24. The number of insurance carriers and administrative boards with which any one employer will have to deal brings a heavy burden of accounting upon industry.

25. There would be great difficulty in applying the provisions to sparsely settled communities where wages and incomes are usually low.

26. No European country pays 66 2/3 per cent to beneficiaries as provided in the bill proposed in Massachusetts.

27. The premiums are based on uniform costs and not upon occupational hazards.

By Strong Central Government

28. Such a scheme of administration is better administered by a strong, central government, the members of which have high notions of civic responsibility, and where the length of service is counted in long terms of years. The danger of creating opportunities for reward of party fealty is a danger to be well weighed by the citizens and taxpayers of Massachusetts.

29. The amount of money necessary for insurance if paid by the commonwealth under an able and efficient board toward the prevention of sickness and the treatment and cure of disease, which is perfectly legal under the powers of the state, would be a much better expedient than the means suggested by the various health insurance bills.

At the present day the average individual has not been able to avail himself of the best of medical advice and treatment, and such a plan of prevention would be educational to the masses; would prevent the beginning and spread of sickness and disease; would result in a better type of individual citizen; would preserve the self-respect of the individual; would treat all classes of society alike, would be entirely consistent with Americanism and comprehends that all contribute to the health and welfare of all.

ATTITUDE OF MEDICAL SOCIETY OF THE STATE OF NEW YORK TOWARD COMPULSORY HEALTH INSURANCE 1

1

The committee's statement, together with its findings and recommendation, as adopted is as follows:

The essential components of all compulsory health insurance

1 Monthly Labor Review. 10 255-8. January, 1920.

schemes are two: I, the provision of a cash indemnity during a relatively brief period of incapacity to labor due to illness; 2, the provision to the insured and their dependents during a determinate time of so-called medical benefits which comprise medical, dental, and nursing attendance, hospital and sanatorium accommodations, maternity attendance, drugs, and all necessary medical and surgical supplies.

The proponents of this legislation rest their demand for the institution of this scheme in America upon two main allegations: 1, that a very large amount of poverty is due to illness causing consequent unemployment and loss of income; 2, that a vast amount of the population receives inadequate and insufficient medical attendance; that is, that medical attendance is grossly deficient both as to quantity and quality.

With the general features of the measures proposed for the legislative enactment of the compulsory health insurance scheme in this state your committee will deal only in the briefest manner; the matter is familiar to you. It is proposed to establish an administrative machinery radiating downward from a division of the state industrial commission composed of a certain number of commissioners appointed by the governor who, in turn, appoint a chief of the bureau of health insurance. Subordinate to the commission and acting under regulations made by the commission function the boards of directors of the local funds, composed of three members elected by the employer members of the local fund, three elected by the employees and one additional elected by these six. All the affairs of the funds are administered locally by these boards of directors. Each local fund employs a medical officer who is permitted to practice and who is practically the medical supervisor of the administration of the benefits of the act. The medical profession is not represented upon any executive body under the proposed law, but is permitted to function solely through advisory committees, local and state. Its sole statutory representative has an administrative, not an executive function.

After consideration of the evidence put forward by the proponents of this legislation in support of their statement that a large proportion of the poor have been impoverished through unemployment caused by illness, your committee finds that none of this evidence is unimpugnable and that it rests upon largely a priori reasoning. The preponderance of evidence is against

the fact that any considerable amount of impoverishment is caused by illness; moreover in those cases where impoverishment is caused by illness, it is due to the long-enduring disability preceding death occurring in the chronic diseases, especially tuberculosis, chronic heart disease, cancer, chronic joint infections, renal and vascular disease which cause a disability long exceeding the period of twenty-six weeks during which the insured is entitled to benefits under the scheme. The statistics of the labor bureau of New York State show that in the main disability from all causes, including accident, injury, and illness, is the source of, on the average, only 5.7 per cent of unemployment, about the same amount as that caused by weather conditions (5.6 per cent) or a little less than half that caused by labor disputes (10.6 per cent), or one-thirteenth that due to lack of work (74.6 per cent). A survey entitled "Poverty in Baltimore and Its Causes; Study of Social Statistics in the City of Baltimore," by the Alliance of Charitable and Social Agencies, McCoy Hall, Baltimore, Md., November 15, 1918, gives strong evidence of the small part illness plays in the cause of poverty; moreover, it evidences strikingly the fact heretofore stated as to the relationship of prolonged disability not covered in any scheme for health insurance to the relatively few cases of impoverishment due to sickness. Your committee would find, therefore, that short illnesses causing ephemeral disability bear no relation to poverty; that where impoverishment is caused by illness it is in all instances due to long-continued disability; and that illness is but a very minor cause of unemployment as compared even to the conditions of the weather or labor disputes.

