The Doctors' Lobby

by JAMES HOWARD MEANS. M.D.

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MEDICAL science has made enormous strides. Are the American people getting the greatest possible benefit from them? Obviously not! The majority cannot afford medical care under the prevailing fee-for-service system, and in many places adequate personnel and facilities are not available. Because of these shortcomings, a rash of medical care bills broke out. in Congress. None of them was passed, and now, with a war on, they will be shelved indefinitely. If government cannot help at this juncture, it is fair to ask whether initiative can be found elsewhere, and to what extent “organized medicine” — that is to say, the American Medical Association and its state and county societies — can improve the situation.

In December, 1948, the legislative body of the A.M.A. — “House of Delegates” is its name — voted to assess all members of the Association the sum of $25 in order to raise a “political war chest ” of 3.5 million dollars to light “socialized medicine.” There was some fuzziness as to whether this assessment was to be obligatory or voluntary, although the word is hardly inlerpretable as “voluntary.” There was, however, so much unfavorable comment, both in medical and nonmedical circles, on the expenditure of such a large sum by the doctors, apparently for the sole purpose of preserving the status quo in the matter of medical care, that the Association could not quite bring itself to enforce payment. To do so it would have had to expel an embarrassingly large number of prominent members. During the at times acrimonious debate which ensued over the assessment, the editor of the Association’s journal, the voluble Dr. Morris Fishbein, came in for so much adverse criticism that in June, 1949, the trustees of the A.M.A. decided to silence him, and subsequently he retired from the editorship.

This conservative attitude of the A.M.A. is of long standing. As far back as 1932 the well-remembered Committee on the Costs of Medical Care, headed by Ray Lyman W ilbur and made up of fifty persons — leading physicians, health officers, dentists, nurses, pharmacists, social scientists, and rep resent a tives of the public — rendered a majority report containing recommendations for voluntary prepayment plans which today look quite innocuous. They were not very different from that to which the A.M.A. is now at least giving lip service, but at that time Dr. Fishbein branded this report as “incitement to revolution,” and the proposed group practice as “medical soviets.” The A.M.A. does progress, but only in the wake of the steam roller of public opinion.

Directly after the elimination of Dr. Fishbein there was hope that at last the A.M.A.’s leadership had felt the force of public opinion sufficiently to adopt a more enlightened policy. The A.M.A. had lost its voice in Dr. Fishbein: it had to find another. In March, 1949, it hired the California firm of Whitaker and Baxter as “public relations counsel.”

This was not the A.M.A.’s first experience with public relations counsel. In February, 1946, in what appeared to be a forward-looking mood, it engaged the public relations agency, Raymond Rich Associates, to study the Association’s public relations and make recommendations for their improvement. This was done and several reforms were suggested. The House of Delegates of the A.M.A. approved the recommendations, and in September, 1946, Raymond Rich Associates were retained to carry them out. However, the trustees of the A.M.A. failed to give sufficient authority, and in June, 1947, Raymond Rich Associates, which has been described as “a firm of unquestioned standing and probity,” resigned from the job, stating that their “position had become professionally untenable.” At a hearing before a Subcommittee of the Committee on Labor and Public Welfare of the U.S. Senate in July, 1947, Senator J. Howard McGrath said that the reasons Raymond Rich Associates resigned “were, in effect, that the A.M.A. does not honestly represent the doctors of America, and in fact refuses to carry out their instructions.” Thus passed a transient progressive mood on the part of the A.M.A. into its more usual one, of standpnttism or reaction.

Whitaker and Baxter have proved to he more to the A.M.A.’s liking. This outfit had previously worked for Governor Warren in fact ran his campaign for governor in 1944. A year later they split with him over Iris proposal for health legislation, and instead they were retained by the Califomia Medical Association to defeat the measure. After a bitter fight, the measure was killed in committee.

Whitaker and Baxter got off to a fast start, and in a year have built up a propaganda campaign of truly majestic proportions, euphemistically called “education. ” So pleased with the results is the House of Delegates that at the annual convention held last June in San Francisco, Whitaker and Baxter‘s contract was renewed amidst acclamation. To support the “education" program, it was voted on December 8, 1949, to levy “dues ” of $25 on all members. In contrast to the previous assessment, payment of dues is mandatory. Members must pay by” January 1, 1951, or else they will be fired from the Association. It can be safely predicted that a goodly number will refuse, and it will then be very interesting to see what happens. The Association will either have to fire these members or lose face.

