Why did President Truman favor Socialized Medicine? - Statistics on the Nations Health - 1947

8/6/2019 Why did President Truman favor Socialized Medicine? - Statistics on the Nations Health - 1947

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Statistics on the Nation's HealthMaurice H. Friedman, M. D.

Washington, D. C.Presented at the 1947 Annual Meeting of the

Association of American Physicians and Surgeons

We should not expect that every onewill approach the problem of medicalcare with the same philosophy. No rshould we expect that every one wouldarrive at the same conclusions after acritical study of a body of unimpeachable data. Even among practising physicians there are bound to be differencesof opinion, and there is no r e ~ s o n whywe should not respect these d1fferencesif they ar e honestly arrived at. Nevertheless regardless of philosophy and reg a r d l e ~ s of differences of viewpoint,honest men should be able to agree onwhat are the facts in the case.

The raw data relevant to the problemof medical care are not hidden deeplyin inaccessible caches. They are available to all who can afford the time tolook at them. But these original dataare not cited in public discussions onmedical care. Instead, the public is being fed half-truths and untruths tortured from this body of raw data, fragmented, selected, and reassembled to>nit the particular purpose of the person using them. One looks in vain fo ran impartial and scholarly discussion ofthis problem either in ou r governmentaltmblications or in the. daily p;ess. Inorder to further their ow n pohc1es sqmeof the proponents of compulsory healthinsurance have painted a dismal pictureof medical care in this country. According to them the medical care a familyreceives is largely, if not entirely, dependent upon the family income. Fami-

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lies o low i n c ~ > m e have more illnessthan familes of higher income and areunable to secure medical care because ofthe economic barrier. In the words ofJ\Ir. Altmeyer, Chairman of the SocialSecurity Board "There are many Americans this very minute who are sufferingand dying needlessly fo r lack of medicalcare." The need therefore, is acute, andthere is no time for experimentationwith voluntary insurance plans. Th ehealth of our Nation is in such precarious state that we must immediatelysurrender the control of medical care tosome Federal Bureau which will operatea comprehensive, compulsory health in-surance plan.

No rational person would claim thatthe medical care in this country is altogether satisfactory. For the conscientious physician, interested in the welfareof his community, the medical careoffered will never be satisfactory. Regardless of what we have alreadycomplishcd, and what we may a c c o m p h ~ h in the immediate future, we shall stlllcontinue to strive fo r something better.But in order to effect any real improvement either in the quality or the distribution of medical care we must knowwhat are the real deficiencies, and wherewe can most effectively apply ou r energies. For


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examined all causes fo r rejection asfurnished by the Selective Service statistics and have done my best to placeeach rejection in one of the above categories.

You, as physicians, will easily understand why we may classify as not preventable and not remediable fo r militaryservice such conditions as congenitalheart disease, rheumatic heart disease,hypertension, congenital absence of atesticle, diabetes, etc. You will alsounderstand why peptic ulcer is placedin this category, even though the symptoms may be held under control fo rmany years- i f not permanently. Thesituation is similar with asthma. On ecan relieve the patient of his symptomslmt one cannot erase the disease andmake the individual acceptable to theArmy or the Navy.

Under the heading of "Correctable"or "Preventable and/ or Correctable"many more rejections have been includedthan would be justified by a judiciousreview of each case. In many cases theabnormality, such as enlarged tonsils,hemorrhoids, hernia, pilonidal cyst, etc.,was no t sufficient to interfere with theordinary demands of civilian life andwas not a cause of discomfort or disability. Certai nly, in many cases, thesober opinion of the physician would beagainst surgical intenention. Yet inorder to be more than fair to our opponents in this question I have includedas preventable or correctable all suchcases and also all cases of deafness ordefective hearing, all cases of otitismedia or perforate tympanic membrane,and all defects of teeth. Regardless ofou r success in treating these conditionsat the present time, the medical profession with the theraputic means thenat hand, most certainly could not haveprevented or corrected all these defectswhen they first appeared in these mensome 5, 10, or 15 years previously. Consequently the inclusion of all cases ofsuch defects definitely overstates thenumber of rejections which could have

