generalise the earnings of the middle income class family*

In 1928 there were around 42*1 per cent of the families

in this classification*

Hence, it is fair to consider this 8 group as almost an economic middle class* Low income group* Annual family incomes -from $1,000 to $2,000 constitute the low income group*

The lower half of

this branch of society might be regarded as a ’’medical indigent class*”

In 1928 almost 41 per cent of the American families

were in this income group.

Since the year 1929 the number

of families constituting the low income class has increased cons ider ably.

Q

Relief income group*

A new class in society has been

created in such countries as the United States with the pro­ longed period of widespread unemployment which wa3 caused principally by the utilization of labor saving machinery and the financial crash of the stock market in 1929*

It was

necessary for the various agencies of county, state, and federal government to take an active part in providing relief to the millions of families that were the victims of unemployment. Inasmuch as the depression of 1929 has been unusually tenacious, this relief class has become an almost permanent aspect of 8Ibid*, p. 4. 9Ibid*, p. 4.

13 American culture.

Medical care for relief class has been

a serious problem* III*

FORECAST OF CHAPTERS

In Chapter II an attempt Is made to depict the origins of group health associations in the United States.

Cooperative

group health association methods are discussed in Chapter III* A characterization of the principal features of proprietary group health associations is made in Chapter IV*

An analysis

of the methods of quasi group health associations is developed in Chapter V.

Correlative developments associated with the

group health association movement are presented in Chapter VI* The central purpose of Chapter VII Is to present a comparative analysis of the administrative structure, management, and control of policy of the three types of health groups*

Chapter VIII

focuses attention on comparative health developments in foreign countries with health groups in this country*

Major problems

and values of group health associations are analyzed in Chapter IX.

The final section, Chapter X, sets forth the findings and

recommendations of this study.

CHAPTER XI SOCIAL ORIGINS OF THE GROUP HEALTH ASSOCIATION MOVEMENT IN THE UNITED STATES In this chapter an attempt is made to describe and analyze adequately some of the basic factors which seem to account for the process of social evolution or growth of group health associations in this country*

Of particular

interest is the fact that many of the historical factors responsible for the creation and maturation of health groups are still operating at the present time$

hence, in a large

number of instances, contemporary verification is possible on a number of points. Cost of medical care to middle class.

One of the

significant but somewhat paradoxical factors which accounts in part for the development of group health practices in this country is the economic fact that the low-middle income group has found it difficult to afford adequate medical services under a traditional fee-for-service type of medical care. Numerous writers and thinkers in the field of social health have observed that ^Only the rich and the poor...get the best medical care;

the rich because they have money, the poor be­

cause they have charity.11^* Studies indicate that both rural ^William F. Foster, Doctors and Disease (New Xorks Public Affairs Pamphlet, No. 10, 1940), p.l»

15 and urban low middle income strata have "been unable to afford adequate medical care* The low income class feels that it has been discrim­ inated against regarding the matter of medical care*

One Los

Angeles citizen commented as follows on the subject of the Los Angeles County General Hospital! I111 tell you what X think about the County Hospital* Iti*s a beautiful set of buildings to have, but as for me, it.might just as well hot be here* Any Mexican can go in there looking hungry and he gets good care* But let an American go in and what happens? He can die while they go through a lot of red tape to find out whether he*s a pauper or not* How if you1re a 1swell* from the West Side you don*t need to come to the County Hospital because you can afford to pay some high class doctor to take care of you* And if you want to, you can come to the County Hospital and pay a good fee and they*11 see to it that you get special attention* And as I said, a down-and-outer is always able to get free care here. But a wage earner like myself tries to work when he*s sick and when he can*t stand any more he scrapes up.enough money to pay a regular doctor and hopes he gets well fast* And mind you, we taxpayers pay for these beautiful buildings, and yet we get nothing out of it at all* Believe me, I*d like to see something done about it, and the sooner the better. 3 The low middle income group finds itself contributing a rather large share of the cost of illness because the paying patient must compensate the physician for the bills that are non-collectable and for his charity work*

A number of socially minded

^For a careful review of the problems of middle income farmers in California see **A Health Program for California Farmers,” by Von T* Ellsworth. Medical Care, Volume I, Number 1, „ 1941, p * .54*

^Interview with W.A.

16 persons have been investigating the possibilities of reducing the cost of medical services and distributing the risk of un­ predictable medical fees among a large number of people*

For

some time, both .in the United States and in Europe, the low income group has experimented with the cooperative purchasing of various food commodities*

There is evidence to support

the view that cooperative consumer stores are becoming an integral part of the American culture complex*

It is therefore

a logical step and natural development that the principle of group or cooperative purchasing be transferred and applied to the purchase of medical and hospital services*

It is also a

significant coincidence that one of the foremost leaders in the cooperative movement in the United States, James P. Warbasse, is a medical doctor.

Under his encouragement consumer cooperators

all over the country have become aware of the possibility of providing medical services to a group of subscribers on a periodic payment plan*

A group health association not only

distributes the risk of the oost of a serious illness among a group of members but also lowers the per capita medical cost because of the saving Involved in the pooling of costly medical equipment among a group of doctors* Frequently the low income person is restricted from taking advantage of so-called free clinics because of the social psychological stigma attached to patients who are without funds

17 and must ask for medical charity.

Doctor Kingsley Roberts

noted that there are millions of people in this nation who do not receive adequate medical care even though they are not ill-housed or ill-fed. tfThere are those who are unwilling to go to a doctor’s office and ask for charity.*1^ Search for low cost methods of obtaining medical services. The cost of purchasing adequate medical care has resulted in a very notable and conscientious search for ways, means, and plans that would make medical services available to the low income class.

While it is true, as pointed out earlier, that

the high cost of medical services alone does not necessarily argue in favor of group health associations,it is nevertheless probable that medical services can be dispensed with less difficulty through a distribution of risk program, which is an .essential principle of group health medicine, than by fee-for-service medical practice* One of the earliest methods devised to reduce the cost of medical services to patients was the centralization of medical personnel and equipment in a suite of offices or even a building*

Such a centralization of medical services was

termed frequently and commonly, a clinic*

The development of

clinical medicine made possible a mutual or cooperative sharing

Kingsley Roberts, f*The Place of Group Practice in the Future of American Medicine,11 Journal of Medicine, May, 1940*

18 of medical knowledge and methods#

It was discovered that it

was becoming an impossibility for every medical- doctor to have a first hand acquaintance with the entire fund of medical and scientific information;

hence an epistemological advantage in

group consultation and interstimulation of clinical practice 5 became evident# Prom an economic point of view, it was manifest that the average physician could not afford modern and costly scientific equipment for his office#

In the clinic the medi­

cal practitioner has free access to scientific equipment as an aid in the diagnosis and treatment of medical illnesses# One of the most successful private clinics in the United States has been operated by the Mayo brothers in Rochester, 6 Minesota# Because the Mayo Clinic did not violate the so-called ethical code of the American Medical Association, it was not opposed and not severely criticized by organized medicine# Traditional fee-for-service and sliding scale methods were incorporated in the economic structure of this clinic#

However,

the unusual skill of the Mayo brothers as first rate surgeons was instrumental in creating for this clinic a national and famous reputation#

The advantages of clinical medicine plus

5 Por a good account of the development of m o d e m medicine see the book by Bernhard P# Stern, Society and Medical Progress Princeton; Princeton University Press, 1941), particularly Chapter VIII. ^James Rorty, American Medicine Mobilizes (Hew York: W.W# Horton and Company, 1939), p. 259#

the great prestige of the Mayo Clinic have been significant factors in furthering the development of tendencies toward group health associations.

Private health clinics, like

the Mayo Clinic, even though they retained the matrix of conservative medical service distribution, nevertheless demonstrated to the American people the advantages of group medical association and consultation.

Modern group health

associations have taken the idea of centralized personnel and equipment from private medical clinics, but the criterion for payment of fees has been changed radically* Another effort to meet the problem of medical services was demonstrated satisfactorily by the United States Army in the first World War.

Doctor Bertram Bernheim, Associate

Professor of Surgery of Johns Hopkins University, significant­ ly remarked concering the nature of medical services of the United States Army in Prance during the international conflict The one thing, though that impressed me most and gave me more cause for thought later was the effective medical and surgical service given the troops, and the high quality of it— once the doctors got themselves together. For here was full time medicine (and nursing) at its height I Every man was working on a salary basis* his pay check came in the first of every month whether he worked or not. There was no private practice; and the high and low, the general and the humblest private got the same treatment. It was superb, grand. There never was anything like it. Hobody, so far as I could see, loafed when there was work to be done.1?

York:

^Bertram M. Bernheim, Medicine at the Crossroads (Ne® William Morrow and Company, 1939), p. 19.