The line followed to date by the Whitaker and Baxter campaign is the same old I ishbein line, which has evolved approximately as follows: down with compulsory health insurance — compulsory health insurance is socialized medicinesocialized medicine is state socialism state socialism is eternal damnation, and so on. Recently it has been claimed that the emphasis has shifted to the positive side. Instead of merely conducting a “crusade” against socialized medicine, a “positive’ promotion of voluntarv health insurance will be made. In the light of history, which shows that herelolore organized medicine has opposed nearly every such ellort, one is entitled to wonder just how ingenuous this change in Iront is.

Tim doctors of the land have been deluged with campaign material portraying the horrors ol government medicine. They are assured 1 hat the voluntary way is the American way whatever that means. Thev are importuned to spread the ofheial gospel throughout the community via their patients to the utmost of their ability. Every doctor is invited to make a political pressure out post ol his private office! The personal physicians of politicians are being urged to put the heat on these, their patients, to vote right on medical bills. I his last seems no longer necessary, as the bills are dead ducks anyway. A Washington lobby to the same end, of increasing size and cost, is being built up.

The type of campaign material which Whitaker and Baxter are circulating in ever increasing volume is insulting to the intelligence both of the doctors and the people. For the campaign emblem a mediocre Victorian painting was chosen displaying an ill child, or maybe a dead one, a frustrated doctor, and a pair of despairing parents. Its selection well betokens the naïveté and obscurantism of the high command of organized medicine. Under the picture is the slogan “Keep politics out of this picture.” Public places have been as thoroughly beplastored with this chestnut as with the advertisements of a popular toothpaste. It is on the same level. Its appeal is purely emotional. A proper legend for this picture would be: “ Keep this picture out of medicine. It has nothing to offer. This child is entitled to be in a modern hospital receiving the most up-to-date treatment that medical art and science have to offer, under a prepayment plan its parents can a/lord.

In connection with the propaganda campaign a book entitled The Road Ahead, by John T. Flynn, is being distributed widely to doctors and others. Doctors and laymen alike are urged to read it. This reactionary screed tries to show that everything which has happened during the last sixty years in Britain, and to some extent in the United States, is taking us toward socialism. The autho‘s inherent sophistry is manifest when he claims there is no fundamental difference between British and Russian socialism. There is a stupendous difference. British socialism is democratic; in Russia, socialism is a form of absolutism, the essential ol a healthy democracy is a strong two-party system. Britain has a very st rung two-party system stronger than ours. Any time the British people do not like their socialist government they can vote it out. they nearly did so at the last general election. The A.M.A., on the contrary, although it makes a great point of its democratic nature, does all it can to discourage any formation of a two-party system. What dissenters there art’ in its ranks, the Association does its ill most to muzzle.

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AT the June meeting of the A.M.A. in San Francisco the speaker of the House of Delegates, Dr. F. F. Borzell of Philadelphia, delivered himself as follows: ” We have seen, it is true, our warfare against the forces that would destroy us progress favorably in the last year. I suppose this refers to the fate of the medical bills before Congress. “We have won many minor skirmishes and some major battles, but theenemv is not yet annihilated. The evil spirit of Fabian Socialism is still riding the stalking horse of Communism. It is becoming more and more evident that we arc the spearhead of attack that, if successful, will spring the gates wide open to thehordes of statism. ” The public may well inquire, “What‘s the shooting all about? Whose medicine is it, anyway? The enemy which Dr. Borzell identifies with “Fabian Socialism" is presumably anyone vvho does not uphold the A.M.A. party line, even the most middle-of-the-road liberal. Certainly there is nothing in Dr. Borzell’s bombast to indicate any departure from the old standpat philosophy.

On the same occasion the incoming president of the A.M.A., Dr. Elmer L. Henderson, a surgeon of Louisville, Kentucky, spoke in similar vein. In his keynote speech he reiterated a warning not only against socialized medicine but against the entire socialization of the nation, and claimed that only the doctors, mirabile dictu, can save the people from this misfortune. Physician, heal thy country!