been prevented or corrected by medicalcare.You as physicians will also easily

understand my entries under conditionswhich are beyond the province of themedical profession. Th e items "Non:\Iedical" and "llliteracy and MentalDeficiency" need no further comment.The lay public, however, would notquickly understand my reasons of including venereal disease under this heading, particularly in view of ou r possession of effective drugs for the treatmentu these diseases. This very situationhigh lights one aspect of medical carewhich is not full)+ appreciated by thosewho have no practical experience. Youmay recall that the armed forces hadmore physicians per thousand population than any civilian community couldhope to have (actually- about 4 doctorsper thousand troop strength). Th e services of these doctors were freely available without cost to the individual. Byvigorous campaigns the medical department and the VD control officers urgedthe troops to take advantage of theseservices. In contrast to the conditionsin World \Var I men who voluntarilydisclosed venereal infection suffered noloss of pay and no punishment. Did thisgenerous provision of free medical service prevent venereal disease in the armedforces? Absolutely not-venereal disease was rampant in every establishmentin the armed forces. It is clear therefore that the prevalence of venereal disease is no reflection either on the adequacy of medical care or on the cost ofmedical care. Primarily, this is a socialand not a medical problem.

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Rejections for conditions outside theprovince of the medical professionamounted to about 20% of the total.Another 48% of the rejections were fo rconditions which are beyond the powersof the medical profession to prevent orcorrect, so that about two-thirds of allthe rejections could not have beena voided regardless of the distributionor the cost of medical care. Fo r 12%

of the rejections the information furnished is insufficient to justify any evaluation. This leaves only 20% of allrejections which could have been infiu~ n c e d medical care, and this figureIS defimtely on the high side, because ofour liberality in classification and because the eradication of every defectamong the rejectecs would demand:I) every person with such abnormalitywoul_d. s e e ~ medical attention, 2) that thephys1c1an 111 charge recommend c o r n ~ c tive m e a s ~ r e s , including major surgery,m every mstancc, 3) that the patientaccepts the recommendation in everymstance, and 4) that the recommendedprocedures would be 100% effective inevery instanc e. \Ve all ma y wish fo r

such. ideal conditions in our privateprac!Jce, but as physicians we know onlvtoo well that ou r daily experience doe-snot justify any hope of such attainment.In brief, of all the rejections by theSelective Service System no more than20% could have been influenced bv the

cost or the distribution of medicalcare.Therefore the rejection rate fo r causesamenable to medical care was about 6%(i.e., 20% of 29%).The proponents of compulsory tn surance have mane much of the factthat the Selective Service rejection ratefor Negroes was consistently higherthan for white men, and much higherfor men from the rural South than fromthe Northern States. The inference isd_rawn that. these differentials in rejection rates were due to the lower income

of the negroes and a lack of adequatemedical care, especiallv in the ruralregions of the South. Thus the membersof the Social Security Board who prepared Senate Committee Print #4 (79thCongress) concluded that these andother similar differentials in rejectionrates "leave no doubt that these rateswere as high as they were becauseofpast medical neglect."

Because of such sentiments it isespecially important that we consider insomewhat more detail the rejection

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statistics fo r Negroes. Syphilis was responsible fo r 30.4% of rejections andgonorrhea for 3.2%. Mental deficiencychmmatcd another 21.4%, and mentaldisease, 5.8%. Thus, venereal diseasemental deficiency and mental diseas;~ c c o u n t e d for about 60% of Negro reJectiOns. I f we examine, instead of thepercentage of total rejections, the actualnumber of all defects found per thou-sand m.en examined, thete are only threecategories in which the number of defects among Negroes exceeded the number found in white men. These threecategories are: 1) venereal disease, 2)cducatwnal ancl mental deficiency, and3) cardwvascular disease. The greatern u m b ~ r of cardiovascular defects amongthe I\ cgrocs was due entirelv to thehigher incidence o h y p e r t e n s i ~ n amongthe colored men. With the exception ofthese three kinds of defects-kinds ofdefects which could not have been influenced by more or better medical care--the number of defects per thousandNegrocs was significantly lower than inthe white man fo r every class of defectlisted !Jy the Selective Service System.I should like to call your attention particularly to those defects fo r which theneclical profession could be expecteddo something. Under hernia we find.S2.1 cases per thousand white men examined and only 40.2 fo r every thousandNegroes. For hemorrhoids the comparah k figures arc 11.6 (white) and 9.1(Negro) ; and fo r varicose veins, 17.3(white) nrsus 9.7 (Negro). Undert:eo]Jiasms (really pilonidal cysts) thehgures are 10.2 (white ) an d 4. 9(Negro). Teeth defects were noted in124.7 whites and only 47.7 Negroes. Th edata on tuberculosis is especially significant. This disease was found in 19.9per thousand white men and 14.6 perthousand Negroes. I f we were to usethe same kind of logic as is being usedby the proponents of compulsory healthinsurance we would conclude that withrespect to tHberculosis the Negro isgettmg better medical care than thewhite. Ob,iously, such conclusion is in-


