NATIONAL HEALTH INSURANCE
Says this writer: "Sickness insurance is bound to come ... it must be a unified national scheme ... and preventive medicine must be emphasized"
JOHN w. s. MCCULLOUGH
FOR 400 years or more, in the majority of civilized countries, the family
doctor has been the chief agent of cure in disease. The three roots of the medical profession in England and elsewhere, the barber, the ecclesiastic and the grocer, became respectively the surgeon, the physician and the apothecary. While in parts of Spain, as late as the middle of last century, the barber’s sign fre-
quently announced that he was prepared not only to shave customers but also to attend midwifery cases, the physician has far depart«! from the role of ecclesiastic, and one is sometimes reminded that the apothecary has again become a sort of grocer.
For years there has been general dissatisfaction with the services afforded for the care of the sick. Notwithstanding an overcrowded medical profession and a multiplicity of hospitals, to say nothing of the medical relief afforded by governments and the official medical societies, a large proportion of the population of this and other countries fails to obtain adequate medical attention and nursing. This failure is less apparent in the larger centres of population, where there are first-class hospitals, organized medical relief and auxiliary public health services, than it is, say, in the hinterlands of the provinces of Quebec and Ontario or on the Western prairies now wrestling with the added problem of crop failure.
.Sickness bears heaviest upon those of the middle class, the small wage earner who is disposed to pay his way, whose independence halts his acceptance of charity. Among this class and in the wide spaces far distant from doctors and hospitals, there are not a few real tragedies associated with lack of medical care.
A solution of the problem of medical care is offered in sickness insurance, or. as it is alternatively called, health insurance.
Sickness insurance had its birth in Germany in 1883. Curiously enough, at the outset this insurance was not designed for the relief of sickness at all. It was instituted for the relief of unemployment due to illness or accident. Following the example of Germany, Austria. Hungary and Luxemburg adopt«l similar schemes by the turn of the century. France followed about 1906. and Great Britain established National Health Insurance in 1912. A Swedish system was set up in the same year, and most European countries have adopt«! some sort of sickness insurance since the War.
The trend of Canadian opinion in this direction is seen in the fact that two of the provinces of Canada. Alberta and British Columbia, have enacted legislation on sickness insurance, though in neither has the law been put into effect. The subj«:t has repeatedly been under discussion by the official medical societies of the country, and these, as well as labor circles, are definitely committed to social measures of the kind. Why, with the experience of Great Britain and other countries and the unlikelihood of any serious opposition to such a proposal. have our legislators hesitated in the inauguration of what would apparently be a popular measure?
In order properly to understand the situation in respect to sickness insurance, one should examine the problem in all its bearings, in order to discover if it will do the things expected of it, particularly if it will lessen sickness, if it can be economically managed, and under whose management the proposed venture should be carried. Since Great Britain has one of the best, if not the best, sickness insurance schemes in existence, we should be able to profit by a study of National Health Insurance which has been in operation as a going concern since 1913.
Disadvantages of British System
XTATIONAL health insurance is compulsory for about 18 million non-manual workers in England and Wales whose annual income is £250 ($1,250) or less. The benefits include medical services and medicines and a weekly sick benefit. Payable after a waiting period of three weeks, the cash benefits are $3.65 per week for men and $2.92 for women. Payment at these rates continues during the duration of illness up to a maximum of 26 weeks. If disablement continues after 26 weeks of sickness, the cash benefit is $1.82 per week for both men and women. There is a maternal cash benefit of $19.47 for an insured woman or $9.73 if the husband only is insured or if the woman is unmarried.
The insurance fund is made up of the weekly contributions of employer, employee and Government. The Government pays two ninths of the total cost. The respective contributions of Government, employee and employer are as two. three and four.
