Fourth Annual Report of the Secretary of Labor for the Fiscal Year Ended June 30, 1946. Washington: U. S. Govt. Print. Off., 1947. 218 pp. 40 cents.

Contains the annual report of the Children's Bureau.

Employment Security

CORNFIELD, JEROME; EVANS, W. DUANE; and HOFFENBERG, MARVIN. Full Employment Patterns, 1950. Washington: U. S. Govt. Print. Off., 1947. 41 pp. (U. S. Bureau of Labor Statistics, Serial No. R. 1868. From the Monthly Labor Review, Feb. and Mar. 1947.)

"Attempts to evaluate in quantitative terms what is involved in achieving and maintaining high and stable levels of employment after full adjustment to peacetime conditions." "Economic and Employment Commission; Program of Work Mapped Out at First Session." United Nations Weekly Bulletin, Lake Success, N. Y., Vol. 2, Feb. 18, 1946, pp. 135138. 15 cents.

FISHER, ALLAN G. B. International Implications of Full Employment in Great Britain. London, New York: Royal Institute of International Affairs, 1946. 201 pp. $3.

An analysis of the interrelations and possible conflicts between the objectives of a national full-employment policy and an open international economy. Examines the nature of international conditions required for the maintenance of full employment and the fluctuations in employment arising from membership in an international economic system.

SNIDER, JOSEPH L. The Guarantee of Work and Wages. Boston: Har

vard University, Graduate School of Business Administration, 1947. 191 pp. $2.75.

A survey of industry's experience with guaranteed wage plans and an analysis of the problems involved are followed by a discussion of the immedate and long-range objectives of stabilizing business and maintaining employment. Outlines various approaches which have been employed and describes measures that business and the Government could take to provide employment security.

Public Welfare and Relief

HOEY, JANE M. "The Amendments to the Aid to the Blind Title of the Social Security Act." Outlook for the Blind, New York, Vol. 41, Feb. 1947, pp. 40-43. 15 cents.

Information on the changes in financing aid to the blind resulting from the 1946 amendments. Points out ways in which State agencies can improve administration by abolishing residence and citizenship requirements and by adopting a State-wide standard of assistance.

Social Work Year Book, 1947: A Description of Organized Activities in Social Work and in Related Fields. Ninth issue. Russell H. Kurtz, editor. New York: Russell Sage Foundation, 1947. 714 pp. $3.50.

This biennial "concise encyclopedia" in the field of social work consists of two parts. Part One contains 79 signed articles, supplemented by reading lists, describing functions, activities, and programs. Directories of governmental and voluntary agencies in the United States and Canada comprise Part Two. TRAYLOR, OBRA F. "Colorado's Bonus Plan for Aged Pensioners." Bulletin of the National Tax Association, Lancaster, Pa., Vol. 32, Feb. 1947, pp. 142-146. 25 cents. Describes the operation of the Colorado provision for distributing among the recipients of old-age pensions the unexpended balance of the old-age pension fund, and comments on the implications.

Health and Medical Care FROTHINGHAM, CHANNING. "The Health of the Nation; a Plea for Public Medicine." Atlantic Monthly, Boston, Vol. 179, Feb. 1947, pp. 52-54. Presents the case for a compulsory health insurance program and shows why voluntary methods are inadequate.

MICHIGAN HOSPITAL SURVEY. Hospital

Resources and Needs; Report of the
Michigan Hospital Survey. Battle
Creek: The W. K. Kellogg Founda-
tion, 1946. 172 pp.

Data on present hospital and public health center facilities and personnel; population; economic, social, and geographic factors; and recommendations and plans concerning an adequate and coordinated hospital system for the State.

MOUNTIN, JOSEPH, and PERROTT, GEORGE ST. J. "Health Insurance Programs and Plans of Western Europe." Public Health Reports, Washington, Vol. 62, Mar. 14, 1947, pp. 369-399. 10 cents.

A survey of prewar, existing, and proposed social insurance programs for medical care and compensation for income loss during temporary and permanent disability in England, France, Belgium, Sweden, Denmark, and the Netherlands.

"Problems of an Aging Population." American Journal of Public Health, New York, Vol. 37, Feb. 1947, pp. 152-188. 50 cents.

