DOCUMENTa v / W ROOM — — £ 17 Per 1000 CHRONIC Per 1000 INFECTIONS - - 29 Per 1000 ACCIDENTS - - 16 Per 1000 PUERDERAL - - 15 Per 1000 ALL OTHER - - 10 Per 1000 DIGESTIVE - - 9 Per 1000 Each Symbol Represents 9000 Cases Source: NATIONAL HEALTH SURVEY Workers* Education - Utah The estimates indicated in the chart (,'/2) en the annual frequenoy of disabling illnesses relate to persons of all ages, but the survey report tells us that persons in the group 65 years of age and over had the highest proportion of sick, about one in every 8 of tho aged being disabled on the day of tho survey, Youth was found to be tho hoalthiest age, the proportion of siok in this age group (15-24) being only one in 40, In childhood, however, the proportion was 502 - CH - 4 - higher, the rate being about the same as that for adults of the working ages, between 25 and 65 years. Acute respiratory diseases (influenza, grippe, pneumonia, colds, and tonsilitis) were the oauses of illness in a mil¬ lion and a half of the total six million persons in the country as a whole estimated to be disabled on the day of the canvas. This high proportion possibly arises from the faot that the survey was made in the winter months when the diseases are most prevalent. Approximately two and one-half million persons were dis¬ abled by chronic disease (rheumatism, diseases of the heart, and circulatory system, arteriosclerosis-, nephritis, cancer and non-malignant tumors, diabetes, asthma, tuberculosis, ulcer of the stomach, diseases of the gall bladder, nervous diseases) and permanent impairments, which were the result of prior disease or accident. Injuries due to accident accounted for the disability of about one-helf million persons. The acute infectious dis¬ eases were the cause of illness in about 250,000 persons, mostly children. Approximately the same number of persons were disabled by acute diseases of the stomach and liver, and appendicitis. Other acute diseases accounted for the disability of the remainder of those found ill on the sur¬ vey date. (3) IN CHILDHOOD, EXCLUDING THE FIRST YEAR OF LIFE, THE PROBABILITY OF DYING IS LOWER THAN AT ANY SUBSEQUENT AGE PERIOD IN THE ENTIRE LIFE SPAN, BUT THE RATE OF SICKNESS IS GREATER. Of disabling illnesses for children under 15 years of age, about 40 percent were due to acute infectious disease suoh as measles, scarlet fever, whooping cough, and diphtheria. Anoth¬ er 40 percent was due to influenza, pneumonia, colds and tonsil¬ litis. Other ranking oauses of child sickness are poliomeylitis, tuberculosis, birth injuries, rheumatic heart disease, deformi¬ ties, etc. It is estimated that there are at least six children in every 1,000 who are crippled or seriously handicapped by diseases or accidents. (4) Aocording to an interpretation of the figures on child diseases in the Utah Planning Board Report "Health Conditions and Facilities in Utah," the problem of childhood diseases from the standpoint of both sickness and death is becoming less acute each year. It is a safe conclusion to say that, by and large, childhood diseases are controllable. In fact the startling fig¬ ures on'the increased span of life" which have been presented to the American publio in recent years are largely attributed to the control of these ciiild- 502 - CH - 5 - hood diseases. In other words, scienoe has not for the most part actually helped old people to live longer but rather has decreased hazards of child¬ hood. This can mean only one thing, that we can expeot a continuing increase in the proportion of death rate from the old age diseases. This is true be¬ cause a larger percentage of people are becoming old enough to be subject to the degenerative diseases suoh as heart trouble, kidney trouble, rheuma¬ tism, cancer, etc. Medioal soience has in the past devoted itself more com¬ pletely to the most important diseases, at the time, which are largely oom- municable and which are to a great extent childhood diseases in nature. But since these have been brought largely under control, medical science must direot its attention more and more to the problem of degenerative diseases. Likewise if a cooperative health society is to meet the needs of the com¬ munity, it must apply itself to these chronic (old age) diseases. VENEREAL DISEASES THE VENEREAL DISEASES CONSTITUTE AN IMPORTANT HEALTH PROBLEM WITH SERIOUS IMPLICATIONS FOR MANY GROUPS OF THE POPULATION. IT HAS BEEN FOUND THAT SYPHILIS STRIKES APPROXIMATELY ONE PERSON OUT OF TEN IN THE NATION AND THAT GONORRHEA INFECTS EVEN MORE. Congenital syphilis is an important and preventable cause of infants deaths, and l*ss of fetal life. Some 60,000 cases of congenital syph¬ ilis occur annually. The syphilitic envolvements of the heart and blood vessels and of the nervous system result in almost 50,000 deaths annually. In addition to those assigned specifically to syphilis, eigjity percent of these deaths could be prevented by adequate treatment of the infection in early stages. The increase in chronic nervous diseases is placing a severe burden on our institutional facilities and,is creating enormous costs for our local and state governments. At least, ten percent of first admissions to mental hospitals are attributable to syphilis in its manifestations as general paresis. (5) There are in Utah about 10,000 cases of syphilis (l out of 50 people) and 60,000 cases of gonorrhea (one out of 10 people) at the present time. (6) While this is below the national average, it, nevertheless, forces us to realize the seriousness of the problem which confronts us here in Utah. .CHRONIC CAUSES OE DJSASJUTY A workable approach in studying the problem of chronic ill health is to consider specific diseases of this larger disease group, even though 6 number of these diseases may be only slightly related. The frequency of the occurrence of various diseases is one basis for judging their relative importanoe. The chart on speoified chronic disonses presents estimates of the prevalence on the day of the canvas of certain chronic diseases for the whole United States based upon Na¬ tional Health Survey data for urban areas. Extension of the data to oover the whole country in these approximate estimates seems to b© justified in view of the paucity of other quantitative information on chronic disease. A CHRONIC DISEASE WAS CONSIDERED TO BE A STATE OF ILL HEALTH, IF, IN THE OPINION OF THE INFORMANT, IT WAS HANDICAP¬ PING. (7) 502 - CH - 6 - fig. No. 3. - IMPORTANT chronic DISEASES, shows us that rheumatism leads all diseases with nearly twice as many cases as any other chronic disease. remember that while sancer is i3th in the list, it's a disease on the rampage with an ever as¬ cending case rate. Venereal diseases have been omitted from this and other lists because of the incompleteness of reports of such conditions in a house-to-house canvass. estimated prevalence of I MPORTANT CHRONIC DISEASES cases disabled three months or longer rheumatism jilnkmink>e%j [■■xmnrm.'mai hernia hemorrhoids heart disease h 1 on ri nnn prfssiirf *1 I 4 (— hay fever and asthma jwbbyj jsbbw |i varicose veins chronic bronchitis kidney disease nervous and mental thyroid disease m sinusitis i cancer 4 other tumors Each Symbol Represents One Million Cases source: national health survey Workers1 Education Utah 502 - CH ~ ' " CONTROL OP CANCER IS ONE OF THE MOST URGENT NEEDS IN A CHRONIC DISEASE PROGRAM. CANCER WAS RESPONSIBLE FOR OVER 10 PERCENT OF ALL DEATHS IN 1936. It is estimated, that thoro are 930,000 living persons suffering from cancer in the U.S. today. With mortality ratos at their prosont level, it is probablo that one parson out of every eight who reaches tho ago of 45 years will ultimately dio of cancor. Yet loading authorities have estimated that at least ono-sixth of tho annual deaths from cancer might bo proventod if all casos received the benefits of modern methods of treatment; an additional numbor of deaths could be prevonted by di¬ agnosis of a larger number of cases in the early stages of tho disease. (8) Charts included in this Handbook do not indicate the truo seriousness of the cancer problem. Remember that while cancor is 13th on the chronis disease list, it is a disease on the rampago with an ever ascending case rate. While Utah has a comparatively low cancer rate, cancer' as a cause" of death is also rapidly increasing in Utah. APPPND]C.mS WHILE THE RATE OF DEATH FOR APPENDICITIS SEEMS TO CLIMB NATIONALLY AS WELL AS LOCALLY EACH YEAR, THE ANNUAL DEATH RATE FROM THIS CAUSE IS MORE SE¬ RIOUS IN THE MOUNTAIN STATES THAN ELSEWHERE. THEREFORE WE SHOULD GIVE THIS PARTICULAR DISEASE SPECIAL MENTION AS BEING A SERIOUS LOCAL PROBLEM. The Mountain States in order of appendicitis death rate per 100,000 people in 1934 were Wyoming, 28.4; Utah, 25.8; Idaho, 24.6; Montana, 23.8; Colorado, 23.2; Nevada, 22.3. Dr. L. E. Viko reported for Salt Lake City an appendicitis death rate d eraging 37.9 per 100,000 population for the ten years of 1923-1932, whereas an average of 60 other cities was less than ono-half, or 17.3 death per 100,000. The rate is much higher in urban localities than in rural, but some of this may bo accounted for by the fact that many oases wore brought to the cities for treatment in hospitals. It may also be partially accounted for by more accurate urban diagnosis. Appendicitis occurs steadily, not in epidemics. (9) DJSPA5PS OP THP HEART, PTC. THIS GROUP OF DISEASES TAKES AN EVER -INCREASING TOLL OF LIVES. WHILE A LARGE PROPORTION OF THE DEATHS ARE AN INEVITABLE RESULT OF AGE, MUCH CAN BE DONE THROUGH PREVENTION AND TREATMENT TO AVOID NEEDLESS CASES, TO REDUCE SUF¬ FERING AND PREMATURE DISABILITY AND DEATH, AND TO MINIMIZE THE ECONOMIC AND EMOTIONAL DISTRESS CAUSED BY THESE DISEASES. Heart disease, in particular, is closely related to increasing age, ex¬ acting only a small number cf deaths among those below 20 years of age. Since 1910, there has been a decrease in the proportion of heart disease cases among people of 20 to 44 years, and an inorease in the proportion of older people with the greatest increases being above the ages of 65. It is an unfortunate psychological experience, from the standpoint of health promotion, that people are more impressed by new and start- 502 - CH - 8 - ling events than by more serious conditions that develop slowly over a considerable period of time. The ocourrenoe of a few deaths from smallpox in a community will usually result in wholesale vac¬ cinations as a preventive measure, while the greater number of pre¬ ventable deaths that ooour in any one year from other diseases ex¬ cites no comment whatever# Few people realize the growing menace to life of heart disease and that its importance as a public health pro¬ blem is greater than that of tuberculosis or cancer. Education is considered by some to be the best medioine for these diseases, (10) 5 UM\ARY Of HEALTH CQHDJTJQNS IN SUMMARY OF THIS DISCUSSION OF THE HEALTH CONDITIONS IN AMERICA IT WILL PROBABLY BE NECESSARY ONLY TO POINT OUT THAT THE MAGNITUDE OF THE GREAT "SICK AMERICA" PROBLEM CALLS FOR IMMEDIATE AND DETERMINED ACTION. The Technical Committee on Medical Care of the President's Interdepart¬ mental Committee to coordinate Health and Welfare activities summarizes its Fig. No. 'h - Medical Services Received and Needed, shows us that there is need for about three times the present hospital carej more than once again the present number of physician callsj three times the dental care, and more than four times the present health examinations. MEDICAL SERVICES RECEIVED AMD NEEDED BY U.S. FAMILIES Days of Hospital Care Physicians Calls RECEIVED ADDITIONAL SERVICES NEEDED Dental Care Health Examinations k J- & A Q m w Each symbol Represents 250 Services Per 1000 Persons Pictorial Standards Project w. P. A. 502 - CH ■* 9 •» pamphlet "The Need for a National Program" with the following statement whioh seems an adequate eonolusion to this discussion: The deaths of women in ohildbirth present a special challenge; with adequate core from one-half to two-thirds of these deaths could be prevented. Mortality of infants during the second to the twelfth month of life, though showing consistent decline, might be further re- duoed by as much as one-half. Mortality in the, first month of life has deolined but little; these deaths also may be reduced by as much as one-half with adequate care of mother and child. The death rates from the acute communioable diseases of child¬ hood have been greatly reduced; further reduction can be brought about by the application of known measures of prevention and core. Appropriate ireatment of children with rheumatic heart disease will restore nearly two-thirds to normal life. Early treatment of chil¬ dren with infantile paralysis is well known to prevent much crip¬ pling. The development of rapid methods of determining the type of pneumonia and the production of sera for many types of the di¬ sease have revolutionized treatment. The benefits of modern thera¬ py must be made generally available, Deaths from tuberculosis can be reduced 50 percent by health supervision of industrial workers in occupations predisposed to the disease, by detection of incipient cases, and by pro¬ vision of adequate medical and institutional care in the early stages of the disease. Each year 518,000 new cases of syphilis go to doctors. More than half a million more resort to self-medioation or "quack" treatment. In addition, the rehabilitation of those insane and blind as a result of untreated past infections consistute a major drain upon welfare, security, and relief funds. Yet the diagnosis and treatment of syphilis are highly perfected; and it has been demonstrated that a program of control oould reduce this toll by more than 95 percent. There is urgent need for a concerted attack on the heart and kidney diseases, cancer and diabetes, whioh are increasing in importance as causes of death and disability in the older age groups, In the light of the high incidence of tuberculosis and pneu¬ monia among industrial workers, and the diseases duo to the special hazards of occupation, inoreased activities in the field of industrial hygiene are ossontial. The health problems of the dependent and low income families neod consideration commensurate with their severity. The amount of medical caro obtained by individuals differs with their eco- 502 - CH - 10 - nomic statusj tho woll-to-do obtain moro, tho poor