MEDICAL CARE BECOMES A RIGHT

...Let's let the conferees take a look at the facts, especially if we can put off the public's taking a look at them...

...However, when the conference finally came off, the AMA was not able to stack it as it wished and its effort backfired, i loudly...

...They are accustomed to being asked for their opinions and are under no compulsion to weigh the merits of these opinions in open discussion with the public, which in their view is a largely undifferentiated laity, certainly with no competence in medical matters, and hence presumably with no right to meddle in matters that could affect medical practice, however tenuously...

...The non-vested pension (and most private pensions are still of the non-vested type) increasingly chains the worker to the particular employer as the years go by—chains him with the golden chains of non-transferable pension credits, but chains him all the same...

...This allows simple central administration and the efficiency possible when both the collecting and the disbursing of funds are handled under one roof...

...It is the main point of reference for social legislation...

...The social security program has been responsive to this situation but is limited...

...For one thing, the system is uncomplicated...

...Nor was the picture of the doctor delegates—confused, defensive, and incoherent—a healthy omen for the AMA of its own effectiveness in the battles still to come...

...The curious fact is that medicine, of all enterprises, has been elected to demonstrate how a business activity— for that is the medical profession's present character—can adjust to a changing America that will not much longer tolerate partisan advantage at the public's expense: the public's needs are going to be served and no business organization, no matter how powerful, is going to thwart this objective indefinitely...

...For two years, remember, organized medicine had suggested that we take it easy on all this nonsense about Federal financing of minimal medical care for the aged at least until the Conference on the Aging...

...In subtle ways, it may injure freedom to spend money as you choose...

...The trouble, it has turned out, is that the act is so minimal in its effectiveness it is setting up the AMA for the knockout blow: the states, almost without exception, have spurned the program because they cannot or will not put up the necessary matching money...

...There has been longstanding and universal (except within organized medicine) agreement that a contributory system is socially healthier than a relief (public assistance) program...

...However, in the more complicated world of the present, its position has been indefensible in this particular area...

...Since it is a contributory system, it follows that benefits are conceived as a matter of right, not qualified by way of a means test...

...Indeed, one of the persuasive arguments for the social security solution to the medical problem of the aged is that there is an efficient, going apparatus already at hand, one in which the administrative expense has been considerably below original estimates—now only about two per cent of benefits paid out, an admirable ratio by insurance company standards...

...he is sustained by wages...

...It is in the political arena that the the profession is altogether monolithic...

...Not one of the 2,700 delegates to the Conference could miss the point nor miss noting the decisiveness of the vote for the social security approach...

...In consequence, loss of wage is the critical factor...

...Though a most elaborate press apparatus was set up to report this affair, outside of Washington the coverage was negligible...

...It can affect our stature with the peoples of the whole world...

...What role will such a leadership play in guiding us to deal with the large and subtle problems of an increasingly complex society...

...Its performance here is precisely as in the matter of aid for the aged...

...Since applied science has so enormously increased productivity, the need for labor has diminished, with the consequence that most people over sixty-five no longer have a place in the labor force...

...The principle here is not a justification for general national health insurance, as medical leaders have implied so often...

...It provides for the Federal government to bolster existing state public assistance (relief) programs for the aged on a stepped-up matching grant basis so as to accommodate medical needs...

...Hospital costs (the biggest factor) and medical costs should be provided for under the social security system for the same purpose as the original measure—that is, to keep the recipients off the public assistance rolls...

...The opposition is the lobby known as the American Medical Association, "just another mean trust," as Harry Truman has put it, plus its cohorts in the insurance business and in anti-social security business circles in general...

...Sometimes it interferes with the freedom to keep your intimate financial affairs to yourself...

...But something "unofficial" happened, nevertheless, that amounts to a sanction almost, if not quite, comparable to such "official" acts...

...Nor can all important events even when observed be accommodated within the peculiar stylistic conventions of press reporting—for example, such requirements as a legitimate news peg, a catchy lead, explicit, easily identified substantiating authority, whether by person or by documents...

...meantime, all legislation must be suppressed in Congress...

...The argument runs like this: In an industrial civilization, the worker has only his labor to sell...

...It is a fact, too, that nearly all active practitioners are quick to point out—and rightly so— the good work of the AMA and its constituent societies in disciplining the profession, in setting standards, and in conducting an essential educational program in medical matters through its literature and meetings...

...Federal aid for student tuitions and for teachers as well as for bricks and mortar is imperative because there is demonstrably no other way to finance them...

...Every knowledgeable doctor will concede this in private...

...What is more, no story, even in the capital, showed appreciation for what really happened—most likely, in all fairness to the press and its stylistic conventions, because nothing "official" did happen...

...Conversely, the case for ministering to the health needs of the elderly retired through the principle of payroll taxes, contributed throughout one's working life for dispersal via the social security mechanism when needed—this principle was supported relentlessly, repetitiously, and irrefutably...

