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The American Public Health Association has proposed the creation of approximately 1,200 public health districts of roughly 50,000 population each, with at least one district health center and one subcenter in each district. These health department centers could in many instances be included in the medical center type of facility described above.

With improved facilities the health departments could undertake expanded public health programs designed to eradicate venereal disease, tuberculosis, malaria, and hookworm; to lower maternal and infant mortality; and to promote health through education. Cooperation would be fostered between the health department and local private practitioners, and both would benefit by a more comprehensive approach to the health problems of the people.

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According to conservative estimates made by the United States Public Health Service, facilities are needed for 100,000 new general hospital beds, 94,000 new nervous and mental hospital beds, and 44,000 tuberculosis beds. In addition, 66,000 general beds, 97,000 nervous and mental disease beds, and 16,000 tuberculosis beds are situated in hospitals that are obsolete and that should be replaced. Approximately 2,400 modern structures are needed to serve as headquarters for local health departments. No estimates of need for chronic disease hospitals or mental hygiene clinics were given.

A program for construction of these facilities would have to be well-planned and well-coordinated, in order to avoid the mistakes which characterized the construction boom following World War I. Areas which need hospitals most should be given priorities for building materials and surplus medical supplies. The hospitals should not only be planned and built along modern, functional lines, but should be staffed and maintained so as to assure a high level of operating efficiency. Voluntary and public hospitals should work together in a coordinated manner. Both, in turn, should cooperate with the health department and private practitioners.

The cost of an adequate health-facilities program cannot be borne by the States and localities alone. Federal grants-in-aid to the States on a basis of need will be necessary.

In order to permit local initiative and control, State programs should be drawn up by State health planning commissions in cooperation with local au

thorities. Such commissions, consisting of representatives of professional groups and the public, could be appointed by Governors in States where they do not now exist. In drawing up State plans the commissions should consider the needs of all sections of the State, should include in the plan all suitable existing public and voluntary hospitals, and should plot the new construction as well as the expansion or replacement of existing facilities needed for adequate service. Before Federal funds could be granted, however, over-all State plans and individual projects should be reviewed and approved by the United States Public Health Service to make sure that they meet certain minimum standards of construction, operation, and complete, coordinated service. There should be reasononable assurance that a new facility will have enough patients to justify its existence. In communities where sufficient income from fees or individua patients does not otherwise appear probable, provision for group pre-paymen: plans or tax-supported services, or both, should be required.

Grants to both public and voluntary institutions included in the plan would be administered through a State agency, in most cases the State health department. To insure continued representation of the public, health advisory councils should be appointed to confer with the State agency administering the plan.

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Much has been said and written about the financial barriers to good medica care. There is general agreement that good medical care is necessarily expen sive; that the burden of illness is unpredicatable and falls unevenly, striking one family much harder than another; that sickness comes unexpectedly an.. may wipe out the laboriously acquired savings of an entire family; and that for these reasons and others a considerable part of the population does not receive either the amount or the quality of medical care it needs and should have In 1942 there were approximately 33.4 million family units in the Unite: States. The following table shows their income distribution and the amounts they spent for medical care; also shown are the income distribution and the amounts spent for medical care by the 41.2 million "spending units," including individual consumers as well as family units:

Income and medical care expenditures of 331⁄2 million families and of 41 million spending units,1 1942

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1 Based on data from Civilian Spending and Saving, 1941 and 1942, Division of Research, Consumer Income and Demand Branch, Office of Price Administration (Mar. 1, 1943). The term "spending unit" includes individual consumers as well as families. * Includes medical, surgical, hospital, dental, and nursing service.

The table indicates that even in the relatively prosperous year of 1942, 70 percent of the families in the United States had incomes of $3,000 or less and 50 percent had $2,000 or less. The average family expenditure for medical care was estimated at $100, but families with incomes under $3,000 spend considerably less than this. Nevertheless, the low-income families spent a larger proportion of their income for medical care than the higher-income families.