loss. This is so notwithstanding tho fact that the poor have more sickness and moro disability and nood moro (not less) service. The ineffective distribution, and, in some cases, lack of medical, dental, and nursing personnel has serious implica¬ tions for the health of those living in small cities and rural areas. There is need for national and regional planning in the field of hospital expansion and construction. An effective system of modern health service is impossible without well-equipped hos¬ pitals which will provide the facilities necessary for the prac¬ tice of modern modicine. Inadequacies in hospital oarc ore known to oxist in many localities, particularly in rural areas and aroas in economic need. As a nation, wo are doing vastly loss to prevent suffering and to consorvo health and vitality than we know how to do through triod and tostod methods. Tho Committee is convinced that cur¬ rent activities are inadoquato to assure the population of the United States such health of body and mind as they can and should havo. Sanitary advance owos much to epidemic or threats of thoir approach, to outbreaks of contagious disease among school chil¬ dren, to floods and other disasters of the past; but we cannot pormit tho future of health services to continue to rest with tho accidonts of history. A good beginning has been made in moro re- cont years toward carrying out health activities through well- plannod and directed offort, but systematic warfare against dis- aa8o on the broad front is long overdue. (11) 502 - CH - 11 - LIST OF REFERENCES Reference Number (l) Report Bulletin No.l. See page 3. Sickness and. Medical Series. A part of the National Health Survey by the United States Public Health Service; a series of 15 preliminary bulletins compiled from the data collected in cooperation with the Works Progress Administration in America's first National Health Inventory. The survey was made during the winter of 1935-36 at which time 2,800,000 persons in 19 states and 84 cities were con¬ tacted in a house-to-house canvas, 1938. Reference Number Reference Number Reference Number Reference Number Reference Number Reference Number Referonce Number (2) Same Report as above. See page 4. (3) Same Report as above. See page 1-2 (7) Same Report as above. See page 1 (4) The Need for a National Health Program. See page 8. (Report of the Technical Committee on Medical Care. The Technical Committee is a part of the Interdepartmental Committee to coordinate Health and Welfare Activities ap¬ pointed in October, 1936, by President Roosevelt to co¬ ordinate the government's health activities and to study and make specific recommendations as to the government's part in a national health program. (1938) 36 pp. (5) Some Report as above. See page 12. (8) Same Report as above. See page 16* (ll)Same Report as above. See page 35. Reference Number (9) Health Conditions and Facilities in Utah. See page 20. D. C. Houston and Rey M. Hill. Presentation of Basic Data Concerning Health Conditions in Utah. Utah State Planning Board, State Capitol Building, Salt Lake City, Utah. 223 pp. Price, free. Reference Number (10)Same Report as above. See page 22. Reference Number (6) Health Policies for Utah, Seo page 18. Contains recommendations and conclusions derived from the factual data contained in the report Health Condi¬ tions and Facilities in Utah. Utah State Planning Board, issued December 1936. 49pp. 502 - CH - 12 - HANDBOOK - Cooperative Health Associations UNIT T WO h\ED J GAL ECONOMIC! The business of supplying medical care to the people of the Ufa ited States is a three billiofa two hundred million dollar industry with tremendous investments in hospitals, equipment, professional training, factories which manufacture medicines, and generous cash outlays to support the cultists who prey upon unhealthy America, Where this money comes from and where it goes is of tremendous importance in the contemplation of change in methods in supplying medical service. A study made in 1928-31 by the Committee on the Cost of Medic al Care (Appointed by President Hoover) gives $43.00 as the average annual expenditure for medical care for families 'with incomes Cinder $1200.00, including all forms of s ervice. Of this smb., about 48 percent went to physicians, 15 percent for dentistry, 18 percent for medicines, 2.5 percent for refractions and glasses, and the remainder for other services. (12) FIGURE 5. - who SHARES THE MEDICAL INCOME, Indicates that the Doctors receive 1(5 percent of the annual average payment of $u3.00 made by families tn the income groups receiving $1200.00 or less per year, WHO SHARES THE MEDICAL I NCOME OF H-O S/| QQ£> — AVERAGE ANNUAL PAYMENT BY FAMILIES WITH INCOMES OF 1200°°0R LESS7 W AT; <1 . . *\ '41... 1,1* MEDICINES v"'"'/. C( . _ . DOCTORS /"'k'-' WT A/'* '*»*.* CIXITMCIK J"T% /At IBS /"x*- \«f> $7.7! l»5^ - $l?.35 SOURCE: COMMITTEE ON COST OF MEDICAL CARE, DENTISTS If £ li ft \* © Ivi/w 180- $7,711 ■ 19^ _ $8.17 WORKERS' EDUCATION - UTAH 502 - CH - 13 - THE FEES WHICH WE NOW PAY FOR THE COST OF MEDICAL CARE WOULD BE ADE¬ QUATE TO GIVE ALL THE HEALTH PROTECTION WE NEED IF THESE COSTS COULD BE DISTRIBUTED EQUALLY UPON THE SHOULDERS OF THE WHOLE POPULATION. Contrary to the general belief, the iMdieal industry gets its main revenues from the individual patients through Qut»of-pogket payments. Ac¬ cording to the latest §©raprfhp|i8iv« estimates, individual patients paid nearly 80 peroent of the amount paid for sickness, the government through WHO PAYS THE COST OF SICKNESS? ••<§•• •$••• ••••• fATIENTS - 8Cji Mill"! GOVERNMENT - INDUSTRY- 2.IJ* PHILANTHROPY » I. Jjt EACH DISC REPRESENTS 5jC OF COST Sourcej Technical Committee on hedicalCare From: "Dollars, Doctors anb Disease", pub. Bv. Public affairs Committee, Inc. FIG. 6. - WHO PAYS THE COST OF SICKNESS? IS IN REALITY 7MO SEPARATE CHARTS, THE FIRST ONE INDICATING THAT THE PATIENT PAYS 80 PERCENT OF THE NATION's MEDICAL BILL, WHILE THE SECOND CHART fATIENTS' COSTS FALL UNEVENLY SHOWS THAT |0 PERCENT OF THE PATIENTS PAY U| PERCENT OF THE BILLS. ^ W 'PATIENTS COSTS EA.LL UNFVFNIY I OUT OF 10 PAYS J PAY U|jC 6 PAY 8ljf ,a l '//*.» '''hi nx' V"'*. ,* . V v iuu; 4 •inkH* ''I/uhk ■UDM ($ K $ ! v i v ^ >* «>»•»'** Xl^Jj''. * r$rmr $t D V ? f ^ *» * * *• C *5/ TJ j? *• - * m. fmk* m. ' C slj I Each Dollar Represents 5$ of Cost SOURCE: Committee on Cost of Medical Care. Workers' Education - Utah taxation paid 16 peroent, industry paid 2»1 percent, while philanthropy paid only 1,9 peroent of the nation's medioal bill. The last figure is especially interesting for it indicates that philanthropy is paying con¬ siderably less than it did in 1929 when it paid 5 peroent of the nation's medioal costs. Philanthropy has been given a lot of oredit for its generous support of the health system, but actually it never has given a large per¬ centage, and what money has been contributed nearly always has gone, into 502 - CH - 14 - th6 building of hospitals and purchasing of equipment or into original re¬ search and not into shoring of the aotual costs of medioal services. It is quite evident that the major portion of the cost of medical care is paid by the individual patients or families, but as we all know this oost is not distributed equally among the entire population. The annual bill for medioal care ($3,&00,000,000) is but 4 percent of the estimated national income for the yor.r 1929. It is difficult to believe that this is an undue burden for all the people of the United States as a whole, for we spend much larger amounts (15 billion) for entertainment, chewing gum, candy, cosmetics and similar items. It comos not from the 130 million potential patients in the United States, but from the 60 percont who receive some medical care, and it comes very unequally from those who in a typioal year make expenditures for medical service. (13) Whon wo stop to think that it is the individual patient who foots 80 peroont of the national medical bill, and whon wo look farther into tho problem to noto that 10 percent of those patients aro paying 41 percont of this cost, it is oasily soon that tho economics of good health is indeed a complicatod problom. Of course, those intorostod in tho cooperative health association, claim that the application of tho insurance principle, whereby the costs of medical sorvico is sharod oqually by all tho population, would tond to solve this particular problom of tho unovon distribution of medical costs. There is no doubt that somo solution can bo found by organized action while there is little hopo that the individual patient will over find a satis¬ factory method by solitary research.All of America's problems have always boon solved through organized action. Tho complication, of course, to a,quick so¬ lution of this modical problom lios in the fact that there aro many more con¬ flicting eoonomio involvements than thoso first cited which darken^our outlook. Bosidos the uneven distribution of modical expenses, wo find that tho major group of siok poople are those closost to poverty, and that ovor 80.percent of tho population aro in an income classification close to poverty. .At least this inoome group (80.6 porcont with incomes of less than $2000.00) have their budgets badly strainod evon by relatively small outlays for medical attention. Why do self-sustaining peoplo with low incomes recoivo inadequate caro? The first basic reason is found in the irregular and un¬ predictable ooourronco of illness and of sickness oosts. Families spend, on an average, 4 to 5 percent of their income for medical care, the proportion being fairly constant up to an annual family income of $5000.00, beyond which it tends to decline slight¬ ly. Thoso average figures do not, howovor, give a realistic picture of tho burden created by medical costs. The need for medical care by a family is uneven and unpredictable. In one year, little medi¬ cal sorvico or none may be required} in another year, tho family may suffor ono or moro severe illnesses among its members and may require medical service costing largo amounts. No particular family knows during any month or any year whether it will bo among the fortunate or among the unfortunato. When serious illness comes, it may bring largo costs and may descend with catastrophic forco on 502 - CH - 15 - the current budget, on savings, on froodom from debt, or the economic independence of tho family. Evory substantial study of modical costs shows that thov aro burdonsome, moro booause of their unoortaintv than beoauso of their average amount. And this is oqually truo for tho urban family, of the indus# trial wago earner and for tho rural family of the former or farm laborer. Nor do the statistics of actual family expenditures tell the whole story* Knowing in advance that they cannot pay large modical bills, many families ask for "free" care, and many go FIG. 7. - AMERICA'S FAMILY INCOME GROUPS. 1935 - INDICATES THAT 65.6 PERCENT OF OUR POPULATION RECEIVE AN INCOME OF $1,500.00 PER YEAR OR LESS, WHILE 5.7 PERCENT RECEIVE $3,000.00 OR MORE AMERICA'S FAMILY I NCOM E GROUPS.. 1935 RELIEF INCOME ( 15.( NON - RELIEF INCOME UNDER $1000.00 (28.7$) INCOME? 1000 to $1500 (21.3$) INCOME $1500 to $2000 (I5.O5O INCOME $2000 TO $3000 (|0.5$) e f>- /£ I ® § it INCOME OVER $3000 (5.7$) NOTE: Income Unknown (3.2$) SOURCEJ NATIONAL HEALTH SURVEY. I Each Family Represent 3$ of Total. Workers' Education - Utah without medioal attention. Nor is it diffioult to picture the distress of those families which incur large bills and under¬ take to pay them. In one case or another, the savings of a lifetime may be wipod out, the hopes and dreams for a home or farm thwarted, educational opportunities sacrifioed, the family deprived of those things which make life pleasant and living worthwhile* Nor do the statistics leave any doubt why physicians and hospitals have difficulty in oolleoting their bill3. Is all this necessary or inevitable? Is there no remedy? Is our system of providing, buying, or paying for medioal oare the bost that can bo devised to meet our present needs? (14) 502 - CH - 16 - In a representative samplo of the urban population studied in the National Health Survey, 44,3 percent of the persons canvassed wore found to be members of families with incomes of less than $1000; 65,6 percent wore in families with incomes under $1500; 80,6 percent in families with incomes of less than $2000. Noarly one half of the group with incomes under $1000 was in receipt of reliof at some time during 1935. These figures are fundamental to any consideration of national health because they are basic to any contemplation of capacity to purchase not only food, shelter and clothing, but also medical care. (15) THE MEDICALLY NEEDY POPULATION THE RESULTS OF PRIVATE HEALTH SURVEYS HAVE THOROUGHLY PROVED THAT THE FREQUENCY OF ILLNESS IS HIGHEST AMONG THE POOR. THIS RELATION IS AUTHORITA¬ TIVELY CONFIRMED BY THE PRELIMINARY DATA COMPILED BY THE NATIONAL HEALTH SURVEY. The annual volume of illness in the population is the result of two factors: (l) the frequency of illness, or the number of cases of illness occurring during the year, and (2) the severity of ill- ness'jthat is, the duration of the average case. The product of those two figures gives the best single index of the annual burden of illness. Illnesses disabling for one week or longer in a 12 month period occurred among families on relief at a rate of 57 percent higher than among families with annual incomes of $3000 and over. It was found that chronic illnesses were 87 percent more frequent among the poor than among the highest income groups. During the year that the National Health Survey was taken (1935-36) two persons on reliof we re disabled for one week or longer by chronic ill¬ nesses for every person in the middle and highest income groups. Those persons in families just above the relief level (income of less than $1000) experienced an illness rate slightly lower than the relief population, but the survey indicated that chronic ill¬ nesses occurred 42 percent more frequently than in families with incomes of $3000 and over. (16) NOT ONLY DO LOW INCOME FAMILIES EXPERIENCE MORE FREQUENT ILLNESS DURING THE YEAR THAN THEIR MORE FORTUNATE NEIGHBORS, BUT THEIR ILLNESSES ARE, ON THE AVERAGE, OF LONGER DURATION, 63 PERCENT? LONGER IN FACT, The annual sickness duration rate couples with the higher freauency of chronic illness in the relief groups, gives rise to an annum per capita volume of disability in the relief group that is nearly three times as great as among the upper income families — 16,5 days as compared with 6,5 days per person. A comprehensive review of the statistics on sickness and poverty would try your patience. Every substantial survey, whether in urban or in rural communities, whether made by government, by philanthropy, or by business concerns, serves only to furnish proofs that siokness and disability are more prevalent among people of small means than those who ore in better circumstances. This is the basis for th<$ conclusion that the poor and those in low income classes need mor© medical care than the vrell-to-do or the wealthy. (17) 502 - CH - 17 - This is the result of two situations. One is that available inoome is not well harnessed to the purchase of medical care. The family spends' its inoomos from day to day and does not save against the day of serious sickness and large medical bills. As a conso4.if.once, many individuals who could pay for medical care if they made regular provisions therefore, either go without oaro when sickness comes, or are forced to ask for oharity. A second situation is that families endeavoring to pay their own way are oftentimes confronted in severe illness with medical bills which they oan pay only with hardship. Tho expense of proper medical treatment in certain illnesses has now bocome an ooonomio hazard like unemployment or death, against which the average family requires protection. (13) FIG. 8. - POOR PEOPLE ARE SICK MORE shows that the individual in the average relief family was disabled for idays in one year as against the average individual in the family with $3,000.00 or over each year who was disabled only ck days POOR PEOPLE ARE SICK MORE THE AVERAGE PERSON IN THESE INCOME GROUPS WAS DISABLED THIS NUMBER OF DAYS IN ONE YEAR BY ILLNESS. UNDER $1000.00 $2,000.00 TO $3,000.00 OVER $3,000.00 Each Disc Represents One Day "CONSUMERS' GUIDE". 