Your committee is unable to find any available evidence that will bear inspection proving that, in the main, medical attendance in this state is grossly deficient in quantity or grossly defective in quality. If these facts were true it is unable to satisfy itself that the people of this state would receive a larger and closer degree of medical attention where one physician may care for either two thousand or more patients as permitted under this scheme than they now receive where the proportion of physicians to population is about as one is to seven hundred and eighty. Moreover, your committee is satisfied that the quality of medical attention would no more be benefited in the United States than it has in Germany, Austria, and Great Britain, by the conversion of medical practice from its present

plan into an enormous scheme wherein the practitioner would be employed from year to year under contract, and in the final analysis subject to lay dictation as to means and methods of practice.

Your committee feels very strongly that the inquisitorial powers which would be conferred upon the state industrial commission and its agents, and upon the local boards of directors must be considered in its effect upon the public health, and especially as to the rôle it might assume in submerging and nullifying the activities of the present state department of health which has played so large a part in the reduction of morbidity and mortality by means of preventive, not palliative, medicine.

There is no uncertainty about the evidence that the relative morbidity rate, mortality rate, infant-mortality rate, and maternal-mortality rate has been much more materially reduced in the United States during the past twenty years than it has been in Germany and Austria, where compulsory health insurance, not alone, but the whole scheme, including invalidity and unemployment insurance and old-age pensions, have been in force. It can, therefore, be seen that compulsory health insurance, as such, plays a very small part in the reduction of length and severity of illness, and that on the whole it has been of extremely little value medically in those countries, while it has been the cause of a profound deterioration in medical service and medical morale. Even in England, where it has been in operation for a comparatively short time, it has proven so defective and ineffective for the purpose for which it was instituted that it is now proposed to inaugurate the plan of state medicine to supplant it.

Your committee therefore finds:

I. There is no necessity for the institution of a scheme covering the major portion of the population of the state, providing for the institution of contract medical practice on a colossal scale in order to furnish medical attendance and other services.

2. In those countries where this scheme has been in operation for many years it has caused a deterioration in medical morale and medical service, and that its effect in this state would be the same; that is, a lessening in the quality of medical service.

3. In comparison with those countries where this scheme has been in operation, the United States shows a more marked reduction in mortality rate, both general and as affecting maternal

and infantile mortality rate. Apparently the morbidity rate under the scheme has doubled instead of being diminished in Germany and Austria since the institution of the social-insurance plan.

4. There is danger of the scheme gradually undermining the functions so extremely valuable to the community at present subserved by the state department of health.

5. Owing to the paucity of accurate and unimpeachable data collected by means of an unbiased investigation, your committee recommends that the legislature of 1920 be requested to appropriate a sufficient sum of money for the use of the health department and such other departments in association with it as it requires for the purpose of making a survey of the State of New York to determine the amount and character of illness in its economical relation to the Commonwealth.

6. If additional legislation is to be enacted, it should provide for a greater development of existing agencies for preventive medicine, together with the extension on a large scale of the present county and municipal functions for both preventive and remedial medicine, and it should make further provision for the inauguration of more widely extended utilization of the present institutional clinical facilities for the diagnosis and treatment of disease in order to facilitate the access of the entire population of the state to modern methods in the practice of medicine.

Your committee therefore, recommends that the house of delegates, and, through them, the Medical Society of the State of New York, unqualifiedly oppose the enactment by the Legislature of the State of New York of any law instituting a system of compulsory insurance against sickness because of its menace to the public health of the state.

MYSTERY AND THE MENACE OF COMPULSORY HEALTH INSURANCE IN THE UNITED STATES1

There appears to be something in common between the influenza epidemic and compulsory health insurance. The origin of the propaganda for compulsory health insurance is shrouded

1 From article by C. D. Babcock, Secretary of the Insurance EcoEconomic World. n.s. 17 489-90. April 5,

nomics Society of America.

1919.