Of interest to the sociologist was the fact that the impracti­ cability of medical individualism as carried on in times of peace became conspicuous in a time of great social unpheaval and military conflict*

Because of the concentration of great

numbers of persons in limited areas, some' method of organizing and conserving personnel and equipment became of paramount concern* A number of famous physicians in the United States have had personal contact Y/ith military medicine and have become leaders for reforms regarding methods of medical eco­ nomics*

Because of the similarity between the United States

Army medical services and group health services, managers of group health associations have pointed out the success q

of group medical practices even under military supervision* Urbanization has also indirectly promoted the evolvement of group health associations*

Social scientists have

noted that urban areas tend to centralize facilities of social living, particularly social institutions and services*

Durkheim

has pointed out that increasing density of population has been a major key in the development of a division of labor*^ ®The Selective Service Proclamation of the United States President, effective October 16,1940, tended to recruit many young physicians into the United States Army Medical Division* - Many physicians today, as in World War Humber 1, will receive a first hand orientation of group medical practices and services* %ogardus, op*

cit*, p* 421.

21 Urbanism facilitates the adoption of group health association principles*

It is an important observation that with the

exception of one group health association, the other health groups have been organized and developed in or very near large American cities*

There is little doubt that urbanism

has been an important factor in the historical development of modern medicine as the following sociologist notes so wells The shift of the western world from a predominately rural to ah urban society, and from a handicraft to an industrial economic order has profoundly influenced the growth of medicine. The aggregation of vast numbers of people into cities changes pronouncedly the patient1s behavior and attitudes, his susceptibilities to disease, his probable contact with an infection, and the nature of his nutrition. The industrial revolution, took place in the social setting of competitive enterprise, when the prevailing attitudes were hostile to any form of governmental regulation. Consequently, as modern cities grew, congested slum areas developed and most communities lacked proper sanitation and adequate water supplies* This situation raised challenging health problems with which both the medical profession and public health agencies had to cope, to prevent the cities from devouring their inhabitants* Advances in proper housing, in the disposal of garbage and waste, in the availability of a pure and adequate water supply, and in other sanitary measures have contributed in no small measures to the ability of medicine to extend the life of man, and to decrease the frequency and duration of his diseases. They therefore form a fitting and necessary background for the understanding of the success of modern medicine.^ A futile search for patent medicines in order to reduce the cost of medical service has been made by the low income ^Bernhard P. Stern, op* cit., p.xv*

22 middle class.

The trial and error practice of self-medication

has been undertaken by many in an effort to avoid ...a !lphysicianfs >* ' call fee” for seemingly unimportant illnesses. Patent medicines with almost f,cure all11 claims have become well known to the

public through newspaper, radio, and

outdoor advertising.

It has been found that the poor spend,

for medicine, a greater proportion of their total medical expenditures than do the middle and upper classes.-^Pharmacists have stocked their stores with thousands of patent medicines. Mr. James Rorty has remarked:

t

rrThey donft want to carry 142

different cough': r ernedies, 148 brands of liver pills, 30 mouth antiseptics and correspondingly burdensome stocks of *ethical proprietaries,1 but the advertisers and the drughouse detail men oblige them to do so, that they may •serve1 the public. Pharmacists probably have not wanted to sell worthless or harmful patent medicines, but many have been guided by the statement, ”If I don1t sell them patent medicines some other 12

druggist will.”

The habit of self-medication has often

resulted in tragedy.

It was clear to a number of people in

the United States that self-medication was not the solution to effective decrease of the cost of medical service. ^

James Rorty, ojs. cit., p. 175.

11

ifria- » P*

12

179*

Personal interview, no. 2.

23 Origins in health insurance procedures and legislation. It was observed more than twenty-five years ago that the cost of illness does not fall evenly upon each person in the community. With this realization, efforts were made to place the cost of medical services on an insurance basis by certain progressive minded groups in the United States. philosophy of health

Perhaps the underlying

insurance revolved around a group of social

principles aimed at circumventing difficulties which may be an­ ticipated before they occur.

Certain cycles have been noted

which point toward the fact that social living, especially when serious illness with its attendant monetary depletion occurs among the lower income groups, becomes a practical impossibility. The social phases of a vicious cycle recur repeatedly in this order, i.e., (1) an employed person becomes ill, (2) his income ceases at a time when his expenditures are great, (3) his lack of income makes it difficult or impossible for him to secure adequate medical care, which prolongs his illness, increases his poverty, and places him among either the unemployed or the un­ employable*

The social principles involved to help alleviate

this cycle are:

(1) to assure cash benefits during illness,

(2) to provide adequate medication during illness through med­ ical benefits, and (3) to carry on a preventive program of medicine. See I.M. Rubinow, The

Quest for Security*

The American Association for Labor Legislation directed a vigorous campaign for the adoption of compulsory health insurance.

Through the efforts of this organization com­

missions were appointed in eleven states to study the entire subject of compulsory health insurance*

Of these eleven com­

missions, a majority of six urged the enactment of a com­ pulsory health insurance program*

Two California commissions

reacted favorably in 1917 as follows* .•.Legislative provision for a state wide system of com­ pulsory health insurance for wage \vorkers and together persons of small income would offer a very powerful remedy for the problems of sickness and dependency in the State of California...Any Legislation on this sub­ ject should...provide (a) for a compulsory system...by non-profit making insurance carriers, (b) for a thoroughly adequate provision for the care and treatment of the sick, (c) for contribution from the insured, from industry, and from.the state.14 Because the California Commission indicated that there were certain constitutional limitations which would prevent the immediate inauguration of a health insurance program, itjj recommended that the measure be sumitted to the electorate. The conservative medical group in California was successful in its fight against the adoption of a compulsory health insur­ ance bill and the people voted more than two to one against the adoption of a health insurance plan for California.

Leaders

Report of the Social Insurance.Commission of California January, 1917, p. 17.

as

i

in the fight for compulsory health insurance in California were bitterly attacked by certain physicians who used almost what might be considered underhanded methods to assure the defeat of such legislation*

In 1919 a second California

Commission on Social Insurance recommended a compulsory system of health insurance.

The committee recommended:

Experience in other countries has demonstrated the necessity of this. A purely voluntary system does not reach those who most need it; its overhead charges are necessarily larger, compulsory contributions from em­ ployers are impracticable, and it does not admit of free choice of doctors, nor of exemption from medical examination* -*-5 In spite of the two recommendations for a health insurance program for California, the people of that state did not command the enactment of health insurance legislation. In February, 1917, the first Massachusetts Commission on Social Insurance unanimously endorsed the principle of health insurance.

The findings of this commission clearly

pointed to the need for a system of health insurance as a means to help solve the.economic burdens of illness.

In

1918, however, a second Massachusetts Special Commission on Social Insurance negated the recommendations of the first commission and proclaimed compulsory health insurance to be a form of !lclass legislation1* not worthy of endorsement. 15Ibid., p. 19. ■^Abraham Epstein, Insecurity^ A Challenge to America (Hew York: Random House, 1938), p. 449•

26 The New Jersey Commission of 1917 set forth the inherent weaknesses in various plans of mutual benefit associations and fraternal organizations*

This commission advocated that

nhealth insurance is a measure which gives great promise both of relieving economic distress due to sickness and of stimulating 17 preventive action* The New Jersey report further stressed that insurance legislation ought to provide medieal care and health instruction which would lend themselves to a plan at once curative and preventive* 18 The principle of health insurance as an approved means of distributing the cost of sickness was suggested by the Ohio Health and Old Age Insurance Commission of 1919*

It

was thought desirable to include health insurance as a require­ ment for all employees, to be paid for by employers and employees in equal proportions.

Administrative costs entailed

by social legislation were to be met by the state.

The benefits

requested by this commission were rather comprehensive as may be noted in the following points:

(1) cash benefits of

6 17

Report on Health Insurance by the New Jersey Commission on Old Age* Insurance and Pensions. 1917, pp. 18-20. •^The State Conference of Health and Welfare. 1939, recommended a voluntary health insurance plan because it offered an excellent area for experimental legislation* For further information see report of the State Conference of Health and Welfare, New Jersey. 1939. p. 68.

a part of the worker1s wages daring a period of disability, (2) full medical care and hospitalization, (5) rehabili­ tation both physical and vocational in cooperation with existing state departments, (4) dental care, (5) medical care for dependents, and (6) a burial benefit for the worker* Private insurance companies fought the adoption of this piece of legislation because it would have competed with death benefits in so-called ,flife insurance" policies. A favorable report was turned in by the first Health Commission of Pennsylvania which endorsed the principle of health insurance.

This commission reasoned that it was the

stated responsibility to make immediate and adequate medi­ cal care available for illness cases and to prevent the financial burden of sickness from falling entirely on the person least able to bear it— the sick wage worker.

Regard­

ing contributions to the program, it advocated some way of distributing the burden of sickness among all the wage earners, industry, or the community as a whole.20 It has been observed that most of the commissions which made a detailed study of the needs for health insurance reported favorably;

while those which rejected health

insurance, with one exception had not made a study of the ^Report of the Ohio Health and Old Age Insurance Com­ mission, February, 1919, pp. 17-18. ^Report of the Health Insurance Commission of Penn­ sylvania, 1919, p. 9.