502 - CH - 18 - THERE ARE IN THE UNITED STATES TODAY PROBABLY 40 MILLION PERSONS (ALMOST ONE THIRD OP OUR POPULATION) LIVING IN FAMILIES WITH INCOMES OP LESS THAN #800. In the emergency of sioknoss somo 20 million persons in the marginal income class above the roliof level, othorwise self- sustaining, become dependent on public aid for the provision of medical caro. (19) Current studies of the cost of living indicate that the sum of #800 supports tho average family of four persons only at an emergency level, and leaves a margin for the purchase of medical care at the risk of deprivation of food, clothing, shelter, and other essentials, equally necessary for the main¬ tenance of minimum standards of health and decency. Included in this group, as of April 1938, is an estimated total of about 11 million persons in families on work relief rolls, six mil¬ lion in families receiving general relief, more than one mil¬ lion in families of persons enrolled in the Civilian Conserva¬ tion Corps,more than half a million in families receiving Farm Security subsistence grants, over two million in households receiving old-age assistance, over one million in families receiving mother's aid or aid to dependent children, and 60,000 in families receiving aid to the blind, under Federal, State or local provisions for these several types of assistance. This group, comprising'a total of over 20 million persons, is do- pendent on tho govornmont for food and shelter, and similarly dependent on public funds or private philanthropy for medical caro. (20) Evidence of the association of sickness and poverty could be enumerated at great length. To summarize all the substantial health studies of both urban and rural populations, let us conclude that sickness rates are higher among the poor than among those who are in better economic circumstances. As a corollary, the poor need more heulth and sickness services than the well-to-do or the wealthy. The poor have much sickness; sickness brings poverty. This circular relation brings anti-social results. The people who are involved in tho vicious circle are trapped; they cannot raise themselves out of it by their bootstraps. Only society, which pays a heavy price for this continuing situation, con intervene and bring relief. (21) The advance toward better national health, to which the Inter¬ departmental Committee on Health and Welfare has directed at¬ tention, have only limited significance for the poor. It is cause for grave concern, and for action, that the poor of our cities (and farms as well) experience sickness and mortality rates as high today as were tho gross rates of 50 years ago..(22) All these facts and figures indicate that cooperative medical societies are tackling a hard problem, especially when we admit that the larger botSy of the country's population (and those most likely to join the cooperative) - CH - 19 - the very poor people are those that have illnesses of greater frequency and severity, and are the least able to pay for these services. FIG. 9. - NO MEDICAL CARE INDICATES THAT l»7 PERCENT OF ILLNESSES IN FAMILIES WITH INCOMES UNDER $1200 PER YEAR RECEIVED NO MEDICAL, DENTAL OR EVE CARE WHILE ONLY 15 PERCENT OF THE ILLNESSES RECEIVED NO MEDICAL CARE IN THE INCOME GROUP WHICH RECEIVED $10,000 OR OVER. ILLNESSES RECEIVING NO MEDICAL CARE. 1935 NO CARE FOR THESE FAMILIES FAMILY INCOME UNDER $1200.00 AAAA $1200.00 TO $2,000.00 AAA $3,000.00 TO $5,000.00 MEDICAL, DENTAL AND EYE CARE FOR THESE /X /X, /\ /X /X OVER $10,000.00 SOURCE: REPORT OF TECHNICAL COMMITTEE ON MEDICAL CARE. WORKERS' EDUCATION- UTAH In order that the reader might have a clearer pioture of the problem disoussed generally under the heading of "who are the siok people", we wish to enlarge upon that whioh we have already discussed. There are really two large groups of the population whioh are"to be classed as the medically needy. First, there is the group of the population (15.6 percent) on relief which cannot pay for adequate services on any fee schedule, and, second, there is the group of self-supporting but very low income (non-relief) families (28.7 percent with incomes of less than $1000) whose income is not large enough for anything but emergency medical attention and then at the expense of food, 502 - CH - 20 - shelter, and other items. A third income group (those with incomes of from $1000 to $2000 - 36.3 percent of the non-relief population) are in an economic class for which a medical contingency is an economio disastor. Although thore are some important exceptions, medical care is, in the main, an "oconomic commodity" which is purchased and paid for directly by the individual who needs it. The fact that this "economic commodity" is ohiefly a professional sorvico does not alter the basic fact. It therefore results that the amount of medical care obtained by individuals differs with economic status; tho well-to-do obtain more, the poor obtain less. This is so not¬ withstanding tho fact that tho poor have moro sickness and more disability, and need more, (not less) service. Thero are some ex¬ ceptions to this generalization. In areas where extensive provi¬ sion has been made for froo hospital care for needy persons, the amount of hospital sorvico roceivod (per capita) by the poor is sometimes actually greater than the amount received by any oxcept the very woll-to-do. But this is only an exception proving tho rules that the amount of medical care received (measured in number of sorvioes) varies with tho person's ability to pay for it. For example, a survey during 1928-31 among representative family groups in 130 communities, scattered among 17 states and the District of Columbia, showed the following volumes of servicos received during a twelve month period. (23) table #1. VOLUME OF RECEIVED BY A MEDICAL S D iRVICE.S -AMI LIES SERVICE Services per person in familios with specified incomo Undor $1200- $2000- i o o o to *■> $5000- $10,000 $1200 2000 3000 5000 10,000 and over Physicians services for sick persons 1.9 2.0 2.3 2.7 3.6 4.7 No. of Days of general hospital caro 0.9 0.7 0.8 0.6 CO • o 1.2 No. of Dental cases (for persons over 3 yrs.of ago) 0.1 0.2 0.2 0.3 0.4 0.6 No. of Health examinations 0.08 0.07 0.07 0.08 0.1 0.2 Immunizations 0. 07 0.05 0. 05 0.06 •. 08 0.1 No. of Eye examinations and prescriptions 0.02 0.02 0.04 0.05 0.09 0.2 From: The Need for a National Health Program. Although there is more disabling illness among the people in the low income groups than among those in the higher brackets, the pro¬ portion who went through a year of life without professional care was more than throe times as high among tho poorest as among tho 502 - CK - 21 - wealthiest families. No physicians core was received in 30 percent o'f serious dis-i- abling illnosses among relief familios and in 28 percent of such illnessos among familios just above the relief lovol, as contrast* od with a figuro of 17 poroont of illnessos receiving no caro by a physician among familios with incomes of $3000 and more. Eighty -per¬ cent of the relief group wore white and 20 percent vroro colored persons; unattended illnosses woro equally frequent in the two groups. Only 1 poroont of disabling illnossos among relief fam¬ ilios roooivod bodside nursing caro in the homo, as compared with 12 poroont in familios with inoomos of $3000 and over. The average child under 15 years of ago in reliof families re¬ ceived about one-half of the number of physician's services and about ono-twentieth the number of services from a private duty nurse that woro received by children in familios with incomes of $3000 and over. Only 5 percent of births woro hospitalized among families on re¬ lief in southern cities of loss than 25,000 as compared with 90 percent of births among familios with incomes of $3000 and over. Nearly 13 percent of births among relief families in small southern cities wore unattended by physicians or midwife as compared with 100 percent attendance by a physician in hospital or home for the upper income class. These findings are in accord with the facts revoaled in numerous other surveys made in various parts of the country. Each study adds additional evidonco that the receipt of medical care depends largely on incomo and that people of small moans or none at all* though having the greatest nood of care, receive the least service,(24) Wo are not unmindful of the brilliant advances which have been made in scientific medical knowledge. Nor do we overlook notable improvements in medical, public health, dental, and nursing educa¬ tion, or 4>n tho progross of research. Nor do we underestimate the contributions of individuals and associations, lay and professional, in raising the standards of professional services. All of these ad¬ vances are written largo on tho credit side of the ledger of national progross .... but, at some points, the committee finds, the re¬ sources exoeed the need, whore they ore used to less than capacity while people in need go without sorvice. There are economic barriers between those in need of service and those prepared and equipped to furnish services. The essential inadequacy in respect to health ser¬ vices is not in our capacity to produce, but in our capacity to dis¬ tribute. The greater use of preventive and curative services which modern medicine has made available wait on the purchasing power rath¬ er than on the need of the community or individuals^ (25) UTAH HEALTH .CONDITIONS Whon the average student reads of social problems, he mokes his study with the reservation that this particular condition is to be found in the Deep South or perhaps in the slums of some distant city; but rarely does he think of the. social conditions as existing right in his own home town. 502 - CH - 22 - The conditions as outlined in this study on medical economics are a sad commentary on our American Civilization and come as a shock to mtoyw^° have thought of the United States as synonymous with "the good lifo", but for those of us who live in Utah there are sadder facts to bo revealed. Many surveys have been made. The Utah State Medical Association made a very enlightening survey in 1934 (not generally circulated); the Utah State Planning Board issued an immense study in April, 1936, titled "Health Condi¬ tions and Facilities in Utah"; and more recently the National Health Survey took 10,474 samples of health conditions in four representative Utah towns. One of the outstanding conclusions that can be drawn from the report is that: UTAH HAS A GREATER NEED FOR MEDICAL SERVICES THAN THE PEOPLE OF THE NATION ON AN AVERAGE. TABLE OF INCOMES TABLE jf2 IN UTAH AND THE UNITED STATES - 1935 Number of Samples Taken United States 2,BOO.000 Utah Salt Lake City 10,474 7,775 Eureka 651 Bingham Canyon 905 Tooele 1.143 Relief Families 15.6 22.4 16.1 31.4 10.3 31.9 $1000 and Under 28.7 31.6 26,8 26.6 40.4 32.6 $1000 to $1500 21.3 24.3 21.2 28.3 32.5 19.2 $1500 to $2000 15.0 10.6 15.4 7.5 10.1 9.4 $2000 to $3000 10.5 6.4 11.6 4.1 5.0 4.6 $3000 and over 5.7 2.7 4.8 1.1 0.9 1.5 Unknown 3.2 2.0 4.1 1.0 0.8 0.8 From: National Health Survey. —j i This statement '.vill be based upon an acceptance of the fact that sicknesr and disability ore more prevalent among people of small means than those who are in better economic circumstances. "Wo see by consulting the Tabje of In¬ comes that there is a larger percentage of people on relief in Utah than in the United States as an average; a larger percentage of people with incomes of less than $1000; and a larger percentage of people in the income group from $1000 to $1500. It is a simplo deduotion then that if wo have a largerper- contage of people in those low income groups than the nation as a whole, that we also have a larger group of people who are in need of medical attention than the nation as a whole. In fact, by consulting the table of Income we find that 65.6 percent of the nation's families have incomes of less than $1500 annually, while Utah has 78.3 percent of its population in this class. Another conclusion which can be drawn from the report is that the Utah figure of 78.3 percent of the population with incomes of $1500 or less is not 502 - CH - 23 - nearly high enough* This error arises from the fact that the survey was based upon urban and small town conditions rather than upon rural conditions. In Utah most of the people live in rural areas. The National Health Survey fig¬ ures indicate