For the Nation's Health

Ever since the first medicine men started to live high off the boar by ordering their patients to bring them the choicest cuts, ailing mankind has been worrying about how to pay the doctor. In the U.S. recently, attention has been concentrated on two rival methods (TIME, Feb. 20, 1950): compulsory national health insurance (favored by President Truman and Federal Security Administrator Oscar Ewing, "socialized medicine," to its opponents) and the present system of private payment to the doctor for each separate service he gives, with a limited exception for prepayment through voluntary insurance (favored by the A.M.A.).

Last week the U.S. was offered a middle way. The President's Commission on the Health Needs of the Nation recommended that the U.S.: 1) put the Truman-Ewing plan on ice, 2) go all out to extend voluntary insurance plans to tens of millions not now covered, 3) let federal and state governments pay the premiums for those who cannot afford to pay them, 4) dot the nation with up-to-date medical centers where doctors would practice in groups. The commission's plans would cost the Federal Government an estimated $1 billion a year, on top of the $1 billion it now spends for health.

To head the commission a year ago, Harry Truman got a topflight surgeon and medical administrator (in the VA), Chicago's Paul Budd Magnuson, who says: "I'm a Republican myself and always have been." The President let Magnuson pick the rest of the commission--14 representatives of medicine, dentistry, nursing, farmers, labor and consumers. And Magnuson now swears that nobody in the Administration "exerted the slightest bit of pressure on the commission."

Payments. The traditional system of paying the doctor and the hospital is breaking down, said the commission, because the costs and complexities of medical care are increasing all the time. The solution proposed: prepayment through voluntary insurance plans. Many of those now operating are all right as far as they go, the commission believes, but they cover only about 15% of bills for medical care. They must, it believes, be extended to cover doctors' services both at home and in the office, and to cover some nursing services, dentistry for children, and costly drugs and appliances.

One trouble now, says the commission, is that doctors themselves have blocked some all-inclusive insurance plans that consumers want. And in several states there is a ban on plans sponsored by consumers. . But the biggest obstacle to the growth of insurance plans is inability to pay. The main groups which the commission lists as unable to buy prepaid medical care are: those on relief, the blind, the aged, dependent children, the growing numbers now living largely on social security benefits, and those eking out a marginal living on small incomes. To provide for all these, the commission proposes:

P: A cooperative federal-state program, each state to set up a single health authority responsible for developing health services, both public and private, and making them available to all.

P: Use of social security funds to pay insurance premiums for those drawing old-age and survivors' benefits.

P:Joint federal and state payments to meet premiums for those on relief or otherwise unable to pay their own way.

Personnel. After money, the biggest problem is personnel, the commission found. "From the big cities and from the forks of the creek," it reported, "the people asked for more physicians, nurses, dentists . . . There are not enough general physicians, and most of those that we have are so busy that they cannot give the patient the time and sympathetic care the old family doctor could give." Acute shortages were found in all specialties "with the possible exception of surgery."

Experts differed on how severe the doctor shortage would be by 1960. The commission could only conclude that then, with an estimated 171 million people, the U.S. will need from 22,000 to 45,000 more doctors. It proposed:

P: Federal grants to schools of medicine, dentistry, nursing and public health, for modernizing and enlarging their plants.

P:Similar grants to help the schools meet their budget deficits, with no interference in the running of the schools.

P: Federal scholarships to help needy students through the costly medical course.

Research. The commission was shocked to find that the $180 million spent in 1951 for medical research was "less than the amount spent on monuments and tombstones." In mental illness the picture is worse yet: the state and federal governments are spending $1 billion a year on the mentally ill, but only $6,000,000 on research into ways of cutting down this staggering tax burden. The commission's answer: spend more for research now, to save still more later.

Hospitals. The hospital outlook is bleak. Many rural areas have none. Mental and TB hospitals are hopelessly overcrowded. Almost as bad, says the commission, is the condition of obsolete hospitals: "It is difficult to practice good medicine in many of these run-down structures, and their weary air is a depressant to both patients and staff." Some should be modernized, others scrapped.

Using the standards already accepted by Congress--one general-hospital bed for every 220 population and one mental-hospital bed for every 200--the commission figures that the U.S. needs 230,000 new general hospital beds and 330,000 for mental cases.

"The hospital of tomorrow should be a well-rounded health center from which preventive, diagnostic treatment, rehabilitative and home-care services radiate to the entire community." To make this vision an actuality the commission proposed that federal grants to help build hospitals (already being made under the Hill-Burton Act, which expires in 1955) should be enlarged and continued.

The Setup. "The genius for organization, so characteristic of American life in general, is conspicuous in health services by its absence," the commission lamented. It charged that the most highly skilled doctors, dentists and nurses waste too much time doing jobs that less highly trained technicians could do as well or better, and that a lot of expensive equipment is not properly used for the benefit of doctor and patient. To get things running better, the commission urged:

P: Federal loans to help local groups get a prepayment health plan started, itsdoctors to practice as a group.

P: Establishment of a Department of Health and Security, to be headed by a secretary with Cabinet rank.

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