Committee on Economic Security (CES)

Volume VII. Health in Relation to Economic Security

MEDICAL ADVISORY BOARD--MINUTES OF MEETINGS

Part 1- Tuesday Morning Session, January 29, 1935

COMMITTEE ON ECONOMIC SECURITY
Medical Advisory Board

Tuesday Morning, January 29, 1935

The meeting of the Medical Advisory Board, held January 29 - 30, Room 237 of the Mayflower Hotel, Washington, D.C., convened at 10:00 o'clock, Mr. Sydenstricker presiding.

CHAIRMAN SYDENSTRICKER: We have adopted the plan of trying to put down in very brief form a statement as a basis of discussion. I will not read all of this, of course. It states briefly what has happened since our last meeting. The staff has had several meetings with some of the members and thrashed things our at length.

You will be interested to know, and you have seen doubtless in the papers, that your recommendations as well as the recommendations of the other advisory boards and committees have been incorporated in the report of the Committee on Economic Security and have been recommended by the President to Congress. We are very gratified that that should be so.

The points which we have for consideration today relate to public health, public medical services and health insurance relationships, first of all. I don't know that it is necessary to read this section of our brief, pages 3, 4 and 5. I assume that it has been read.

DR. CUSHING: As I understand it, I don't recall that at our last meeting we necessarily expressed ourselves in favor of health insurance, but isn't that impression given in the report? I think it quotes some of the things that we agreed upon and immediately launches into the question of health insurance. This is the thing that disturbs me most about the program. In your description of what we are here for, does this mean that we are not to discuss the principles involved in the program of health insurance which has been worked out? The principle itself you imply is to be discussed after we have gone into the details of the operation.

CHAIRMAN SYDENSTRICKER: No. Probably the phraseology is unfortunate. As I understand it, the staff is charged with the duty of studying the risks and especially charged with the study of how health insurance might be applied to American conditions. We were not charged with debating as to whether or not health insurance was a wise measure or not a wise measure. In the President's last message, you recall, he said at that time he had no plan of health insurance to present because it was still being studied. That does not promise that he will present a plan for health insurance, but he wants a plan for health insurance and that is to be our job. On that phase of it we simply want your advice.

DR. CUSHING: The point is, are we here merely to discuss whether this program which has been laid down is practicable, or are we to discuss whether there is any other program which might be considered? Are we not to discuss the principles?

CHAIRMAN SYDENSTRICKER: As to the merits of health insurance, we could sit here and debate for months. I think that if we confine ourselves to the job that the President and the Cabinet have given us we will be far better off, that is simply, on health insurance, to find out under what conditions, of and when health insurance does come, it can best be worked out. We shall be in a hopeless morass if we do otherwise.

There are other measures, of course, of providing medical care. We took them up in a brief way last time, and I would like to get your opinions on those. There are other methods besides health insurance, possibly, and if there are suggestions of how to meet the situation, let us hear your suggestions, but we have to consider not the principles, but what sort of a system, if we have it, is best applicable to American conditions.

In regard to the report to the Committee on Economic Security, I would call attention to the fact that it was not intended that what was said in the report in any way committed any advisory committee to health insurance.

DR. CUSHING: I am quite sure it didn't, but I think nevertheless it gives the impression that these paragraphs represented the voice of the advisory committee. It gives that impression because the advisory committee is spoken of in a paragraph here and then the report launches right into a discussion of health insurance as presented in part through the document which we had discussed. I don't think that that was intentional, but nevertheless it has given that general impression.

CHAIRMAN SYDENSTRICKER: I invite your attention to the words on Page 42 of the report of the Committee on Economic Security:

"Until the results of these further studies are available, we cannot present a specific plan of health insurance. It seems desirable, however, to advise the professions concerned and the general public of the main lines along which the studies are proceeding."

And then it gives some idea of what those lines are. In no way, in our staff report to the Committee on Economic Security, did we hold responsible any members of any body for what we had to report. The report is ours, and it is a staff report only. Of course, any member of any body has a perfect right to submit a statement on any point or on the whole question of health insurance if he wishes, and I shall be glad to see that that gets to the Economic Security Committee, but the report will be a staff report, it will not be a report of this committee. If any views are expressed by any member, those views will be brought to attention along with our report to the Committee on Economic Security.

DR. CUSHING: I merely wanted to do something to make our position clear, because I get the impression that the program is already made out. It represents, I understand, a vast amount of work and honest endeavor on the part of yourselves, but we have been asked to come on the committee without any opportunity of discussing general principles involved. We are put in the position of advisers on a medical program without any opportunity to discuss.

CHAIRMAN SYDENSTRICKER: If you take this report today you will find it has been modified considerably.

DR. CUSHING: In very minor points. But the principle that there must be health insurance is something we are not to discuss.

CHAIRMAN SYDENSTRICKER: Dr. Cushing, you are at perfect liberty to make a statement and we will see that it gets to the Economic Security Committee, on the whole question of health insurance, but we as a staff are charged with the study of health insurance. For the staff's assistance, various medical boards were invited to sit in to see whether or not our studies, assuming we have health insurance, are in the right direction.

DR. CUSHING: Everybody all the way through, the whole committee, has said that the doctor is the keynote in this thing, but the question is, under health insurance what is going to happen to the doctor and whether or not we are destroying that keynote and whether, if we make any form of insurance workable, the doctor is going to deteriorate.

CHAIRMAN SYDENSTRICKER: Don't you think that those questions will naturally come up in our discussion?

DR. CUSHING: I trust so. I seems to me that is so very fundamental that if we get off on the point of analyzing this program we will lose sight of the woods for the trees.

DR. ROBERTS: Dr. Cushing, if I may be permitted to say this, I am going to agree with you to this extent, that I have many constructive and sympathetic criticisms of this report that has been submitted, many of them, and I must agree with the Chairman that all those things will come out that you are striking at, in our discussions. Wouldn't it be better to proceed to the discussion and to the criticisms and to the advice, with the understanding that what you say is true, and that we shall be frank and free to bring them all out here in the discussion?

DR. BIERRING: Mr. Chairman, it does seem to me that there is a basic principle that should be considered. You all admit that we must preserve quality among those served and those who render the service. Let us look back in the past to American medical education and as it is in its present state. Has it been a governmental agency? No, our teaching faculties and our organized societies have made a contribution in the last twenty-five or thirty years of all the new things which have come from the American laboratories and the American schools and the profession, and I think if you admit that you will understand why there is that inherent fear and concern on the part of the medical profession of America that anything will be proposed that will not preserve the profession. True, in this document you do say that there shall be a professional control, but what assurance is there that if this goes to the Department of Labor or some other Government department, that the governing head may not be another Brigadier-General Charles E. Stutz, that the men in charge in the states may not be Middlesex graduates, that they may not be osteopaths in California. If you give that assurance, then will enlist the cooperation of the medical profession, and you need them to carry this through. All this is not in the spirit of criticism, it is with a sense of concern and apprehension, and it seems to me if you can have this assurance placed into this document, then the matter of these details will be simple. We will all agree to the principle that something must be done to provide medical service for a certain class of society, but if it is entirely under governmental control I can't see how you can avoid the political phases that have been so inherent in the European situation.

CHAIRMAN SYDENSTRICKER: Dr. Bierring, I quite agree with all you say. The point is how to get that into this report. That is what we want to do.

DR. BIERRING: There is just one other element of fear, too. You have just said that no matter what we say today or tomorrow it will be a staff report.

CHAIRMAN SYDENSTRICKER: Yes, but you have a perfect right to put on record anything which you wish to say, and we will pass it on. You may have your ideas put into this report.

DR. BIERRING: The American Medical Association is going to have a House of Delegates meeting for this purpose on the 15th and 16th of February, and I can assure you if you give us this assurance that this will be under strictly organized medical control all through, from top to bottom,then you will get the support and you will accomplish the same thing, you will accomplish all you want to do.

CHAIRMAN SYDENSTRICKER: Let's look into it first and see whether those ideas are here or not rather than discuss the general principle.

DR. BIERRING: As you know, Dillinger has not got my report.