that the rural areas have a larger percentage of low income families than urban areas. It follows then that if we have a larger percentage of low income people that we are also less able to pay for these badly needed medical services. Can there be a doubt then to the original statement that: Utah has a greater need for medical service than the nation as an average and Utah people are less able to pay for these services than the people of the nation on the average. Doctors sometimes say that we are overhospitalized; that we rush every minor case to the hospital. These doctors give this as one reason for the mounting cost of medical care. Contrasted against this we read that There is need for national and regional planning in the field of hospital expansion and construction. An effective system of mod¬ ern health service is impossible without well-equipped hospitals which will provide the facilities necessary for the praotice of FIG. 10. - AVAILABLE AND NECESSARY MEDICAL FACILITIES, indicates that in I?J0 we needed one additional doctor for every six now practising; that we needed over 2-g times as many dentists as we now have, that we needed nearly as many more nurses as we now have and that we need about half again as many hospital beds. Q. .n*/. AVAILABLE AND NE MEDICAL FACILITIES AVAILABLE IN I 530 PHYSICIANS DENTISTS, TECHNICIANS, ETC. NURSES HOSPITAL BEDS ■ . f til I si ADDITIONAL NUMBER NEEDED life ilL ID u hi ti Each Human Figure Represents 25,000 Doctors and Nurses Each Bed Represents 250,000 Hospital Beds. PICTORIAL PROJECT - W. P. A. - 24 - modern medicine. Inadequacies in hospital care ore known to exist in many localities, particularly in rural areas and areas in economic need. Professional standards of adequacy indicate a need for general hospital facilities in the ratio of 4.6 beds per 1000 persons; nervous and mental hospital facilities in the ratio of 5.6 beds for 1000 persons, and tuberculosis facilities in the ratio of two beds per annual death from this disease. In this country today, over two-thirds of the states fall below those standards in general hospital facilities, nine-tenths are below the standard for mental hospitals, and throe-fourths of the states fall below the standard for tuberculosis hospitals. For general hospitals, oven a minimum standard of two beds per 1000 persons for areas (mostly rural) which are fifty miles beyond a large hospital cen¬ ter, would require substantial additions to existing facilities. A total of 31 million people now live in areas with less than two general hospital beds per 1000 persons. Nearly 1300 (42 percent) of the counties (43 percent in Utah) in the United States have no registered general hospital. This condition is natural being large¬ ly rural or sparsely settled, but these rural counties include 15 percent of the population. This means that there ore 18 million people who are living in counties with no local hospital facili¬ ties. Special surveys would be required to determine which have hospitals in adjacont counties and which need additional local facilities. (26) The Utah State Planning Board says: "There are no hospitals at all in twelve of Utah's twenty-nine counties." (27) The Utah State Medical Association states: Government units in the state have failed to furnish their share of hospital facili¬ ties in the state. This is especially true of beds for tubercu¬ losis patients, but those for mental cases have been increased considerably in the last few years though still low by compari¬ son with national standards. The total of general beds avail¬ able in the state as a whole is not so far short of national standards in numbers, but maldistributed geographically, and in some hospitals standards of quality are low. All of these re¬ sult in the large part from the low density of population; many isolated areas could hardly support a hospital. Two divergent trends are evident—one toward the building of new hospitals in rural areas, the other toward the building of a state-owned, centrally located hospital. Each trend has its advantages and disadvantages. (28) In addition, health and diagnostic centers are greatly needed in rural areas where they may serve as centers for the local health department staff, visiting nurse services, maternal and child welfare staff, for basic laboratory and other diagnostic services, for local physicians, for emergency beds, etc. It may be conserva¬ tively estimated that about 500 such centers might properly and usefully be built in areas throughout America which are without local hospitals but, being adjacent to areas which have hospitals, 5UZ-^H - 25 - can have the needs of their people and their physicians met by these centers, (29) DENTAL EACJLJTJES There are at present about 71,000 dentists in the United States or an average of one per 1,724 of the population. (Utah has one dentist per 1,498 of the population). Estimates of the needs for adequate dental care for all our population indicate that the number of dentists could be doubled •without reaching a figure in excess of the true need. As in the case of physicians and nurses, the numbor of dentists is partic¬ ularly inadequate in rural localities and small towns and other areas where income is low. (30) SUPPLY Of RUPEES Tho supply of private nurses according to the Technical Com¬ mittee's report is probably sufficient to moot the present need of the population. However, nurses are not evenly distributed throughout the country; there is a concentration of available nurses in tho citios, and a limited supply in rural areas. Again, the inability to pay for service accounts for tho major part of the nursing problem. Thero is a definite undorsupply of nurses to visit in homes of the low incomo groups to give bedside care and health instruction, and to rondor assistance in clinics. (31) There are 165,000 physicians in the United States today, or a ratio of one physician per 781 of tho population, the Technical Committee reports. (In 1934 "Health Conditions and Facilities" reports 508 physicians and surgeons practicing in Utah, or about ono per 1000 of the population. The ideal generally believed best would bo about 700 of the population per doctor). Tho national average of 781 people per physician would be approximately suf¬ ficient in number to supply tho medical needs of the population if they woro better distributed in relation to the need for ser¬ vice and if their potential services wore being effectively or fully utilized. Young, woll-trained men turn to urban centers to begin practice where professional and economic opportunities are greatest because of hospital facilities and higher average in¬ come of the people, despite the fact that many of these centers already have an adequate, or more than adequate, number of physi* cians# Many rural areas, small cities and whole states are under- supplied with physicians. More recognition of the uneven distri¬ bution will not solve the problem; practice in the underjprivileged aroas must bo made attractive from both a professional arfd eco¬ nomic viewpoint bofore the young physician can be expected to set¬ tle in these aroas where his services are most acutely needed. (32) - CH - 26 - In Utah tho doctor must try to servo his sharo of the staters people (which, of course, he can't do) and in addition must cover a great deal more territory. Mew York doctors average about two square miles of territory. California, 26.0; Kansas,38.0, South Dakota,131j Utah,168; doctors in Nevada, must cover 838 square miles. The mileage problem will be a real consideration to be studied by cooperative health society planners. Maldistribution of doctors in Utah, which is already underdoctored, adds to the medico-economic problem. TABLE #3. 1934 POPULATION PER PHYSICIAN AND SURGEON IN TYPICAL COUNTIES IN UTAH Number of Physicians Population per Physician I'll 1 1 i I. U 11 1 : Number of Physicians Population per Physician Salt Lake 270 719 Sanpete 10 1602 Piute 2 978 Beaver 3 1712 Iron 7 1032 Juab 5 1721 Utah 47 1043 San Juan 2 1748 Weber 49 1065 Davis 8 1753 Cache 25 1097 Grand 1 1813 Carbon 16 1112 Rich 1 1873 Kane 2 1118 Wasatch 3 1879 Morgan 2 1268 BoxElder 9 1979 Summit 7 1361 Millard 5 1989 Emery 5 1408 Duchesne 4 2066 Washington 5 1484 Wayne 1 2067 Uintah 6 1506 Garfield 2 2321 Sevier 7 1600 Tooele 4 2703 508 1000 From: Health Conditions and Facilities in Utah. Consulting the table we note that Salt Lake County apparently has plenty of doctors, but when specialists and technicians are eliminated each physician who is left must take care of about 900 of the population. Let us tie up some of the statistics that have been offered regarding the economically depressed areas of the state and see how these areas fit into areas which are unoconomic fields for the physician. Let's study one of the darkest spots on Utah's medical map. Turn back to the Table of Incomes in 1935 on page 22, note that Tooele had 31.9 percent of its population on relief, 32.6 percent with incomes of' loss than $1000. It has a total of 83.7 percent of its people receiving less than $1500 annually. Note the number of physicians practising in Tooele County in 1934. (Best figure available Table #3). There are four or about one doctor for each 2,703 of population. It do-sanl; take much imagination to picture healt conditions in that county. Study your own county in the light of the averages offered in this hand¬ book, or better still, make your own study of tho sources listed in the biblio¬ graphy. 502 - CH - 27 - J W SUMMARY Horo is a dramatic summary of the whole problem of medical economics as it appearod in a recent issue of the Survey Graphic undor the title "STATE OF THE UNION FACTS AS TO HEALTH AND SICKNESS" "This staggering aggregate of suffering and death can and must be lightened."— Josephine Roche. --Fifty million Americans are in families receiving less than $1000 income a year. Illness and death increase their toll as income goes down; medical care decreasos sharply as need for it mounts. —For the ton most deadly diseases, tho dcathrato is almost twice as high among unskilled workers as among professional workors. For seven of these, thore is a steady increase in deathratos as incomo goes down. --Two thirds of our rural areas are without child health centors or clinics. --One half to two-thirds of maternal deaths are preventable. --The death rate of infants in tho first month of life could bo cut in two. --Our gross pneumonia mortality could easily be reduced by more than 25 por- cont by tho use of serum. Not one out of twonty now roooivos it. --Annual saving of 30,000 lives could be effected by more widespread uso of surgory and radiation in the treatment of cancer. --Evory year 70 million sick persons lose more than one billion days from work. --People of low income obtain little hospital service oxcept in areas having a reasonable proportion of tax supported or ondowed beds. —Over 40 percent (1938) of the countios in tho United States do not contain a registered general hospital to serve their total of 17 million people. —Solf supporting families with incomes up to $5000 spend on an average of from 4 to 5 percent of their budgots on medical care; but unpredictable sori- ous illness may descend upon them with catastrophic force and wipe out their earnings and savings—the economic independence of the family itself. --The gross sickness and mortality rates of the poor of our largo citiejs are as high today as they wore for tho nation as a whole half a century ago^. —No physician's care is received in 28 percent of soriously disabling ill¬ ness among the belt of normally self-sustaining families just above the'1 re¬ lief levol. —In the case of disabling illnoss lasting a week or more, one out of foiar receives no medical care whatever among 20 million people in tho relief • groups, or among tho 20 million pooplc nbovo that level who can purchase it only at risk of curtailing food, clothing, shelter or other essentials of health and decency, —In 1936, nearly a quarter of a million women did not have the advantage of a physician's caro at tho time of delivory. —For the great majority of tho million births attended each year in th$ home by a physician, there is no qualified nurse to aid in caring for mother and baby. (33) 502 — CH - 28 - LIST OF REFERENCES Reference Number (12) THE NEED FOR A NATIONAL HEALTH PROGRAM - see page 27 (Annotation on page 11.) Referenoe Number (15) Same Report as above - see page 21 Reference Number (18) n 11 it it IT ti 25 Reference Number (21) II it it ti It w 24 Reference Number (22) it n ii n II n 22 Reference Number (23) n n n ii n n 25 Reference Number (24) ti ti ii n ti it 25 Reference Number (25) ii it ii ii ti ti 1 'Referenoe Number (26) it II it it it it 33 Reference Number (29) ii ti ii ii ii ii 33 Referonce Number (30) ti it ii it ii it 31 Reference Number (31) ii il m ti ii ii 30 Reference Number (32) IT n ii it it n 30 Reference Number (13) DOLLARS, DOCTORS AND DISEASE - Public Affairs Pamphlot No.10. Published by the Publics Affairs Committee, Inc. 32 pp. Reference Number (14) REPORT TO THE NATIONAL HEALTH CONFERENCE, see page 58. A report containing the National Health Program re¬ commended by the Technical Committee on Medical Caro to tho Interdepartmental Committee to Coordinate Health and Welfare Activities and presented to the profession and general public at tho National Health Conference, July 18, 1938, Washington, D.C. 75 pp. Reference Number (19) Sane Report as above - see page 42 Reference Number (20) " " " " 11 "43 Reference Number (16) Report Bulletin No.2, NATIONAL HEALTH SURVEY. (Annotation on page 11) Reference Number (17) Samo Report as above - soe page 1 Reference Number (27) HEALTH CONDITIONS AND FACILITIES IN UTAH. See page 88. (Soe reference list on page 11 for annotation.) Reference Number (28) PRELIMINARY REPORT BY THE COMMITTEE ON MEDICAL ECONOMICS PUBLIC POLICY AND RELATIONS OF THE UTAH STATE MEDICAL ASSOCIATION - Soo pago 18-19. A survoy which shows tho doctors problems in relation to tho whole medical economic problem. Issued December 1934. 35 pp. Reference Number (33) THE UNSERVED MILLIONS. See page 439. An article report* ing the National Health Program as outlined at the National Health Conference in Washington, D.C. July 1938. Survey Graphic - September 1938. 