CARE RECEIVED VARIES WITH INCOME

Other studies, particularly those of the Committee on the Costs of Medical Care, show that low-income families not only spend less for medical care but also receive much less care than those with higher incomes. The highest income group in 1929 received more than twice as much physician's care and more than three times as much dental care as did the lowest income group. Yet it is the low-income group that needs the most medical care. Sickness and poverty go together. In 1935 wage earners in families with incomes under $1,000 per year suffered about twice as many days of disabling illness as did workers in families with incomes over $3,000, according to the National Health Survey. Facts do not support the observation that "the poor and the rich receive the best of medical care; only the middle class suffers." High-quality care on a charity or low-cost basis is available to the poor in relatively few places. Even in those places, low-income families are often reluctant to accept charity.

In 1933 the Committee on the Costs of Medical Care estimated that adequate medical and dental care, with proper remuneration for those furnishing the service, could be provided at an average annual cost of about $125 per family under conditions of group practice. Since this estimate was made, prices of medical goods and services have risen so that the figure would probably be about $150 if it were brought up to date. Other authorities, basing their calculations on ordinary fee-for-service schedules, have placed the average cost of providing adequate services at a much higher figure. It is evident from studies of family budgets that the 50 percent of our families with incomes under $2,000 cannot afford to pay $150 a year for medical care and that this amount imposes hardship upon many families in the $2,000 to $3,000 income group. The result is that doctors' bills pile up and many people will not call a doctor until they are seriously ill.

FEE-FOR-SERVICE VERSUS INSURANCE

Evidence such as this leads the subcommittee to conclude that the "pay-asyou-go" or fee-for-service system, which is now the predominant method of payment for medical service, is not well suited to the needs of most people or to the widest possible distribution of high-quality medical care. It tends to keep people away from the doctor until illness has reached a stage where treatment is likely to be prolonged and medical bills large. It deters patients from seeking services which are sometimes essential, such as specialist care, laboratory and X-ray examinations, and hospitalization. Individuals with low in

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comes, whose need is greatest, are most likely to postpone or forego diagnosis and treatment.

The solution of this problem will not be easy. Undoubtedly it lies in some form of group financing which would make it possible to share the risks and distribute the costs more evenly. This might be achieved by voluntary or compulsory health insurance, by use of general tax funds, or by a combination of these methods. Insurance methods alone would not be enough, because they are not applicable to the unemployed or to those in the lowest income groups. In order to meet the requirements of the public and of the professional groups concerned, any method which is evolved should offer complete medical care, should be reasonable but not "cut rate" in cost, should include substantially all of the people, should afford the highest quality of care, should permit free choice of physician or group of physicians, should allow democratic participation in policy making by consumers and producers of the service, should be adaptable to local conditions and needs, and should provide for continuous experimentation and improvement. Insofar as possible, it should also avoid the charity relationship.

VOLUNTARY VERSUS COMPULSORY INSURANCE

The way in which these aims can best be achieved is now the subject of considerable debate. Advocates of voluntary health insurance, such as the Blue Cross hospitalization and the medical society prepayment plans hold that such plans will fulfill all needs if given sufficient time, and if supplemented by taxsupported grants for medical care to all recipients of public assistance. Others believe that only a small percentage of the population will ever obtain complete medical care through voluntary prepayment plans, and propose compulsory health insurance along some such lines as those set forth in the Wagner-MurrayDingell bill (S. 1161, 78th Cong.). Still others maintain that needs would be met most satisfactorily and economically through a universal system of taxsupported medicine. At this stage of its investigation, the subcommittee is not prepared to pass judgment on these differing opinions. It is in agreement, however, with those who feel that remediable action is overdue and should not be long delayed.

Pending the achievement of a solution which will assure complete medical, dental, and hospital care for the whole population, more adequate provision should be made for medical care of the needy. This will require increased appropriations by local, State, and Federal governments. Under the Social Security Act, Federal funds are granted to State programs for aid to the needy aged, the needy blind, and needy dependent children. Federal funds can be used for medical care of individuals in these categories if the State law so provides, and in most States public-assistance budgets make some allowance for medical costs. By and large, however, the payments for medical care are utterly inadequate. Furthermore, Federal funds are not available to State programs for aid to needy individuals other than the aged, the blind, and dependent children. Legislation introduced in the Seventy-eighth Congress provided for amendment of the Social Security Act so that Federal and State funds would be available to help States finance medical care for the needy, regardless of category. Proposals have also been made to alter allotment procedures governing distribution of Federal funds to State public-assistance programs so that more money could be given to States where needs are greatest, and to allow Federal matching in programs which pay the practitioner directly. These measures, if approved, would help relieve the financial load on hospitals and practitioners, who now give a great deal of free care. Such relief for hospitals and physicians would permit them to lower their charges to prepayment plans and thus encourage the enrollment of more people from the group able to bear the average cost of medical care.

