New Deal for Health
A doctor prescribes Health Insurance for Canada, but warns that treatment should be given with greatest care
DR. JAMES B. McCLINTON
HEALTH insurance is coming, in Canada. Perhaps next year anyone will be able to call the doctor without paying. Forty per cent have been doing that anyway, but they say the Dominion Government is going to legalize it at the next session.
So far very few people are bothering their heads about health schemes. A leading paper stated it was not interested. An excellent booklet issued by the Government summarizing Canadian activities last year mentioned mines, muskrat hides and mortality lists. It made no mention of health. The program of the Canadian Institute of Public Affairs, which is supposed to include addresses by the most informed minds on the most pertinent matters, makes no mention of sickness, which costs Canada three hundred million a year.
There is nothing new about paying ahead to be kept well. It is as old as the Ming Dynasty. Man has always been willing to pay a lot to get into heaven but a lot more to postpone the trip. The wisdom of introducing a health scheme in Canada with its sparse population, particularly during wartime, must be questioned. The taxpayer’s back is bent almost as badly as it was two months before he was born and it is questionable if he can stand any more. The effect upon immediate health, preventive medicine and medical research are also a few of the phases of this vexed question which should be carefully dissected by the Canadian public before the next parliamentary session.
Health insurance is needed in Canada. One in ten never see a doctor. An eminent doctor recently pointed out that we have the poorest medical service of any white country in the Empire, since more than 13,000 children under one year died in Canada in 1940. More than 900 mothers died having babies. Many people never see a doctor until in semicoma or unconsciousness. I once treated an unconscious, wealthy patisnt for three days. I was chagrined to learn that when he woke up and had his wits about him he immediately asked for another doctor.
Many sick Canadian folk can visit no doctor because no doctor is near. Others have no money. Still others are afraid to spend what little funds they have. A fourth group never call a doctor until someone is within the shadow of the tomb. In some districts the doctor’s car is still a sign of great tragedy. A fifth group never call the doctor for fear of what they will be told.
Some Canadian people are not only too poor but also too proud to go to the doctor. In Ontario, where I know people, a day’s trip revealed a farmer’s broken wrist splinted with a plow handle, a baby dying with dysentery, a tuberculous hip in a kitchen, and a case of boils that nature was healing. Nature had been “working on them” for three years. All within eight miles of a doctor. Those people didn’t have the money, and as they belonged to that strange'disappearing group of saintly common folk who still consider a debt an obligation, they just “didn’t go.” Lack of money should not prevent people from getting medical care in a bountiful country where people are advised to grow less wheat.
Canadians Aren’t Fit
MEDICAL care is too expensive for people who work. Seventy-five per cent of all doctors are general practitioners, and they get their bread and butter from the middle class and the poor. The poor pay nothing, so the middle class pays the shot. The rich do not pay for the poor. They pay for themselves and go to the top-notch city doctor who rarely sees an indigent in his office. A few doctors treat the rich and nobody else, while a lot of doctors treat the middle class and everybody else. An appendix operation involving all the costs of doctor, hospital and drugs, as well as loss of time, has often swept away the savings of a frugal couple.
Health insurance is needed in Canada because the people are not fit. Of applicants for the Army, whose standard is excellent, 29.4 per cent are being turned down as unfit. Citizens should be physically fit for peace or war. Tuberculosis, from which more than 5,600 died in 1940 and thousands of others suffer, should be wiped out. Every person should be X-rayed and it could probably be done at about
ten cents a piece. Everybody with active tuberculosis should be isolated.
Syphilis should be deleted. From this disease at least 4,900 suffered in Ontario in 1940, and at least 465 died in the Dominion last year. Obviously many deaths are not reported, since it hasn’t been considered just the thing to mention that Grandpa wasn’t particular about his friends.
Every individual should have a complete examination once a year. Before obtaining a marriage license every couple should be subjected to a careful examination, and people with such diseases as hereditary types of insanity, hereditary blindness, epilepsy and cleft palate should not be allowed to marry until they are sterilized. People do not die too often but they die too soon. In Toronto many more people, per thousand, die in “the ward” than up in Rosedale. The test of any medical scheme will be its ability to prolong healthy life.