A series of papers, presented at the annual meeting of the American Public Health Association, which includes: Setting the Stage, by Louis I. Dublin; Care of the Aged and Chronically Ill, by Theodore G. Klumpp; and Sheltered Care of the Aged, by Joseph H. Kinnaman.

"Progress Toward a World Health Organization." Public Health Reports, Washington, Vol. 62, Feb. 14, 1947, pp. 225-248. 10 cents.

Information on the first two meetings of the interim commission, the technical committees established, and relationships with other agencies. "Union Health and Welfare Plans." Monthly Labor Review, Washington, Vol. 64, Feb. 1947, pp. 191-214. 30 cents.

Two articles, the first of which describes typical plans developed through collective bargaining and gives information on the number of workers, industries, and unions involved. The second article describes the program of the International Ladies' Garment Workers' Union and the experience of that organization.

U. S. OFFICE OF VOCATIONAL REHABILITATION. Annual Report of the Federal Security Agency; Section Three ... for the Fiscal Year 1946. Washington: U. S. Govt. Print. Off., 1947. pp. 197-230. 15 cents.

A survey of activities carried on by the Federal office and by the cooperating State agencies in working with disabled persons.

U. S. PUBLIC HEALTH SERVICE. Annual Report of the Federal Security Agency; Section Four . . . for the Fiscal Year 1946. Washington: U. S. Govt. Print. Off., 1947. pp. 231-395.

WISAN, J. M.; GALAGAN, D. J.; and CHILTON, N. W. "Studies in Dental Public Health: I. Cost Analysis of the New Jersey Dental Treatment Program, 1944-45." Journal of the American Dental Association, Chicago, Vol. 34, Mar. 1, 1947, pp. 322-329. 40 cents.

Data on the cost of the children's dental care program.

U. S. GOVERNMENT PRINTING OFFICE: 1947

The Month of April

Economic activities continued on a high level in April: the output of motor vehicles fluctuated around 100,000 a week; production of steel ran 85 percent above the prewar level; consumption of electric power and oil was 25 percent above 1943 figures. The same month, however, brought certain symptoms of increasing economic difficulties and frictions. The number of commercial failuresalthough still very low in relation to the 1930's-had tripled in comparison with those in the same month of the preceding year. Currency in circulation did not increase between April 1946 and April 1947 as much as prices did over the same period. Department-store sales were still high, but their volume was less than in 1946, with correction for the rise in prices during the 12 months. The main source of the growing difficulties is believed to be the resistance of consumers to inflated prices.

In April, efforts were made to ease the situation. The Council of Economic Advisers and the President recommended voluntary cuts in prices by producers and distributors. Labor and management reached agreements in wage disputes in some key industries, on the basis of a moderate raise in hourly wage rates. Thus, simultaneously with partial cuts in prices the purchasing power of workers is being bolstered. The readjustments are not universal but may be regarded as straws in the wind, showing the direction in which the leading forces of the Nation are going in their search for a solution of pending difficulties, before these difficulties develop into a general set-back.

Despite the increasing friction, the economic system was still operating in April on the full-employment level. Unemployment-estimated by the Bureau of the Census at 2.4 million at the beginning of April-was predom

742970-47-1

inantly seasonal and frictional. But there were definite indications that the influx of job seekers was greater than could be explained by seasonal factors. For the first time in 1947, the weekly numbers of initial and waitingperiod claims exceeded those in the same weeks of 1946. The comparable data for the 4 weeks ended in March and the 4 weeks ended in April are shown in the accompanying table.

The jump in initial and waitingperiod claims in April of both years was due to seasonal and administrative factors (including the beginning of a new benefit year in several States), but the rise in 1947 was con

In this issue:

SOCIAL SECURITY IN REVIEW:

The month of April__

March in review__

Number 5

spicuously larger than that in 1946. It is worth mentioning, also, that the Weekly number of claims for unemploy ment insurance benefits in March and April, 1946 and 1947

Month and week

March

1st week.

2d week.

3d week 4th week

April

1st week. 2d week.

3d week. 4th week.