CHAIRMAN SYDENSTRICKER: I think it would be a good idea if we proceeded, and if you don't think we are conserving the rights and quality and privileges or anything else of medicine, why say so and give us some advice as to how we may do it. That is what we are here for. I would suggest we proceed to the consideration of this. We have gone over this thing pretty carefully in the preparation in the last few months and have tried to put in everything we knew how. You recognize there have been changes in this report. The reason more differences do not appear is because we are fairly agreed on things. There are two or three alternative proposals. I suggest that we start on health insurance and public medical services point by point and see whether or not the points that you have raised are properly represented. If they are not, I want you to speak right out and say exactly what you think. I think one may get the impression from reading pages 3,2, etc., that we have considered only one scheme, and I would like at this time to amplify what has been said here. The scheme which we generally propose is a system of health insurance in which we include public medical service. By that I mean that it will all be one plan, with people insured up to $500 or $300 at the top and the indigent at the bottom; the premiums for the indigent and medically dependent will be paid by the Government, and those at the top will be paid almost entirely by the insured individual.

Now I realize fully that our object is the provision of medical care to people who can't pay for it. That is the purpose of the study. Suppose the state doesn't want health insurance. Will it get any medical care from tax funds of the Federal Government at all? It might be considered by some that that plan is a sort of bludgeon to force the state to come into the health insurance plan. That is one way of doing it. Another way of doing it, of course, is to consider public medical service so far as aided by the Federal Government as a thing distinctly apart from health insurance, so that if a state has the need for Federal assistance in supplying medical care of one kind or another, it can apply to the Federal Government for that and not be compelled to have health insurance in order to get that medical care; the health insurance plan might be apart from the public medical service plan, so that then we would have a state which was to have health insurance applying to the Federal Government possibly for some subsidy. I offer that as an alternative. It is implied in here. Of course, if the state wishes under that system to include in its insured population not only the self-supporting wage earner and his family, or near self-supporting wage earner and his family, but also the indigent, it is perfectly all right. I don't think that point is amplified fully in our text, and I would offer that for consideration at this point before we go into the details of it.

You will notice in the section beginning on page 9 we reviewed certain things considered at the last meeting of this board, that is, construction of hospitals, federal relief or work-relief, and grants-in-aid for the maintenance of new rural hospitals, and then on page 11 payment of physicians for service in clinics, and so on.

I think we have probably emphasized too much in our report, prepared in a hurry, trying to make it an all-inclusive system, that health insurance should include public medical services for the care of the poor. There is a perfectly logical alternative, it seems to me, and that is we might consider public medical services entirely apart from health insurance and health insurance entirely apart form medical services. That is a point which I would like to get your advice on before we go into the details of that.

DR. ROBERTS: May I ask what you would include briefly under public medical service? What do you include under that, for our information?

CHAIRMAN SYDENSTRICKER: As I say, on page 9, paragraph 4, "In view of the substantial extent to which local, state, and federal tax funds are now used to provide medical service and hospital care to certain groups of the population, and for certain diseases and conditions to practically the whole population, two questions must be raised with respect to public medical service in connection with any plans designed to increase the security of the individual against the losses and costs of illness: (1) In what degree should public medical services of different kinds be extended in order to meet existing needs? (2) What should be the relations of public medical services and health insurance?"

Now in Appendix 1 you will find there is given here a list of the seven types of public medical services now found in this country:

1. Hospitals and clinics for mental disease and tuberculosis.
2. Hospitals and clinics for general and acute diseases.
3. Tax payments for care of certain patients and in non-governmental hospitals.
4. General medical care for legally dependent persons.
5. General medical care for the unemployed and their families under the Federal Relief Administration.
6. General medical care for entire communities in rural areas.
7. Medical care for certain diseases or conditions which are infused with a public interest.

"The Medical Advisory Board, the Dental and the Hospital Advisory Committees at their November meetings approved the following recommendations regarding the extension of public medical services:

"a. That, through executive order, funds for the construction of needed hospitals and medical buildings in rural areas be provided as part of the Public Works Program; that this program be undertaken at a rate so timed as to permit careful study of suitable areas and sites; that such studies be made by existing federal agencies in cooperation with the Public Works Administration, and be associated with the program of the United States Public Health Service for extending public health work in rural section. It is probable that expenditures at the rate of ten to fifteen million dollars a year would be desirable. The total program would cost about sixty million dollars over a period of four to six years."

And on page 10: "In view of the frequent shortage of hospital beds for patients with mental diseases and for patients with tuberculosis," and on page 10 also, "That for the purpose of effectuating adequate hospital care for the unemployed and their families, federal relief or work-relief funds pay, through the states, the sum of $1 per day for care furnished these persons in approved hospitals, provided funds from other sources pay the remainder of the cost."

No. 6, page 10: "That grants-in-aid for the maintenance of the new rural hospitals (contemplated in 5-a above) be made from federal funds, meeting only a portion of the cost of maintenance during the first year of operation, and on a diminishing scale thereafter for not more than two succeeding years."

Then on page 11: "7. The following matters concerning public medical service were discussed by the Medical Advisory Board, the Hospital Advisory Committee, and laid over for further consideration." Then comes the question under (a) of payment of physicians for services in clinics, and (b) the question of "more adequate local tax appropriations and arrangements with physicians, medical societies, hospitals, or clinics to supply effective care to persons who are legally dependent, but who do not come within the scope of the relief system, and to other person who, while self-sustaining during health, are not able to pay fees for professional or for hospital care during sickness, and who would not be able to contribute to any sickness insurance plan."

Page 12, (c) the question of the Saskatchewan plan, the hiring of physicians on full time in areas where physicians do not settle.

Those are some of the things that are included in public medical service. Many other things might be included also.

DR. CUSHING: Doesn't this deal with a great many things which are scattered in innumerable departments in the Government now?

CHAIRMAN SYDENSTRICKER: To some extent.

DR. CUSHING: If this vast expenditures and organizations is put into effect, oughtn't we to have some central portfolio or department to tie them all together?

CHAIRMAN SYDENSTRICKER: That is an important question to be raised. We were not charged with the discussion of that question at all.

DR. CUSHING: There is a vast number of things, vital statistics, public health, drugs, veterans' bureau, perhaps hundreds of things which pertain to this which it seems to me would be most economically handled by drawing them all together with some central authority.

We said very little at the last meeting about public health. We all realize the importance of it, but I think it ought to be said that the public health official is where he is on account of the doctor; the doctor has backed him, the doctor has fought legislation adverse to him, the doctor has sponsored vaccination laws, and public health depends vastly on the good will and backing of the medical profession. An example of what I think is likely to happen is what has happened recently here in Washington with the appointment of a successor to the District Public Health Officer, I needn't tell the story, but that is the sort of thing. Somebody has to go and see the people higher up to get somebody or other to put in charge of the Public Health Service. The doctor plays an extraordinarily important role, but I think now he is being made a pawn in this game and he is going to lose character. I think the doctor should be behind this whole movement because he has got to do the work.

If the situation is such as has happened in other countries where the doctor ceases to become a doctor and becomes pretty much a clerk, the people will get less good medical care under any of these systems that they did before, because the man who delivers the medical care retrogresses, deteriorates. There must be some way to protect the doctor from the beneficiary below and from the bureaucracy above, otherwise we defeat our own purpose. I don't see how we can discuss these things without finding some way to protect the agencies that have got to carry these things out.

CHAIRMAN SYDENSTRICKER: I am not quite clear as to what you mean. I quite agree with you about the protection of the doctor. That has been said over and over again, that is perfectly clear, that is the reason we are here, to find out how it can be done.

The other point, that is the centralization of all there things in a Federal agency, is an interesting thing to consider. The Public Health Committee did recommend or specify that public health agencies of the Federal Government should eventually be centralized.

I should like very much, Dr. Cushing, if I could, to get your advice, your reaction, as to the point I was trying to make just now, and that is: Should we in our report propose a plan whereby health insurance would include public medical services of all kinds? What conditions would you stipulate for a state to get subsidy for public medical service? Do they have to have health insurance also, or should we separate the two and really in effect put up two sets of proposals, one on Federal subsidies and aid for public medical service in states, and the other for health insurance? I would like to get your reaction to that point. Let's go around the table on that.

DR. BIERRING: May we ask, Mr. Chairman, who is to control or supervise the state plan?

CHAIRMAN SYDENSTRICKER: The insurance plan?

DR. BIERRING: Insurance plan or whatever it is. Who is to do that?