Health insurance must have as its aim the keeping of a nation fit and the inducement of its people to seek careful examination rather than to rush in and rush out of the doctor’s office about a two-minute headache or a twenty-minute gossip.
Health insurance is needed because disease is an important cause of dependency.
The cantankerous old lad, who lives on the family and sits on the chesterfield, where the granddaughter and her beau want to be, isn’t all to blame.
According to H. H. Wolfenden, Toronto social health authority, this “indigent” has thirty chances out of a 100 of having been sick most of the time, six chances of having lived too long, ten chances that luck was dead against him, seven chances that he didn’t get enough money and ten chances that he threw away what he had. He had thirty chances of being drunk too often.
Create a healthy nation and indigence wanes. Relief costs and taxes will also go down. Two per cent of our friends are sick all the time.
Free Clinics Aren’t Free
HEALTH insurance should not mean State Medicine. In the latter the Government takes over the entire medical problem on a civil-service basis and the politicians immediately get their feet in the trough. State medicine may be ruinously free while health insurance is constructively paid for by those who are insured.
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People are likely to be enthused over free medicine. When the rural telephone was introduced everybody thought they were going to be able to talk freely to everybody else. That is just what they did and all at the same time. Health insurance must be carefully controlled. It should be managed by a nonpolitical commission that is more interested in epidemics and urinalyses than in votes. Certain principles must be observed if better health for everybody is achieved.
Health insurance must not be free. After the citizen’s contribution there must be a small charge for the first visit to the doctor each month. This takes the edge off the tendency to rush in and rush out of the doctor’s office. It shouldn’t be large enough to prevent treatment if people are ill.
Free clinics where patients are inoculated against typhoid are not free. Somebody pays for office rent, light, heat, buildings, doctor’s time, syringes, needles of stainless steel and typhoid vaccine, meticulously prepared in laboratories costing more than a brewery. The patient pays by taxes, licenses, fees and fines. Taxes, such as Federal, Provincial and Municipal, twenty per cent amusement tax if he goes to the movies and eight per cent on light if he stays
home and reads the Bible. An income surtax if he works hard and makes money. If he does not work and can show no reason, he is fined for vagrancy. Such are sources of revenue that pay for free clinics.
Free medical service should only be provided for indigents, penniless widows, orphans and mental defectives.
Health insurance must protect the public teaching hospital. An aerial attack is never possible without factories probably 5,000 miles behind the fight. Victories over disease are never achieved without factories to make doctors. It is in the public teaching hospital where students learn to be doctors, and such hospitals must be most carefully protected in any health plan.
If such a plan makes an indigent so affluent that he does not enter the public ward, no patient is left for students to examine. Their training would then be equivalent to a correspondence course in flying. If anybody becomes unconscious in a strange city he will be fortunate if his registration card tells the Samaritan to take him to a public ward in such a hospital. A postscript telling the amount of alcohol he can usually consume would help. People will admit diabetes and epilepsy but
never the habit of “getting soused.” In such a ward he will have a short nightgown and a hard mattress but will also receive the skilful care that the best medical staffs of this continent can offer. In a public ward the patient gets the minimum treatment and is left alone, which is good treatment. The wealthy man in a private ward gets all the frills and is bothered all the time, which is poor treatment. Our members at Ottawa would be well advised to investigate the value of the public teaching hospital.
Pay Doctor Well
HEALTH insurance must be comprehensive.
There are now three types of medical schemes, the prepaid, postpaid, and never paid. The prepaid comprises some groups already organized in Canada. They pay ahead. The postpaid are ordinary patients who pay their bills willingly or when caught. The never paid comprises thirty-three per cent in good times and fifty per cent in hard times. Of the many different doctoring schemes in Canada, no two are alike. Some give drugs. Others don’t. Some take out your appendix. Others leave it in. Some leave you in hospital until bed sores wear you down. Others get you out before you have the address of the best looking nurse. Some exclude the rich. Most schemes definitely exclude the poor. Some are controlled by one doctor, and others by committees as large and heterogeneous as the disciples. Some older plans still in existence involve the contract doctor.