Every registered doctor in England and Wales may, if he wishes, be “on the panel.” that is to say he may accept patients under National Insurance. The scheme at present involves about 17,000 doctors who are paid a stipulated annual capitation fee of from 7 to 9 shillings (this varies from time to time). A doctor may have any number on his list up to 2.500. One thousand, which is a little above the average list, brings the doctor an income of about $2,250. The doctor may have private practice as well, and he usually secures the practice among the others in the family. Medicines are supplied on the doctor’s prescription except in remote districts, in which case the medical man supplies the drugs.
The total cash and medical benefits paid for the 25 years of operation has been the equivalent in Canadian currency of $3,000,000,000.
It was promised and expected at the beginning that national health insurance would serve to lessen sickness, that it would be an economical way in which to care for the sick, and that it would work a revolution in the health of English people. These expectations have not been completely fulfilled.
Sickness, in England and Wales, if one can judge from greatly increased demand for sick benefits, increased days of illness, and bottles of medicine furnished, has not only not been diminished, it has greatly increased. As a matter of fact, sickness always increases if there is a sick benefit. Someone will rise to remark that the insured person is “swinging the lead.” that is malingering. Not so. Only 5 per cent of such sickness is faked. Ninety-five per cent is genuine illness. Accepting the fact that the increase of sickness under insurance is a genuine one. what is the explanation? It is this:
The man, overtaken by illness or injury, finds himself after a few days rather comfortable. He has probably worked very hard all his life. Under national insurance, he
is not forced to return to work, perhaps before he is really fit to do so, in order that he and his family may avert starvation. He has, in the insurance benefit, a weekly income, small it is true, but certain. He loses the will to get well. He develops a neurosis, a condition misunderstood by those who have not filled the sick man’s shoes or who are lacking in knowledge of disease. The developed neurosis is a genuine illness. Doctors understand it, and the man’s physician honestly certifies the man as unfit for work.
The demand for medicines increases hugely under sickness insurance. Sir Kingsley Wood, Minister of Health in the British Government, recently expressed himself as being concerned with the number of bottles of medicine that were being prescribed to quench what might be described as a national medicinal thirst. “In the last twelve months,” he said, “the number of prescriptions issued in England and Wales had increased from 43,800,(XX) to 66 millions.” It is for these reasons that no sickness insurance scheme, under existing conditions, can be an economic success.
While the insured in England and Wales are undoubtedly receiving better medical attendance than they formerly did. the “bottle habit” indicates that much of it is of a routine nature. Sickness insurance, even under the control of a single government and in a country of compact population, is extremely expensive. Its expensive nature is seen in the increasing ratio of expense to income.
In the earlier years of the scheme, the ratio of total expenditure to total income ranged between 59 and 79 per cent. Between 1926 and 1930 the lowest and highest percentages were 98 and 103 respectively. The extraordinary demand for sick benefits in late years has increased this ratio to an alarming extent. In 1916 the average income of the fund per member was $7.91 and the average expenditure $5.09. In 1930 the average income was $11.26 and the average expenditure $11.03. The report of the Government actuary shows that during the period 1921-27, the claims of men for sick benefit rose by 41 per cent, those of unmarried women by 60 per cent, those of married women by 106 per cent, while in all three categories the rise in disablement benefit was even higher.
The total cost over a period of about twenty-five years, namely £600,000.000 sterling, seems a most expensive plan of bringing patient and doctor together.
Alberta’s Proposed Plan
HTHE DEFICIENCIES in English National Health -*• Insurance make it unsuitable as a complete model for Canada. It covers but one third of the population; it fails to provide for those without employment; the public health facilities are not fully utilized. Up to the present time there is no provision for persons under sixteen years of age, although this deficiency is likely to be remedied ere long. On the other hand, the wide areas of Canada, our sparse and scattered population and the greater tendency of our people to move from one part of the country to another, create difficulties in administration not found in England and Wales.
One of Canada’s problems in respect to social legislation is that of jurisdiction as between the provinces and the Dominion. This difficulty has been accentuated by the recent decision of the Privy Council which seems to assign to the provinces the control of this legislation, and by the seeming reluctance of the provinces to surrender (as seen in respect to unemployment insurance) any jurisdiction in
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such matters. If a similar stand is taken regarding sickness insurance, it would, in the event of the enactment of a measure of the kind, mean nine separate bureaucracies of administration, enough to damn economically every one of them.