::

28

needs of wage earners and health insurance* 21 Apparently, the commissions with the most realistic understanding of the problems of the low income group were most in favor of the adoption of some form of health insurance* Although the Wisconsin Commission of 1918 had not undertaken any extensive study of the problem of health insurance, it reported that there was no demand for health insurance and purported that it tfsaw no reason why sickness of the wage-earner cannot be fully met by diminishing sickness*

pp

This same commission stated further I

We see no reason why sickness of the wage earner can­ not be fully met by diminishing illness, without attaching at the same time to this effort a complicated plan of insurance as contemplated by the proposed Health Insurance Legislation* Practically all the provisions of the socalled Standard Bill refer to the method of inaugurating the Insurance System and the question of the prevention of illness receives but little, if any consideration*' We believe that prevention rather Jban indemnification is a better solution of the problem. ^ It is surprising that such recommendations should come from one of the outstanding progressive states in the United States* It was granted by the Connecticut Commission of Public Welfare that there were some strong arguments in favor of

Abraham Epstein, op. cit*, p. 451. 22

Report of the Wisconsin Special Committee on Social Insurance5 1919, p. 49. 25Ibid., p. 49.

29 health insurance, but it declined to endorse such legislation because it was

nexperimental”

and it would have necessitated the expenditures of large sums of money* 24 In Pennsylvania the American Medical Association made

its opposition to the principle of health insurance extremely obvious.

The second Pennsylvania Commission which reported

in 1921 admitted that it had received representation and support from the American Medical Association.

It was odd that both

the State Chamber of Commerce and organized labor opposed health insurance legislation.

The combined pressure of

organized medicine, business, and labor was instrumental in influencing the second commission to negate the favorable suggestions of the first commission regarding the desirability of health Insurance legislation for Pennsylvania. The majority opinion of the Illinois Health Insurance commission, after an extensive survey, declared

nthat its

findings do not justify its recommending compulsory health insurance.

This commission expressed the conviction that

workers could provide themselves, with health insurance if they were to be more thrifty.

A minority report which was written

by Doctor Alice Hamilton and Mister «3ohn E. Hansom vigorously ^^Report of the Connecticut Public Welfare Commission, 1919, p. 16. 25 Report of the Illinois Health Insurance Commission, May, 1919, pp. 165-166.

30 criticized the majority report of the Illinois H ealth Insurance commissions in the following manner:

With reference to the point made in the majority report that compulsory health* insurance has not been an important factor in the prevention of sickness, we would not claim that compulsory health insurance Is intended as a pre­ ventive medical measure. Like many other forms of insurance it is not intended to eradicate the risk against which it offers.26 Evidently the majority report expressed a somewhat confused conception of the nature and role of health insurance measures. Previous to the^development of the foregoing health plans which have been reviewed, the American Association for Labor Legislation proposed a fIStandard Bill11 in cooperation with a, committee of the American Medical Association.

Sickness,

accidents, and death benefits were provided for all employees earning less than $100.00 a month.

A panel of physicians would

have been set up to insure the free choice of physicians by subscribers.

In several ways the medical administration and items

under the "Standard Bill" resemble and antedate quasi medical groups now in operation in many states.

The cost of such

legislation was to be met by the combined contributions from state, employer, and employee.

Specifically, the state was

to contribute one fifth of the expense and the balance was to be shared equally by employers and employees. 86 Ibid., pp. 172-173.

A medical

31 advisory committee was to take care of medical problems and a social insurance commission would have charge of administrative 07

duties* The outlook for group health insurance from 1910 to 1919 was rather encouraging and hopeful.

For many years the

Socialist Part carried in its platform a health insurance plank.

In 1912 Theodore Roosevelt recognized the need for

health insurance and its probable "voting appeal" to the extent that he included it as a plank in the platform of the Progressive Party.

The' tendency toward health insurance had

become quite significant when American political parties and politicians insisted on the inclusion of some reference to health reforms in their campaign literature.

Professor Epstein

reviews succintly the movement for health insurance as follows; In 1916, the standard bill was introduced in the legislature of Hew York, Massachusetts and Hew Jersey. In 1917, twelve state legislatures considered the sub­ ject. The investigating commissions called two national conferences, at Washington in 1917 and Cleveland in 1918. Governors Samuel W. McCall of Massachusetts and Alfred E. Smith of Hew York were especially active in support of compulsory health insurance*28 In fact, Governor Alfred Smith of New York said to the Legislature, "The incapacity of the wage earner because of *

27

Abraham Epstein, op. cit., pp. 453-54. Ibid., pp. 454-55.

31 advisory committee was to take care of medical problems and a social insurance commission would have charge of administrative 07

duties. The outlook for group health insurance from 1910 to 1910 was rather encouraging and hopeful.

For many years the

Socialist Party carried in its platform a health insurance plank.

In 1912 Theodore Roosevelt recognized the need for

health insurance and its probable “voting appeal“ to the extent that he included it as a plank in the platform of the Progressive Party.

The tendency toward health insurance had become quite

significant when American political parties and politicians insisted on the inclusion of some reference to health reforms in their campaign literature.

Professor Epstein reviews

succintly the movement for health insurance as follows. In 1916, the standard bill was introducted in the legislature of New York, Massachusetts and New Jersey. In 1917, twelve state legislatures considered the sub­ ject. The investigating commissions called two national conferences, at Washington in 1917 and Cleveland in 1918. Governors Samuel W. McCall of Massachusetts and Alfred E. Smith of New York were especially active in support of compulsory health insurance*®8 In fact, Governor Alfred Smith of New York said to the Legislature, “The incapacity of the wage earner because of ■v

^Abraham Epstein, op. cit., pp. 453-54. 88Ibid., pp. 454-55.

illness is one

of the underlying causes of poverty.

The

enactment of a health insurance law, which I strongly urge, will remedy this unfair condition.tf

Although the Davenports

Donohue health insurance bill passed

the Senate, On April 10,

1919, the New York Assembly failed to vote on the measure. Such a fate was met by health insurance measures in a number of states already reviewed. The health insurance movement had advanced far enough to prompt the comment that 11compulsory health insurance in 1920 is in about the same relative position as workmen*s compensation for industrial accidents was, with regard to legislative adoption in 1910.ff^

Unfortunately, the develop­

ment of health insurance from 1919 was blocked by various vital forces.

Professor Armstrong has noted carefully the

interests that were opposed to the principle of health insur­ ance in the following manner: All the effort and interest that went into the social health insurance plans in the years 1913 to 1919 was buried by an avalanche of adverse propaganda fostered by a strange alliance of interests which illustrated the truth of the saw, ‘Politics makes strange bedfellows,1 certain commer­ cial insurance companies, certain employers associations, Cited by James Rorty, o£. cit., p. 75. 30

John A. Lapp, American Labor Legislation Review. Vol. 10, p. 27.

33 physicians and Christian Scientists. Of the four groups the first two were the most important politically as they were better organized, more experienced, and better heeled for battle. 3**Another authority in the field of social insurance has observed critically that ffProm 1920 until 1932, when the reports of the Committee on the Costs of Medical Care began to appear, all public interest in health

insurance seems to have disappeared.

Despite the recommendations of the various commissions, nothing concrete was accomplished.

No state, municipal, or other

governmental agency in this country has in any way provided 'rpnr— —

— —

°1 Among

—

the nationally known leaders m cooperative medicine who also led discussion at the Institute ares Doctors Hugh Cabot, Kingsley Roberts, Michael Shadid.

130 of it.

The Group Health Journal serves as an agency of inter­

communication between member and member.

The following

case was published in this periodical which sets forth the advantages of group medicines I know Civic Medical Center...know the wonderful work they1re doing. Uj family— that*s my wife and I and three children...pay $4 a month for the prepayment plan* It;*.s the best investment I ever made. You remember the appendicitis operation my wife had to have last year? That was worth our membership for many a long year. And there was the examination that showed I had gall stones. I*m certainly glad the doctor found that one early. And then there*s a world of security in knowing the children are checked regularly.88 Mr. Petro Lewis Patras, Chairman of the Hospitalization Com­ mittee of Chicago Host Office Clerks* Union, has related his experiences with Civic Medical Center as follows: I had opportunity to become personally familiar with the health service offered by the Civic Medical Center in Chicago, a private group clinic. Members and their families come in at least once a year for a thorough medical examination when well. If a member has any disease or illness such as a persistent stomachache, backache, headache, skin disease, rheumatism, or any of the thousands of different sicknesses, he comes in for diagnosis and treatment. He may see a general physician, specialist, have X-rays taken blood and urine tests, diathermy, in short he is entitled to the attention of every man and machine that modern medicine has developed for the protection of lives* All of this without cost, beyond his membership dues* If he gets sick at home he does not have to worry about the-doctor bill* If he needs to have an operation he goes to the hospital with a lighter heart he won*t have any surgeon*s fee.89

8&cited in Group Health Journal, lt4, May, 1941. 89pe tro Lewis Patras, !lSearch for Health Security,11 Medical Care. I: 161, April,.1941.

131 The steady Increase in members has made manifest the fact that the educational program of this group health association has awakened many people to the advantages of group medicine* Prom the standpoint of medical problems, one of the notable advances made by this health group has been in pre­ ventive or protective medicine.

In an effort to diagnose

pulmonary tuberculosis and arrest this condition in its earliest stages, every subscriber to Civic Medical Center is requested to have an X-ray examination of his chest*

The examination

is given without charge and probably was the first time an American group health association has undertaken so extensive a preventive health campaign.