...the latter category usually looks up to the societies and in fact constitutes their backbone...

...Other practical administrative arguments for social security are equally impressive and were advanced cogently by several speakers at the White House Conference...

...On the whole, the law keeps the Federal government quite out of the picture, except for the financing...

...No means test is involved, which is to say the discretionary element is reduced to a minimum—simply whether or not you are sixty-five— and hence does not involve human judgments, some subjective and delicate, on a mass of personal data...

...This is a necessary prelude to understanding why the profession is silent in the face of their political brass's suicidal support for the position represented by the Kerr-Mills law, the measure passed in the rump session of the 1960 Congress...

...Doctors are fond of pointing out that theirs is not a monolithic profession with a single view...

...each state is allowed to set its own range of benefits and to determine by its own criteria who should be eligible...

...In retrospect, at least, it will be seen to be of great consequence to the American people...

...This will have happened in no small degree because EDWARD T. CHASE recently attended the White House Conference on Aging...

...This had to be done to defeat the opposition and convince the ignorant...

...This is more than domestic news...

...Thus the first great system of health insurance to develop in this country, workmen's compensation, is tied to the wage-loss-restoration principle...

...There are other equally basic principles to be noted...

...Finally, no one seriously disputed the hard core of facts which are at the heart of this whole great fight: that four-fifths of the 15.8 million people sixty-five years and over have annual incomes under $2,000, that three-fifths have under $1,000, yet the aged have double or triple the average national incidence of illness and only half of them have any degree of health insurance at all...

...It also impedes many of the other typical freedoms...

...The backfire was this: the AMA's favored expedient, the theory of medical care for the aged offered through the state public assistance programs on a means-test basis, was discredited throughout the Conference by reasoned, factual presentations...

...The old AMA saw about the "compulsory" nature of the Forand bill and McNamara bill was also dealt with harshly when it was pointed out repeatedly that all tax-funded measures are compulsory, the mandatory feature being a characteristic of tax laws...

...Public assistance not only impedes freedom of movement, since assistance may not be available for extended periods in a new state...

...That is, Congress did not pass a law, a high court did not announce a decision, nor did the President issue an order...

...They work extremely hard, read little, and must conserve their reading time for medical material...

...First, a most important roadblock was removed in the effort to perfect the American "welfare state...

...Now the AMA is pushing state adoption of Kerr-Mills desperately, aware that the measure's dramatic failure is vividly underscoring the need and arousing even further the public demand for action through social security...

...It is the concept that medical care now is a right, like the classic triad of food, clothing, and shelter—plus, in modern times, a free education...

...Practitioners learn early in the game that a small private business that depends on referrals and on organizational status within the profession's institutions, especially the hospital, does not encourage political idiosyncrasy...

...It is worthwhile to restate the social security position because the election campaign debates on the issue distorted it, and because we are going to be confronted with a rousing revival of the whole fight before President Kennedy has been in office six months...

...More significantly, a long stride was taken in establishing the acceptance of what can best be described as a new basic social right...

...the results of this long-awaited Conference cannot be used to strengthen the hands of the opposition in the upcoming Congressional debate, but instead will exert the heaviest pressure for affirmative action on the social security approach...

...This is true, in a broad sense...

...Also, there is a great variation in social sophistication between, on the one hand, research doctors and teachers at the universities and those with salaried governmental jobs or with large pre-payment medical plans practicing on a group basis, and on the other hand the solo practitioners who consciously view themselves as conducting a small private business for profit, whether they be famous surgeons on Park Avenue or general practitioners in suburb or small town...

...But not the official leadership...

...The magnitude of the risk is beyond the scope of private insurance, which could not conceivably acquire the reserves needed for the whole nation's future social security liability...

...It is simply the principle that when income is stopped by retirement or disability, provision of medical benefits is to be provided precisely as in workmen's compensation...

...Nor would it be naturally forthcoming in many doctors anyhow...

...The same test of freedom creates a crushing presumption favoring social security over public assistance wherever the substitution can be made...

...With the vast amount of preparation at the state level, literally thousands of pre-Conference conferences, the White House affair was bound to be an important landmark...

...It is small wonder that the White House conferees came away with a renewed appreciation for the social security system and puzzlement over the AMA line...

...There are many other details that could be reported from the Conference—such oddities as the fact that the AMA, in plugging for the Kerr-Mills measure, is backing a law that, among a number of other violations of hitherto sacrosanct AMA principles, does not stipulate the very arch principle the organization always harps on—freedom of choice of doctor—though the Forand and McNamara bills do provide for just that...

...it is largely local rather than Federal since each state determines its need and participates to the degree it sees fit...