502 - CH HANDBOOK - Cooperative Health Associations UNIT-THREF . PRPVSMTJVr A\£DJCJM£ Preventive modicino has been ably discussod by C. E. A. Winslow, Pro¬ fessor of Public Health at the Yale University School of Medicine, in on article titled "Preventive Modicino in a Cooperative Health Program," Provontion or Cure, It used to be tho fashion to dofino the ro- spoctivo functions of tho health officer and the practitioner of medicine by saying that tho hoalth departments doal with pre¬ vention and tho private practitioner with cure. With tho passing years, this convoniont slogan h"S become increasingly inadequate. Public Hoalth deals more and moro with individuals and the doctor becomes moro and more interested in prevention. Any antithesis is essentially meaningless. Tho draining of a mosquito-brooding marsh is provontion, pure and simplo; but when a child is found to be underwoight and, under advice as to diet, improves, is this pre¬ vention or euro? Clearly, it is euro of the existing malnutrition and provontion of moro sorious results which might havo followed. Wlion an early case of tuberculosis is sent to a sanitarium, -when an early cancer case experiences a successful operation, the same principle holds. In oaoh case, the damage already done is cured (so far as may be possible) and further damago is provonted. Even in ordinary minor surgery, tho prevention of infection is ofton tho most important objoctive in view. (34) Provontion Pays. In order to get some conception of what prevontivo moaiures can do in tho elimination or control of disease let us digress for a moment from Prof. Winslow's discussions and consider ono particular instance whore a roal application of this sort has been made. Since 1904 there has been a public crusade against tuberculosis. Before this time the ever incroasing number of persons contracting tuberculosis, and tho mysterious and dreaded nature of the contagion had creatod a foar among the populace almost to equal that inspired by tho darkest plagues of history. Since then, through the aid of the National Tuberculosis Association this fear has been gradually brought under control, and tho spread of tho disease has boon greatly decreased. Through tho money derived from selling penny Christmas seals to tho Amori.can public, this association takes the period each year betweecn Thanksgiving and Christmas to stross publicly tho need of oarly diagnosis of suspected casos and prompt treatment of tuberculosis. Dr. Winslow has written many articles on preventive modicino. One titled? "Can Hoalth Be Bought?" in which he analyzes Metropolitan Lifo Insurance Company tables, proves boyond any doubt that prevontivo tactics,do pay. It is apparent that the total doorcase in mortality (592 deaths per 100,000 during the period 1900 to 1932) much more than half or (334 deaths per 100,000) has been contributed by four diseases alone: typhoid fever, diphtheria, diarrhea- enteritis, and tuber¬ culosis. Tho death toll from the first three of those diseases - 29 - - CH - 30 - has docraasod 90 percent and that from tuborculosis about 70 porcont while the death rato from all other disouses taken to¬ gether has diminished by loss than 22 poroont. It can scarcely be an accident that the four diseases whioh are so strikingly diminished are procisely thoso diseases which have been made the objectives of organized attacks by the health forces of tho nation. Campaigns of similar nature to that launched against tuber¬ culosis and other diseases are now under way for cancer and venereal diseases. The benefits of such remedial measures would probably be of inestimable value. Yet why could not a method of prevention and early diagnosis and treatment be car¬ ried over into the whole field of medicine under some system of medical organization which would make practicable tho appli¬ cation of preventive measures on a paying basis satisfactory both to tho prospective patient and the doctor? FIG. H. - PREVENTIVE MEDICINE DOES PAY, indicates that the disease toll has been reduced by organized attacks. |n the case of tuberculosis the re¬ duction has been from 200 deaths per 100,000 in 1900 down to 60 in 1932; and the Diarrhea and Enteritis from |to deaths per 100,000 in 1900 to one dfftth per |00,0p0 f|y| 1932. PREVENTIVE MEDICINE DOES .PAY TUBERCULOSIS DISEASE TOLL REDUCED BY ORGANIZED ATTACK 1900 0 fig) 00 00000 00002) 00 00© 1552 00000 0 GREATEST DEATH RATE DIARRHEA AND ENTERITIS '5® 00000 00000 02)00 1532 RATED 2nd In Deaths EACH SYMBOL REPRESENTS 10 DEATHS PER 100,000, SOURCE: METROPOLITAN LIFE INSURANCE COMPANY (Survey Graphic - December i939 Workers' Education - Utah 502 - CH - 31 - But whilo all modical praotico, private or public, involves some prevention, the substantial gains which can be made have not been evon approached. If preventive measures are to be moro than pious aspirations it is ossential that the tradi¬ tional medical economic relationship bo so modified that the barriers blocking both physician and patient bo romoved. The service itself must be separated from its financing, and Co¬ operative Medicine is one answer. Preventive modieino is one of the principal reasons for Cooperative Modicine and it is an essential in any Cooperative Health Association. (35) PREVENTIVE JAEDJCJNE PROGRAM PREVENTIVE MEDICINE, AS AN INTEGRAL PART OP A COOPERATIVE MEDICAL PROGRAM INCLUDES POUR MAJOR LINES OP ENDEAVOR: - FIRST, THE EARLY DIAGNOSIS AND PREVENTIVE TREATMENT OF ABNORMAL TENDENCIES OB' ANY KIND? SECOND, THE INCULCATION OP SOUND HABITS OP PERSONAL HYG'ENE FOR THE FUTURE,' THIRD, THE FACT THAT THROUGH THE COOPERATIVE, THE DOCTOR HAS A DEFINITE ORGANISATION THROUGH WHICH A CAMPAIGN CP PREVENTIVE EDUCATION CAN BE CARRIED OUT; AND FOURTH, TIIE WORKING OF THE COOPERATIVE METHOD CAUSES PEOPLE TO BE MORE MED¬ ICALLY AND SOCIALLY CONECIOUS AND THEREFORE THE MEMBER WILL BE BETTER ABLE TO ASSIST IN THE PREVENTIVE PROGRAM. Early Diagnosis and Provontivo Treatment of Disease. The primary function of the physician in dealing with his individual patients is to detect deviations from the normal at a stage where the chances of cure aro maximal; and one mechanism which has been proposed for this purpose is the periodic health examination. Such an examina¬ tion is eminently dosirable and one of the roal values of a Cooper¬ ative Health program is that it facilitates health examinations by eliminating the financial barrier which vail always prevent their general application when they are given on a free-for-servioetrath- or than on an annual paymont basis. But if half the effort generally spent in urging annual health examinations were devoted to convincing the public that they should consult the physician WHEN SOMETHING IS WRONG, we might, perhaps, accomplish greater results. The AiNNUAL health examination, as a formal routine, has been great¬ ly over-emphasized. The statistics presentod as indicating a vast number of ''defects11 rovotvle'd by routine examinations are highly mis¬ leading, for analysis shows that almost all of the defects found ore of a minor nature, and that the serious conditions found in this way are quantitatively very few. What is important is'not the examination itself but the use to which it is nut. , Sueh an effective program of immediate consultation implies tho development of a high ideal of health, and perception of the fact that the slightest deviation from such an ideal means "SOMETHING WRONG". Again, before such ready recourse to medical advice can be approached, it is essential that financial inhibitions should be eliminated. Only when the patient feels free to oall the doctor at tho least sign of discomfort or inefficiency^ and only wh.en tho - 32 - doctor feels free to send for the patient whenever he feels that contact would bo helpful, can the ideals of preventive medicine be even approximated. The annual payment plan is the only one which makes for idoal froodom in tho porsonal relationship bo» twoon physician and patient. Thus opening the way to really preventive modicino, tho Co¬ operative Health program should make convenient, not only an adoquato physical examination, but also free use of tho lab¬ oratory and other tests which have dono much to enlarge the possibilities of early diagnosis. Really unsuspootod "Silent Sickness" is more often discovered by such tests than in any other way. The X-ray, for example, is tho only approach to an early diagnosis of tuberculosis, and tho Wasscrmann or Kahn test is invaluable for prompt recognition of syphilis. Instruction in Personal Hygiene. The socond function of the doctor, in dealing with his patient, is calculation of the principles and practices of porsonal hygiene. Doctors should not only be diagnosticians and therapeutists, but also health counsellors. Only the physician can fulfill these functions. There aro certain broad principles which can be broadcast to a whole population. We can talk with some advantage about foods, frosh air, exorcise, and rest. But the really important thing is "how much" and "what kind" of food doos Johnnie Jones need with his particular constitutional history? Tho physicians should, therefore, feel it a definito part of their duties to study tho individual dietary habits of tho patient, for with each passing year the importance of relative¬ ly minor dietary deficiencies is becoming more and more clear. Posture and exorcise, rest, fresh air, habitual bowel movements, all come within this purview. Active immunization against diphtheria and smallpox may be considered today as essentia?, elements in good personal hygi¬ ene and should be urged upon parents for the protection of their children at an early age. In areas where typhoid fever is still common, immunization against this disease should be added to the list of universal measures; protection against scarlet fever or other diseases may be indicated under special circumstances of exposure. Finally, I would strongly urge that the family physician must be, first and foremost, a mental hygienist. Nearly half of all our hospital beds are occupied by patients suffering from ner¬ vous and mental disease, and it seems certain that if we could estimate the burden placed upon society by minor mental and emotional deviations, we should find it equal to the total of all so-called "physical" ills. Our fears, suspicions, inhibi¬ tions, hesitancies, and prejudices, do more than common colds and rheumatism to destroy both happiness and efficiency. All theso mental and emotional handcaps have their causes. They are not "sins by symptoms." The available supply of psychiatrists is wholly inadequate to cope with this problem. We must look to - CK - 33 - the teacher, the nurse, the social worker and., particularly, the family physician--for the upbuilding of a saner world. Only insofar as the practitioner is alert to detoct emotional maladjustments, and is ready to deal with them by modifying the social environment so as to roduce undue pressures and by .helping the individual to adjust himself to that environ¬ ment, will we make real progross in this difficult task. If a program of Cooporativo Hoalth gives its physicians time to deal with the mental hygiene problems of its members and provides for its doctors some measure of expert assistance in developing their capacity to deal with such problems, it will have met one of the major challenges of the presont day in the field of public hoalth. (36) Organization for Education. Added to tho two lines of endeavor suggested for the Cooperative Medical Organization by C. E, A. Winslow, is the important preventive education which tho organization itself will carry out. The personnel charged with an educational responsibility among adults soon learns that it is necessary to have an organization through which a campaign can bo conducted. This holds true in the case of preventive medicine, Tho Cooperative Medical Association, by means of its education committees, its special reserve funds for education of the membership, and its regular membership meetings, is oertainly an ideal agency for a program of a preventive nature. As the organization grows it will probably begin to publish a news organ in which preventive medicine articles should play an important role. As the need for campaigns on certain subject develop, tho organization, through the educational committee, can set up a plan for action with tho assistance of tho doctors, and then carry out tho program as it would carry out any other of its responsibilities, • Tho Cooporativo Health Association will surely bo a strong -right arm assisting tho doctors in their campaign against disoase and medical ignorance. Just the faot that the medical men have a layman's organization behind them should add considerably to tho:.effectiveness of tho preventive med'icine campaign. Tho initial indifferenco of members has been overcome wh^n they are interested enough in the organization to pay the fees. Self-imposed Health Practices. Dr. James Peter Warbasse adds a fourth point to tho cooperative organization of preventive medicine. If cooperative organization of medicine did no more than to increase the desire in the individual to incorporate more healthful practices in his daily life and to control ill health by notioing the early signs of disorder in the body, this alone would justify it as a modern progressive social practice. It is strange that with all our knowledge of how to prevent and control disease we must still have such tre¬ mendous wasto of human resources as now exists because of ill¬ ness. 502 - CH - 34 - Only the physician really appreciates the importance of reoognizing disease in its early stages. Only the physician., unhampered by satis¬ factory financial arrangements, oan render this important service to all adequately. The family doctor, visiting the home in a friendly way to disouss the health problems of the family, will have called to his attention the minor ills, and particularly if it is not going to cost anything to get his advice. The slight loss of appetite, the little headache, the fluttering of the heart, the shortness of breath, or the little lump are the beginning signs of the disease which kills most adults, and these symptoms are present weeks and months before the disease becomes bad enough to drive the patient to the doctor. Under the competitive system of private practice, the disease usually existed a long time before the patient became sufficiently uncomfort¬ able or alarmed enough to consult a physician. He has first tried faith and hope, then somo simple remedy, and when he has become wor- riod sufficiently ho goes to tho doctor—too often with his disease in full bloom and far advanced toward his destruction. Each day doc¬ tors sec cases of whom they says "Alas, too latoj" This is the current situation. Yet, the ordinary competent family dootor can recogniz© those oarly symptoms of tho fatal diseases, and when recognized, most of them can bo ameliorated or cured. It is a tragedy of modern times that tho multitude go on and suffer and die. Cancer, venereal diseases, tuberculosis, heart and kidney troubles, which are responsible for so large a percentage of deaths each year, con be recognized and chockod with some surety in this early stage, in fact, in practically all contagious diseases the harm can bo minimized by early application of medicine to the sick persons, and more impor¬ tant still, tho spread of such may be stopped by early recognition of the nature of the disease. Doctors, while they live in a machine age and continually use machines, they ore not machinists. Their methods are not factory methods. How¬ ever, they are a port of an economic world in which they function. Doc¬ tors should depond for their income upon their product - Health. As a profession, thoy could produce more health if theyr could treat tho pa¬ tients in time to prevont them from becoming sick; and incidentally, in time to save them from stoppage of income because of the failure of timely preventive measures. (37) REFERENCE LIST Reference Number (34) Reference Number (36) PREVENTIVE MEDICINE IN THE COOPERATIVE HEALTH PROGRAM. July 1938 issue of "Cooperative Health", Bureau of Cooperative Medicine, 5 East 57 St. New York City, Same as above. Referenco Number (35) CAN HEALTH BE BOUGHT? - Survey Graphic, Dec.