Doctor Lawrence Jacques, one

of the physicians and surgeons for Civic Medical Center, has disclosed the importance of preventive medicine, especially in a group health association, as follows: What are the specific advantages of group practice in the field of preventionf We cannot in any direct sense ’prevent1 gallstones, appendicitis, most types of cancer, heart disease, defects of visions or injuries received in automobile accidents. But we can, by early examination and persistent treatment, cure them when they can still be cured, and prevent many of their complications and end results. Early examination is another prevention. Unfortunately there have been two serious obstacles to early diagnosis and treatment: (1) the financial barrier, (2) lack of education, on the part of both doctors and patients. And herein lies the twofold advantage of group medicine. For properly organized group practice should

132 dissolve the financial obstacle for a large segment of our population, and a proper relationship of groups of doctors to groups of patients should permit an adequate program of education.^ Health Journal has called attention of members to the importance of X-raying each health group member. Xt is hoped by both subscribers and physicians that the corrosive opposition of the American Medical Association was stopped in Washington D.C. because of the verdict which designated that the medical society had been guilty of violating the United States ^mti-trust” laws.

Doctor Jacques comments

on the testimony of Doctor Olin West, Secretary and General Manager of the American Medical Association, in the following way: Civic Medical Center, it should be noted, does not include all the physicians in this locality. This is fnot necessarily* unethical. The Civic Medical Center is a partnership. This is *not necessarily1 unethical. Practice by a group of doctors and group prepayment is not in itself unethical. It would seem then that in the eyes of the secretary and general manager of the A.M.A. the Civic Medical Center is 1not necessarily1 unethical.91 The emphasis and place of an educational program have been given a prominent hearing in this group health, association. A high degree of social and medical organization characterizes Group Health Cooperative. 90 "'Preventive Medicine,” March, 1941. 91

Group Health Journal, 1:3,

Lawrence Jacques, ”A.M.A. Trial,” Group Health Journal, . 1:2, April, 1941.

133 GROUP HEALTH COOPERATIVE OF NEW YORK CITY This health organization was the first group to define, itself as a cooperative plan.

It was organized a few years

ago under the general directorship of the Bureau of Co­ operative Medicine, and the initial capital was contributed by individuals and agencies interested in fur the ring the principle of cooperation, especially as it applied to medical care* A subscriber to this health cooperative has the right to the services of a general physician, including an annual physical examination.

Surgical and other technical services

are offered by specialists practicing in thi3 cooperative health

group.

Patients receive whatever laboratory and other services

are necessary for complete diagnosis of a case.

go

About the same health conditions are excluded from service in this association as in the health groups previously analyzed and reviewed.

Conditions existing at the time of

enrollment, such as mental or nervous illnesses requiring treat­ ment by a specialist in psychiatry drug addiction, chronic alcoholism, routine eye refractions, Workmen1s and Veteran1s ^ H o w to Pay Your Doctors1 Bills 9 (New Yorks Group Health Association Inc., £1940,3

Compensation cases, or cases requiring treatment in an asylum, sanatorium or isolation case in a public institution are not included in the service regime of this group health association. Maternity care by qualified obstetricians is available when the expected date of birth is at least months after both parents associate themselves with Group Health Cooperative.^^ Ho plan of group hospitalization has been developed as yet by this group health association#

It is presumed that

when the group has become large enough to support group hospital zation, it will be incorporated in the plan.

However members

may now secure adequate hospitalization through the Associated Hospital Service of New York, a Blue Cross plan# Group Health Cooperative has no enrollment fee.

Payment

of the first quarterly premium includes a qualifying examina­ tion.

If a subscriber is rejected because his state of health

does not meet medical requirement for membership, he loses the first quarterly payment,# basis.

Payments are made on a periodic

However, a saving of one dollar Is made if prepayment

of dues is made one year in advance#

The following table on

the next page sets forth the specific costs charged by this health group.

An extra fee Is charged in cases where diagnostic

X-rays are necessary if the charge does not exceed ten dollars.

135

TABLE V

rThe differ­ ence between panel practice and private practice,f she says, 1is that you give private patients a complete overhauling and medicine for a half-crown, whereas you give panel patients a complete overhauling and a pre­ scription for nothing* The panel patient gets the prescription filled free at his chemistfs and you get your quarterly check from the Insurance Committee*f Another general practitioner claimed that an important ad­ vantage

of the scheme was that the physicSan had no book± 4 Ibid.~p. 149

306 keeping to do for his panel patients; hence no accounts to keep, no bills to send.

Such a scheme more than compensates

for the "paper work" required in signing certificates and medical cards, and "putting the

ticks" of visits and

surgery attendances*

A somewhat

analogous development to quasi group health

associations in the United States has been applied to the dependents of health insured persons in England*

The British

physicians, through the Public Medical Service, have organ­ ized a plan whereby the dependents of insured workers may receive medical services by paying a voluntary contribution. The contributor has free choice of physician.

In adminis­

trative control the scheme is similar to California Physicians* Service inasmuch as control is vested rather completely with physicians.

Apparently British medicine realized that it

was ethically and financially sound practice to place the cost of medical care on a voluntary insurance plan through small budgeted payments for dependents of low income workers. British cooperative societies have been instrumental in furthering the principle of health insurance.

One of the

significant elements of genuine cooperativeness is democratic

Xb Ibid. ~p.

149.

16 Ibid.. p. 155.

307 control of policy by members*

The Co-operative Wholesale

Society of Great Britain has established a special department for health insurance.

Considerable controversy was generated

in the cooperative movement by the proposed National Act of 1911.

Insuraaace

Before the act was passed, the commercial insur­

ance companies were successful in obtaining the passage of a section which permitted the insurance companies to vote separate sections to operate health insurance on a non-profit making basis.

It was this concession which opened the way

for the cooperative movement to do likewise*

While the

connection between an approved society which is a special section of profit making concerns is not, in strict law very close, yet in practice the connection is much closer, since the parent body also provides good will and special facilities 17 for operating. Professor Garr-Saunders specifically sets forth the detail of the health insurance section as follows: Control of the G.W.S. Health Insurance Section, therefore, vest formally in the insured members* The membership is divided into groups of not less than 750 members each group being attached either to a co-operative society or group of co-operative societies, or to a depot of theC.W.S. $ach group of members is entitled to elect from its membership

Alexander M. Saunders, P. Sargant Florence, Robert Peers, Consumers1 Co-operation in Great Britain (New York: Harper and Brothers, Publishers, 1938), P« 180*

308 one delegate for every 1,000 members to transact business at the annual general meeting of the section and at special general meetings.18 It is worthy of note that the total number of Insured contributors for England and Wales increased from 15,894,000 at the end of 1929 to 16,710,900 at the end of 1935, an increase of 5 per cent*

During the same period the member­

ship of the Co-operative Wholesale Society Health Insurance Section increased by 132,000 or 49 per cent.

It is thus

clear that cooperative health insurance has grown rapidly in recent years and is now the seventh largest approved society in that country.19

In the United States, however,

cooperative medicine effects a greater economic saving due to the pooling

of scientific equipment than Is true in

Great Britain. SCANDINAVIAN COUNTRIES In 1891 Sweden adopted a system

of voluntary health

insurance which was subsidized by the government.

Compulsory

health insurance in Sweden has not been accepted largely because of the cost of such a welfare program.

Cash ben­

efits have been more emphasized than medical care as a ---

Ibid., p. 180. 19 Ibid., p. 182.

509 national program#

20

Norway, in 1909 adopted compulsory health insurance legislation which offered medical care for wage earner and dependent#

The official carriers of health insurance were

either private or public sickness societies. sickness society was required by law in

At least one

each commune.

Provision has been made so that private sickness societies could substitute for public societies.

Doctor John E.

Nordskog, Professor of Sociology at the University of Southern California, portrays well the nature and

extent

of health insurance legislation in Norway in the following manner: It is also worthy of stress that not only may the insured member who has been contributing to the sick­ ness fund receive compensation, but the spouse and children or adopted children under fifteen years of age who are dependent upon the member may receive compensation for medical and dental aid, and nursing. To a member’s spouse is to be given compensation of 75 crowns for burial expenses, and for children or adopted children who are dependent, a benefit of 50 crowns. A wife -who is not herself a member of the fund may receive compensation against confinement, and in addition, 30 crowns as aid for each child birth. For children and adopted children under seven years of age who are dependent upon the member, and who have been born with defects for which early med­ ical care might effect cure or relief, such medical aid is to be provided from the sickness fund. 21

Barbara Armstrong, ©£. cit., p. 317. 2 John E. Nordskog, Social Reform in Norway (Los Angeles? The University of Southern California Press, 1935), p. 131.

310 Norwegian health legislation contains a sliding scale of health, cash, benefits which is adjusted according to the number in the family.