CHAIRMAN SYDENSTRICKER: Let's call it insurance plan, if you please. Now suppose the Federal Government should pass a law giving subsidy to the states for insurance. Obviously there must be somebody in charge of handing out subsidy for the Federal Government, but as to the operation of the insurance plan in the state the greatest latitude possible ought to be allowed to the state in conducting the plan in the way it wishes. But you realize certain fundamental things in regard to the medical profession which ought to be included in the Federal law so that no state could go outside of that. Something was said about osteopaths. I can't see that the Federal Government has any tremendous amount of supervisory power, but they do have to be assured that a state would conform to certain standards.

DR. BIERRING: Could a permissive Federal law designate that the examining medical officer shall be a member of organized medicine?

CHAIRMAN SYDENSTRICKER: That is a point we want to consider here.

DR. BIERRING: It doesn't state that in here. It can be an osteopathic association just as well.

CHAIRMAN SYDENSTRICKER: Let's take that point when we get to it. Can I get your opinion on this other point? You see, if we get to rambling around all over the map we will never get anywhere at all. I think we must proceed in an orderly fashion. I would like to get your judgement as to the two propositions and whether they shall be considered as one or separate.

DR. BROWN: Mr. Chairman, I have read this report very patiently and I hope with some intelligence. I move you that public medical service and health insurance be combined.

CHAIRMAN SYDENSTRICKER: There is something to talk about.

MR. GREENOUGH: Mr. Chairman, in answer to the question that you put, I think that we must admit it would undoubtedly simplify matters in setting up two entirely different departments if those two were combined. On the other hand, I think the present situation is such that matters of policy have to be considered, and I believe fully that an alternative acceptance of either one or the other, or both, projects by an individual state would lead to greater ease of development of this general plan, and on that account and only on that account I am disposed to advise that the two be offered separately to the states instead of making it necessary for a state which wishes to get Federal assistance for its public medical service to be obliged to develop an insurance plan.

DR. ROBERTS: Mr. Chairman, I would have to disagree from pole to pole with my faint-voiced friend from California. I feel that one of the reasons for this anxiety that has been discussed here resides right in this very point that you have asked us to bring out and declare ourselves upon. Indeed, so acutely do I feel it that before I came up here I went out into a better class Georgia county and found that the medical services in such counties were divided into three parts, like Caesar's all Gaul, and no one of the three was co-operating with or having any relation with either of the other two, and we have in this country, already grown up, a tripartite medical group in each county at the present time.

Now what are these groups? First, the organized medical group which practices medicine for pay - if it can get it, if not it practices with people that send for the doctor. In the second place, the public health officer, who does what he can in the county; and in the third place, the indigent who come under a public service program and who are run, fostered, nurtured and financed through the Red Cross as represented by the Red Cross agent and such social workers as the South is able to provide. Now then, right there is the cause of the feeling on the part of the member of organized medicine, the doctor that he is afraid of the social worker, of the Red Crosser, he calls it.

The public health officer has been afraid somewhat to tackle the indigent and the Red Crosser's department because he would antagonize, in the first place, the Red Cross; in the second place, he hasn't resources to give medical services to the indigent; and in the third place, he would be accused by the organized medical profession on whose good will his position depends of attempting to practice medicine. Those are the three reasons, Dr. Bierring, that the public health official hasn't jumped in: he hasn't the resources financially, he is afraid of the public condemnation of the Red Cross which has the they public eye and ear and approval, and he is afraid of the criticism of the organized medical profession.

In the minority report of the Committee on Costs of Medical Care, which represented the opinion of the leaders in organized medicine on that committee, the first statement said: "that we are in favor of the Government or government agencies taking over the care and practice for the indigent." Do you remember, that is the first sentence in it. This thing of public medical service taking over the indigent already has the approval of organized medicine, for which I speak, and it should have it. To that end, therefore, Mr. Chairman, I am highly in favor of separating health insurance from public medical services. It is the only possible way to avoid friction, and it is the only possible way to meet the good will and the approval of the medical profession.

In settling these problems we not only have to be philanthropists in regard to the needs of the people, we not only have to realize the acute needs of the people for adequate medical service, but we have got to be practical sociologists and practical economists and, if need be, Mr. Chairman, I am going to be a practical politician too.

You will never, in my judgement, get the approval of organized medicine in this country. I am in favor of going ahead (Dr. Cushing is going to have to forgive me for this statement) whether we get it or not by vote, if we can help the people and at the same time preserve the profession. I want to be loyal to the people, to the profession, and to the future, but we will never get it if we mix up health insurance with the care of the indigent and the public health officer.

May I say a word about the public health officer and his department? Dr. Cushing said that the public health official had grown up under the approval of medicine. Well, he has, but he has had a terrible fight on this hands on his own account. If there is anybody who gets sympathy from me it is the public health officer. He is always up against trouble and criticism. Isn't that true? But I think in this next great move of medicine in America, preventive medicine has got to be allowed to grow up with health insurance as its twin brother, but separate from it, united in purpose, as Booker Washington said, as a hand itself, but as separate as the fingers of the hand. We have got to allow preventive medicine to grow up with health insurance, and in the eyes of the public, public health is just a childish toddler here in the medical world. Dr. Parran will have to forgive me for that, but it is true.

DR. PARRAN: Quite right.

DR. ROBERTS: We have got to realize that. The suffering and the need is in curative medicine today. I know we can save a lot with preventive medicine, but the sense and the value of public health and preventive medicine must be demonstrated in the people and in the profession; it must be demonstrated and developed.

I went to a meeting on roads the other day to see how many people attended, and there were five thousand people there. I went to a meeting on public health at the University of Georgia, and there were just enough to barely fill a little room, and they called it a round table conference. We have got to realize that the sense of public health and preventive medicine has not been either demonstrated or developed in the people or in the profession, and to do that we must not only for purposes of administration make separate departments of them, but it seems to me we should put all public medical services under a separate administration and keep curative medicine separate from public medicine; it has always been that way and I think always will be that way.

DR. HORSLEY: I agree very largely with the opinions expressed by my predecessors who have spoken. I think that the public health insurance should be a separate unit, but necessarily closely cooperative with the other.

One of these reports that struck me as being extremely wise was that certificates for disability should not be signed by the general practitioner. It seems to me that it is quite possible that the public health officer, some stated official on salary, should be made to sign those certificates, but it is undoubtedly true that there is, especially in the country districts, a great deal of antagonism between the general practitioner and the public health officer, often. Frequently the antagonism is senseless, baseless, magnifying some incident, but if we start to recognize that that antagonism does exist to some extent and that a man struggling for his existence and sometimes for his actual bread, as many of these country practitioners have to do in our sections during the depression, feels that they public health man not infrequently, unconsciously possibly, infringes upon his own preserves and thereby indirectly cuts his income, we can do something to alleviate that situation. I think it is going to be difficult anyhow to put over this rather complicated, intricate matter, but if you start having them combined, with the public health man entirely dominating, it is going to be very much more difficult. There should be very close cooperation, but in my judgment they should be separate.

CHAIRMAN SYDENSTRICKER: Our recommendation at the last meeting was that public health should be a separate and distinct sort of thing, although we recognize that it would have to be in close coordination with public medical service.

The particular question which the staff is interested in today is, in proposing Federal aid, Federal implementation of public medical services and of health insurance, whether or not they should be put in one scheme or whether they should be separate. I assume you agree on that point.

DR. PIERSOL: Mr. Chairman, leaving aside the question of any details, and speaking to fundamental principles, it seems to me that the two things should be separate. It seems to me it would be a poor scheme to have any arrangement which might be construed by the states as any sort of threat or method of coercion. After all, in the last analysis this has to be worked out by the different states because there are different situations. There are undoubtedly some that are not prepared to take up the health insurance scheme, yet the public medical services should go on in those states, so I would be in favor of keeping the two things separate.

DR. CUSHING: I don't think there has been any friction between public health officers and the medical profession. I think the medical profession leans on public health as one of its most important arms, and it has been so in all communities in which I have ever been. The public health official is the most important man in the community.

I think there is a lot of buncombe about prevention. I am utterly opposed to these periodic health examinations because they don't get anywhere, except neuroses. The thing that disturbs me about all this is the man I speak of as the pawn who is going to practice under these circumstances.