-1934, Reference Number (37) COOPERATIVE MEDICINE. A pamphlet by Dr. James Peter Warbasse, president of the Cooperative League of the U.S.A. and well known surgeon- lecturer. Issued by the Bureau of Cooperative Medicine. 502 - CH HANDBOOK - COOPERATIVE HEALTH ASSOCIATIONS UNIT- FOUR In the foregoing sections, a brief survey of the health conditions of the United States was presented along with a discussion of medical economics. From this we can appreciate the appalling need for some change in our present medical set up, as well as appreciate some of the factors which will influence any effort to effect a change. Perhaps the best remedy offered as a solution to this situation is the plan of payment for medical care on an insurance basis; the cost of the service being distributed over a number of years and borne by the citizens at large instead of by the sick person who is confronted with a large cash outlay for medical services at a time when he is least able to pay for it. The possibilities of ah insurance plan was recognized shortly after the Norld Ear, and, consequently, there have been several attempts made to work out a plan whereby budgeting can be done by the average person so th^b doctor and hospital fees may be collected for and set aside well in advance of the time medical service is required. Many enterprising insurance companies, as well as many hospitals, have formed organizations to collect for hospitaliza¬ tion in advance. Various associations of doctors have been effected in the form of medical clinics which have gone a long way towards distributing the cost of medical services among a larger number of people. Factory owners, as well as labor organizations, have recognized the medi¬ cal need of their employees or members, and have provided certain services and have hirod doctors. More recently the governments, both federal, state and local have been forced to siipply medical services to indigents and to relief clients. Beginning in 1929, the patients of various communities have organ¬ ized Cooperative Health Associations, which they operate'democratically to supply themselves with medical services, hospitalization, dental services, etc. It is the Cooperative Health Association method of solving this complex problem in medical economics which has inspired this handbook. It is hoped that these associations will be better understood in the future by those look¬ ing for a "way out", and that nodical cooperatives already in existence will be able to use the Handbook to an advantage in the educational program whibh it offers its members. Before wo study the cooperative health association, lot us look briefly at a few of the many methods of supplying medical services in the "budget plan". In considering most of the health insurance proposals now in existence, it may bo well to note that d few of them are set up on the Rochdale Princi¬ ples of Cooperation, and are,'therefore, not democratically controlled. Be¬ fore outlining existing plans, it may be well to discuss briefly the Rochdale Principles of Cooperation and show how they are applied to the Cooperative Health Association. - JO - 502 - CH - 36 - In. 1884, in the dreary mill town of Rochdale, England, twenty- eight weavers founded the first consumers' cooperative store. It had taken a year before the store opened its doors for these workers to save a pound apiece out of their scant earnings to make that first cooperative capital of less than $150. During that year of saving and planning and talking together about the kind of world they wanted, they worked out, one by one, the simple rules for running their store, which are known today in many languages as the Rochdale Principles. In the purchase of tea and oatmeal and flour that passed over the counter, the world was given a new way of operating business. Cooperation is a distinct movement, conscious of social aims. It is, as Dr. James P. ?farbassc, President of the Cooperative League of the U.S.A., defines it, "a non-political, voluntary movement expressing itself through economic action." Its primary aim is either to supply its members with goods and services, or to mar¬ ket products of the members without profit, or both. It hopes to make impossible the large, privileged incomes from monopolies and speculation. It aims to win back the ownership of property for the people, and to thereby encourage the sense of thrifti- ness and responsibility that goes with ownership. Cooperation is dependent upon a working together for a common end, (38) RQCH DAL£. ER1 MCJ RLE.5 There were cooperative activities long before the Equitable Society of Rochdale Pioneers first opened the shutters of its little shop on Toad Lane and there have been wavos of coopera¬ tion with every depression right up to this day. With evory rise and fall of cooperative enthusiasm, wc find only a fow surviving societies. As we look back over the long line of"co¬ operative failures and successes and analyze the two groups, we find invariably that the successful organizations used the principles (which follow) first adopted by tho cooperative group on Toad Lane in Rochdale, England. I. OPED MEMBERSHIP Perhaps the most far-reaching idea which the Pioneers applied to their cooperative work is this principle of Universality. The weavers were probably tho first body of coopcrators to welcome all men'and women on an equal basis'into the fraternity of their society, irrespective of their race, color, or creed. On the' day those people of Rochdale adopted this principle> some say, tho cornerstone of an International Alliance was laid, II, PILE MiiMBBR - ONE VOTE Up until tho time of the Pioneers, democracy was only thought of in connection with politics. The Rochdale Pioneers brought the idoa of democracy into their economic organization. No doubt the Chartist members of the society insisted upon the principle. For the Pioneers, democracy was not only a form of government, but also an economic declaration of the rights of man. By their method, the poxiror to govern was given to each member as a human being, irrespective of the amount of capital he owned. 502 - CH - 37 - III. THE PATRONAGE DIVIDEND In a'capitalist stoclc company, aftor all'business expenses are paid, and all legitimate reserves set up, and advertising budgets are mot, the net gain (profit) is paid as a dividend to the stockholder. A cooporativo association, which sells at the regu¬ lar market price and allows for regular expenses, sets up re¬ serves for education and depreciation, and finds it has a net gain (saving). This saving in the cooperative society is re¬ turned to the member-patron as a "patronage dividend" in propor¬ tion to the amount of his patronage during the business period. IV. BUSIiJESS FOR CASH Hovrevcr otherwise credit trading may bo regarded, it is a method which necessarily creates additional expenses. The Pioneers de¬ sired to cheapen the cost of the goods to eliminate all forms of waste so that their own needs could be more cheaply satisfied. They realized that this idea of economy is irreconcilable with debt. V. INTEREST RATES LIMITED Capital invested in the Cooperative society, if it received in¬ terest, shall receive not more than a fixed percentage, which shall not be more than the minimum prevalent rate. VI. SALTS AT MARKET PRICE The cooperatives soon learned not to antagonize other business men by cutting prices on commodities. Small and inexperienced cooperative groups cannot afford to stimulate price wars. They also learned that it was impossible to forecast their business expenses, and those groups which attempted to sell on a "cost plus expense" basis are mourned today by their membership. VII. RESERVES FOR EDUCATIONAL TIORK Ever since the time of the Rochdale weavers, the idea has been in vogue in Consumer Cooperatives that part of the earnings should bo set aside for cultural and educational work. The re¬ sult of'this has been an extensive local and central educational program. (39) The framerc of a cooperative health society will want to take advantage of the Rochdale Principles since they arc the basis of all successful ventures in which Consumers of commodities or services set up their own service socie¬ ties, but, of course, the principles will have to be adapted to the new type of organization. The principle used would probably be something like the following: First,'one vote for each member; no proxy voting. Second, open membership. Third,'service on a cash basis. Fourth, cooperative and medical education. Fifth, political, religious, and racial neutrality* 502 - CH - 38 - The purposes of these principles are democratic control within the health society and the creation of a system whereby medical services may be obtained at the lowest possible cost to the members, commensurate with a reasonable service, and, at tho some time, furnish a fair remuneration to physicians. 'Cooperative Medicine' means applying the very old method of Co¬ operation to the protection of health. ... A Cooperative Health Association is composed of people who unite in the spirit of mu¬ tual aid to supply themselves with services and things for the sake of their health; Under the prevalent competitive business practice of medicine, the medical profession is earning its living largely from the very small percentage of tho population who are sick. Cooperative medicine is the only method which in its opera¬ tion puts such practice on a sound practical basis and makes its unlimited expansion possible. Cooperative medicine preserves the family doctor in his private practice in contrast to a steadily growing employment of dbctors by the state. It represents the free choice of physicians, be¬ cause the patients voluntarily join the Cooperative Health Asso¬ ciation, and in so doing they must, of course, choose a doctor. (40) The ideal health association would scorn to bo"one which conducts an in¬ tensive educational campaign on preventive medicine, provides preventive medical services, contracts for tho members with tho doctor of the member's choice for physician's services, and collects foes agreed upon out of which doctors and hospitals arc paid. It would also sot aside reserves for current contingencies, and for the enlargement of tho society's facilities.' A society serving this purpose would not only be of great value to tho member, but Would, likewise, bo of equal value to the physicians with whom tho various members wish to contract, G SO US AVE D J C A L SLA MS Now that wc have had a quick introduction into the Rochdale Principles which arc the guide to tho democratic development of Cooperative Health Asso¬ ciations, as well as a Very sketchy outline of the general plan of tho Coopera¬ tive Health Association, let us study briefer seven types of group medical plans. There are many methods which have been found workable, but for the purpose of this study, wc will discuss only a few. DOCTOR OWNED CLINICS As the saying goes, there arc clinics and there arc clinics* More to tho point, there arc clinics which are owned by groups of doctors which enable the doctors to pool their knowledge, equipment and expenses; and then there are clinics which go even farther by offering to take large groups of employed people on a prepayment plan, guaranteeing a reasonably complete service. It is this latter typo of service which wc shall discuss here, ROSS-LOOS MEDICAL GROUP Information regarding a doctor-owned clinic was digested from "New Plans of Medical Service", a Julius Roscnwald Fund publication compiled by Michael M, 502 - CH - 39 - Davis, Director for Medical Services, Julius Rosenwald Fund, Chicago, which described completely the setup of this typical voluntary sickness insurance plan for employed groups and their families under the auspices of this private clinic, providing complete medical and hospital services. This is a plan of group practice combined with voluntary health insur¬ ance, organised and operated by Dr. Donald S. Ross and Dr. H. Clifford Loos, and their staff of approximately fifty-five full-time physicians. They own and occupy a clinic building at 1501 South Grand Avenue, Los Angeles, Cali¬ fornia. The private group clinic had been established for some years before the employees of the Department of Hater and Power of Los Angeles sought and (in 1929) arranged for service on a group payment basis. The medical services include house calls, office calls, diagnosis, and medical treatment; also surgical treatment of all kinds either at the clinic or in the hospital. There is no extra charge for eye refraction for sub¬ scribers, or for hospitalization. Employed members