Where there

was only one dependent

a twenty per cent cash benefit, was given, and where there op were two dependents a 35 per cent cash benefit. The ad­ ministrative details of Norwegian health insurance

are as

follows : ...the State pays two sixth of the average premium for each member; the community where the work is done pays one sixth; the employer pays one sixth of the average premium for every compulsorily insured member in his employ...For each sickness insurance fund there is to be a governing body consisting of five members, three of whom shall be insured persons and one an employer liable to pay contributions, and also personal substitutes, elected by the communal council for three years at a time. Chairman and vice-chairman are selected by the governing body itself. Each fund has a business manager, auditor, or auditors, and the governing body may appoint nurses, masseurs, et cetera, such appointments to be approved by the National Insurance Institution. Eligi­ bility to the governing body of the fund is subject to certain limitationss every person who is entitled to vote under the Act respecting elections to the Storthing shall be eligible, provided that the business manager and auditor of the fund, other paid employees of the fund, and medical practitioners and midwives who practice on behalf of the fund under a contract shall not be eligible. The Act also provides that every person who is eligible shall be bound to accept office if elected, unless he has attained the age of sixty years or is chief guardian or a member of the standing committee of the commune or has acted as a member of the governing body during one term of office. Management may be provided separately for each fund, or jointly when suitable and efficient. ^

Barbara Armstrong, o£. cit., p. 313*

^

John E. Nordskog, o£. clt., p. 145.

311 Denmark adopted in 1892 a more thorough.-going system of voluntary health insurance than The

that in Uorway or Sweden.

government granted rather liberal subsidies to registered

societies having at least fifty members.

Both medical care

and cash benefits were provided for the insured population. Barbara Armstrong suras up the Danish health insurance system as follows t Denmark fund had achieved a fine organization of medical care, often furnishing specialists services and convalescent treatment for both the insured per­ son and his dependent children, setting a standard that was not equalled under some of the compulsory systems.2^ The success of voluntary health insurance in Denmark is heartening to struggling group health associations in the United States.

Mr. Frederic G. Howe relates the

Danish health insurance as follows: not designed exclusively for workmen.

extent of

f,Sickness insurance is It is open to all men

and women of similar economic standing, and includes small farmers, agricultural workers, civil servants, and the life. Two-thirds of the population are insured against sickness through their local agencies operating under general state supervision.1,25 It is significant that by 1925 almost every sickness

^

Barbara Armstrong, op. cit., p. 318.

25 Ibid., p. 309.

312 fund made available to the insured person not only complete medical care by a general practitioner but also treatment by a specialist if necessary.

Drug and nursing services

have- become quite generally accepted by the Danes as imper­ ative elements of health insurance.

Until the advent of the

second World War Denmark had become a leader in the fielf complete medical

of

services financed through voluntary health

insurance under state supervision. GERMANY Germany inaugurated the first compulsory system of health insurance on a national basis in 1883* 26 Pour general types

of benefits were

provided by this health legislation:

sickness, cash benefit, maternity benefit, funeral benefit. Local sick funds were the chief insurance carriers.

A good

example of local fund and organization may be gained from a brief review of the Leipgig plan.

Free medical attendance

and care was administered from the first day of illness.

A

cash benefit was given from the second day of disability not to exceed 55 per cent of the basic wage.

Instead of the

two foregoing benefits, a disabled insuree received medical treatment in a hospital or sanitarium.

In addition to the

Emory S. Bogardus, Sociology (New Yorks millan Company, 1941), p. 450.

The Mac­

313 cash benefit, pecuniary provisions were made in the following cases:

maternity, death, and members of the family not 27 gainfully employed* More than four decades ago a panel was organized in

Leipzig, Germany, made up of more than three hundred physicians, to offer medical services on a contract basis*

The inclusive­

ness of the physicians associated with the Leipzig panel resembles quasi group health associations in the United States* By having a majority of physicians practicing in the city on the panel list it was possible to allow for free choice of doctor.

Medical doctors were paid on a per capita .basis*

Health resorts and medicine were available to members.

In

1911 the German compulsory insurance law was extended to a larger number of workers, including teachers and homemakers* In 1932 more than three-fifths of the total population of Germany were covered by compulsory health insurance, ap­ proximately three-fourths of the medical profession were em­ ployed by insurance organization*

The increase in family sick­

ness benefit was stated as follows: Whereas in 1911 about 37 per cent of the funds provided medical service for the family of the insured worker, thus reaching nearly five million people not required to be benefited by the act, in 1925 over 85 per cent of the local 27Ibid., p. 309

314 and rural funds, comprising nearly 94 per cent of tiie insured workers, provided such service for more than fourteen million dependents. Nearly five million more (family members) were included under the rules of substitute funds and the miners funds, thus raising the number of family dependents receiving medical care through the insurance system to nineteen million prior to the compulsory inclusion of family benefits.^8 Liberal hospitalization

and dental service were

obtainable by a large segment of the German workers. of the most encouraging trends

One

of the pre-Hitler period

was toward the incorporation of preventive medicine methods as a part of the national health insurance plan.

An effort

has been made to utilize visual aids to dramatize the im­ portance of preventive and early curative steps as factors reducing the seriousness of illness. UNION OP SOVIET SOCIALIST REPUBLICS Medical

services in the Union of Soviet Socialist

Republics have been subjected to the most thoroughgoing changes.

Imperial Russia had developed certain important

aspects of health insurance.

Writers on health

insurance

point out that the system of health insurance in Soviet Russia is more inclusive than in any other country in the world.It would be difficult, Russian

in fact, to imagine now

health insurance could be more inclusive.

income groups are included under the system.

28 Ibid.., p. 312.

All

The Soviet

315 worker was eligible for medical services and cask benefits beginning the day be became disabled.

All medical services

including specialists, hospitalization, and medicine were provided free.

Not only is the eu^jloyed worker protected,

but all his dependents as well. liberal when it

Maternity-grants are quite

is considered that the employed expectant

mother is requested to take a leave of absence from twelve to sixteen weeks with full compensation.

Nearly all pregnant

women in the U.S.S.R. are not eligible also for these benefits, whether employed or not.

Possibly one serious drawback of the

Soviet medical program is the lack of freedom of choice of medical doctor, especially in

view of organized private

medicine in this country and Great Britain, which seems to meet with favor on the part

of the patients.

Soviet medicine is frequently described as State med­ icine inasmuch as the government supervises and financially supports medical care for the Russian people. 29 Harry Elmer Barnes, a liberal writer,says, Whatever one may think of Soviet economics in general, no honest or informed observer can well deny the remark­ able achievements which Russia has made with state med­ icine. In spite of severe, if not unique, handicaps, Russia provides better medical service for the mass of

It might be said that state medicine in Soviet Russia is merely a reflection of the social and economic organization of that country.

316 its citizens than any other country in the modern world. This has resulted wholly from the introduction of State medicine.3^ Dootor Henry E. Sigerist spent considerable time and study in the last few years in the Soviet Union.

He has

become one of the most forceful physicians in this country demanding reforms in the payment and servicing of medical care.

Doctor Sigerist remarks t

Nobody can deny that Soviet medicine in the short period of twenty years and under the most trying cir­ cumstances, has stood the test and has created powerful measures for the protection of the peoplefs health. It has demonstrated that Socialism works In the medical field too, and that it works well, even now, in the early beginnings of the socialist state. It has a system that is full of promise for the future— for a very near future... State medicine differs from voluntary group health associations in several ways.

Under state medicine, the

lay person cannot feel that a particular clinic is !this health group .® He does not select his own physician. physician is assigned to him at his place of work.

The The

growth of proprietary attitudes on the part of either lay members or physicians can not develop very firmly.

Under

a system of government or state medicine the worker pays his contribution into a common fund;

30Harry E. Barnes, op.

hence there is little

clt., p. 477*

3^*Henry E. Sigerist, Socialized Medicine in the Soviet Union (Hew York: Norton Book Company, 1937), p. 307.

317 specific nexus between pecuniary contribution and medical services#

It is rather impersonal relationship, probably

more so than exists under fee-for-service group health medi­ cine#

Lay participation in the control and administration

of medical services is a worthy educational activity of the American group health association* for it makes for health consciousness.

State medicine, as practiced in Russia,

eliminates this personal interest.and constitutes a serious shor tcoming . I39DIA In Bengal, India, an Interesting health movement has been under way.

About 30,000 people were organized into twelve

socities in 1939, training and care,

These societies have stressed public health A common problem has been to devise methods

for controlling malaria.

The doctors are paid monthly by a

group of contributors drawn from semi-rural areas.

Members

receive medical services upon the paynent of regular dues.

In

some cases the farmers have traded farm' products for medical care.

Industrial and public health services are thus offered*

A central laboratory for research for research is maintained by the cooperative health societies#

Each week a health union

318 conference is held and the problems are analyzed. 32 SOUTH AMERICA A tendency worthy of comment is the fact that in the Western Hemisphere, the relationship between individual and environmental services is close.

When health insurance is

instituted in South American countries, it begins with primary emphasis on health and medical services and with lesser em­ phasis on compensation of disability wage loss.