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defensible-especially since the deathrate for tuberculosis is much higher inthe Negro than in the white man. Thepoint that should be made !S ~ h a t statistics of the Selective SerVIce System arenot really relevant to the present d!s.:ussions. No man who was both competent and honest would attempt to usethese statistics in any argument for oragainst any particular program of medical care.

The statistical support for the existance of an economic barrier to goodmedical care is also subject to considerable question. The claim has been ~ a d e that the volume of medical care receivedby a family is largely, if not wholly,dependent upon the fa:nily i n ~ o m ~ , andthat the incidence of Illness IS h1ghestin the low income groups.

If we look at the original data ofFalk, Klem and Sinai, as published bythe Committee on the Costs of l\fed1calCare, we see that the i n c i ~ e n c e of illnessis lowest in the lowest mcome g_roupsand rises progressiYciy with e a ~ h m c r ~ ment in family income to be highest 1_nthe highest income groups. Th1s. ISexactly the opposite of what Dr. Falkhas been telling the Senate Committeeand what the newspapers have been publishing as a result of the material furnished bv Dr. Falk and his colleagues.P e r s o n ~ l l v , I was surprised when I sawthese original data of Falk, Klcm anclSinai, fo r I ha d expected the itH;idenceof illness to be higher in the low mcomegroups. However, when one i ~ s p e c t s the age distribution of each mco_megroup there is less reason for surpnse.We note that the number of older persons was much higher in the high incomegroups than in the low ipcome groups.Indeed the number over 45 years of agein the highest income groups wasleast twice as great as the number 111the lowest income groups. In view of themuch higher incidence of disease in theolder age groups, especially serious. ~ n d chronic disease, it is no t so surpnsmg

that Falk found a higher disease ratein the higher income groups.I am aware of the Public Health Survey conducted in 1935 and 1936, and I

am cognizant of claims made, on thebasis of citations from this survey, thatthere is a very definite relation betweenincome and incidence of disease. Widespread publicity ha s been given to thearticle on medical care in the report ofthe 20th Century Fund. It shouldnoted here that the section on pubhclicalth and medical care was written by).I argarct Klem, an associate of J?r.Falk. It should also be noted that M1ssKlem has perpetuated in this article thesame errors and distortions of ~ h e Selccti1 e Service Statistics. \Vhat IS morestriking is the deliberate selection of;hose parts of the data of the PublicHealth Survey which could be usedfurther the thesis of the economic b a ~ 1 s for disease, despite the fact that_ the picture given by the complete data 1s something quite different.

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There is not sufficient time to subjectthis data to a detailed analysis at thismoment. I should like fo r you to ~ o n sider, however, two important pomts.First of all, the data were gathered .byuntrained persons taken from the r e h ~ f rnll s in those years. Th e lack of detailsconcerning the type of illness reported,the inadequate definition of terms, a_ndvagueness of classification are all stigmata of this kind of work. Only 35%of the reported illnesses were verifiedbv reports from physicians. Yet, assumi ~ g that these data are entirely correct,thev do no t justify the picture presented.T he r article for the 20th Century FundMiss Klem contrasts the incidence ofillness in the families of the very highest income brackets with that in thefamilies on relief. It is quite true thatthere was more illness reported in relieffamilies than in those with the very!1ighest incomes, (table 1) bu t if oneexcludes the relief families the c o r r e ~ a tion of incidence of disease with family