...The Federal social security credit by contrast is transferable from job to job, state to state, industry to industry, leaving the worker complete flexibility to come and go and choose jobs without worrying about effects on his social security rights...

...The position of the AMA on legislative matters affecting the profession is the position of the profession...

...Don't rush these radical moves, we were cautioned...

...Most are totally absorbed in their demanding professional work...

...This wise counsel will be forthcoming when medicine appreciates once again that it is a profession, not a business...

...An important point is implicit here, one which was made tellingly at the White House Conference on the Aging by Republican egghead Arthur Larson, Eisenhower's former speech-writer...

...In the face of a clear-cut crisis in the supply of physicians, with the ratio of doctors to population dropping steadily, the AMA has stuck to an impossible position...

...A case in point is a remarkable development that took place during Dwight D. Eisenhower's next-to-last week in office: The White House Conference on the Aging...

...This merely recognizes that an urban, industrial society is a wage-based society...

...Finally, it has required the exasperating procedure of re-arguing at a White House conference the whole case for social security that was fought out a quarter of a century ago...

...This occurred last year when both parties, in their campaign platforms, supported Federal financial aid to medical care for the aged...

...Larson put it this way: "No American freedom is more typical than the freedom to move and change jobs at will...

...It remains a key controversy in mid-century America...

...This is, of course, exactly what happened in 1960...

...If it is sensible for retirement owing to age to be cushioned by pension payments, then, when age also creates the problem for these retirees of above average incidence of illness and steep medical costs, social security could, and should, function to meet this problem, too...

...Does a relief recipient dare to be seen picking up a six-pack of beer in the supermarket, or driving a 1931 Chevrolet...

...No one was frightened that the economy or the Federal budget would be adversely affected by spreading the cost for medical assistance for the aged over the entire wage-earning population...

...May not some taxpayer see him and grumble, 'Look at him riding around like a king on my money...

...Well, perforce we did wait...

...More particularly, they are conscious of the self-seeking character of the county medical societies, which carry on the brunt of medicine's organizational activity...

...But for the first time, the odds now run strongly that the social security principle will prevail in this 1961 Congressional session...

...Horror at the prospect of Federal involvement obscures all reasonable argument...

...It has required an unconscionable amount of time even for the principle of Federal involvement to be accepted by both major political parties...

...A vast number, possibly even the majority of doctors, are bored with or hostile to the AMA...

...And this is, or certainly should be, news—important news...

...But it is more interesting to reflect upon the longer-range implications of organized medicine's performance...

...It has required a national spectacle of several millions of citizens—the elderly lacking the income for decent medical care—undergoing severe and needless privation, to elicit the interest of the rest of us...

...Disability from industrial injury or illness is to be compensated for at a level to keep the beneficiary from pauper status, yet not so prosperous as to encourage malingering...

...The social security system is a contributory one, that is, a tax on pay rolls—the worker and his employer paying in the active, independent years for the benefits to be dispersed in the period of retirement and dependency...

...It is a position easy to predict, slow to change, formidably pressed by the drum-beaters of each local society as well as by the AMA, and it is one that is almost never challenged, at least audibly, by the doctors in the ranks...

...Anyone with the slightest knowledge of the matter appreciates that the overriding motivation of the AMA in supporting the Kerr-Mills legislation is that it is the most minimal of the various bills considered, the least the AMA could get away with without having to adopt the politically inexpedient posture of being publicly against any government assistance...

...Historically, AMA's contribution to medical education has been admirable...

...For there will be a battle—and soon...

...As for the states, they cannot efficiently or equitably administer coverage of individuals for their entire lifetimes in all the various state jurisdictions and even in foreign countries...

...Eisenhower's last White House meeting, an ironic development, of course, since it is in dead conflict with his known beliefs...

...The AMA supports this measure, claiming it does the real job properly: that is, it copes with the proven needy by a means test...

...It is a right, which is to say that it is not to be compromised by personal economic adversity...

...not limited by one's ability to pay...

...Furthermore, the social security system is a Federal, not a private or a state, insurance system because of overriding practical advantages...

...What we must hope for is positive counsel of the highest order from the medical profession, not the anti-social nonsense that has characterized its recent efforts to maintain its economic privileges...

...The former category is hostile or indifferent to the medical societies...

...This is not all too bad because it establishes the need for periodicals of comment and interpretation like The Progressive...

...To a truly surprising degree, all this was brought off at Mr...

...Yes, another one of those vast, pompous, earnest symposia...

...It has taken a long time and some doing to get to this point...

...All this is in flagrant contrast to the AMA-backed Kerr-Mills approach (also the Javits approach) of a state-by-state system, whereby the country would wait (indefinitely, as the evidence now emerges) for each state to pass, set up, and finance its own particular plan...

...He has written on social and economic themes for a number of publications, including Harper's, The Reporter, The Commonweal, and Commentary...