A rather close

bond has been established between insurance and public health o b j e c t i v e s . T h e cooperation between these two agencies is certainly important and natural. A good example of health insurance legislation and procedure may be ascertained by an analysis of the situation in Chile*

In this country a comprehensive and broad social

insurance law and enactment was passed in 1924, covering the risks of old age, invalidty, sickness, and death*

The

health insurance measure was enacted as a community measure because the death rates were unnecessarily, high and because tuberculosis and other diseases, whose incidence is closely associated with socio-economic factors, were excessively prevalent. 32

In 1938 the law of 1924 was supplemented by a

Doctor Emory S* Bogardus, "Social Principles of the Co-operative Movement," a class lecture, December 4, 1939#

319 preventive medical act, which, stresses the necessity for early detection and treatment of tuberculosis, syphilis, rheumatism, afflictions of the heart and kidneys, and the 33 occupational diseases# In order to aid in the detection of these diseases all persons covered by social insurance are required to submit to a health examination once a year.

The

importance of medical care as compared with cash sickness benefits is well related as follows? In the social insurance budget of Chile, provisions for medical and hospital services take the leading place. In 1937-38, expenditures for these services were seven times as large as disbursements for cash sickness benefits, and accounted for 77 percent of the total cost of benefits* In the development of its sickness insurance system, Chile lays particular emphasis on the construction of hospitals, the establishment of clinics, and the organization of medi­ cal centers in rural areas. In effect, where basic per­ sonnel and facilities are lacking or inadequate to pre­ serve health or prevent illness, the new social insurance system attempts to meet these needs. It develops an in­ tegrated program, largely avoiding the traditional divi­ sion of effort among public health, private medical service, and social insurance protection of individuals.34 The majority of group health associations in the United States, no matter what type, have ignored and excluded from treatment persons afflicted with syphilis.

Such exclusion discloses a

rather archaic attitude toward these so-called “social diseases.1* Adequate preventive and early treatment of persons afflicted ^I. S . Palk, “Medical Services Under Health Insurance Abnoad,*1 Social Security Bulletin, 3?1^, December, 1940;/f-zo, I 34 Ibid., p. 13.

5B0

would be a wise step in the reduction of the prevalence of these diseases.

.American public health officials have been

endeavoring to convince the public that elimination of social diseases is bacteriological rather than a. purely moral(question Chapter review.

Schemes of health insurance have been

adopted more generally in ©urope than in the United States. As a rule voluntary plans of insurance preceded compulsory health insurance.

Numerous agencies which formerly administered

voluntary health insurance have served also as carriers for compulsory health insurance, which has resulted in unnecessary but inevitable duplication of administrative machinery.

There

is evidence for viewing what seems to be a ,fculture lag" in this country regarding the adoption of health insurance as a possible advantage, since the possibility of adopting com­ pulsory health insurance, if considered socially desirable, may proceed without hindrance of "overlapping administrative machinery"

which so much encumbered the development in

European countries reviewed.

It would be erroneous to com­

pare voluntary group health associations in the United States with the Friendly Societies offering voluntary health insurance prior to the adoption of compulsory health insurance in Great Britain, or with similar societies in other European countries, since the former comprise a complete, centralized, administra­ tive organization with medical information and scientific

321 equipment concentrated in focal areas easily accessible to member clientele;

while the latter represents incomplete,

decentralized, heterogeneous administrative organizations lacking the close interaction of medical personnel and uti­ lization of common medical equipment*

Considered from a soci­

ological point of view, group health associations in the United States represent a further and more efficient social advance than even the most exemplory systems of compulsory health insurance in contemporary operation in Europe*

Xt

would be a comparatively simple process to effect a social fusion of the average group health association in the event that the government decided to set up numerous compulsory health groups throughout the nation, because of administrative centralization of clientele, personnel, and equipment. 2*

Medical doctors in Europe were reticent at first

to adopt health insurance as a means of financing the cost of medical care*

A definite social psychological shift in

attitude toward positive acceptance of health insurance is observable in European countries.

Comparatively speaking,

it is significant that American physicians have realized quite recently that it is now ethical to pay for medical care on a periodical basis.

European medical doctors who have in­

surance panels probably have more economic security than do many fee-for-service physicians in the United States* Economic

322 security, thus offered, constitutes the satisfaction of a basic wish and makes for less emotional anxiety about pe­ cuniary matters on the part of the physician. 3*

Usually under compulsory health insurance insurees

do not control their local insurance carriers since commercial insurance companies have 11stepped into the picture11 and taken over control*

As might be expected, democratic control is

most manifest in cooperative carriers of health insurance in Europe*

Gooperative health groups in the United States are

well known for the democratic lay control of basic adminis­ trative policies*

In fact, lay groups are important co­

owners of the health group in this country. 4*

Even though, legally, group health associations

in the United States are sometimes considered as falling to *•? employ the principle of insurance, there are several factors which reveal that, socio-eeonomically, health groups, at least indirectly, use the insurance principle*

For instance,

both health groups and schemes of health Insurance involve the budgeting of payments by a group of members or insurees*

It

is this group budgeting of payments of health services which makes it possible to share the cost of severe illness among a large number of people* a great number co-members* insurance ass

The risk of illness is thus met by Sir William Beverridge defines

nThe collective bearing of risks is insurance*

323 It is insurance, whether the individual contributes specific premiums to meet &ach specific risk, or whether hr receives free insurance out of the general resources of the community or of industry.

It is insurance whether the contributions

are voluntary or compulsory*n35 in short* insurance may be considered as an attempt to guarantee another against less by a contingent event.

Illness may be thought of as the

contingent event with medical care offered as compensation for the loss of health. 5.

It seems quite doubtful whether either compulsory

health insurance or state medicine as organized in European countries will be adopted soon in this country, inasmuch as the obvious lack of membership control of administrative policy is almost diametrically opposed to the prevailing democratic culture pattern in the United States* epitomized in the development of cooperative group health associations around a democratic ethos. 6.

The relative free choice of physician and ease

with which a member may switch physicians

are common practices

and elements of both health insurance and group health associ­ ations.

Preventive medicine is practiced by the panel physician

under compulsory health insurance because it reduces the num­ ber of services on his panel, and, since he is paid on a capitation basis, reduction of panel illness recurrences auto­

324 matically frees him for additional time to devote to private patients from whom he receives a fee-for-service remuneration* Preventive medicine is practiced by group health associations because it is advantageous to the economic security of the health group*

Economically, it is unsound for physicians

under quasi group health plans to practice preventive medicine, since their incomes depend upon the types and number of health services rendered*

Therefore, preventive medicine must be

left to the altruism of the individual physician under the quasi group health plan. Unfortunately preventive medicine has been advocated largely because of its economic soundness rather than as a means of 7*

practicing social telesis. Probably it is true that quasi group health associ­

ations in the United States are more closely analogous to compulsory and voluntary health insurance plans as conducted in European countries than are other types of plans operating in this country because they lack coordinated pooling of equipment and have the same duplication and overlapping of apparatus and medical information as is found in Europe. Prom the standpoint of social organization and progress, European health insurance schemes and American quasi group health associations manifest unfortunate culture lags.

CHAPTER IX MAJOR CONTEMPORARY PROBLEMS AND VALUES OP COOPERATIVE AND PROPRIETARY GROUP HEALTH ASSOCIATIONS Attention is focused in this chapter on the general problems confronting, and values emerging out of health groups in the United States*

In preceding sections of

this study unique problems of particular group health associations were analyzed in considerable detail, but this chapter contains analyses of a cross section of com­ mon and significant difficulties experiences by these health organizations# MAJOR PROBLEMS 1.

Group health associations have been troubled

with the problems of increasing their membership*

The

American people have not been so^d completely on the idea of group medicine.

In fact, many people have

never heard of the group health association.

Besides

the lack of awareness of the group health movement, quite a number of potential members fear health groups because they are seemingly contrary to our capitalist ethos

326 of the American culture pattern# Group health association administrators believe that a health group

ought to have a minimum membership of between

5,000 and 5,000 in order to operate satisfactorily and effi­ ciently.

It has been noted earlier that members in smaller

group health associations pointed

out that If they had more

members many of their problems would be solved. words, there seems to be a law of operation.

In

other

increasing returns

In

A membership of 3,000 compared with 500 would

make available the following facilities and services to members:

j£l) a greater range and variety of health services,

(2) a'greater range of choice of medical doctors by individual members.

This fact has

expressions of members.

been repeatedly made manifest by the It is very doubtful that two or

three doctors in a small medical group can satisfy the eccentricities of enough members.to instill confidence in their ability.

Members, like consumers, want to shop around

a bit for their doctors, and a feeling of social rapport between doctor and patient must be established before treat­ ment can be effective.

(3) A larger membership makes pos­

sible a reduction in the per capita cost of health services given, and (4) more medical equipment could be centrally located which would automatically help facilitate the utilization of such tools.

327 Group health associations in their initial stages of organization and function are in an unfortunate situation. One member of a Midwestern health association expressed quite well the plight which is true of a number of small health groups as follows; vicious circle.

,f0ur problem is literally a

If we only had more members we could give

better service for less, which would in turn attract more members to our health plan.

During the first period of

growth we have to appeal to the farsightedness and cooperative spirit of people in order to convince them of cooperative health.

the values of

As our health plan becomes larger it

will be possible to point out the pecuniary savings involved in our plan, besides

the underlying spirit of cooperation.

In short, if we had a larger membership most of our present problems would be s o l v e d . T h e addition of new members and the maintenance of old members of group health associations.

is certainly a central problem Other insights into the problem

of recruitment of members will be gained by an analysis of some typical attitudes expressed by non-members as to why they did not join a group health association.