The Alberta Health Insurance Act was unique in that it sought to cover all classes of the population, including indigents; that it provided for utilizing in the scheme the forces of public health; that there were no cash benefits; and that, in the opinion of competent authority, it was actuarially sound. Perhaps the chief objection to it is that it was necessarily provincial in scope.
Under the scheme, which was passed in 1935, it was proposed to establish medical districts for the purposes of administration under a commission which would include in its membership a Minister of the Crown, the Deputy Minister of Health (a medical man), and a medical practitioner representing the profession.
The municipalities in a district were made responsible for a sum equal to $11.28 per head of population each year. The Government similarly was made responsible for the sum of $3.23 per head. In each of the districts, collection of the first sum was as follows: $2.01 per month from persons on salary or wages, and 81 cents from employers of such persons. Casual workers were obligated to pay one cent per hour of such employment, while their employers were to pay a half-cent per hour. Every other income earner (with the exception of married women whose incomes, independent of the husbands’, did not exceed $100 a year; domestic servants receiving $12 a month or less in wages, exclusive of board and lodging; and any male under eighteen years who was a relative of, and provided with, an income earner and received no remuneration other than board, lodging and clothing and had no other income) was obligated to pay $2.82 per month.
These figures were based on an estimate of a cost of $14.50 per head annually for public health and medical services.
The benefits proposed were: Hospitalization, nursing, medical and surgical attention, dental service, laboratory including X-ray service, drugs and medical and
surgical appliances. The doctors and ! dentists involved were to be paid by the commission charged with the administration of the act according to the medical j tariff, and subject to the conditions prescribed by the act or by the regulations made thereunder. The plan was a compulsory one, and the beneficiaries were free to choose any medical practitioner. Permission was given the commission to carryon public health services.
It was proposed by the commission to j begin operation in a suitable district in ! order to determine the merits of the plan. ! 'The act had been proclaimed and the I commission appointed by the Brownlee j Government. An election was pending, and in this election the majority of the electorate, with the vision of a bonus of $25 |x:r head promised by the Social Credit party, exchanged, as it were, the substance for the shadow, and voted for the party which promised most. In consequence, although the machinery for the carrying out of the Alberta Health Insurance I Scheme remains intact, the act has so far j not been put into force by the existing ! Government.
Abandoned in B. C.
HT HE DRAFT BILL for health insurance in British Columbia represents, in the opinion of a prominent social worker in the province, a distinct “American” rather than a “European” approach to the problem.
This bill was designed to "include practically all wage earners, farmers, indigents and other persons of low or moderate income, with their dependents.”
It was to be financed by contributions from employees, employers, rural municipalities (in behalf of farmers and their families), voluntaries and the Government. Employees were obligated to pay not more ¡ than 3 per cent of their wages and em| ployers not more than 2 per cent of their respective payrolls. Rural municipalities were required to pay sufficient to cover the cost of medical benefits granted, and they were allowed to raise the cost by taxation. Voluntary contributors were assessed sufficient to cover the cost of benefits to
themselves and their dependents. The provincial share included the full cost of benefits to indigent persons and one half the total cost of administration, this not to exceed $1,2(X),(XXj in any one year.
The benefits included: Medical, including maternity care, hospital service for 21 weeks in a year, and 75 per cent of the cost of another ten weeks if such were required; the services of medical specialists; the cost of drugs and medical and surgical supplies to the extent of 75 per cent; laboratory services; limited home nursing; limited dental service; and special additional services mainly of a preventive nature. The latter were limited to 5 per cent of the total annual cost of medical benefits. Cash benefits might he paid but only to those insured as employees, and at the rate of half the ordinary wage, and not to exceed $10 per week. Whether or not all the medical and cash benefits would be paid rested with the Government. Insured persons were allowed to choose their own doctor and druggist. The remuneration of the doctors employed was to be determined by the commission appointed to administer the act.