CHAIRMAN SYDENSTRICKER: Under what circumstances?

DR. CUSHING: Under the circumstances of an insurance scheme, state or otherwise.

CHAIRMAN SYDENSTRICKER: I don't think that is the question before the house. I would like to get your opinion on this particular point. You are at perfect liberty to express your opinions on other points later on. Excuse me for interrupting you as the Chairman. We are interested in getting your advice, in the preparation of a report to the Committee on Economic Security, as to whether we shall report on public medical services separately and as a separate scheme, a separate plan, from health insurance, or should we combine them as we have suggested in this document.

DR. CUSHING: Feeling dubious, as I do, about the way health insurance works, I should say therefore that I can only state I would prefer that be split, at least until there is some opportunity of working out a different program.

DR. BIERRING: I think that it is not understood that marked changes are taking place in public health services and the progress that is being made is where the medical society and public health and organized medicine and teaching institutions are all involved. I feel that in such states where it has been developed in combination, as in Indiana, Iowa, and other states, when subsidies come from the Federal Government through either the Public Health Service through the Department of Labor as in some of these new proposals, if it goes to the Health Department, the Health Department by reason of its relation to organized medicine and the teaching institutions can distribute those subsidies in the proper way. When the Federal Relief Administration in Iowa asked for a general director they took the recommendation of organized medicine. When indigent care is concerned, agreements are made between organized medicine and the governmental agency, the board of supervisors. I feel that as this correlation has been developed the best standards and the best service will result. I feel now that that is a problem by itself. It is being enlarged. It is of course recognizing that community public health is the province of a governmental agency and officer, that individual health, though, comes within the sphere of the individual doctor, and it is by the development of that and the health phases and health maintenance that much of the income, or a large part of the income, of the practicing doctor is going to come. I can see no reason why, if we consider health insurance, it may not be worked out in the same way.

CHAIRMAN SYDENSTRICKER: Separate?

DR. BIERRING: I think they should be considered by themselves; as these various interests are coordinated the best results will be obtained.

CHAIRMAN SYDENSTRICKER: You mentioned the question of the Department of Labor. So far as I know that matter has never been considered by this staff at all.

DR. BIERRING: But part of our recommendations or our endorsements of the first two parts, you know, are now to be administered through the Department of Labor - child welfare, maternal health, crippled children.

CHAIRMAN SYDENSTRICKER: I don't think this Board considered that at all.

DR. BIERRING: But part of our recommendations or our endorsements of the first two parts, you know, are now to be administered through the Department of Labor - child welfare, maternal health, crippled children.

CHAIRMAN SYDENSTRICKER: I don't think this Board considered that at all.

DR. BIERRING: But that is the outcome of it. That is where this money is going.

CHAIRMAN SYDENSTRICKER: The question of further aid to states for public health services is a question on which this board made a recommendation. The question of maternal health was not brought before the board.

DR. BIERRING: Is there any difference between them?

CHAIRMAN SYDENSTRICKER: Certainly.

DR. BIERRING: No.

CHAIRMAN SYDENSTRICKER: One is under the Children's Bureau and the other the Public Health Service.

DR. BIERRING: But this Wagner Bill definitely indicates what this appropriation of $5,000,000 is to be for; it is to be distributed to the states to aid in the medical care of this particular class of individuals. The appropriation of the $10,000,000 or the $8,000,000 for the Public Health Department is to be for the development of rural sanitation and improvement and rural health and local health service.

CHAIRMAN SYDENSTRICKER: That was the subject at the last meeting to which you gave your benediction and which is now before Congress. If you, the American Medical Association, or any other body, wants to get up and protest against the Wagner Security Bill, I say go ahead, by all means, and do it. Let's stick to our question as much as possible.

DR. BROWN: I have nothing more to say.

DR. CRILE: All the points that have been in my mind have been expressed by the other speakers, and I certainly approve of dividing these two questions. It seems to me it would be very much better not to join them.

CHAIRMAN SYDENSTRICKER: In a plan.

DR. CRILE: Yes.

DR. PARRAN: Mr. Chairman, the Wagner Security Bill that is now before Congress carries out several things. In one instance it sets up a federally operated system of old-age insurance, operated by the Federal Government. In another instance, namely temporary old-age assistance, it is a plan by which the Federal Government cooperates with the states if they meet certain standards.

As regards unemployment, the same principle obtains, although rather great latitude is allowed to the state governments as to the several types of unemployment insurance which might be set up.

In each of those instances, I should say, the Federal funds serve to coerce the states. We can be sure that we shall have a nationwide system of old-age pensions.

I am opposed to any provisions of Federal law relating to medical care which serve similarly to coerce the states and to force them because of the economic inducements to put in a system of health insurance. The reasons for that I think we haven't time to take up now.

I have three points I should like to make: (1) that Federal aid is necessary in providing better medical care to dependent and to lower income groups of the population; (2) that such Federal aid for providing better medical care should not be limited to those states which adopt an approved plan of health insurance, but should be equally available to those states which extend and improve their systems of public medical care to meet minium Federal standards; (3) public medical services should be under competent medical direction in the Federal, state and local government, and integrated so far as possible with existing public health services.

CHAIRMAN SYDENSTRICKER: If you like, we will try to prepare for the afternoon session some statement covering this. I gather that it is the general sense of the members of this board that we shall deal with the question of public medical service as quite distinct, quite different, and quite apart from any proposal of health insurance, and take health insurance up separately.

DR. ROBERTS: I would like to ask one question in which I see some danger involving the lack of good will on the part of the medical profession in the community. No. 6 under Public Medical Services is "General medical care for entire communities in rural areas." That is in Appendix 1. It seems to me that could be qualified in some way. I understand that in a great drought area like the Dakotas they should have general medical care in an epidemic, or something, but an administrative officer, even a doctor, might read that differently, and that opens up the door into medical practice and health insurance. I would hesitate or be reluctant for the idea to get out in the rural areas of this country that they were entitled to general medical care. These rumors for free care on the part of the Government can go very fast, it's like the wireless. It seems to me that ought to be qualified in some way.

CHAIRMAN SYDENSTRICKER: You will find it amplified on Page 5, Appendix 1. I think it is perfectly proper, as Dr. Roberts has done, to take up specifically now the question of public medical service and begin anywhere you want.. He has begun with this Saskatchewan plan, so to speak. I am very glad to hear that suggestion.

The only thing we had in mind there was that there are certain areas in the United States where there are no doctors at all and no doctors will come.

How does the Saskatchewan plan meet the objection that Dr. Roberts brought out, Dr. Falk? Does it meet it?

DR. FALK: It does. We have to judge by the facts in the case ex post facto. Judging from that point of view it does, because it is a locally desired service which is supported locally by a special tax which the people have imposed upon themselves. Now our problem would be to what extent is it desirable to offer Federal aid to the states for the development of such a plan in such local areas within the state where the need exists and can be demonstrated and the justification for Federal aid warranted. There is nothing, I think, in our present statement which indicates any broad approval of or any broad recommendation of such a plan. One of the questions, I think, is to what extent should any recommendation in respect to the availability of Federal aid apply to such a form of public medical service.

CHAIRMAN SYDENSTRICKER: Ought we to recommend it all?

DR. DAVIS: I think certain other facts ought to be presented in discussing this. The plan involves in a number of the areas the element of institutional care, that is, say, the building of a public hospital out of tax funds in view of the fact that there may be no hospital there, and when there are very few physicians there are not likely to be hospitals, and the problem of building and supporting the hospital after it is built has to be met by locally imposed fax funds.

It is an important point that in Canada and in some of our states, New York for instance, a local hospital will be contributed to by state if it meets certain requirements; the original construction cost for the local hospital will be in part financed by the state. We have in this state and in Canadian provinces the precedent for state funds. Federal aid would always be extended to the state, not direct to the locality.

Another point that I think should be borne in mind is that in both Manitoba and in Saskatchewan the provincial medical societies have taken an active part in this plan (in Manitoba first), outlining the general standards under which the physician should be employed, including indications of minimum salary, applying to these areas, and the other conditions under which he should work, including such provisions as vacation and opportunity for postgraduate study. The provincial health authorities through which the medical societies deal have, I think, worked the thing out so thoroughly with the medical societies that I don't think there has been any complaint from the provincial medical societies in the provinces. There has been some complaint from local physicians particularly in some of the areas in which these plans have been at work. I think in the last report there were about thirty what we would call counties, they call them municipalities.