A college

professor of the University of Southern California interviewed as to why he did not join a grotp health clinic replied as

Personal interview with O.J#

5£8

follows * Ho, I am not a member of the clinic. I have. investi­ gated them,, however, and perhaps they are all right if you live in"the city. But if you live in a suburb they have a branch office, and they do not appeal to me. In my case I live in a community where they have a Branch Office, but I was not favorably impressed. In charge is a doctor who does not appear any too compe­ tent. It would not do to trust my wife and children to his care. He has one nurse. The set up is too small, and there is no choice. Of course, you can come in to the city to the clinic, but that is too far away for us. It wouldn’t work in case of emergency. The Branch Office is quite impossible. We middle class people certainly get soaked when it comes to medical service. The wealthy can pay and the poor get service free, but we have to pay prices that we cannot afford. The group health idea is good. But still I d o n ’t know whether a doctor on a salary will take as much interest in his patients as one on a personal fee basis. I ’m afraid most of them would take an impersonal attitude and not be really interested. Why should they take a personal interest when you d on’t pay them directly? Some of them are too young and inexperienced. But we are in dire need of something like the group health idea. Ho, I wouldn’t be interested to help run the clinic. I ’d be satisfied with first class service and moderate rates and would let the doctors rim it. It is up to them to make good as doctors.2 The ecological location

of the central office seems to be a

pro Diem in the mind of this interviewee.

In the branch office

there is probably little !tgrouping of medical personnel and medical equipmentH which prevents the promotion of attitudes of confidence.

The interviewee also thinks that attitudes

2 Interview with A,H.

339 of confidence are inhibited because he feels that doctors on a salary basis

might not take as personal an interest in

patients as doctors on a fee-for-service basis might.

If

the emotional definition of the non-member is that the physi­ cians in a group health association are impersonal,

to all

practical purposes the situation may be considered as

real,

even though there may be little of actual fact to support this feeling.

On the other hand, if by demonstration,

physicians employed by the group medical plans can show that they are interested in their patients, and that they can give service as good as under a system of individualistic medicine, then a reversal in

attitude on the part of patients is pos­

sible. Another non-member of a

group health clinic expressed

his feelings as follows; I have thought of joining the clinic several times partly because several of my colleagues belong, and partly because I believe in the idea. I would like to try them out in minor ailments, but I*d rather keep my family physician for major illnesses. I wouldn* t want to trust them for really serious care, I understand that they are very busy there, and that they do not have enough doctors, and some of my friends who are members have had difficulty in getting one of their doctors out to the house when some one needed emergency care. This happened, in one case I know of, and after considerable delay a young doctor came out, but he did not engender confidence in the patient. I wish there was a real cooperative medical plan operating here, with competent doctors. I have

330 investigated one in Los Angeles but it is small and a high-strung doctor is in charge. It doesn’t give me confidence in the plan, although I believe in the idea and would like to help develop a strong health cooperative where the members control it and not the doctors. However, not all my friends would care to be bothered with voting. Some of them would rather play bridge or write books or do research. Xt is woeful the way intellectual people are not informed about cooperative undertakings. They are so individual­ istic that they don’t want even to be cooperative unless it will help them in their personal interests. So few people want to be cooperative for cooperation’s sake. I guess that it is the fault chiefly of education in homes and schools Failure to recruit this member who believes in the principles of cooperation is due to the fact that he does not have confii ence in the quality of medical service dispensed by the

group health association.

In the grave

and serious medical case the confidence of the patient is taxed.

Members have repeatedly

that the physicians sent

made mention of the fact

on home calls are not of a

type

to generate deep-seated feelings of confidence in the patient* Our mores have cultivated a physical stereotype into which the

public feels medical doctors must fit.

Thus, the

unknown group doctor sent out on a home call must fit the preconceived social psychological stereotype of the patient or he is viewed with distrust even before he is able to demonstrate his ability.

Interview with

In this the private practitioner

T#W#

331 has the advantage, for he is usually called to a patient*s home after having had an opportunity to prove h i s •worth in the traditional medical surroundings of his own office, which fits into the mental stereotype of the patient's notion of what the medical doctor in attendance upon him should be like. ethos.

This case also gives insight into our individualistic Our culture pattern stresses individualism to the

extent that it is becoming difficult for people to think in terms other than those prescribed by capitalism. cooperation becomes more of an accepted

As

pattern, group health

associations will probably not meet with as much opposition from the citizens as they do at the present time. Another major problem mentioned earlier which confronts nearly every member of a group health association operating in the United States relates to the physical distance which

some members have to travel in order to

obtain medical services.

Efforts have been made by a good

many group health associations to have district group health offices located in satellite communities surrounding larger cities*

However, as in the case just cited, some

of the

members insist that they do not have a range of choice of physicians in these district offices.

Two other problems

become clear which have been touched upon, namely, the small group health association cannot support regional offices

332 because of a small membership, and, on the other hand, the large group health association which endeavors to provide regional clinics is criticized because it does not have enough physicians in each office*

In the regional offices

there are not enough members to warrant the additional ex­ pense of hiring more doctors*

Perhaps some form of shifting

doctors around until they are able to locate physicians who are acceptable to a majority of the local member-residents might help to alleviate this problem*

A member of a group

health association in the East expresses her feelings re­ garding the problem of location of the central office as follows: It is a difficulty which I am confronted with each time I desire medical attention* I have to drive nearly ten miles to receive medical care. I have been for­ tunate enough to be in pretty fair health and thus have not had to experience the full import of such a condition* The ill ambulatory patient is put to a lot of inconven­ ience by having such a distance to go* If you feel quite ill it is a problem to know whether or not a person ought to attempt to visit the doctor* After a medical examination I often feel psychologically upset and . driving back home is somewhat dangerous* Yes, I know that it is possible to have a physician call at my home, but that involves an extra charge, and I feel like my periodic payments are partial when I do that. Of course, you know that we are working hard on a plan whereby a district office will be established*^1 lit

A somewhat similar attitude is revealed by a member 4

Interview with M*P*

333 of a cooperative group health association in the Midwests I am used to doing all my shopping and taking care of nearly all my business with local stores and people* I find it a bother to have to take the street car down to the doctor's office. All the big stores are beginning to have branch stores in our community. I hope it will be possible for our health group to have a branch clinic near my home.5 Some of the group health members do not realize that it is a financial impossibility to provide a district clinic for only a few members.

There is also the possibility that some members

of health groups still feel that they are buying something and

nsalesmanship”

deserve

attention*

Many group health members

fail to remember that they sometimes had to travel some dis­ tance to reach the office of the private practitioner of their choice before they joined a health group*

Not every kind of

specialist is found in the neighborhood, and what general practitioners are handy do not invariably meet with the ap­ proval of all the residents of the area.

In the case of group

health members, perhaps there is realization ahd appreciation of the merits of cooperative medicine.

The problem is prob­

ably not one of more deficiency of group methods as compared with private medicine, but rather one of hope for more of a good thing. 3* 5

Organized opposition of the American Medical Associ-

Interview with P.P.

334 ation to plans of group health constitutes a serious problem for the majority of group health associations operating in the United States*

The traditional interpretation of ethics

of medicine has clashed rather directly with the recent social development and organization of new health plans aimed at alleviating and improving the health status of the low in­ come middle class in this country*

Hospital administrators

sense the prestige value of having the name of their hospitals listed as being among the approved hospitals in a bulletinpublished annually by the American Medical Association, for it gives the hospital social status to be so listed.

It is

clear that group health physicians cannot function as effi­ ciently as general practitioners if they are denied the right to utilize the tools and equipment of modern hospitals*

In

certain types of illnesses necessitating hospitalization, such discrimination seriously endangers the member-patient1s health as well as the good will of the group health association*

In

a few instances group health doctors have been threatened with license revocation if they continued to be affiliated with group health medicine* It was pointed out earlier in this study that the Group Health Association of Washington, D.G* was instrumental in taking a number of leaders of the American Medical Association to trial on the ground that the medical body was guilty of

535 violating the Sherman anti-trust laws*

6

The twenty-one defendants

were found not guilty, hut the American Medical Association was found guilty of the charge*

Legally speaking the American

Medical Association's policy of direct suggestion and antag­ onism to health groups has "been frustrated by this trial, yet the social-psychological effect of the campaign which they have waged for so many years still persists as may well be observed by the response of the following group health mem­ ber: Our problem is in trying to straighten out the mischief which the A.M.A. has been responsible for so many years* They have confused the issue rather completely* Both the medical doctors and the public are in a state of confusion regarding just what is group health medicine* I have talked with a number of fairly intelligent people as to why they did not become members of our health plan, and do you know what they generally reply? 1I asked my doctor what he thought of the plan and he said that it was a step in the direction of socialized or communistic medicine.1 Everyone has heard horror stories which circulate about as to how patients are treated under state medicine, so they do not want to become connected with anything that smacks of communism* It will take a long time to recon vince those people that our type of group health care is strictly American and not the idea of some crack-pot in Europe* The evil seeds sown by the A.M.A. are still growing weeds. For many years cliques within the American Medical Association have effectively indoctrinated physicians practicing in this ^For an excellent and fair review of this trial see ,fThe Medical 'Anti-Trust Trial.1 n Medical Care, Is272-76, July, 1941. 17

Interview with A.V.

country with the idea that health groups ultimately lead to socialism or socialized medicine, labels not acceptable to the American people#

Physicians in turn have imbued their

patients with the same distaste for group medical practice# Hence, many non-members, vfhen interviewed as to why they did not affiliate with a health group, frequently responded in much the same vein as the followings Our private doctors are opposed to such new fangled ideaoup Health, Group Health Mutual Inc., St. Paul, Minnesota How to Pay Your Doctor1s Bills. Association, 1940.