Middle American institute on social security_

Page

122

998 1,018

2

Veterans' unemployment allowances. Nonfarm placements---

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OLD-AGE AND SURVIVORS INSURANCE:

Workers with earnings of $3,000 or more under old-age and survivors insurance in 1944__.

26

Monthly benefits in current-payment status, March 1947, and benefits awarded, January-March 1947-

Employers, workers, and taxable wages, fourth quarter, 1946-

PUBLIC ASSISTANCE:

Public assistance and related legislation, 1946_. Program operations_-_.

SOCIAL AND ECONOMIC DATA:

Social security and other income payments_

All income payments to individuals__--
Social insurance and related payments_.

Estimated pay rolls in covered employment, fourth quarter, 1946_ The third actuarial valuation of the Railroad Retirement Act-Report on health services for British India---

State accounts in the unemployment trust fund in 1946_. RECENT PUBLICATIONS--

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30.

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36

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number of compensable claims remained fairly steady in both March and April although the seasonal rhythm would suggest its decline.

A closer analysis of the movement of benefit claims by State shows that the nonseasonal increase of initial and waiting-period claims was concentrated in New York and New England. This development might have been due to a temporary slump in local nondurable industries. March in Review

In unemployment insurance, a drop of 40,400 in new claims filed during March was responsible for a decline in the total number of initial claims filed. All but 15 States reported fewer initial claims than the February number. There was a slight drop in the average weekly number of continued claims, indicating that seasonal unemployment was continuing to taper off, but the 2 additional reporting days in March caused the monthly total of continued claims to rise slightly. Despite another slight decrease in the average weekly benefit check-to $17.72-the amount dis

1947

7 21 5 19 JUNE JULY

bursed in benefits rose from $65.9 million to $71.5 million, a relative increase no greater than that in the number of reporting days during the month.

OLD-AGE AND SURVIVORS insurance benefits were being paid at the end of March to slightly more than 1.7 million persons at a monthly rate of $33.1 million; in March 1946, 1.4 million persons received benefits totaling $26.2 million.

During the first 3 months of 1947, more than 133,000 monthly benefits were awarded-10 percent less than in the same period in 1946 but 19 percent more than in October-December 1946. For the first time, the awards included those to survivors of workers who had wage credits under both old-age and survivors insurance and the railroad retirement system. A provision coordinating benefits under the two programs, included in the 1946 amendments to the Railroad Retirement Act, became effective January 1. From that date to the end of March, 31 awards were made by the Bureau of Old-Age and Survivors

Insurance to the survivors of workers

who had wage credits under the two systems. In addition, nine old-age and survivors insurance beneficiaries had their benefits recomputed to take into account credits earned in railroad employment.

THE UPWARD MOVEMENT both in the total amount of payments and in the number of recipients continued during March in all three of the special types of public assistance. Administrative and legislative action, however, rather than changes in need brought the largest State increases. In the general assistance program, also, total payments increased slightly, although there was a slight decline in the case load. Total expenditures for the four programs rose 2.3 percent above the February level to almost $121 million; a year earlier, assistance expenditures totaled $94 million. Middle American Institute on Social Security

The Social Security Administration, in cooperation with the Department of State, is sponsoring an institute on social security for specialists in this field from Mexico and the Central American Republics. The institute, which was planned as a part of the program of the Interdepartmental Committee on Scientific and Cultural Cooperation, is being held in Washington from June 9 to 30. Each of the 10 Republics has been invited to send a representative as a guest of this country.

The purpose of the institute is to' discuss social security and its basic philosophy in relation to the democratic way of life, including the interrelation of social insurance, assistance, and child welfare, broad aspects of administration and financing, and the relationship between social security and other Government programs, such as health and education.