Finally the president-elect, Dr. J. W. Cline, a surgeon of San Francisco, who will succeed Dr. Henderson a year hence, said a vociferous Amen! to Dr. Henderson’s remarks. There will be no deviation from the party line under his leadership either. He enriches the official vocabulary with the terrifying term “coercive statism.”

When it comes to coercion, it makes a lot of difference who is being coerced! One resolution passed by the House of Delegates would “outlaw” the system, now in wide use and generally satisfactory, whereby hospitals often place certain of their doctors on salary and collect from patients for their services. This applies particularly to radiologists, anesthetists, and pathologists, and in certain of the teaching hospitals to full-time physicians and surgeons. Of course A.M.A. law is not the law of the land, and is enforciblc only in so far as the A.M.A. can bring pressure to bear through its own or affiliated organizations. “Organizational coercion” we might call it, to match Dr. Cline’s “coercive statism.”

The methods of coercion open to organized medicine include expulsion from membership, which would cut off, in considerable measure, the doctor’s opportunity to keep in touch with his professional brethren—and without such contact the doctor rapidly stagnates intellectually. Also loss of hospital appointments might follow expulsion, which might make it difficult for the doctor to earn a living. It will be interesting to observe how much force will be exerted on the great teaching centers of the country to conform to such resolutions of the House of Delegates.

One wonders what may be back of such a resolution. Chiefly, I think, it is organized medicine’s inherent distrust and hatred of any element of lay control in matters pertaining to the provision of medical care. The doctor knows best — not only how to treat the patient, but also how the doctor shall be employed and what he shall be paid. No layman can tell him anything about it, or have any voice in the matter. That seems to be the attitude.

Next I should like to mention the opposition raised by the House of Delegates to government aid to medical schools. In the Atlantic for last June, Dr. George B. Darling of Yale outlined convincingly the financial plight in which our medical schools now find themselves. The medical schools arc obviously necessary to the production of doctors; so are the teaching hospitals, but unless aid from government or private sources is forthcoming, some of the schools may have to close, and that would be a national misfortune. Dean George P. Berry of Harvard Medical School has said that rather than let a school close, the government would take it over and run it; but surely this Would be far less desirable than keeping all the schools going under their own steam by timely aid. Yet organized medicine has persistently obstructed legislation which would permit Federal aid to needy schools. Actually, of course, many of our first-rate schools are already operated and supported by state governments.

Thus it becomes clear that organized medicine has no use for any extension of government participation in the provision of medical care to the American people. It also appears to be against the government’s coming to the aid of medical schools. If government medicine is inherently bad, and if organized medicine provides no solution, where is the public to look for a solution? The answer is: to agencies other than the A.M.A. and its components.

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SOME promising beginnings have been made. In New York City, for example, under the sponsorship of the late Mayor La Guardia and with his power behind it, a Health Insurance Plan (H.I.P.) was started in 1947, in the first instance primarily for city employees, but not operated by government and open to anyone. It provides complete medical care, either at home or in hospital or doctor’s office, all for a fixed annual premium of $34 for an individual, and increasing by approximately that amount, for each member of a family until a ceiling is reached at $103.68, beyond which no further charge is made, however large the family covered. For persons with incomes of over $5000 for individuals or $6500 for families, these premiums are approximately 50 percent greater. H.I.P. makes use of various previously existing first-class hospitals and has recruited its doctors from among the best. The plan does not cover hospital bills when hospitalization is necessary, only doctors’ bills; but H.I.P. requires its subscribers to join the Blue Cross and the two plans give complete medical and nearly complete hospital coverage. When it started, the county medical societies of the regions served were invited to send representatives to the Medical Control Board of H.I.P. Some of them refused to do so, their chief objection being that there was a majority of laymen on the board of directors. Attempts were also made in certain instances to scare doctors away from joining the plan.