receive all services and supplies free, except certain types of expensive medicines such as insulin, salversan, or eye glasses. Dependents of members may receive all professional services, but are re¬ quired to pay their own hospitalization'and for any supplies or apparatus used in their treatment, such as X-ray films, medicines, orthopedic splints, etc; There is also an extra chargd to the dependents of 50^ for each office call, and $1.00 for each home call, and other small charges for special procedures. The costs of the services arc $2.00 per employed person per mOnth for the benefits above'stated. The average extra charges for home calls, hospital¬ ization, medicines, etc.,'"were 65tf per family per'month during the year 1934, making a total cost of $2.65 per coiaplcto medical, surgical, and hospital care, not including dental sorvico. In the autumn of 1955, there were approximately 20,000 employed sub¬ scribers,more than sixty different groups of persons, constituting with their families ofor 60,000 persons. These'include groups from many walks of life, industrial, commercial, professional, as well as employees of certain civil- service subdivisions. Each body of employed persons has a contract with the Ross-Loos Medical Group. A register of the persons entitled to benefits is maintained at the clinic. Payments are made by each group directly to the clinic on behalf of eligible subscribers or dependents. Individuals may be¬ come members. The Ross-Loos Medical Group is organized as a partnership under the laws of California, Financial and professional arrangements between the clinics and the groups of subscribers arc negotiated by specially organized health committees in each group. All complaints and adjustments must be made through" these health committees. No employed solicitors arc engaged to sell contracts. Besides the full-time medical staff of 55 salaried physicians, there are affiliations with about fifteen private practitioners in the outlying dis¬ tricts who are engaged to make house calls on behalf of the clinic. House calls in Los Angeles arc made by eight members of the full-time staff who de¬ vote thoir services entirely to this work. Specialists from the clinic make house calls only for purposes of consultation, when rccomcndod by the general practitioner in charge of the caso. 502 - CH - 40 - During the year 1933, there was an average of approximately fifteen office calls per average family of 3.02 persons, representing a subscriber and his dependents. This represents more than the amount of care received by fam¬ ilies of similar income in the genoral population. "The subscribers, whose hos¬ pital charges aro included in the flat monthly rate, use proportionately twice as much hospital care as do their dependents, whose bills must be paid directly. Because of the alleged solicitation of patients in"connection with the voluntary health insurance plan, Drs. Ross and Loos'were, in 1934, expelled from membership in the Los Angeles Medical Society, although the other physi¬ cians in the clinic have been permitted to Potain and renew'their'membership. This action was upheld by the State Society, but in January,'1935, the Judicial Council of the American Medical Association declared it void, on the ground that the requisite notice and other elements in a fair trial had not been com¬ plied with in the procedure of expulsion. The foregoing plan, while not a true consumer cooperative, does resemble a cooperative in many respects inasmuch as the clients are organized into groups, said groups being composed of people in the Same work or profession. The contract with the clinic is made on a group basis., The main disadvantage to this plan is the same as previously mentioned X7ith regard to industrial health insurance; that is to say, that a person,to belong to one of these group medi¬ cal associations, must be employed in a certain line of work, and individuals, who in many cases are only'temporarily or part-time employed, are excluded from membership. The foregoing, however, does illustrate what can be done under group medicine, and, likewise, furnishes conclusive proof that the cost of med¬ ical service can be greatly reduced under any collective medical plan. HOSPITAL SPONSORED PLANS Group hospitalization, as it is called, is a type of group medicine -which has boon sponsored by various hospitals throughout the country. Today, there arc ouch groups serving 'upwards of sixty communities in the United States, en¬ rolling more than 2,000,000 subscribers and involving several hundred partici¬ pating hospitals. The general plans of group hospitalization do not involve the services of the family doctor and leave the subscriber free to choose and pay for his oxm physician or surgeon. The annual cost of membership in the group hospitalization plans range from five to twelve dollars per subscriber, depending upon the cost levels of the area. The hospitalization usually fur¬ nished is twenty-one days of'free care, including the use of a semi-private room, nursing service, moals, the operating room, X-ray service and laboratorids. The main points not covered by this plan arc that doctor fees arc not included, and there is a noticeable absence of membership organizations or any chance for the patient to voice an opinion, except to withdraw from the group. The point has also been mo.de that this hospital sponsored plan was conceived primarily as a benefit to the hospital. GOVERNMENT MEDICAL PLANS The Government, both federal and stato and local, has been gradually drawn into the medical picture, very often against the best intentions, of those in responsible administrative positions. Vlith the completion of the National Health Survey and the issuance <5f the cad information which this comprehensive health inventory had to give us, the"Federal Government, through an interde¬ partmental commit toe on medical care, has developed a National Health Prop-ram which will bo offered to Congress for its approval or disapproval. ^ 502 - CH - 41 - Relief agencies of the state, county, and city governments have often been forced to cope with the medical service problem. A group of such agencies in San Juan County have taken a step toward developing a method of handling this problem. (See San Juan County Cooperative Health Association.) MUNJCJPAL DOCTOR A plah which is becoming very popular in Canada and known as the Saskat¬ chewan Plan, is another form of government health service. It covers the following points: / ' Th6 doctor is employed at a regular salary ranging from $3,000 to $5,000 per year, the monoy for which is derived from tax assessment. Of approximately 300 rural municipalities in the Province of Saskatchewan, more than sixty em¬ ployed full-time municipal doctors during the year 1938. In addition to the areas'employing full-time doctors, a number of other municipalities make grants of $1,500, or less, as an inducement to physicians to practice in the community and act as health officers and provide medical care for indigent persons0 Under this plan, preventive medicine is carried on, particularly among the children of school age, and the physician agrees to give medical care to each resident of the area without cost, and to devote his full tine to the munici¬ pality. The Saskatchewan plan has been criticized, especially by American medical men, as being "State" medicine, and as incorporating many features which they consider objectionable. It appears to have the siipport of the public in Canada and is probably well rooted as a method of medical economy. J M S U RANGE COMPANY PL AM S. Very little need be said about the'Insurance Company method of budgeting against unforeseen medical contingencies, for it is so expensive that few who read this manual will ever be bothered by the agents. The general plan is for the policyholder to pay the regular premium on his policy, and in the event of sickness, the policyholder submits the doctor's bill or the hospital bill to the insurance company for'payment. This plan'has found some favor among those able to afford it, but, generally speaking, it is not considered a desir¬ able practice for a profit-making third party to cone between the doctor and the patient. There is the added disadvantage in that insurance companies take risks on predictable losses, and in order to do this, the service must bo so limited in its application that many of the costly illnesses, those which worry us the most, have been eliminated in the policy. JNDUSTRJAL MEDJCAl PRACTISE Many large industrial concerns have some sort of medical service for' the employees. This is especially true where the accident hazard is great, such as in mining, construction, and the heavy industries generally. Under this Industrial Group Medicine, the employee is charged a certain fee which is deducted each month from his pay check. "The fee occasionally covers not only the employee, but his dependents as well. While this type of group medicine has gone a long way toward distributing the cost of medical service among a larger group of people, there is usually an absence of member organizations and democratic control so highly desirable. 502 - CH STATE MEDJCAL ASSOCJATJOM FLAM The Utah State Medical Association, through its House of Delegates, has recently announced the undertaking, by that association, of a non-profit hos¬ pitalization and medical expense reimbursement plan. This is in recognition of the fact that the majority of the residents of the state are not"only an¬ xious, but intend to pay for medical attention without outside help. Plans sponsored by commercial companies have, of course, been available, but their coverage was limited largely to employed groups. As'a result, Such plans found acceptance in such centers as Salt Lake, Ogden, and Provo, but could not apply to the rural districts. The Medical Association, therefore, felt it its responsibility to attempt, by means of careful experimentation, to evolve some plan to meet the need for a non-profit hospitalization and medical expense reimbursement'plan. In working out its proposal, there were two main considerations: First, the medical profession does not feel that it is proper for a third party, acting for profit, to intervene between the doctor and his patient. The plan is, therefore, designated as non-profit, and is controlled by the physicians themselves. Second, that in consideration of the need for such plans, it appeared that accidents and illnesses, which resulted in the greatest burden, were not small sicknesses resulting in occasional office and house calls, but rather those incidents of a catastrophic haturc, repairing hospitalization and surgery. The plan of the Association, therefore, will provide for hos¬ pitalization and partial reimbursement of major modical and surgical condi¬ tions. Those plans particularly provide that those who subscribe to them shall have a free choice as to hospital and physician. The Medical Association realizes that this plan is only a partial at¬ tack upon the problem, but changes and improvements will be made as oppor¬ tunity affords. Since some of the technical details of putting these plans into operation are still being worked out, it is impossible to incorporate in this publication full information, but those interested may obtain such information in due time from the Executive Office of the Medical Association, or through the local component modical society. (41) TYFJCAL CO-OFSFATJVE ASSOCJATJOM We have discussed briefly some of the main types of Medical Plans. Now let us study the Cooperative Health Association to sec how it compares with the plans already studied. Three cooperative plans are discussed, the- Farmers1 Union Cooperative Hospital Association, which is a "complete service1' society, which owns its hospital and has even hired its own doctors; the San Juan Cooperative Health Association which is a small one-doctor organization in a rur.al area; and lastly, vjc offer a suggested setup for Utah Cooperative Health Associations, located in areas already served by many reliable physicians. FARMERS1 UNION COOPERATIVE HOSPITAL ASSOCIATION The following plan is a cooperative organized on the principles of Rochdale Cooperation and is apparently gaining considerable headway. The discussion is a quotation from "New Plans of Modical Service" prepared by Michael M. Davis, Director of Medical Service, Julius Rosenwald Fund, Chicago. ' The Farmers1 Union Cooperative Hospital Association of Elk City, Okla¬ homa, offers a voluntary sickness budget plan providing medical care and hos¬ pitalization for the members and their families. 502 - CH - 43 - Organised in 1929, the cooperative hospital has been a pheno¬ menal success. The original membership of 300 has been in¬ creased to more than 2,000 families. A three-story hospital has been erected with the capital provided by tho member patients. To this a new wing was added last year to accommodate additional members. With seven years of experience to draw upon, the cooperative is reorganising its method of operation, making very few changes in the original plan, but adding a now service for members living at greater distancos. Under Plan'Number One, for complete service, duos will bo $12 one person, $18 for two, $22 for throe,and $24 for four or more per family. Hospitalization costs $2 per day, including room, board, general nursing carc, medicines,end serums. Anaesthetic and operating room foes range from $8 for minor to s)18 for major operations. All medical service, - physical examination, treat¬ ment, surgery, deliveriesarc included in the duos for "in¬ patients". For "out-patients" (those not confined to tho hospital) tho duos cover all'medical care except medicine and serums. Free dental examination, X-ray of the tcoth,and extraction are includod. Plan Number Tito, which has just boon added, is designed for pa¬ tients living at greater distances who will receive treatment only when they need hospital care. It is an adaptation of tho Group Hospitalization Plan and does not include treatment when a patient is* not confined to the hospital. Duos for this plan range from $6 per year for one person to $12 per year for a family of four or more. Special rates are available to Hospitalization subscribers at any time they may desire to see a doctor at his office. Participants in the health service benefits arc limited to tho families of stockholders, each of whom owns one share in the Community Hospital. Tho hospital is of fireproof construction and contains the offices and scientific apparatus for Use by the medical end dental staff. The shares cost $50.00 each, payable $20.00 "down" and $15.00 each succeeding November. The income from share capital is used only to pay for hospital Idnd, buildings,and equipment. The stock is not assessable, but stockholders must pay for their shares in full when hospitaliza¬ tion is received. The hospital is managed by a board of five directors elected by the stockholders. The board employs a business manager for the hospital; also the director of the medical staff. Extra charges to stockholders arc made as follows:' home calls, $1,50 plus 25^ per mile ono my; ambulance service, $1.00 plus 100'per mile ono way; X-ray films (other than dental) $3.00 for one, $2.00 each for additional films. Membership has grown steadily, reaching 800 families in 1934 and 1200 by tho autumn of 1935. Elk City, Oklahoma, is a town of 6000 population and Beckham County has a population Of 28,991. Other residents of the community may uso the modical, dental, and hospital services on payment of the regular fees charged for similar services in the community. There arc 25 other physicians in the county. 