While the draft bill for the scheme was, in the judgment of official medical opinion, not perfect, it appears to have met with considerable favor with the medical profession. From 75 to 90 per cent, according to various estimates, seemed willing to accept it in good faith.
Far different was the reception afforded the act as finally passed. Of the two measures, the Bulletin of the Vancouver Medical Association, May, 1936, said;
‘‘The original draft bill was not in any way perfect; in many ways it was bad; but it was a long way better than this one. It (the draft hill) did purjxirt to kxik after all the members of the community whose yearly income, whether from indigence or low wages, fell below a certain level. It did acknowledge the fact that the Government should contribute to the act by at least half the cost of administration. It did acknowledge the medical profession. It seemed to recognize the fact that medical men will lxnecessary in the working of this act, and it gave us a certain amount of say in its administration. It did make some attempt to ensure that the income obtained from assessments, etc , would more nearly meet the necessary outgoing.”
The bulletin goes on to emphasize its indictment of the act as finally passed by saying:
‘‘But gradually under the pressure, not of clearer knowledge and riper judgment but of political necessity, this hill was pruned and shorn of these characters till after a battle never equalled, as we believe in these parts at least, the bill has emerged, a sorry enough spectacle. It is a pale shadow of its former self, anaemic and paralyzed in its lower limbs, or in its lower income levels it no longer makes a pretense at humanitarianism, which we were led to believe was the main impulse animating its progenitors. The indigent, the domestic servant, the casual laborer in fact all the ixxrple who really need medical aid most and cannot afford it at all, are. or may be. excluded. The Government’s contribution is removed. the contributions of those who do pay are not sufficient, on any calculation. to give what we would consider to be an adequate medical service.”
From the foregoing one judges that the doctors of British Columbia had been roused from the usual lethargy of the medical profession where their own interests are concerned, by the palpable deficiencies of the act as finally passed. In the face of this opposition, the measure was abandoned by the Government.
Unified Control Essential
TN VIEW of the experience with provincial legislation for sickness insurance, thinks that this
lack of financial resources, is likely to dampen further effort of the kind. But one also thinks that sickness insurance as well as that for unemployment is. stxmer or later, bound to come. With this in view, how may a scheme of the kind be designed and managed so as to afford the best results at the least possible cost? Is there a solution? One thinks there is.
The first essential to this end is a single unified scheme under the Government of Canada. We must have unified control, even if the much abused British North America Act has to be remodelled. The care of sickness is a matter of national concern. It is an outstanding problem of first importance; it is quite as important as preparation for war.
The second essential in relation to sickness is to sharpen up our tools of prevention. The annual cost of sickness in Canada every year reaches the enormous total of $311,(XX),000. Careful students of public health in this country, men and women with practical knowledge of every phase of the situation, are of the opinion that an annual expenditure of at least $2.50 per capita in disease prevention or a total of less than $30 millions, or one tenth that now spent ineffectively on disease cure, would revolutionize the health of the country. Such an initial expenditure could not, of course, be expected unless the courage of the governing class in Canada had a remarkable stimulation. One thing, however, might be done. The existing forces of public health in Canada might with distinct advantage he pooled under Dominion leadership and made auxiliary to a Dominion administration of an approved scheme of sickness insurance. With respect to any scheme of sickness insurance, it goes without saying that it should be actuarially sound.
Prevention Better Than Cure
ROUNDS for relying ujxin preventive VJ medicine in the solution of the problem of sickness insurance are ample. Within the present century the progress of public health has been remarkable. This progress is observed in the extension in the average duration of life, an extension in the period of at least fourteen years, or about 30 per cent. Man has, largely through his unaided efforts, made the world a safer place of abode. What is equally remarkable is the fact that the improvement referred to has been made during the greatest war of all times, in the face of the worst epidemic (that of influenza in 1918) in modern times, and coincident with the severest period of economic distress seen in the history of the world.