DR. FALK: Forty-two.

DR. DAVIS: If these areas are large they may have a town and then a large rural area, the rural area having very inadequate medical service and the plan being applied chiefly to the rural area where there is inevitably some risk of competition and feeling between the physician or physicians in the town and in the rural area to which the plan primarily applies, because there are a certain number of people who have been moved from one to the other. That has been, so far as I know, the only source of difficulty arising in these particular plans.

DR. FALK: I would like to make this point, which perhaps will sharpen our discussion. I think the problem which is before us and which is the intention of the document which we have for discussion is this: if we make proposals in respect to the opportunity of the Federal Government through financial assistance which it may furnish to the states to aid states where there is a demonstrated need in the provision of medical services for needy classes or needy areas within that state, shall such proposals specifically mention that such medical aid may be given to a state which chooses, for certain groups in the population or certain areas, to use the Saskatchewan procedure as one of its approved methods in meeting local needs? I think the problem there, granting the general principle that the Federal Government has an obligation and an opportunity in this general field, is on this as a procedure which if the state chooses to use it can, and apply to the Federal Government for aid, upon which Federal aid shall be given.

CHAIRMAN SYDENSTRICKER: I assume that in your mind, Dr. Roberts, is the thought that this could be abused. I suppose you recognize that there are places where there are no doctors at all and something has to be done about it. We have not tried to outline here a procedure by which, in the first place, such an area should be recognized as lacking medical care, and, secondly, a means by which the medical profession may choose how it shall be provided. Perhaps we could put that in some way.

DR.BIERRING: Could this purpose proposed by Dr. Falk be attained by considering part time health officers (Federal aid or assistance for part time health officers could be provided) who in the other part of that time could furnish medical service?

DR. FALK: It is a fact that in the Saskatchewan plan in many of the areas the local municipal physician, as they call him, is also the local health officer. He is doubly charged with the preventive work of the community and the curative work for the population covered by the plan.

DR. BIERRING: He could provide service for these communities. It could be a division basis with the states, perhaps. But what would be one way of furnishing medical service and at the same time following this public health service that is definitely proposed.

DR. CUSHING: There is one difficulty about that. So few public health officers have a medical degree.

DR. BIERRING: I think there is a greater tendency now to have public health officers who are M.D.'s.

DR. ROBERTS: May I discuss this a moment? On No. 6, "General medical care for entire communities in rural areas," if we let a public health officer go to practicing medicine--

DR. BIERRING (Interposing): I beg your pardon, it is the other way around, it is the doctor that is a part time health officer.

DR. ROBERTS: All right, that is true. Let's get these two figures in our minds. In this country there are six and half million rural families who own their homes - of course most of them are mortgaged but theoretically they own them - and there are five and a half million rural families who are tenants, which gives us twelve million rural families in this country. Let's face that. Five would be sixty, four would be forty-eight and three would be thirty-six - there are probably forty-eight to fifty million rural families. As Dr. Cushing intimated there, in this No. 6 we get a single effect: public health servants go to practicing medicine in these rural areas.

DR. BIERRING: It is the other way around. We want to teach our doctors to meet public health conditions at the same time.

DR. CUSHING: That is what has been going on for a generation.

DR. ROBERTS: Maybe so, but the great school of Mr. Hopkins has a few public health students and they are fostered by the wrong foundation.

DR. BIERRING: They don't supply the public health needs.

DR. ROBERTS: I grant what you say 100 per cent, but at the same time you have got a doctor who is a public health officer and who is practicing medicine for the indigent and being paid by the United States Government. He is getting two salaries, one from his local government and one from the state government for practicing for these indigents.

DR. CUSHING: Can't that be worked out?

DR. ROBERTS: That is what I am going to get to now. How are we going to work it out?

DR. BIERRING: I am a State Health Commissioner but I couldn't live on that salary.

DR. ROBERTS: Let's get away from Iowa and get all over the country. The real thing that made me decide that in loyalty to my people, my profession and my region I was for health insurance was just on account of No. 6. The average income of the tenant family in the Southern states is $350 a year. Get that in your minds. Between the Rio Grande and the Potomac the three states of Georgia, South Carolina, Alabama and also Mississippi, have the lowest per capita wealth in the Union, around $1200 to $1500 per capita, and you gentlemen from New York run over $4000 and Ohio over $3000 and Michigan over $3000. Ninety per cent of the people in the states I have mentioned have an income of less than $3000 a year. If you put in this limit of $60 a week for health insurance, ninety per cent of the people are going into it -- I am off the subject now a minute -- and ten per cent would be left as pay patients, a most radical thing, due to the poverty of those states between the Potomac and the Rio Grande. Your state of Virginia, Dr. Horsley, has a per capita of about $2300 and Mississippi goes rapidly down to $1200.

You gentlemen, if you do me only one favor here, will get in your minds the poverty of the South.

On the hand, I do not believe that our Anglo-Saxon people are going to take to the Saskatchewan plan. The paid doctor before the Civil War in the South was a slave doctor, and then the paid doctor in the South got to be the county physician, and woe to the man in the South who gets to be county physician; if he does he practically loses his practice, as a rule. There are some exceptions to that, but the people shy away from the county physican. He also is physician to the chain gang.

I think this one of the most difficult problems we have here. Those people have got to have medical attention, or should have it, they must have Government aid, but I do not believe they will vote for any such plan as salaried practitioners after the manner of the Saskatchewan plan. It is contrary to the two or three hundred years training of the people. I am discussing human nature now. They won't do it.

I don't know how to work out No. 6. Theoretically I am in favor of the Saskatchewan plan, but when I run up against the people and against the state and against the poverty and against their combination of ignorance and poverty -- remember that, there is why a lot of people don't need medical service in this country, it is not only poverty, it is ignorance and poverty that we are contending with -- I don't believe they will adopt the Saskatchewan plan. If somebody will suggest a better plan I would like to hear it.

CHAIRMAN SYDENSTRICKER : I may point out, Dr. Roberts, that this is a permissive proposition. If your state has such poverty and is probably prejudiced against the plan, it doesn't have to take it, but there might be some other state that would want it.

I would like to get an expression of opinion on this thing. Should we even mention it at all, contrary to American traditions and all that sort of thing? We simply suggest it as a method which has been tried apparently successfully in other parts. It has been tried in our country in industrial communities. There are, therefore, two questions before us. One is, should we propose this at all, in your opinion, as one possible way of supplying medical care to the areas that have no doctors? Secondly, if we do, under what safeguard is the choice of physician to be made?

DR. GREENOUGH: Isn't it true that the Saskatchewan plan can be used in the form of a subsidy and still make a minimum charge for the service to the patients?

CHAIRMAN SYDENSTRICKER: That is done.

DR. GREENOUGH: You don't need to pauperize a community by employing a physician at a retaining fee we will say, for a year, to work in that community. You can allow him to make moderate charges and you can even let your remuneration to him be in the form of a guarantee over and above what he is able to collect from his individual patients.

CHAIRMAN SYDENSTRICKER: My understanding is that he gets a salary but he also gets fees from patients.

DR. CRILE: I think there is a lot to be said for the Saskatchewan plan from the point of view of the young men going into medicine. There are just a lot of them who would welcome a chance to get some subsidy and then the remainder of their time go right on and develop their practice - just a little living wage, you see. I think that would settle an enormous amount of our problems with a minimum expenditure of money and offering very nice help in the beginning practice for the young doctor.

DR. HORSLEY: That is the principle of the Saskatchewan plan, isn't it?

CHAIRMAN SYDENSTRICKER: Yes.

DR. DAVIS: I think the plan would have to be flexible enough to provide for the type of area in which a subsidy with the privilege of private fees is allowed, or a type of area in which a subsidy with the privilege of private fees is allowed, or a type of plan such as is in existence in some of the Canadian areas where the physician is on salary but is allowed to charge for certain kinds of services, and the other type of plan in which there is no charge, so that could be used in the very poorest areas, some of those in the South and other parts of the country in which there is just as much poverty only in smaller areas, where the practicability of getting any fees that amount to anything from most of the population is so remote that the main support would have to come from a salary. There has to be flexibility.