THE LACK OF ADEQUATE PROTECTION against the unpredictable costs of medical care and against wage loss due to sickness and disability represents the most serious gap in this country's social security program. In line with the Social Security Administration's statutory responsibility for studying methods of providing economic security through social insurance, the Division of Health and Disability Studies of the Bureau of Research and Statistics has undertaken a study of voluntary plans that have been developed in the United States and that provide some protection against the risks of sickness and disability. The analysis of various aspects of voluntary prepayment medical care organizations-their scope, administration, operation, charges, and service provisions-has consequently been a major project of the Division in the past several years. As a part of this analysis, a detailed study has been under way of medical services provided at Trinity Hospital, Little Rock, Arkansas, under a grouppractice plan that has provided medical and hospital services on a prepayment contract basis for more than 15 years. In addition to furnishing data on the amount of medical services

*Chief, Medical Economics Section, Division of Health and Disability Studies, Bureau of Research and Statistics. Margaret F. McKiever and Zelma A. Miser assisted in the preparation of the article. In publishing this article the author and the Bureau of Research and Statistics wish to thank Dr. M. D. Ogden, Medical Director of Trinity Hospital, and his staff for their interest and cooperation, without which this study would not have been possible.

provided under this voluntary prepayment organization, the study will give detailed information useful in estimating the volume of service likely to be requested under a comprehensive voluntary or compulsory health insurance program.

Trinity Hospital was originally established in 1920 for the purpose of making available to private patients in the community the most modern methods and facilities for diagnosis and treatment. In 1931 the organization began to offer medical and hospital service on a prepayment basis to persons in the community who joined on an individual or group basis. Since then, it has continued to provide services on both a prepayment and a fee-for-service basis.

The hospital is privately owned and operated by a group of physicians who are all on a salary basis but who also receive a proportionate share of the organization's total net income. In providing services, group-practice techniques are used, and a consolidated medical record of each patient is maintained. The patient has free choice among the physicians on the staff and may see any staff specialist; referral by a general practitioner is not required. Before the war the total staff numbered about 75 persons-10 physicians, a hospital superintendent, 27 graduate nurses, 2 laboratory and 2 X-ray technicians, a business manager, an accountant, a pharmacist, a dietitian, a housekeeper, and business and maintenance personnel.

The organization is housed in a modern, well-designed building. On the first floor are the physicians' offices, the laboratory, the X-ray de

partment, the pharmacy, and other facilities. Each physician has a suite

of two examining rooms, a dressing cubicle, a nurse's room, and a consultation room. A 47-bed hospital occupies the second floor. Most of the rooms are designed for 2 beds, but a few private rooms are available.

At the time this study was started, a substantial proportion of the membership in the prepayment plan had been enrolled for 5 years or more, and it seemed reasonable to assume that most members were well accustomed to receiving care on a prepayment basis. Services at Trinity can therefore be considered as indicative of the care provided to a group in which the majority of the members were fully acquainted with the type of services available and were well past the first stage of membership, when the novelty of requesting services because they were already paid for could have resulted in an abnormally heavy service load.

The list of subscribers at Trinity was once described by Dr. M. D. Ogden, the medical director, as a true cross section of the entire community, with every gradation of income and social status, including bank presidents, many of the wealthier people of the town, and factory girls. The member families ranged in size from 1 to 9 persons, with an average size of 2.3 persons.

The study covers the 2 years from March 1941 through February 1943. The first year was a period not seriously affected by the withdrawal of physicians from civilian practice to serve with the armed forces. In the second year, however, the shortage of physicians began to be acute. The first study year ends at the date when the hospital, because of reduced staff, took steps to reduce services to the less serious cases.

During both years of the study the same type of detailed information was collected on the services provided and on the characteristics of persons eligible for care under the prepayment contracts. The plans for the study, the schedules, and the instructions for their use were prepared after consultation with the hospital staff. Separate office and home or hospital service schedules were prepared for each person having office, home, or hos

4

pital care during each month of the study years. Each type of care received was listed on the schedules, with the date of each service, the code number for any doctor who saw the patient, the type of hospital accommodation used, and the laboratory or X-ray service provided. Information on the composition of the families who had made new contracts or canceled contracts during the month was also prepared, and all schedules and lists were mailed to Washington each month for processing.

This article gives in summary form the major findings for the first year. More detailed data on the study for that year, as well as data for the second year, will appear in a monograph to be published in the near future.

Membership Restrictions

Persons wanting to join the prepayment plan at Trinity Hospital must meet fewer membership requirements than are imposed by many such organizations.' People in all income classes are eligible, for example, and no entrance physical examinations are required. There are no age restrictions, but the charges for any nongroup subscriber 57 years of age or over at the time of enrollment are increased by 50 percent when he becomes 60 years of age.