502 - CH - 44 - The medical and dental staff receive $12.00 of each $25.00 of annual fees paid, with $13.00 being applied to hospital ex¬ penses. Fees from non-member patients go directly to the attending practitioner or to the hospital respectively. All fees are'assessed and collected by the business office of the hospital. Members of the medical staff receive one month's vacation annually, with full pay. (42) SAN JUAN COOPERATIVE HEALTH ASSOCIATION The San Juan County Cooperative Medical Society was formed in the spring of 1938 to make it possible for the people'of San Juan County to have a med¬ ical doctor within the limits of the- county. It might bo stated that San Juan has an area approximately the size of the State of New Jersey and a pop¬ ulation of about 3,500, widely scattered. Up until the time the Cooperative Health Society was formulated, it was necessary for the people to go as much as 75 to 100 miles in order to receive medical attention at Moab in Grand County. Through the formation of their society, the people of San Juan County wore able to guarantee a certain minimum income to a resident physician which would make it possible for him to live in the county. The amount paid by each of the 200 family-unit members who have joined the association is $25,00 per year. About 40 of these arc clients of the Farm Security Admini¬ stration, who have borrowed money through the Administration to pay their annual fees. The Board of San Juan County Commissioners has placed $500.00 in the treasury of the society the first year to care for the indigent sick who must bo taken care of by the county. The incorporated towns of Monticello and Blanding have placed their funds for health officers for distribution by the society. The San Juan School District has placed its funds for school health examinations in the organization. This development in San Juan County is especially interesting in view of cortain recommendations made by the National Health Conference called by the President's Interdepartmental Committee on Health and'Welfare Activities hold in the Mayflower Hotel in Washington, D. C., in July, 1938. On page 62, the report of the conference states: "If effective medical services are to become a reality, people of small means must be able to ob¬ tain those services without facing the costs at the time the services are needed. The cost can be distributed among groups of people and over periods of time through the use of taxation, or through insurance, or a combination of the two." By forming their association, the people of San Juan County have made it possible for them to distribute their medical costs among a larger group of people and over a period of timo. Through the association, also, tax money furnished by the Board of County Commissioners is being used to pay the costs of medical care for indigent charges, and at the same time the taxing units have not gained strategic political positions in the medical field, as feared by some. Thus it seems apparent that through associations, such as the one sot up by the people of San Juan County, it is possible to work out a coordinated system for medical care which is in line with the recommendations "f the peS8St1pSri3ns.Conf0rGnCG' rJld VJilich wil1 includc both independent end de- 502 - CH - 45 - It would seem highly important that any American National Health Pro¬ gram should be set up on such a basis in order to be in line with the best American democratic traditions and ideals. Any practice which would discrimi¬ nate between the rich and the poor would be certain to introduce many fea¬ tures into American medical practice which no one wishes to see. SPRING-VILLE-MAPLETON COOPERATIVE HEALTH ASSOCIATION The proposed Springville-Mapleton Cooperative Health Association plan, while it incorporates features of many other plans, was worked out by Mr. Uayne Beck, Adult Education teacher at Springvillo, in cooperation with local physicians and the staff of the NPA Workers1 Education Program. It is based on the Rochdale principles, which have been discussed previously in this hand¬ book, and the association worked out under the plan will be governed by a board of directors elected by the membership. It is felt'by the originators of the plan that it can be'used, with certain adaptations, in communities which have a single doctor, in small communities which have three or four doctors, or in cities which have many. / / Under the plan, the association itself does not hire any physicians, •but rather acts as an agent for making individual contacts between the mem¬ bers and the physician of their own choice. The member pays into the associ¬ ation his yearly fees (the schedule of which will appear later), and one- twelfth of the physician's portion'of this yearly fee is paid to him each month by the association. That is, if there arc four doctors who accept the association's contracts, each doctor will receive a monthly chock from the association in the same proportion as the number of members who have chosen that doctor as their physician. The plan then, if it were followed out in this way, is based primarily on the traditional relationship of the individual practitioner to his patient. The patient, of course, has a right to change his doctor if he is not satisfied with the services he receives from that doctor. In larger communities, where there is enough medical practice to permit of specialization and the formation of clinics, this same plan could be used to contract with the clinic for the group as a whole rather than to contract for each individual member with his own individual general practitioner. Under the plan, preventive medicine will be encourhgpd because of the fact that'the physician is paid when the member is well, as well as when he is sick, and it is to the best interests, therefore, both of the patient and of the physician to have a healthy rather than a sick community. It goes without saying, of course, that if a physician's full time were' not taken up by the services ho renders to members with whom he has contracts, he can accept any private practice he wishes. Under the plan, the member, therefore, has his free choice of physician, but the proposed Springvillo- Mapleton plan also contemplates that the physician should choose his pa¬ tients. That is, a patient is not finally accepted into the association un¬ til the doctor ho chooses has expressed his willingness to accept that parti¬ cular member as a patient. The services to be provided under the plan are the services ordinarily rendered by a general practising physician, including home and office * calls, obstetrical care, as well as surgery in the homo, office, or hospital. The plan contemplates eventually'that the association will give complete'hospi¬ tal care. However, at first, it anticipates charging each member $1.00 per day while ho is using the hospital. The group docs not plan to have its own 502 - CE 46 hospital, hut rather'to contract with some hospital in the county on a flat rate basis. That is, they plan to contract for their total amount of anti-' cipated hospitalization with a single hospital in the county. The hospital, they feel, will be able to give them a satisfactory rate on this basis be¬ cause it will be possible for the hospital to anticipate more definitely in advance what the drain on its facilities will be. The proposed fee schedule of the association is as follows: First, a member shall pay $5.00 for one share of stock in the association, which will entitled him to all rights and privileges of membership in the association. These five-dollar membership fees will be set aside in a general reserve fund, which will be used for unforeseen contingencies, and for other purposes which will promote the general welfare of the association. "The plan contemplates a service charge of $20.00 per year for one person, $25.00 per year for two per¬ sons, and $55.00 per year for threo or more persons. The allocation of those funds is suggested as follows: Those interested in the association feci that it will not bo difficult to get 600 members in the association at this rate. There would bo, then, a total of $21,000,00 per year paid into the society. The doctors vrould re¬ ceive $12,600.00 of this. There would bo $6,300.00 available for hospital service; :>1680,00 available for tho expense of the society; $105.00 per year for preventive medical education and cooperative education; and $315.00 per year for general'reserves, which may bo used fob contingencies, expanded ser¬ vices to members, and other worthwhile projects, as tho board of directors =oc fit- CQ-QfHKAJJVE A\£DJCJN£ ADVANTAGES. AMD DISADVANTAGES Tho practice of medicine has traditionally been carried on as a respon¬ sibility of the individual practitioner, and- some persons in the medical pro¬ fession have felt that any group health organization was a transgression of their prerogative. There seems to be at tho present time a considerable divi¬ sion of opinion within the American Medical Association with rospcct to group medicine. Some of the loading physicians and surgeons of the Association have openly advocated group medicine, while local Associations have expelled from membership in tho Medical Association doctors who have deviated from tho principle of individual practice. One real job that appears necessary for those who have a vital interest in eoopcrativo modicina and the general -pro¬ blem of health is to give the physicians in their local communities a clear and unbiased picture of the purposes, potentialities, and accomplishments of cooperative mcdicino. FOR THE PHYSICIAN The advantages for tho physician contracting with cooperative health so¬ cieties arc: First, a steady income of funds to pay for future medical services; said' funds being composed cf relatively snail amounts from a largo number of people. For doctors For hospitalization For expense of tho society For reserve for education For general reserves 502 - eg - 47 - Second, more economical practice, as it has been proved that under group medicine doctors only spend from 18 to 20 percent of their gross income on expenses, whereas in private practice, as high as 40 percent of their gross income is spent to meet the expenses of maintaining practice. Third, reparation cf professional duties from business management, he may be relieved of this burden since the health association does all of the collecting and leaves the physician more time to devote to professional duties. There is no 25.00) paid by each and every contracting family, and according to the terms and by-laws of the association of which this contract is a part, agrees'to furnish to each family unit approved by the Association and the Doctor, and to every member thereof, for a period of one year from the date of this agreement, the following services, to-wit: 1. Professional attendance in case of illness or injury. 2. Surgical operations with assistants and anaesthetists necessary and in accordance with the rulos of good surgical practice (excepting operations requiring the services of a specialist). 3. Such laboratory examinations as may be necessary for the proper diag¬ nosis of disease. 4. Attendance on maternity cases including pre-natal and post-natal care. (Notification of such care being desired should be given at least 90 days prior to date of confinement.) 5. Medical advice regarding the health of any or all members of the family unit, and periodic health (physical) examinations, at least once a year, if desired, by each and every member of the family unit. 6. Medical advice, care and/or treatment of indigent cases approved as such by the Association, if the County or the organization will pay for in¬ digent families, THE DOCTOR DOES NOT AGREE TO DO AND HE IS NOT RESPONSIBLE EOR: 1. Dental work of any kind, 2. Insanity, those diseases due to alcohol, drugs, criminal abortion, or venereal disoases. 3, Severe injuries to eye, oar, nose or throat, excepting such cases as may ordinarily be treated by a general practitioner. 4, Any type of work which is contrary to the code of ethics of the medical profession, 5, Any work which does not come within the duties of a general physi¬ cian or surgeon. 6. The fitting of glasses, furnishing of appliances for cripples, medi¬ cines, X-rays, serum, vaccines, toxins, antitoxins, insulin, drugs, special dressings, casts or appliances. 502 - CH - xviii - 7. It is mutually understood and agreed that the Doctor's services in all cases will be provided only by the contracting doctors. This does not ezclude nor prohibit consultation or service of other doctors if requested and paid for by the patient. 3. Cases of illness or injury that will be paid for by industrial in¬ surance. The'board of directors of the association rail give final disposition of disputes, even to nullification of contracts.. IN WITNESS VEjEHSOF, the parties hereto have set their hands and seals on the day and year first above written. Contractee Doctor EMERY" COUNTY HEALTH ASSOCIATION: By: Members of the Contractee's family at the time of signing are as follows: Name Age Signature of Contractee