DR. ROBERTS: Would it be possible to leave out that awful word "Saskatchewan" plan? Couldn't it be given an American name? That nearly kills it to start with. Why couldn't you call it the county subsidy plan.

CHAIRMAN SYDENSTRICKER: We will be very glad to leave out that word. We put it in because it suggested the plan.

DR. ROBERTS: The state legislatures would run away from that like they would a mad dog.

CHAIRMAN SYDENSTRICKER: Rural subsidy plan or something of that sort.

DR. ROBERTS: Yes, rural subsidy plan.

DR. CRILE: In the cities there is a very great district of that same kind. We have 200,000 people on relief in Cleveland. We need all the Saskatchewans and subsidies we can get right there in Cleveland. That comes and goes; for a cycle we need a lot of it, then again we need a little. I don't think we ought to discuss the doctor's side too much, but after all there are a lot of physicians on relief.

CHAIRMAN SYDENSTRICKER: We have that covered in another point.

DR. BROWN: Why couldn't you say general medical care on a flexible plan for entire communities and rural areas?

DR. HORSLEY: Why not just use the word "subsidy" plan?

CHAIRMAN SYDENSTRICKER: We are thinking in this particular case of rural areas.

Are there any other comments on this? I want you to feel free, Dr. Leland and Mr. Simons, to enter the discussion.

DR. DAVIS: I think it would be worth while using that word "rural subsidy" as a separate plan. Obviously there is a problem also of subsidizing the care in the cities, but in the rural area, Dr. Roberts brought out, is such a large problem in this country and in some states is a predominant problem. Unless any plan is one that will work in rural areas it will not be of interest or of service to those people, so it seems to me the word "rural" ought to be in this plan without any prejudice to the idea of the necessary subsidy for the care of indigent in urban centers.

CHAIRMAN SYDENSTRICKER: Are there any further comments on this? You agree in a general way to the idea that in certain rural areas undoubtedly physicians need subsidies. Suppose we have no physicians at all. I am not talking about a place where there is a poor struggling physician, but a place where there is no physician at all. Who is going to select the doctor and give him the subsidy? The Canadian plan has some set of standards drawn up which are pretty good.

DR. ROBERTS: The way they do now, they write up to one of the medical centers of the South or to the Board of County Commissioners: "Send us a doctor and we will make him county physician if he will come and settle here." Remember, when we talk about paying him in the South the school teachers come up to the school board and say,"Gentlemen, we are two years behind, we haven't been paid in two years. We don't see any use getting a doctor when we haven't been paid for two years."

CHAIRMAN SYDENSTRICKER: We are talking about Federal subsidy now.

DR. BIERRING: Isn't that the original thing we brought up? Who is going to do this selecting? Why not choose organized medicine?

DR. ROBERTS: Are we going to leave this under public medical services? Is that where it belongs?

DR. BIERRING: Yes. Isn't it?

DR. ROBERTS: I just wanted to know.

CHAIRMAN SYDENSTRICKER: To the extent that we subsidize the physician I should say it was.

DR. ROBERTS: Then it would come under the State Commission of Health for that state, wouldn't it?

DR. DAVIS: It does in Canada. There being a provincial subsidy, it clears through the provincial officer of health and he uses the standards laid down by the general medical society.

DR. ROBERTS: He is a part of organized medicine, isn't he?

DR, DAVIS: Yes. They set certain requirements for a physician, and he must be a graduate of such-and-such experience in order to be qualified for appointment.

DR. LELAND: Mr. Chairman, this is not anything radically new. There are a number of localities in the United States that are already paying their physicians out of local funds a kind of subsidy of guarantee that will enable those physicians to be assured of a livelihood.

CHAIRMAN SYDENSTRICKER: How are they chosen?

DR. LELAND: They are chosen in various ways, sometimes by writing to medical schools, sometimes by writing to medical societies, sometimes by writing to agencies that have a list of medical personnel seeking positions. There are any number of ways in which that can be done, but in some way it ought to be safeguarded.

The difference in this idea from the one that is already operating is that these people now are paying the physicians out of local funds raised either through taxation or voluntary contribution. This would merely provide a different avenue through which they would receive their pay. There doesn't seem to be any opposition to this procedure. In a broad sense it comes under the main heading of contract practice, but that form of contract practice which we consider both ethical and necessary and legitimate.

CHAIRMAN SYDENSTRICKER: Let us suppose, first that the Federal Government would say that a certain amount of money would be appropriated for public medical service to the states upon presentation of need. Let's take a state with some areas where there are no doctors. They apply to the Federal Government and say, "We need five doctors and we propose to give then so much subsidy, out of which the state can pay a certain amount." The Federal Government has nothing in the world to do, so far as I can see, with the selection of those doctors; it is left to state authorities, to the state medical society, perhaps. Is there some particular plan you would like to propose that the medical society or some group should have a hand in this, or how shall it be done?

DR. LELAND: As a rule, the state medical society has information concerning certain men who are not getting along so well or who would like to make some change. Whether that is the best way or not of course may be open to question, but that would seem to be one logical way of approaching the question.

CHAIRMAN SYDENSTRICKER: We might leave it entirely to regulation by the state medical society and the Department of Health.

DR. ROBERTS: Dr. Parran, if you were state health commissioner of New York and you had to employ a certain man for a certain area, you would like to have the say-so as to who was employed, wouldn't you? He would be under you.

DR. PARRAN: Yes, although I have no authority in the appointment of local health officers; that is entirely a local matter, but they must meet broad standards of experience or training laid down by the state.

CHAIRMAN SYDENSTRICKER: Suppose, Dr. Parran, that there was such an area in New York State where there were no doctors and you wanted a doctor. Suppose you could get, say, $500 from the Federal Government, and the state would pay another portion. What do you think of the way that doctor should be selected?

DR. PARRAN: I think his selection might be by the state health commissioner with the advice of the state medical society as to medical qualifications.

DR. BIERRING: I think that would be a very logical way.

DR. GREENOUGH: Doesn't this rather switch the program from public medical service to the program for the Public Health Department of the state? Are we not confusing two separate services?

CHAIRMAN SYDENSTRICKER: Isn't it true, also, Dr. Greenough, that public medical service is quite a varied affair? Some things might have to be under the state health officer, some might have to be somewhere else.

DR. GREENOUGH: My only thought was that we are trying to keep these three different activities, the Department of Public Health, the public medical service, and whatever may develop in the way of insurance as separate activities, and I should think personally that the candidate for this particular activity of public medical service might perfectly well be determined by the health commissioner acting under the advice of the state society. Must we not also contemplate the possibility of having to develop a state medical officer other than under the Department of Public Health to assume the responsibility of the public medical service in that state, especially if we are going to deal with the Federal Government?

CHAIRMAN SYDENSTRICKER: It may come about that way.

DR. ROBERTS: I am a little uneasy about this. I have to go over here and stand with Dr. Cushing now, because there is a great danger here. These are country people, you know. I am one of them and I understand them, I think, and I am just as much at home in a cotton patch as I am here in this distinguished body, probably more so, some of you might say, but if one rural community says, "We subsidize this fellow and it doesn't cost us anything to get it from the Government and the county commissioner," it may spread like wildfire, and that is the reason I was in favor of its being under a public health officer who himself is responsible for wildfire and who can control it.

CHAIRMAN SYDENSTRICKER: We will try to reframe this in accordance with your suggestions, and it may be that later on after other things have been discussed you may have further suggestions.

Shall we go back to this list of seven? Next comes the question of hospitals and clinics for mental disease and tuberculosis.

There is a question of whether or not this Committee on Economic Security should recommend to the President Federal aid for hospitals and clinics for mental disease and tuberculosis. The Committee has already passed on that, of course.

DR. ROBERTS: Will you excuse me just one second? If there is some overlooked service in this country it comes right there. There are twelve million Negroes in this country - twelve million, and here in Washington between sixty-five and seventy-five Congressmen almost had a philanthropic epilesepsy to get the vote for them. I want the right to have the same philanthropic epilepsy to get some adequate medical care for them, which is much more important.