Under family contracts, membership is limited to the subscriber, spouse, and minor dependents. A dependent is defined as an individual who is totally dependent on the subscriber for support, occupies the same residence, and is related to the subscriber by blood or marriage.

A group must have at least five subscribers to be eligible for a 50 cent reduction in dues allowed because of group collections, but, unlike many other prepayment medical care organizations, Trinity does not require a certain percentage of the entire group to enroll.

1 Margaret C. Klem, "Voluntary Medical Insurance Plans, Their Extent and Limitations," Medical Care, November 1944, pp. 263-276. For a description of restrictions in individual plans see Margaret C. Klem, Prepayment Medical Care Organizations, 3d ed., June 1945. (U. S. Social Security Board, Bureau of Research and Statistics Memorandum No. 55.)

Benefits and Charges Under Trinity Prepayment Contracts

Under the most inclusive of the several contracts offered at Trinity, both subscribers and their dependents are eligible for physicians' care in the office and hospital, for home visits on payment of an extra fee, and for hospitalization. The additional charges for home visits are $2 for a day call and $4 for a night call within the corHosporate limits of Little Rock. pitalization is provided in a two-bed room and covers a period not exceeding 6 weeks in any 1 year to any one individual. Persons wishing private rooms pay an additional charge.

Before 1939 these inclusive benefits were offered on a nongroup basis to individual subscribers at $2.50 per month and to families at $5. The hospital stopped offering the contract at these prices in 1939, but persons with such contracts are allowed to continue at the same rate. The majority of the subscribers enrolling after 1939 chose the same inclusive contract at the following cost to nongroup members: individual subscribers, $2.50 per month; two persons in family, $5; three persons, $7; four or more persons in family, including all minor dependents, $8.50. The practice of reducing these charges by 50 cents for group members continued.

Although most of the Trinity members were enrolled under this inclusive contract, subscribers had a choice of several other contracts that provide the same services to subscribers but less to dependents or that provide limited service to both subscribers and dependents. In all contracts the charges to group members were 50 cents less per month than to nongroup members.

The fields of medicine covered by the contract include, among others,

2 Under nongroup contracts offering inclusive coverage for subscribers, hospitalization for dependents on a prepayment basis, and medical services for dependents at reduced fees, the monthly charges are: subscribers, $2.50; 2 persons in family, $3.75; 3 persons, $4.50; 4 or more persons, $5. Under nongroup contracts offering inclusive services for subscribers and all services at reduced fees for dependents, the monthly charges are: subscriber, $2.50; all dependents, regardless of number, 50 cents. Other contracts provide limited service to employees only in certain industrial establishments.

internal medicine, surgery, obstetrics, pediatrics, eye, ear, nose, and throat. All surgical procedures (except brain surgery), laboratory tests, X-ray examinations and treatments, and physiotherapy are also included. Benefits do not include drugs and medicine or orthopedic appliances. Refractions and glasses are provided at reduced fees.

Except for acute conditions needing immediate attention, no hospitalization or medical or surgical services are furnished, during the first year that the agreement is in effect, for diseases or conditions existing at the time the contract is made. Maternity care is provided after 10 months of membership of husband and wife. Care is not provided for cases of pulmonary tuberculosis, mental or nervous disorders, or drug addiction, after diagnosis as such. Diseases quarantinable by the city or State authorities are not accepted for hospitalization.

Total Services Provided

In studies of the services provided by physicians in individual private practice, a call at the physician's office usually has been counted as a visit whether the physician himself or a nurse or technician gave the service. In the Trinity Hospital study, a somewhat different method has been used. For example, visits to physicians frequently resulted in orders for care to be given by some other member of the Trinity staff-a nurse or a laboratory or X-ray technician. When such service was received during calls made to see a physician, it was not counted separately. In instances when patients saw only a nurse and/or a technician the call was counted not as a visit to a physician but as a visit to "other staff members." A call to receive care from other staff members was counted as only one visit, regardless of how many different staff members were seen or how many services were received during the call. When a patient visited two or more physicians during the same call at the hospital building, however, the visit to each physician was counted separately.

During the first study year, more than 31,000 office visits to physicians were made at Trinity-about 85 percent of them by persons eligible for care under all types of prepayment