income is no t a good one. Once an annual family incom1o0 of $1,000 is reachedthere is no significant correlation between family income and the incidenceof disease. I feel certain that an impartial survey of our population woulddisclose certain diseases in which theeconomic status of the individual is adefinite factor, though perhaps indirectly, working thru the effects of inadequate housing, nutrition, and sanitation.The medical profession would welcomereliable data on these points, but neitherthe medical profession nor the lay public stands to profit from the kind ofpresentation now being offered by persons who are more interested in missionary work for their cause than in thedissemination of our existing knowledge.You may recall that the Committee onthe Costs of Medical Care investigatedthe volume of medical and dental sen-ices available to people of each len! offamily income. To facilitate the comparisons, I have calculated the volume

of care in each category as the percentof the volume received by the lowestincome group. You will note (table 2)that there is a progressive rise of thevolume of dental services with each increment of family income, so that thepeople earning $2,000 to $3,000 per yearreceived more than twice as much dentalcare as the people who earned less than$1,200. On the other hand, with r ~ : s p c r t to physicians' calls or visits, the peoplewith family incomes of $2,000 to $3,000received only 20% more care than thepeople in the lowest income bracket. Atthis point, I should like again to callyour attention to the fact that the proportion of older persons was progressively higher as family income increased,so that we should expect not only ahigher incidence of illness, as was actually found, bu t also a higher incidenceof the serious, degenerative diseasescharacteristic of older people. With respect to hospital care there is no correlation whatsoever between family income and volume of care. Similar!:.there is no correlation between family

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income and health examinations or immunizations.I f all aspects of medical care weredominated by the economic factor, and

if all types of service were equally af fected by this dominant factor, we shouldexpect that the volume of each kind ofmedical care would rise progressivelywith income, and that the rising curvefo r each kind of service would parallelthat fo r every other kind of medicalse n ice. But the curves relating volumeof services to family income are notparallel. They vary independently ofeach other. We must therefore concludethat if there is an economic barrier tomedical care, it does not affect all typesuf medical service equally. \Ve mustalso conclude that factors other thanthe economic one are operative in thedistribution of medical care and thatthey equal or exceed in importance theeconomic factor.

The proponents of compulsory healthinsurance do not broadcast the facts Ihave just cited. Instead, they selectfragments of this very same body ofdata (Committee on the Costs of Medical Care) and headline them to alarmour people about widespread medicalneglect. Fo r example, each of you hasmany times seen in print the statementin any one year 40% of ou r people gowithout anv medical attention. Thiscitation is f ~ o m the original data of Dr.Falk and his coworkers and is absolutelycorrect. But what is not cited from thedata of these same authors is the factthat 47% of our people go thru the yearwithout any illness. Therefore the number of persons who go without medicalcare each vear is less than the numberwho report no illness fo r the year. Probablv the statement which more than anyoth-er carries the innuendo of widespreadmedical neglect is the one which says,"37% of all illnesses, disabling and nondisabling, reported by families earningless than $1,200 pe r year were unattended." Again the statement is takenfrom the work of Falk and his collaborators and again the citation is absolutely


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correct. But what are these unattendedillnesses? According to Dr. Falk andhis colleagues one definition of an illness is "any condition for which 50 centsor more were spent on drugs." Of allillnesses recorded in their survey 47%were not disabling; that is, did not interfere with the usual activities of work,school, or play. Eight percent were disabling in that sense hut did not reqmrethe afflicted person to go to bed. In otherwords, about half of all of recorded illnesses allowed the patient to be up andaround and did not interfere with hisusual activities. Forty percent of these"illnesses" were minor respiratory episodes or minor gastrointestinal upsets.Js there any wonder that 37% of suchafflictions were unattended?

Although we have been blessed withriches beyond those of other nations ournational resources are not unlimited. \Vecannot afford to dissipate our energieson everv minor problem. There aremajor p ~ o b l e m s which f a ~ e us. The.seproblems are concerned w1th thos_e diseases which kill, such as heart d1sease,cancer, nephritis, vascular disease, andtuberculosis, and those diseases whichmaim : mental disease, tuberculosis, vascular disease, etc. You may note thatthe same diseases appear in both groups.To the extent that infection plays a rolein som

Why did President Truman favor Socialized Medicine? - Statistics on the Nations Health - 1947

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