New Yorks

Group Health

The Answers About Group Health. Group Health Association of Washington D.C., September, 1940. Prepayment Plan, Chicago;

The Civic Medical Center, jl940^1

Voluntary Civic Plan, Missouri and Southern Illinois, July,1940. Your Doctors and hospitals Offer Health Service for You! California Physicians1 Service, 194TI 450 Physicians, Surgeonsa and Specialists. King County Medi­ cal Service Corporation, Seattle, Washington.

376 G.

NEWSLETTERS

Chicago Teachers Union Medical Center Plan, Provided by Civic Medical Center, 1941. G.H.A* News, Annual Report of Group Health Association Inc., Washington B.C.: Jl94l7j Contract Proposed by the Board of Directors. belt Health Association, June 24, 1941.

Greenbelt;

Green­

The Medical Care Program, for Farms Security Administration. Farm Security Administration, 1941• Weitsman, Edward I., Newsletter, ¥une 24, 1941, Association. H.

Greenbelt Health

NEWSPAPERS

Los Angeles Times, March 6, 1941. Henry E. Sigerist, Newspaper J? M., October 4, 1940. The Ohio Co-Operator,

April, 1941.

The Cooperative Builder, May 3, 1941.

APPENDIX

377 COPY OP ORIGINAL-CONTRACT WITH LOS ANGELES COUNTY EMPLOYEES ASSOCIATION Dated July 25, 1929 AGREEMENT FOR MEDICAL AND HOSPITAL SERVICES THIS AGREEMENT made and entered into this 25th day of July, 1929, by and between the LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION, hereinafter referred to as party of the first part, and the ROSS-LOOS CLINIC, a co-partnership composed to Doctors Donald E. Ross, and H. Clifford Loos, hereinafter referred to as party of the second part, WITNESSETH: That the ROSS-LOOS CLINIC will provide complete medical, surgical, and hospital services for members of the LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION under the following terms and conditions: I Every active member of the said association shall be eligible to receive benefits of this service upon the terms hereafter mentioned. The party of the second part hereby agrees that they will not enter into any arrangement or agreement for medical

378 or hospital services with any individual or group of individuals employed by LOS ANGELES COUNTY unless said individuals are members of the LOS ANGELES COUNTY EMPLOYEES1 ASSOCIATION,

If a member other than an active member desires

to subscribe for the service mentioned herein, he may do so with the consent of the party of the second part# II The party of the first part will pay to the party of the second part on the last day of each and every month a sum equal to two dollars ($2,00) for each and every member of the

LOS ANGELES COUNTY EMPLOYEES' ASSOCIATION who has

subscribed for and is entitled to the service mentioned herein and who has been so certified by the party of the first part to the party of the second part.

It is under­

stood that if an Individual is so certified on a day prior to the 15th of the month that the full sum of two dollars > ($2,00) is to be paid for said month, but if any individual is thus certified after the 15th of any month that no fee will be paid for such individual for said month. Any cost necessarily incurred in making collections from the persons mentioned herein is to be borne by the party of the second part.

379 III This contract may be terminated by either party hereto upon the giving of written notice to the other party of intention to terminate this agreement not less' than 90 days from the date of said notice, IV It is agreed that the service to be rendered by the RO0S-LOOS CLINIC SHALL BE as follows: (A)

To all members certified to the party of the second

part as heretofore mentioned without further payment of any kind: 1.

All medical and surgical attention intention includi

diagnosis, clinical or laboratory tests, X-ray examinations, treatments, operations, professional consultation, and visits. 2*

All medicines and drugs with the exception of insulin,

needed in the conduct of a case of sickness or of surgery which may be prescribed by the medical attendents. 3*

All dressings, splints, etc*, prescribed by the medi­

cal attendant, exclusive of orthopedic appliances, eye glasses, dentistry, crutches, wheel chairs, sicknoom furniture, etc. 4*

Hospitalization of any subscriber where such treat­

ment is prescribed by the medical attendant for such period as

380 may be necessary in the treatment of any acute or chronic condition, providing the period of stay in the hospital of any one individual does not exceed three months in any one calenyear.

Said hospitalization is to include ward bed in a first

class hospital selected by the R0SS-L0Q3,CLINIC, such hospital selected by the ROSS-LOOS CLINIC, such hospital to be a privately operated institution.

Should a subscriber desire

other accommodations than those covered by the terms of this agreement, he will pay the difference between the ward bed rate of the private hospital selected by the ROSS-LOOS CLINIC and the cost of such accommodation as he may select*

Hospitali­

zation shall be construed to mean bed, meals, general nursing, X-ray, laboratory tests, operating room, medical, and surgical supplies used, anesthesia, special diets, drugs, or any other adjuncts in ordinary usage in hospital procedure. 5.

All cases of sickness and disease both medical and

surgical are to be treated with the exception that cases of mental derangement and drug addictions are to be treated only up to such time as the patient may be legally committed to a state Hospital and provided further that the term ,fhospitalizationfl should not. be construed to include treatment in a tubercular sanitarium. 6.

The ROSS-LOOS CLINIC will maintain a complete and

modern centralized office where all parties covered by this agreement residing In the metropolitan district of the city

581 or county of Los Angeles will report for service either by way of office or home calls; the said metropolitan area is hereby designated as being that portion of the city or county of ^os Angeles within a radius of ten miles from the Los Angeles County Court House.

An office will be designated

by the ROSS-LOOS CLINIC in the Los Angeles-Long Beach Harbor District; the San Fernando Valley; the Santa Monica Bay District;The San Gabriel Valley; and elsewhere as may be determined by both parties*

All surgical operations will be

performed by the surgeons of the central office and subscribers in all sections of the county will report to the central office for such work to be done, excepting in those cases where transportation would be to the detriment of the patient, or in emergency cases in which case the surgeon in the sub-office or the central office will render services required as may be requested by the patient. 7.

Regular office hours will be maintained at both

central office and sub-offices to meet the convenience of patients. 8.

A 24-hour service by telephone will be maintained

at both central and sub-offices with prompt response to meet demands for house calls, and it is further agreed that in emergency cases should the patient be unable to obtain the services of the physician at the sub-office, the ROSS-LOOS

382 CLINIC will respond to a call regardless whether the call is within or without the metropolitan district heretofore mentioned, 9» Except as above specified, the subscriber will not demand house calls to be made when he is in such physical condition that a visit to the office during regular office hours would not be detrimental to his well-being. 10.

A subscriber residing outside the metropolitan

district as heretofore defined may have residence calls made upon him upon the following conditions as to payments (a) If he resides within five miles of one of the designated suboffices, no extra charge. (b) In the event he resides more than five miles from the designated sub-office, the physician of the nearest sub-office will respond to the call, charging the subscriber mileage at the recognized rate as charged in the neighborhood where such call is made, providing, however, that such mileage charged shall not, in any event, exceed the sum of 50^ per mile both going and coming from the call, the mileage each way being computed on the basis of the difference between the dis­ tance from the sub-office to the call less the district of five miles• 11.

Only regularly licensed physicians of high scientific

383 and professional standing, graduates of recognized, reputable medical colleges duly licensed to practice in the State of California, will be retained by the ROSS-LOOS CLINIC.

In

those cases where a specialist is required and provided that such specialist is not on the regular staff of the ROSS-LOOS CLINIC, the CLINIC will engage such a specialist, selecting one of recognized standing in the community. (B)

Service to family dependents of subscribers? 1*

Family dependents includes bona fide members of

the subscribers1 immediate family residing with him and wholly dependent upon him for support. 2*

Family dependents will receive the same service

and be entitled to the same privileges as the subscriber him­ self under the same rules as enumerated above and without pay­ ment of any fees for or on behalf of said dependent with the following exceptions to wits The family dependents will pay the cost priee for all medicines, drugs, dressings, splints, X-ray films, hospitalization and specialist as may necessarily be called in from outside the staff of the ROSS-LOOS CLINIC AND ITS SUB-OFFICES. ¥ IT IS FURTHER AGREED that in the event of a controversy

384 "between the.ROSS-LOOS CLINIC or their representatives, and a subscriber, or should the said ROSS-LOOS CLINIC desire to drop from the list of subscribers any member of the LOS ANGELES COUNTY EMPLOYEES* ASSOCIATION, an arbiter shall be selected by the said Association, one by the said Clinic, and a third selected by these two and any decision arrived at by a majority of said arbiters shall be final and binding upon all parties concerned* IN WITNESS WHEREOF the representatives of the parties hereto caused the same to be signed, delivered this 25th day of