The Southern states (I hesitate to say this) are doing nothing for the Negro tuberculous patient because they can do nothing for him. It is pathetic. They have a few hovels in each state which they call the state tuberculosis sanitarium for the Ethiopians; they are a hovel and cabin and a little boarding house attached. We will never get rid of tuberculosis with the rate per 100,000 among the Negroes over 200 in the South and the rate for whites sixty-five to sixty-eight per 100,000. The only solution of this is that we recommend unreservedly and emphatically that there be Federal grants for the care of these individuals, particularly the tubercular, on those states that cannot otherwise provide it.

CHAIRMAN SYDENSTRICKER: I will ask you to turn back to this brief. That shows where you have already acted and where the Committee on Economic Security has acted. Page 9, B, Public Medical Service Program. "The Medical Advisory Board, the Dental and the Hospital Advisory Committees at their November meetings approved the following recommendations regarding the extension of public medical service:

"a. That, through executive order, funds for the construction of needed hospitals and medical buildings in rural areas be provided as part of the Public Works Program."

There is one new point there that was brought in by the Hospital Committee that I think probably ought to be brought to your attention. It is in Appendix 2 of the blue bound book. Appendix 2 goes into some detail as to the size of the hospital, etc. Appendix 2, page 3, points out at the bottom of the page:

"6. Sections will be found in which, because of good roads and automobile transportation, most cases requiring hospital care can be taken to a hospital some distance away, and in which the conditions of population, medical profession, and financial resources would not justify building a hospital wherein major surgery and serious medical cases would be undertaken. On the other hand, such areas are usually in need of better local medical facilities for their people and their physicians. In England 'cottage hospitals', so-called, have been located in a number of small places as an attempt to provide a medical center for the physicians, certain laboratory and other diagnostic facilities, and a very few beds without provision for surgery. Such medical buildings are greatly needed in many areas in the United States in which hospitals would not be advisable. These medical buildings or 'cottage hospitals' should furnish: (a) offices for physicians and in some places for a dentist; (b) waiting rooms for patients; (c) facilities for simple laboratory work; (d) a simple x-ray installation; (e) office space for the public health officer and staff, including the public health nurses of the area; (f) a few (three or four) beds for patients during a brief diagnostic period or temporary care preceding transportation to a hospital. No facilities should be provided for surgical work, or other than such as would be performed by a physician in his office. It is probable that about as many medical buildings are needed as hospitals. Their cost would range from $15,000 to $25,000 a piece, the average probably about $20,000."

Would anybody like to speak to that?

DR. CRILE: We discussed that on the side at our last meeting here. What I would like to speak about is the experience of the American College of Surgeons in its hospital surveys and hospital standardization program. I think that all of us who received the reports of that and followed them realized the difficulties and the dangers of a small hospital undertaking surgical work, particularly of the type that is beyond the capacity of the local surgeon and the local institution. Some terribly unfortunate results have come out of that. If you could just have medical centers like that and a few beds for diagnostic purposes and acute illness and what-not and divorce the undertakings of major surgery from the little hospitals, and have a larger, well organized hospital further away where they would get medical care, it would be much better.

DR. GREENOUGH: I think it is evidently a sensible idea, but I just suggested to Dr. Roberts it would provide a nice place for the patient to wait while his appendix was getting ready to "bust".

DR. DAVIS: Some of these studies have been made in the hospital group. At the first meeting the tentative estimate was that five hundred rural hospitals would be advisable. That was based on a study not then completed. Since then it has been completed, covering the rural counties of the United States, of which there are 1300 with no hospitals. In the first place it became quite apparent that the county, in many of the states, was too small a unit to consider as a hospital area, and every state has been studied including consideration of the roads, the population, the existing hospitals, the location of physicians in those areas. Dr. Leland and I have talked over some of those state maps together. The result is that the estimated number of needed hospitals has been cut from five hundred to three hundred and these medical buildings have been added in about the same numbers as the hospitals. No attempt has been made in these studies to actually locate sites of hospitals. They merely indicate that in such states so-and-so many hospitals or hospital beds are needed, located in such-and -such areas, because a study of the actual site would require a field man, a physician or a health officer with proper training to go on the ground and consider all those factors involved, but I think the studies that have been made show quite clearly that the original estimates were too high just because of the fact that you speak of. The general sentiment of the hospital group, a small subcommittee, Dr. Rankin and one of the other men and myself having looked over this, is that the minium size hospital in general should be not less than thirty beds, the idea being to make the units as large as possible for obvious reasons. There are one or two of the whole hospital committee who feel quite strongly that there are areas in which you would have to put small hospitals, smaller than that, but those would be exceptional.

DR. ROBERTS: Mr. Chairman, I am in favor of both, the three hundred hospitals and the cottage hospital having doctors' offices and public health offices and a laboratory in it.

DR. CRILE: A medical center.

DR. ROBERTS: A medical center idea. I think they will dash your appendicitis cases to the city anyhow.

DR. CRILE: I still think it would be better for a well trained man to ride in his motor car twenty or thirty minutes even to go to a house, rather than to commit the patient's destiny to a little bit of a hospital with a poorly equipped surgical staff and nothing right about it. What do you say, Horsley?

DR. HORSLEY: I heartily endorse what you say. Personally, from the disasters that come in smaller hospitals, as I mentioned in the previous meeting, and because with their local civic pride because of a new operating room or some gadget, the King's Daughters or someone insists on the patient going to the hospital without any regard whatever for the man who is going to operate, it seems to me this idea as elaborated in here is excellent. It covers a want without providing the opportunities for such catastrophes as I mentioned. I endorse what Dr. Crile says.

DR. PARRAN: The State of Iowa has gone to the other extreme through its central university hospital, bringing patients from all over the state and assigning them on a quota basis. I wonder if Dr. Bierring would discuss the relative advantages of centralization as represented in that institution and the idea of decentralization.

DR.BIERRING: Of course that has brought out further problems of transportation. They have been solved to a certain extent, first by the quota plan, which has been very satisfactory, then by the employment of ambulance from the central hospital, which have brought in a great many. Yet it has been recognized that an occasional emergency case is better taken care of at home. It is unwise to disturb an acute emergency condition by transporting it that distance.

I would think that a rural hospital would be largely for emergency and local proposes. A case of typhoid fever, a maternity case, certainly would be better cared for in a place like that than in the average rural home.

CHAIRMAN SYDENSTRICKER: I assume that you gentlemen really approve the general principle of these small rural hospitals. I want to get your opinion as to how these medical centers or medical buildings in certain areas will function.

DR. BIERRING: I should think this could be applied to areas, not to all states or to all parts of a state, but that could be determined. There is a need, I think.

DR. FALK: I think, Mr. Chairman, it should be said, perhaps, that what is covered in the very bald statement at the bottom of that paragraph, namely that this recommendation was approved by the Committee on Economic Security, really conceals that it was quite enthusiastically received by the Committee on Economic Security and the opnion was expressed there that this offered an opportunity for an extremely desirable form of public works operation and of Federal aid and that it would be recommended quite heartily to the executive authorities who would have to approve implementing program.

CHAIRMAN SYDENSTRICKER: There is one thing that bothers me a good deal - it may not bother the physicians. A state may ask the Federal Government for funds for the building of hospitals of this sort and for Federal subsidy and aid. What guarantee have we that the physicians are competent to render service in those hospitals?

DR. CUSHING: Who is going to appoint them?

DR. FALK: The Public Works Administration made very clear to us when this matter came up for discussion in considerable detail, particularly before the public health committee where it happened that one of the distinguished public health authorities was chosen on that ground a member of that committee (a Public Works Administrator), that the rules under which the Public Works Administration operates in respect to projects in the category in which this type of proposal would fall, already are so exacting in respect to requiring that the burden of proof rests upon the community first to demonstrate not only that they want, that they need, that they are competent to staff such an institution, or that they will hold out the necessary incentives to bring people into the community if they are not already there to staff it, and have the means to maintain them afterwards, and so on, that the danger is rather that the rules are too exacting rather than too liberal in permitting a community to get aid for this type of institution which requires a longtime maintenance. That was in general the sentiment of the hospital group which considered this in considerable detail after this board had met in November.

DR. CRILE: I should think that the words "medical center" could be used, would carry the whole idea, instead of "medical building".