No suggestion of the contract doctor, who is the servant of a thousand and can be fired by one, should ever enter any health plan. It dates from lumber-camp days when the doctor received a monthly dollar per man and seldom saw his patients. In a contract scheme the doctor has no incentive to become efficient. Subscribers rush in and out at will. The doctor, demoralized, gives the same tablet in three different colors—two white and two pink every two hours, with two yellow on rising. He is afraid to launch into competitive private practice and is afraid of his boss and the boss’ wife. One day the doctor has a lucrative job, and the next day—if the boss had a bad night keeping in with the directors—the doctor is out on his ear.
Health insurance must be complete. It must provide all medical,
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surgical, hospital and nursing care. Also necessary drugs, physiotherapy, laboratory and X-ray services.
Health insurance must pay the doctor well, because he must be able to read and write and a lot more. After learning to read in public school, the doctor has nineteen years study before he is a trained surgeon, twelve years for a degree and seven years internship. It costs somebody, somewhere, somehow, $20,000 to train a doctor. He must be highly trained to know his stuff and to know that he never really knows his stuff: scientific discoveries come so fast. It is twelve million years since the Miocene era when man began to emerge “as is.” During the lifetime of the average docile member who rests at Ottawa several months each year, more has been learned about man than in all those previous ages of time. It is not the doctor’s fault that such an expensive servant as he cannot be obtained for the sparsely populated West. It is the “fault” of the Great Creator who made man so complicated that it costs a lot of money to find out a little about him. It is also the fault of the politicians who neither take people out of a desert nor make provision, by irrigating, reforestation and scientific planning, to put more people in. If there were more people the doctor could attend more.
The doctor must be paid enough. He has to earn as much in one day as the ordinary fellow makes in three to make up for years of study, years of poverty after hanging his shingle, and a few years with a little jam on them. He never retires. He simply fades away.
Not For the Rich
THERE must be free choice of doctor by the patient. Many families have been going to the same doctor for twenty years and to the sameoffice for fifty. There isn’t much in the doctor’s bag, since “sure cures” like sulphanilamide, are rare. There isn’t much in his pocket book, but much there is in the repository of his heart—“Secrets only he can hear.” Heart breaks, sorrows, mistakes are told and he must listen and never tell. They come singly, faltering with fear of impending death, or in loving pairs chittering like canaries. They come to their doctor and there unburden their soul.
This delicate relationship between patients and their medical confessor must never be disturbed in any scheme.
Health insurance must be closely associated with Public Health. Provincial Departments of Health, Health Boards, and Medical Officers of Health must be maintained. Doctors are interested in saving a few lives each. Departments of Health are interested in preventing epidemics, saving the lives of cities, prolonging the lives of everybody. It requires a lot above the ears to act well in an emergency, but a superior intelligence is required to prevent an emergency. A general practitioner can fuzzle around and lose one life but the Medical Officer of Health can lose scores of lives by winking at milk that is not pasteurized.
Health insurance must be considered as a national investment, and if properly controlled it will pay large
dividends. It is easier to make good and profitable citizens out of the physically fit than out of weaklings. A study of your local jail will prove that.
Health insurance must not include the rich. The ordinary person when sick wants a quiet clean bed and ordinary care. The rich must have two or three rooms and specialists galore. No scheme in the world would ever satisfy the wealthy. It doesn’t really matter, they don’t want it anyway. They are too few to bother with and their numbers will be less with each Canadian budget.
It must take care of the poor and needy. There will always be flotsam and jetsam on the beach. There will be the sick poor, unearning cripples, penniless sick widows and the mentally unbalanced. Hitler is reputed to destroy them. The Eskimo used to seal up the old lad in the igloo and frigid nature did the rest. The Spartan heaved them into the river. We care and tend them. The lot of caring for the poor has been the doctor’s. It has become such a burden that his own children are left poor. Municipal and Provincial bodies will disfigure towns with poles and wires and dinky little parking stands with ringing bells. They will build edifices superb with bonds that default, but they will fight viciously against paying for a doctor’s visit to one of their sick indigents.