The Journal of the A.M.A. also disapproved of H.I.P. editorially. H.I.P., despite the opposition of organized medicine, is a going and growing concorn, and shows how private enterprise can solve the medical care problem when there is a will to do it,

A similar example is furnished by the Permanente Health Plan in California. Set up under the guiding genius of Dr. Sidney R. Garfield, this enterprise is an offspring of the health plans developed for the workers at Grand Coulee Dam before the war and the Kaiser shipbuilding plants during the war. For a premium of $36 for an individual, and $70 for a family of two or more children, and for a charge of $1 for office visits and $2 for home visits, it gives complete coverage for both medical and hospital care. That is to say, it serves the purposes of H.I.T. in New York and Blue Cross combined. It owns its own hospitals, the major one being in Oakland.

I have visited this hospital and talked with both doctors and patients therein. The doctors are evidently topnotch and the patients very much pleased with the plan. Nevertheless the county medical societies have resisted it in various ways. For a time they refused membership to Permanente doctors. The Alameda County Society, Dr. Garfield tells me, has now admitted all his staff, but not the San Francisco society. Dr. Garfield has also been brought to trial before the disciplinary board of the societies on various charges of unethical behavior, of all but one of which he was acquitted. The one on which he was found guilty was of unduly promoting the health plan. For this he was reprimanded. Nevertheless the Permanente Health Plan is growing and meeting a very real need in the community.

Throughout the country there are other such plans in successful operation: the Group Health Association in Washington, the Ross-Loss Clinic in Tos Angeles, the Labor Health Institute in Si. Louis, and others. All voluntary prepayment plans of this type have been greeted by organized medicine with coercive tactics designed to force doctors not to associate with them. In 1943 the Supreme Court of the United States found the A.M.A. and the District of Columbia Medical Society guilty of illegally obstructing the Group Health Association in Washington.

The plans that organized medicine claims to support are of one specific type: namely, those which pay doctors on a fee-for-service basis and permit, them to charge patients fees in addition to the amount paid by the insurance plan. In general these plans cover only fees for surgery and obstetrical deliveries in a hospital. A few also pay fees for nonsurgical physicians’ services in a hospital, and a very few pay fees for home and office \ isits and diagnostic services outside a hospital.

While these plans are of some assistance in aiding surgeons and obstetricians to collect their fees, and while they act as a bit of a cushion for tho patient facing a big bill for a surgical or obstetrical procedure, they obviously have glaring deficiencies. For one thing, they probably do not cover more than one sixth of the average family’s annual doctor’s bill, so that they are hardly more than a token of economic aid.

Yet these inadequate voluntary insurance plans are the only ones which have received the support of organized medicine. If a nonmedical group like a coöperative tries to reach an agreement with doctors to look after its members; if an attempt is made by an insurance plan to set professional standards and to offer its subscribers only the services of physicians thoroughly qualified to perform them; if doctors are paid salaries, retainers, or annual per capita amounts instead of fees for every service, then organized medicine not only gives no encouragement but usually does its best to prevent such plans from being organized or from operating successfully.

In conclusion I submit that in recent years organized medicine has taken on a rapidly expanding political function. In my opinion this is being exerted in a way which is not in the best interest of the people, for whom, after all, medical service is supplied. Medical care is for the people — not for the doctors. At the present time the provision and financing of medical care in many areas of the country are in an unsatisfactory state. The skyrocketing costs put a rapidly increasing number of people in the medically indigent class. Some way of prepaying for complete medical and hospital care and of lowering their costs through more efficient organization and professional teamwork is urgently needed. Being no socialist, I should much prefer to have these things accomplished by private enterprise than by government, but I am certain that if private enterprise fails in this regard, we shall have government medicine whether we like it or not.

In this emergency I consider that organized medicine has failed dismally. Its public relations are deteriorating. People look upon its motivation with increasing suspicion. It cries now for voluntary health plans but does little actually to produce them. The record shows that when others have sought to do these things, organized medicine has obstructed them. A learned profession has sunk, or been dragged, in its political sphere, to a distressingly low level. Individually the American doctor of medicine is, in most instances, an honest, sincere, and generous person. Certainly he is a hard-working one. When he organizes, however, his collective behavior is, at times, less noble than that which he displays when acting on his own initiative.

If organized medicine would drop its obstructionist tactics and instead devote its energy and money to the creation of adequate health plans like H.I.P. and Permanente, it would more effectively forestall government medicine than it will with its present costly propaganda campaign and Washington lobby. What organized medicine needs in serving its political function is a new and more enlightened leadership.