DR.PARRAN: Having approved of this in principle, I sense the general sentiment of the Committee is to urge that any such program be safeguarded, first as regards the quality of professional service, the actual need of the community, bearing in mind also that small hospital units are difficult to operate efficiently, and that as a means of providing safeguards it might be desirable for a study to be made in each state by a committee on which would be represented the state medical society, the hospital administration, and the public health administration.

DR. ROBERTS: Is that in the form of a motion?

DR. PARRAN: I will state it in the form of a motion.

DR. CRILE: I will second it.

DR. DAVIS: I think it would be very desirable for the committee to express itself on the need of the safeguards. As to the machinery for carrying it out, I should think there should be some latitude there, because I think if they follow precedence in the Public Works Administration they may call upon the office of the Public Health Service to make the preliminary general studies. In each state the location of the particular hospital in areas requires people familiar with the state and the locality and would require drawing from those three groups.

CHAIRMAN SYDENSTRICKER: I think Dr. Parran had in mind probably that this should not be left entirely to the Federal Government, but the state ought to have something to say about it.

DR. ROBERTS: May I raise a point which is an enlargement of Dr. Crile's point. It seems to me that we should go further in the question of a competent hospital. All that has been said is true, and if Dr. Parran approves it, it could be incorporated in his formulation (he is a great formulator). Why shouldn't each state have a great hospital for the difficult cases? There is no place for them to go in the South. Dr. Greenough tells me that Maine has three general hospitals. Maine began with one and now has three where the difficult cases go. There is only one in the South, and that is the Charity Hospital in New Orleans, which we might say now Mr. Huey Long has adopted, but there is nowhere for these people to go, they just die; there is no place for cases of cancer to go, they just stay home and the Lord takes them. Isn't one general hospital per state just as important in another sense as cottage hospitals in greater number?

CHAIRMAN SYDENSTRICKER: You have brought out a new idea, Dr. Roberts. Suppose we dispose of this other thing. Do you approve in general of Dr. Parran's idea that the state should come in on this study?

DR. PARRAN: I should be glad, if it would simplify matters, to change my motion to include the concept of a competent group in each state to study this and other aspects of the hospitalization problem of the state and make recommendations with respect to hospital problems, both special, additional centralized facilities, and additional rural hospitals, additional medical centers.

CHAIRMAN SYDENSTRICKER: I should assume that ordinarily the point you make, Dr. Parran, that the request for medical center buildings come from the state, would mean that the state has to originate the request and would have to make a study before it originated the request. Then, of course, it would be necessary in a way to have a check on this by the Federal Government. If we want to go into detail and suggest the precise procedure by the state, all right. Do you agree to Dr. Parran's suggestion? It might be well to incorporate that suggestion in here.

Dr. Parran suggests that before a request should be made to the Federal Government for a subsidy for the maintenance of hospitals and for the building of small hospitals, the state should make a careful survey in which the medical profession and director of hospitals and public health administration collaborate. If there is no objection I will be glad to incorporate that suggestion.

Now Dr. Roberts has raised a very important point which is not on our program. That is the question of general hospitals in states where they have not general hospitals.

DR. CRILE: May I say a word about that as to surgery? The United States as a whole has been surveyed many times. I think there are more competent places than one might suspect by sitting and thinking at the moment, but there are dotted all over the United States now wherever they can be supported, surgical institutions. There are so many other needs that I think are greater, granting what Dr. Roberts has said, but those places you can do very little about now until this development shows some way of doing it.

DR. ROBERTS: May I give just one illustration? A philanthropist established one of the best cancer clinics in the world in Atlanta. It was open to the state. The local profession decided that it couldn't be open to the state because it took cancer practice away from them, so it was closed to the state. Now the poor people in Georgia have nowhere to go for cancer. They stay at home and take morphine and die.

DR. CRILE: They have hospitals.

DR. ROBERTS: They can't pay. I am speaking of the lower income groups, the indigent classes. I am way down at the bottom now.

CHAIRMAN SYDENSTRICKER: I suppose there is no reason, Dr. Roberts, why the people of Georgia couldn't apply to the PWA right now for an appropriation.

DR. ROBERTS: A statement with regard to state hospitals from this board would give it an impetus which an application from Georgia would look rather puny beside.

CHAIRMAN SYDENSTRICKER: I would like to have your views on Dr. Roberts' suggestion.

DR. ROBERTS: Another illustration. In Michigan a patient goes up to the state hospital at Ann Arbor, the county pays his railroad transportation expenses there and back; it is done in Iowa, it is done in Wisconsin, it is done in Oklahoma, which is the only southern state in which it is done.

CHAIRMAN SYDENSTRICKER: Are you talking about facilities of a hospital or are you talking about provision for paying for patients that enter the hospital for medical aid?

DR. ROBERTS: I am talking about hospital facilities of a general hospital for expert medicine and surgery in the low income groups and the indigent groups, which is not covered so far as I have been able to find in this study.

CHAIRMAN SYDENSTRICKER: There are two questions mixed up, of course. Assuming that you have hospital facilities, what you want is some way for the poor people to get into that hospital.

DR. ROBERTS: Yes.

CHAIRMAN SYDENSTRICKER: That is an entirely different question from the building of hospitals.

DR. ROBERTS: Perhaps so, yes.

CHAIRMAN SYDENSTRICKER: Should we take up the question of getting in our program the matter of building general hospitals? That is quite a distinct thing from paying for indigent or poor people to get into a hospital where one does exist.

DR. DAVIS: I would like to say regarding facilities that I think it is pretty clear that in the cities in which hospitals of the type which Dr. Roberts has in mind would necessarily be located, that is hospitals doing expert work, there are ample facilities in almost all parts of the country, and the problem is the equalization of those facilities which on the average now are only general hospitals, except the non-governmental hospitals, in the few cases.

CHAIRMAN SYDENSTRICKER: Do you agree with Dr. Davis on that point, Dr. Leland?

DR. LELAND: There is another phase to this which is a little beyond the proper deliberations of this board, but as we see this picture there is an opportunity for some method of lethal facilities to be applied that will result in a hospital mortality among hospitals that do not deserve to exist at present. There are such institutions which are struggling to exist, but which actually ought not to exist, and we ought not to lend any support to their further existence. I am wondering whether Dr. Crile wouldn't agree with me on that. That is just the way it appears to us. It is another phase of the question.

DR. ROBERTS: Mr. Chairman, that's fine, but it is not on my point at all. In the State of Florida there is not a brain surgeon, for instance. In the State of Florida there is not a single institution to which the indigent and lower income class can go for expert surgical service on cancer, for radium work, for x-ray work on cancer, for study of what Mr. Davis would call problem cases, for brain surgery, for heart cases, for neurological cases. There is in Maine. They can go to one of the Maine hospitals, can't they?

DR. GREENOUGH: I don't know how far those special departments are developed in all those three hospitals.

DR. ROBERTS: In states like Dr. Bierring's they can. Shouldn't this board recommend either that the facilities which Mr. Davis says are not used can be used by furnishing money to do it, or a general hospital for each state which doesn't have one be provided? I am perfectly neutral between them, but I am not natural in trying to get these expert facilities in problem cases for the indigent and low income groups.

CHAIRMAN SYDENSTRICKER: That is a question which we discussed at considerable length at the last meeting. I think those recommendations were made and were put before the Committee on Economic Security, and I think they were approved.

It is specifically stated on page 10 of our abstract: "No recommendation is made for the construction or extension of new general hospitals in cities, since most cities now possess sufficient general hospital beds."

I think the point Dr. Roberts has raised is a good one, but it was raised at our last meeting and we all agreed it was a darned good point and included it in our recommendations.

DR. ROBERTS: Have we got facilities for this group of people requiring expert services and problem cases?

CHAIRMAN SYDENSTRICKER: We assumed that was furnished.

Also, your recommendation as to the sum of $1 per day for care, adequate hospital care, for the unemployed and their families, and so forth, was approved by the Committee on Economic Security in principle.

Your recommendation also for grants-in-aide for the maintenance of the new rural hospitals was considered but not approved as yet by the Committee on Economic Security.

On page 11, there are two points that have not come, as yet, before this board in detail. One relates to the payment of physicians for service in clinics, and the other, more adequate local tax appropriations.

We can continue this discussion after lunch.

... The session recessed at 12:40 p.m., to reconvene at two o'clock.....