The poor and needy in Canada must be included in a health scheme, to resuscitate them economically if possible, but mainly because we are humane—which Hitler cannot understand.
$18-828 a Year
A DOMINION health plan must be under control to prevent the unscrupulous from making money out of it. The wheels should run without grease. It should prevent the doctor from operating when he shouldn’t, and it should not allow people to get services for which they have not subscribed, and which are quite unnecessary. The control of the finances must be by keen businessmen who have proven their business ability. The control of the doctoring end must be by doctors who are trained and have proven their professional ability. We don’t want any committee of miners, farmers, businessmen or dentists deciding when to operate on our patients. I have actually known a lay committee to suggest what treatment should be given.
Health insurance must be competi| tive as well as co-operative. The doctor who is invited to see twenty patients must be paid more than he who is invited by one. Years ago a winning personality would fill a doctor’s office. Today the public : want to know something about his j training.
Municipalities with municipal doctors, some of whose qualifications at present appear to be a strong back j and a snow shovel, should have larger ; grants if their doctor has better I training. Competition always helps, j The doctor should feel the nip of ; competition. Competition can be j maintained by free choice of doctor, I fees according to service and public 1 rewards for scientific achievement.
Departments of Education give larger grants to schools whose teachers have high standing. So should grants be given to clinics of high standing, low cost, and manned by well-trained doctors. That would be co-operation.
A health plan must be educational. In any health insurance scheme people should be constantly told what it is all about. They should be made health conscious. At present the public is only conscious of pain or impending death. Of 100 cases who entered a doctor’s office for the first time in 1941, over sixty complained of pain. Some were frightened with hemorrhage. Only one asked what he could do to keep fit and live long. People should go to their doctor for their lives’ worth not for their money’s worth.
Health insurance will not cost anybody too much. The estimated cost is somewhere between eighteen and twenty-eight dollars per person per year. Payments should be made at the source of wages. Farmers and those not on salary could use a stamp book like the present unemployment-insurance form. Every person eligible should have such a book and might be require to produce it before receiving treatment. The subscriber should know what he is paying for. It gives him a different feeling when he enters the doctor’s office. A man with seven children must pay more than the man with one but not in proportion. The scheme must be actuarially sound. It must eliminate red tape—which will be awfully hard on Government departments.
Too Few Doctors
HEALTH Insurance must keep the doctor in practice. We don’t know what the boys at Ottawa are cooking up. If medicine is going to be the same price to everybody, why should not law be? Then you could be tried for and hung for murder at the same price as being fined for parking. The medical profession should not be avoided in Governmental deliberations at Ottawa. The general practitioner is telling his boy not to enter medicine, the future is so uncertain.
The health of any community is directly in proportion to the number and quality of its doctors and there are too few doctors in emergencies like war and epidemics. Eighteen per cent of our doctors are now in the Army, and twenty-five per cent were in uniform during the last war. Any scheme that wears down and inadequately remunerates the general practitioner will deplete the profession of its great men in twenty years.
Before 1900 the best doctors were in Germany. For twenty-five years they were found in Great Britain. Today the best laboratories, hospitals, and a high percentage of the most scientific doctors are on this continent. If health insurance makes the general practitioner a slave and not a servant of the public he will move quickly to senility rather than to mental magnificence. The doctor must still be encouraged to continue his thirst for knowledge, his appetite for accuracy and love for his fellow men.
Health insurance must not interfere with scientific medical develop-
ments. Such developments take time, money and great men. We have not read of any great discoveries like diphtheria anti-toxin, liver extract, insulin or the sulphanilamides being discovered in any socialized medical scheme.
The ideal health plan for this Dominion will mean that every ill person from Halifax to Victoria can go to the doctor he chooses in his vicinity. He will. have paid in advance for his treatment and will
enter the doctor’s office with his chin up. He will receive all necessary treatment but will not be permitted to impose on the services. The doctor must be highly trained and will be paid a fee according to his services. If people who need medical treatment receive such, and if the quality of the doctor is maintained, the garage man and the postman, the farmer and the soldier, the printer and the fisherman, will be more physically fit for an all-out effort in peace or war.