The application of effective legislation in Canada has shown its influence in the control of the venereal diseases in a manner not excelled in any country. The benefits of pasteurization of milk have been thoroughly exhibited in the rapid decline in the diarrhoea and enteritis of infants, and of those infections directly traceable to the use of raw milk. The improvement of the public water supplies and the use of other preventive agents have dissolved the dangers of typhoid fever and other intestinal disorders. The efficacy of antitoxin as a curative and preventive agent in diphtheria and the more recent use of diphtheria toxoid, have made whole communities impervious to the assaults of an affection which forty years ago destroyed 50 per cent of those attacked by diphtheria.
The most striking feature of the public health picture has been the decline in the mortality of tuberculosis. A generation ago. tuberculosis was among the chief causes of death in childhood, adolescence and young adults. The public fail adequately to mark the contrast between then and now. Not only has the death rate from tuberculosis been reduced to a remarkable degree; this very reduction has had a decided effect in reducing the former chances of infection. The mortality figures from this plague at the beginning of the
period are not available for Canada, but those for Ontario may be taken as an index of the reduction. This rate in 1910 was 102 per 100.000; in 1935 it was 41.8; that is to say that 102 persons in every 100,000 died of tuberculosis in 1910, as compared with 41.8 persons in 1935. The triumphs of preventive medicine have so far been among infants, children and young adults. In older persons there has been conspicuous extension of life in the diabetic and those afflicted with pernicious anaemia, through the use of new remedies.
In the heart diseases, which are the chief causes of death at present, in cancer, in kidney disease, in mental disorders and in many others so far almost untouched by the saving agents of preventive medicine, there are ample grounds for hope in the efficacy of such agents.
Improvement of the standards of living, better homes, adequate heating, lighting and ventilation, contribute no small share to the comfort of life and its extension. Shorter hours of labor, the removal of occupational hazards, better nutrition, better cooking and rational exercise are sound weapons irr the conquest of disease.
The acquisition of knowledge is in itself a potent agent in man’s defense against disease. By degrees man is learning the advantages of immunity to the many ills that beset him. Sooner or later he will be convinced that the machinery of the body, like the other machinery and tools he uses, must be kept in repair or scrapped. Periodical physical examination, by discovering minor ills and by allowing opportunity for early attention to these ills, will serve to nip otherwise fatal conditions in the bud. Such examination is now in active use in many industries, as for instance the periodical examination of operatives in rock mining, in order to avert the deadly silicosis. In the Canadian mining industry alone, thousands of lives and much money have been saved by timely examination of the men who delve for gold in the bowels of the earth.
While most of the new inventions of medicine are the work of doctors and are gratuitously donated by those doctors to the public, a well-organized nursing service is essential in the public health field. Education is one of the prime weapons against disease; and in this field the work of the school, district, and social-service nurse, and also the schoolteacher and dentist, can spread education of the kind in thorough fashion. A sickness insurance scheme, to be successful, should enlist every doctor as a working health officer and should employ all the auxiliary factors available.
It is only by co-operation of the forces of preventive and curative medicine that sickness insurance can be made successful, that it can be made to pay. If such a course had been followed in England and Wales, the Minister of Health in the Motherland might have had a different story to tell. There would have been, one thinks, a reduction of sickness, with all its miseries. There would have been much less of the “bottle” habit, and the huge and annually mounting costs would have been kept within reasonable bounds. Cure in many affections, such for example as the communicable diseases, tuberculosis, the venereal diseases, etc., is partly preventive. The foci of infection are removed.
If we are to have sickness insurance in Canada, one prays that the forces of disease prevention may be employed in conjunction with those of curative medicine. and that the funds accumulated will not be frittered away in a multiplicity of administrations. The latter would be a calamity of which one might well say, “Good Lord deliver us.”
I f it becomes impossible to have a unified plan of sickness insurance, employing all the forces of both curative and preventive medicine, and one which seeks to care for both employed and unemployed, we had better stick to the family doctor whose services in the past have always been available for both rich and poor.