MEDICAL RESEARCH

Magnificent progress has been made in medical research during the war. The curative powers of penicillin and of the sulfa drugs, the lifesaving value of blood plasma and serum albumin, the efficacy of DDT powder and typhus vaccine. and the development of new malaria-control methods are all fruits of a concentra tion and expansion of medical research resulting from determination to win the war. Adequate financing, coordination, and teamwork have been the keys to this success. Through governmental agencies such as the Army, Navy, and the Office of Scientific Research and Development, and nongovernmental agencies such as the National Research Council, the universities, and other groups, the Nation's resources for research have been mobilized in a vast cooperative effort.

With victory in sight, we now approach the challenge of peace. Many problems await solution. Much long-term as well as short-term or "practical" research into the causes and cures of cancer, arteriosclerosis (hardening of the arteries), hypertension (high blood pressure), dental decay, and nervous and mental disorders must be undertaken in order to assure further progress against disease. The Office of Scientific Research and Development has served well as an emergency agency through which to channel Federal aid for medical research. Federal aid must continue if the great possibilities offered by medical research are to be realized. The way in which Federal aid is to be given and administered must now be carefully considered.

Government cannot, and must not, take the place of philanthropy and industry in the sponsorship of research. It is essential, however, for the Federal Government to provide resources for coordinated attack on medical problems which affect the country as a whole. In no other way can science be given full freedom and opportunity to serve the Nation in peace as it has in war,

EDUCATION, LEGISLATION, AND ORGANIZATION

The subcommittee recognizes the complexity of the task of providing good medical care to all the people. We believe that there are three necessary methods of approach to this task. One approach without the others would be unrealistic and ineffective.

The first involves education of the people, of the professions, and of the Government. We must collectively accept the fact of widespread existence of disease, disability, and injury, much of which medical knowledge today is able to prevent,' alleviate, or cure.

The second approach is through legislation. For example, there is urgent need for modern medical facilities in many places throughout the Nation, especially in rural areas and in crowded war-industry communities. To meet these needs money must be provided, and Federal financial assistance will be necessary.

The third approach is through better organization of medical services. There is wide agreement that improved organization would result not only in a higher quality of service but in considerable economy of time, effort, and money. The necessary reorganization can best be achieved, and the welfare of the professions and the public advanced, by regional planning such as that provided for in the health and medical center proposal set forth above.

RECOMMENDATIONS

On the basis of the preliminary findings outlined above, the subcommittee

1. Recommonds that Federal grants-in-aid to States be authorized now to assist in postwar construction of hospitals, medical centers, and health centers, in accordance with integrated State plans approved by the United States Public Health Service. (See cut on pp. 10-11 and text on pp. 14-17.) 2. Recommends that Federal loans and grants be made available to assist in postwar provision of urban sewerage and water facilities, rural sanitation and water facilities, and milk pasteurization plants, in communities or areas where such facilities are lacking or inadequate.

3. Urges State and local governments to establish full-time local public health departments in all communities as soon as the needed personnel become available. With this aim in view, consideration should be given to rearrangement and consolidation of local health jurisdictions and to amalgamation of existing full- and part-time local health departments with overlapping functions. The Federal Government should increase the amount of its grants to State health departments to the end that complete geographic coverage by full-time local health departments may be achieved and that State and local public health programs may be expanded in accordance with needs.

4. Recommends that the Army consider the feasibility and advisability of expanding its program for induction and rehabilitation of men rejected because of physical and mental defects; and that an emergency program of rehabilitation of IV-F's be undertaken immediately under the terms of the Barden-La Follette Act.

5. Recommends that the medical records of the Selective Service System be preserved and that funds. be appropriated for further processing and study of these records.

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